Early Pregnancy Loss in Emergency Medicine Treatment & Management

Updated: Jan 03, 2017
  • Author: Slava V Gaufberg, MD; Chief Editor: Jeter (Jay) Pritchard Taylor, III, MD  more...
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Treatment

Prehospital Care

Maintain routine universal precautions in view of potentially heavy vaginal bleeding. Emergency medical services (EMS) personnel should be aware of the potential for hemorrhagic shock and should treat any hemodynamic instability.

Obtain vital signs and establish an intravenous line in all pregnant patients who have abdominal pain and vaginal bleeding. If the patient is hypotensive, an intravenous bolus of normal saline (NS) is indicated for hemodynamic stabilization.

Administer oxygen.

Encourage the patient to bring any passed tissue to the hospital for evaluation.

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Emergency Department Care

Management

Treat all patients with vaginal bleeding of any etiology as follows:

  • Determine hemodynamic stability and treat instability. If the patient is in hemorrhagic shock, treatment includes the Trendelenburg position, oxygen, aggressive fluid resuscitation (at least 2 large-bore IV lines with lactated Ringer [LR] solution or normal saline, wide open), and hemotransfusion.
  • Determine pregnancy status (qualitative and quantitative).
  • Make laboratory determination of hematocrit (Hct) level and Rh status.
  • Perform a pelvic examination to determine the rate of bleeding; presence of blood clots or products of conception; and condition of cervical os, cervix, uterus, and adnexa.
  • Perform pelvic ultrasonography to determine intrauterine and/or extrauterine contents (fetal heart activity) and/or to clinically classify spontaneous miscarriage.

The American College of Obstetricians and Gynecologists (ACOG) recommends generally limiting expectant management to gestations within the first trimester owing to potential hemorrhage as well as a lack of safety studies of expectant management in the second trimester. [1] An estimated 80% success rate in achieving complete expulsion when adequate time is allowed (≤8 weeks). For women who wish to reduce the time to complete expulsion but do not wish to undergo surgical evacuation, treatment with misoprostol may be considered. [1]

Nadarajah et al found no statistically significant difference in the success rate between 360 women who underwent expectant or surgical management of early pregnancy loss, nor was there any difference in the types of miscarriage. [17] With expectant management, 74% patients had a complete spontaneous expulsion of products of conception. Of these patients, 106 (83%) miscarried within 7 days. However, the rates of unplanned admissions (18.1%) and unplanned surgical evacuations (17.5%) in the expectant group, were significantly higher than those in the surgical group (7.4% and 8% respectively). [17]

Diagnostic specific management

Inevitable miscarriage

The goal of treatment is evacuation of the uterus to prevent complications (eg, further hemorrhage, infection).

Incomplete miscarriage

If tissue, blood clots, or products of conception are found in the cervical os, remove them with ring forceps to facilitate uterine contractions and hemostasis. For the same reason, use oxytocin in cases of severe bleeding (10-20 mcg/L of NS, wide open).

Administer RhoGAM to a gravid patient who is Rh-negative and is experiencing vaginal bleeding.

Consider hemotransfusion in the case of severe bleeding, hemodynamic instability, or both.

Consider treatment with misoprostol to facilitate completion of the miscarriage.

Complete miscarriage

Treatment of a patient who has had a complete miscarriage varies depending on the degree of certainty of the diagnosis. Diagnosing complete miscarriage in the ED can be difficult, unless an intact gestational sac was expelled.

If pelvic examination produces fetal tissue (or material of similar appearance), send it to the laboratory for identification of possible products of conception.

Missed miscarriage

Treatment may vary depending on gestational age as follows:

  • First trimester: Most patients pass the products of conception spontaneously. Coagulation defects secondary to a dead fetus are rare. Expectant management, [18] suction curettage, or misoprostol for medical management to facilitate passage of products of conception may be performed. [19]
  • Second trimester: The uterus is emptied by dilatation and evacuation; alternatively, the uterus is emptied by induction of labor.

Hospitalization

If vaginal bleeding cannot be controlled in the ED, transfer the patient to the operating room (OR) for examination. Anesthetize the patient and perform uterine evacuation.

Transfer

Transfer patients with evidence of a coagulation disorder to a higher level of care.

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Consultations

Consultation with an obstetrician/gynecologist is indicated in all patients with the diagnosis of inevitable or incomplete miscarriage; patients with severe hemorrhage or patients who are hemodynamically unstable require immediate consultation for assistance with definitive treatment. Definitive treatment may be to evacuate the products of conception from the uterus with curettage. Depending on hospital policy, curettage may be performed in the emergency department with subsequent observation of patients for 4-6 hours after curettage, and then discharge if no complications occur. Curettage is generally reserved for those patients who are at risk for hemodynamic instability due to the briskness of bleeding or for those in whom endometritis is a concern. However, most patients with inevitable or incomplete miscarriage are candidates for medical management with misoprostol. [20, 21, 22, 23]

 

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Prevention

A study by Coomarasamy et al randomly assigned 836 women with recurrent miscarriages to receive treatment with progesterone or a placebo to investigate whether the live birth rate would increase in the group that was treated with progesterone. The study did not find a significant increase as the rate of live births was 65.8% (262 of 398 women) in the progesterone group and 63.3% (271 of 428 women) in the placebo group. [24, 25]

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Long-Term Monitoring

Threatened miscarriage

Counsel all patients discharged from the ED (with any stage of miscarriage) regarding possible complications. OB/GYN follow up in 1-2 days should be arranged.

Incomplete miscarriage

After the first dose of misoprostol is administered intravaginally, the patient may be discharged to follow up with her OB/GYN in 24-48 hours.

If a curettage is performed in the ED, the patient should be observed for 4-6 hours. If stable, the patient can be discharged.

Administer the standard dose of Rho(D) immune globulin (ie, 300 mcg) to women who are Rh-negative to prevent Rh immunization (see Medication).

Send the products of conception for pathologic evaluation.

Missed miscarriage

Ultrasonographic findings, in association with presence or absence of significant clinical bleeding, may aid in determination of medical versus expectant management as well as urgent versus routine follow-up.

In the case of expectant management, advise the patient to return to the ED or to contact an OB/GYN if severe cramping, bleeding, fever, and/or passage of tissue occur.

In the case of medical management with misoprostol, the first dose of 800 micrograms may be administered intravaginally in the ED, with follow up to an OB/GYN in 24-48 hours. Patients should be warned to return to the ED or contact their OB/GYN immediately for severe cramping, bleeding, fever, and/or passage of tissue.

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