#200 Early Pregnancy Loss Flashcards
What is the definition of early pregnancy loss?
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
What % of all clinically recognized pregnancies end in early pregnancy loss?
10%
What % of cases of pregnancy loss occur within the first trimester?
80%
What % of early pregnancy loss are due to fetal chromosomal abnormalities?
Approximately 50%
What is the most common cause of early pregnancy loss?
Fetal chromosomal abnormalities
What are the most common risk factors (2) identified among women who have experience early pregnancy loss?
Advanced maternal age and prior early pregnancy loss
What is the frequency (%) of recognized early pregnancy loss for women age 20-30yo? 35yo? 40yo? 45yo?
20-30yo = 9-17% 35yo = 20% 40yo = 40% 45yo = 80%
What ultrasonographic findings are diagnostic of pregnancy failure?
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
What type of ultrasound is required to diagnosed pregnancy failure?
Transvaginal ultrasound (for early pregnancy failure)
What findings are suspicious, but not diagnostic of pregnancy failure?
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)
True or false, slow fetal heart rate (<100bpm) at 5-7wks gestation is associated with early pregnancy loss?
True, follow up in 7-10d
True or false, subchorionic hemorrhage is associated with early pregnancy loss?
True, follow up in 7-10d
In broad terms, what are the options for management of early pregnancy loss?
Expectant, medical, surgical
What is the rate of complete expulsion with expectant management for early pregnancy loss? How much time should you give?
80% will achieve complete expulsion within 8 weeks.
What are the commonly used criterion for complete expulsion of pregnancy tissue?
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)
In which patients can you consider medical management for early pregnancy loss?
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.
Compared to expectant management of early pregnancy loss, does medical management affect time to expulsion or rate of need for surgical intervention?
Medical management decreases time to expulsion and increases the rate of complete expulsion without the need for surgical intervention
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?
Vaginal, sublingual, and oral
Vaginal or sublingual administration is more effective than oral.
Sublingual route is associated with more cases of diarrhea
What is the complete expulsion rate by day 3 after 800mcg vaginal misoprostol for early pregnancy loss? After second dose of 800mcg misoprostol?
71% after one dose. 84% after second dose.
What is the recommended misoprostol regimen for early pregnancy loss?
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.
What is the preferred medical management regimen for early pregnancy loss?
200mg oral mifepristone 24 hours prior to administration of 800mcg vaginal misoprostol +/- second dose of misoprostol
What are recommendations regarding Rh negative women receiving medical management for early pregnancy loss?
If Rh(D) neg and unsensitized, should received Rh(D)-immune globulin within 72h of first misoprostol administration
What follow up, if any, should occur after medical management of early pregnancy loss?
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
What is the next step if medical management for early pregnancy loss fails?
Patient may opt for expectant management for a determined amount of time or suction curettage
How does use of mifepristone-misoprostol vs misoprostol alone compare for outcomes in early pregnancy loss?
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.
For women with incomplete pregnancy loss (ie, incomplete tissue passage), does misoprostol administration affect rates of complete evaculation compared to expectant management?
Does not clearly result in higher rates. Insufficient evidence to support or refute the use of misoprostol among women with incomplete pregnancy loss
What are the bleeding precautions you should give a patient receiving medical management of early pregnancy loss?
Soaking of two maxi pads per hour for 2 consecutive hours
In which patients with early pregnancy loss should you perform surgical uterine evacuation? In which would it be preferable?
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
What is the success rate of surgical evacuation for early pregnancy loss?
Approaches 99% success rate
What is the success rate of medical management for anembryonic gestation vs embryonic or fetal death vs incomplete or inevitable early pregnancy loss?
Anembryonic (81%)
Embryonic or fetal death (88%)
Incomplete or inevitable early pregnancy loss (93%)
What are the only strong predictors of success for medical management of early pregnancy loss?
Bleeding and nulliparity
What are the rates of hemorrhage-related hospitalization with or without transfusion for patients treated medically or surgically for early pregnancy loss?
0.5-1% (similar between both groups)
What is the overall infection rate after medical or surgical management of early pregnancy loss?
1-2%
Are antibiotics recommended with surgical management of early pregnancy loss? With medical management?
A single dose of 200mg doxycycline 1 hour before surgical management.
Benefit of antibiotic prophylaxis for medical management of early pregnancy loss is unknown
Among the choices of expectant, medical, or surgical management of early pregnancy loss, which is most costly?
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)
Among the choices of expectant, medical, or surgical management of early pregnancy loss, which is most cost-effective?
Medical management with misoprostol
How should patients be counseled regarding interpregnancy interval after early pregnancy loss?
No quality data to support delaying conception after early pregnancy loss to prevent subsequent loss or other complications
Should patients abstain from vaginal intercourse after complete passage of pregnancy tissue (early pregnancy loss)?
Abstinence for 1-2 weeks is generally recommended to reduce risk of infection, but is not an evidence-based recommendation
Can women immediately start hormonal contraception after completion of early pregnancy loss?
Yes
What are the contraindications to placement of IUD immediately after surgical treatment of early pregnancy loss?
Septic abortion
What is the IUD expulsion rate with insertion immediately after suction curettage in the first trimester vs 6mo post op?
5% immediately vs 2.7% at 6 months
After how many early pregnancy losses is work up recommended?
After second consecutive early pregnancy loss
What thrombophilias are consistently shown to be significantly associated with early pregnancy loss?
Only antiphospholipid syndrome
Are there any effective interventions to prevent early pregnancy loss?
No
In which population of women would you consider progesterone therapy in the first trimester?
Women who have experienced at least three prior pregnancy losses
Do the use of anticoagulants, aspirin, or both decrease the risk of early pregnancy loss in women with thrombophilias?
Only in women with antiphospholipid syndrome
Does routine use of sharp curettage along with suction curettage in the first trimester provide additional benefit?
No, as long as provider is confident that uterus is empty
Does the recommendation of rhogam administration change depending on method of management of early pregnancy loss?
Should be considered for medically managed and expectantly managed. Patient’s managed surgically should be given rhogam (higher risk of alloimmunization)
