Society of Family Planning Clinical Recommendation: Medication management for early pregnancy loss

Abstract

Early pregnancy loss (EPL) occurs in 15% to 20% of clinically recognized pregnancies. We recommend that patients experiencing EPL have equal access to all treatment options, including expectant, medication, and procedural management, when urgent treatment is not necessary (GRADE 1A). We recommend a patient-centered approach that uses shared decision-making to diagnose EPL through ultrasonography, serial quantitative hCG measurements, or symptoms (GRADE 1C). We suggest a shared decision-making approach for continuing expectant management of EPL up to 8 weeks after diagnosis in the absence of medical complications or symptoms requiring urgent intervention (GRADE 2C). We suggest against Rh testing and Rh-immunoglobulin administration before 12 weeks of gestation for patients undergoing medication management of EPL (GRADE 2B). We recommend a combined regimen of mifepristone with misoprostol for medication management of EPL (GRADE 1A), using mifepristone 200 mg orally followed 7 to 48 hours later by misoprostol 800 mcg vaginally or buccally (GRADE 2A). When used without mifepristone, we recommend misoprostol in two or more doses of 600 to 800 mcg sublingually or vaginally at intervals of at least 3 hours (GRADE 1B). We suggest ibuprofen 800 mg orally for pain control during medication management of EPL (GRADE 2A). Clinicians should offer all patients, but not require, in-person confirmation of completed EPL (GRADE 2B). We recommend against using endometrial thickness alone as a criterion for recommending additional intervention after medication management of EPL (GRADE 1B). We recommend institutions and clinicians make thorough efforts to obtain and maintain access to mifepristone in clinical settings where patients receive EPL care (GRADE 1C).