#200 Early Pregnancy Loss

Question 1

What is the definition of early pregnancy loss?

Answer 1

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 12w6d of gestation

Question 2

What % of all clinically recognized pregnancies end in early pregnancy loss?

Answer 2

10%

Question 3

What % of cases of pregnancy loss occur within the first trimester?

Answer 3

80%

Question 4

What % of early pregnancy loss are due to fetal chromosomal abnormalities?

Answer 4

Approximately 50%

Question 5

What is the most common cause of early pregnancy loss?

Answer 5

Fetal chromosomal abnormalities

Question 6

What are the most common risk factors (2) identified among women who have experience early pregnancy loss?

Answer 6

Advanced maternal age and prior early pregnancy loss

Question 7

What is the frequency (%) of recognized early pregnancy loss for women age 20-30yo? 35yo? 40yo? 45yo?

Answer 7

20-30yo = 9-17%
35yo = 20%
40yo = 40%
45yo = 80%

Question 8

What ultrasonographic findings are diagnostic of pregnancy failure?

Answer 8

CRL of 7mm or greater with no heartbeat.
Mean sac diameter of 25mm or greater and no embryo.
Absence of embryo with heartbeat 2wks or more after a scan that showed a GS without a YS
Absence of embryo with heartbeat 11 days or more after a scan that showed a GS with a YS

Question 9

What type of ultrasound is required to diagnosed pregnancy failure?

Answer 9

Transvaginal ultrasound (for early pregnancy failure)

Question 10

What findings are suspicious, but not diagnostic of pregnancy failure?

Answer 10

CRL of less than 7mm and no heartbeat.
Mean sac diameter of 16-24mm and no embryo.
Absence of embryo with heartbeat 7-13d after a scan w/ GS without a YS.
Absence of embryo with heartbeat 7-10d after a scan that showed a GS with a YS.
Absence of embryo 6wk or longer after LMP.
Empty amnion (amnion seen adjacent to YS with no visible embryo)
Enlarged Yolk sac (greater than 7mm)
Small GS in relation to size of embryo (less than 5mm difference between MSD and CRL)

Question 11

True or false, slow fetal heart rate (<100bpm) at 5-7wks gestation is associated with early pregnancy loss?

Answer 11

True, follow up in 7-10d

Question 12

True or false, subchorionic hemorrhage is associated with early pregnancy loss?

Answer 12

True, follow up in 7-10d

Question 13

In broad terms, what are the options for management of early pregnancy loss?

Answer 13

Expectant, medical, surgical

Question 14

What is the rate of complete expulsion with expectant management for early pregnancy loss? How much time should you give?

Answer 14

80% will achieve complete expulsion within 8 weeks.

Question 15

What are the commonly used criterion for complete expulsion of pregnancy tissue?

Answer 15

Absence of a gestational sac and an endometrial thickness of less than 30mm (however, no evidence that morbidity is increased in asymptomatic women with a thicker endometrial measurement and does not require surgical intervention)

Question 16

In which patients can you consider medical management for early pregnancy loss?

Answer 16

Considered in women without infection, hemorrhage, severe anemia, or bleeding disorders who want to shorted the time to complete expulsion, but prefer to avoid surgical evacuation.

Question 17

Compared to expectant management of early pregnancy loss, does medical management affect time to expulsion or rate of need for surgical intervention?

Answer 17

Medical management decreases time to expulsion and increases the rate of complete expulsion without the need for surgical intervention

Question 18

What are the three studied routes of misoprostol administration for management of early pregnancy loss? Which is(are) more effective, which is(are) associated with more side effects?

Answer 18

Vaginal, sublingual, and oral
Vaginal or sublingual administration is more effective than oral.
Sublingual route is associated with more cases of diarrhea

Question 19

What is the complete expulsion rate by day 3 after 800mcg vaginal misoprostol for early pregnancy loss? After second dose of 800mcg misoprostol?

Answer 19

71% after one dose. 84% after second dose.

Question 20

What is the recommended misoprostol regimen for early pregnancy loss?

Answer 20

800mcg vaginally, with one repeat dose as needed, no earlier than 3 hours after first dose and typically within 7 days if there is no response to the first dose.

Question 21

What is the preferred medical management regimen for early pregnancy loss?

Answer 21

200mg oral mifepristone 24 hours prior to administration of 800mcg vaginal misoprostol +/- second dose of misoprostol

Question 22

What are recommendations regarding Rh negative women receiving medical management for early pregnancy loss?

Answer 22

If Rh(D) neg and unsensitized, should received Rh(D)-immune globulin within 72h of first misoprostol administration

Question 23

What follow up, if any, should occur after medical management of early pregnancy loss?

Answer 23

Ultrasound exam within 7-14d to document complete passage of tissue.
Serial beta hcg measures if ultrasound not available. Patient-reported symptoms should also be considered when determining whether complete expulsion has occurred

Question 24

What is the next step if medical management for early pregnancy loss fails?

Answer 24

Patient may opt for expectant management for a determined amount of time or suction curettage

Question 25

How does use of mifepristone-misoprostol vs misoprostol alone compare for outcomes in early pregnancy loss?

Answer 25

Mifepristone-misoprostol regimen had increased rates of complete expulsion (RR 1.25); decreased risk of surgical intervention with uterine aspiration (RR 0.37).
Pain and bleeding similar between groups.

Question 26

For women with incomplete pregnancy loss (ie, incomplete tissue passage), does misoprostol administration affect rates of complete evaculation compared to expectant management?

Answer 26

Does not clearly result in higher rates. Insufficient evidence to support or refute the use of misoprostol among women with incomplete pregnancy loss

Question 27

What are the bleeding precautions you should give a patient receiving medical management of early pregnancy loss?

Answer 27

Soaking of two maxi pads per hour for 2 consecutive hours

Question 28

In which patients with early pregnancy loss should you perform surgical uterine evacuation? In which would it be preferable?

Answer 28

Perform for hemorrhage, hemodynamic instability, or signs of infection.
Preferable: presence of medical comorbidities such as severe anemia, bleeding disorders, or cardiovascular disease.
Also per patient preference

Question 29

What is the success rate of surgical evacuation for early pregnancy loss?

Answer 29

Approaches 99% success rate

Question 30

What is the success rate of medical management for anembryonic gestation vs embryonic or fetal death vs incomplete or inevitable early pregnancy loss?

Answer 30

Anembryonic (81%)
Embryonic or fetal death (88%)
Incomplete or inevitable early pregnancy loss (93%)

Question 31

What are the only strong predictors of success for medical management of early pregnancy loss?

Answer 31

Bleeding and nulliparity

Question 32

What are the rates of hemorrhage-related hospitalization with or without transfusion for patients treated medically or surgically for early pregnancy loss?

Answer 32

0.5-1% (similar between both groups)

Question 33

What is the overall infection rate after medical or surgical management of early pregnancy loss?

Answer 33

1-2%

Question 34

Are antibiotics recommended with surgical management of early pregnancy loss? With medical management?

Answer 34

A single dose of 200mg doxycycline 1 hour before surgical management.
Benefit of antibiotic prophylaxis for medical management of early pregnancy loss is unknown

Question 35

Among the choices of expectant, medical, or surgical management of early pregnancy loss, which is most costly?

Answer 35

Surgical management in an operating room.
Surgical management in the office without general anesthesia may be less costly than medically managed (fewer follow up visits)

Question 36

Among the choices of expectant, medical, or surgical management of early pregnancy loss, which is most cost-effective?

Answer 36

Medical management with misoprostol

Question 37

How should patients be counseled regarding interpregnancy interval after early pregnancy loss?

Answer 37

No quality data to support delaying conception after early pregnancy loss to prevent subsequent loss or other complications

Question 38

Should patients abstain from vaginal intercourse after complete passage of pregnancy tissue (early pregnancy loss)?

Answer 38

Abstinence for 1-2 weeks is generally recommended to reduce risk of infection, but is not an evidence-based recommendation

Question 39

Can women immediately start hormonal contraception after completion of early pregnancy loss?

Answer 39

Yes

Question 40

What are the contraindications to placement of IUD immediately after surgical treatment of early pregnancy loss?

Answer 40

Septic abortion

Question 41

What is the IUD expulsion rate with insertion immediately after suction curettage in the first trimester vs 6mo post op?

Answer 41

5% immediately vs 2.7% at 6 months

Question 42

After how many early pregnancy losses is work up recommended?

Answer 42

After second consecutive early pregnancy loss

Question 43

What thrombophilias are consistently shown to be significantly associated with early pregnancy loss?

Answer 43

Only antiphospholipid syndrome

Question 44

Are there any effective interventions to prevent early pregnancy loss?

Answer 44

No

Question 45

In which population of women would you consider progesterone therapy in the first trimester?

Answer 45

Women who have experienced at least three prior pregnancy losses

Question 46

Do the use of anticoagulants, aspirin, or both decrease the risk of early pregnancy loss in women with thrombophilias?

Answer 46

Only in women with antiphospholipid syndrome

Question 47

Does routine use of sharp curettage along with suction curettage in the first trimester provide additional benefit?

Answer 47

No, as long as provider is confident that uterus is empty

Question 48

Does the recommendation of rhogam administration change depending on method of management of early pregnancy loss?

Answer 48

Should be considered for medically managed and expectantly managed. Patient’s managed surgically should be given rhogam (higher risk of alloimmunization)