Early pregnancy loss - ACOG updates guidelines
Washington: Early pregnancy loss (EPL) is defined as a nonviable, intrauterine pregnancy with either an empty gestational sac or a gestational sac containing an embryo or fetus without fetal heart activity within the first 12 6/7 weeks of gestation. In the first trimester, the terms miscarriage, spontaneous abortion, and early pregnancy loss are used interchangeably, and there is no consensus on terminology in the literature.
Recently, ACOG has released updated clinical management guideline for early pregnancy loss highlighting the recent evidence regarding the use of mifepristone combined with misoprostol for medical management of early pregnancy loss. It also includes limited, focused updates for prevention of Rh D Alloimmunization.
Besides, the new guideline released recently by the American College of Obstetricians and Gynecologists (ACOG) also reviews the diagnostic approaches and describes options for the management of early pregnancy loss. It is an updated version of the previous guideline released in May 2015.
Important takeways from the updated guidelines include
Protocol for the Medical Management of Early Pregnancy Loss:
- Misoprostol 800 micrograms vaginally, with one repeat dose as needed, no earlier than 3 hours after the first dose and typically within 7 days if there is no response to the first dose
- A dose of mifepristone (200 mg orally) 24 hours before misoprostol administration should be considered when mifepristone is available
- Prescriptions for pain medications should be provided to the patient
- Women who are Rh(D) negative and unsensitized should receive Rh(D)-immune globulin within 72 hours of the first misoprostol administration
- A follow-up to document the complete passage of tissue can be accomplished by ultrasound examination, typically within 7–14 days. Serial serum b-hCG measurements may be used instead in settings where ultrasonography is unavailable. Patient-reported symptoms also should be considered when determining whether complete expulsion has occurred
- If medical management fails, the patient may opt for expectant management, for a time determined by the woman and her obstetrician-gynecologist or other gynecologic providers, or suction curettage
The following recommendation and conclusion are based on good and consistent scientific evidence (Level A):
- In patients for whom the medical management of EPL is indicated, initial treatment using 800 micrograms of vaginal misoprostol is recommended, with a repeat dose as needed. The addition of a dose of mifepristone (200 mg orally) 24 hours before misoprostol administration may significantly improve treatment efficacy and should be considered when mifepristone is available
- The use of anticoagulants, aspirin, or both, has not been shown to reduce the risk of early pregnancy loss in women with thrombophilias except in women with antiphospholipid syndrome.
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The following recommendations are based on limited or inconsistent scientific evidence (Level B):
- Ultrasonography, if available, is the preferred modality to verify the presence of a viable intrauterine gestation
- Surgical intervention is not required in asymptomatic women with a thickened endometrial stripe after treatment for early pregnancy loss
- The routine use of sharp curettage along with suction curettage in the first trimester does not provide any additional benefit as long as the obstetrician-gynecologist or other gynecologic provider is confident that the uterus is empty
The following recommendations are based primarily on consensus and expert opinion (Level C):
- Accepted treatment options for early pregnancy loss include expectant management, medical treatment, or surgical evacuation. In women without medical complications or symptoms requiring urgent surgical evacuation, treatment plans can safely accommodate patient treatment preferences.
- The use of a single preoperative dose of doxycycline is recommended to prevent infection after surgical management of early pregnancy loss
- Although the risk of alloimmunization is low, the consequences can be significant, and administration of Rh D immune globulin should be considered in cases of early pregnancy loss, especially those that are later in the first trimester.
- Because of the higher risk of alloimmunization, Rh D-negative women who have the surgical management of early pregnancy loss should receive Rh D immune globulin prophylaxis
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