Guideline No. 460: Diagnosis and Management of Intrauterine Early Pregnancy Loss

Abstract

Objective

To provide an evidence-based approach to guide the diagnosis and management of intrauterine early pregnancy loss.

Target Population

This population includes patients experiencing pregnancy loss/miscarriage and incomplete pregnancy loss in the context of a normally sited intrauterine pregnancy. It does not include patients with a pregnancy of unknown location, ectopic pregnancy or recurrent pregnancy loss (2 or more pregnancy losses).

Benefits, Harms, and Costs

Incorrect diagnosis of a pregnancy loss increases the risk of harming a live, normally sited pregnancy. Prolonged waiting for confirmation of a diagnosis can increase anxiety and delay treatment. Patient-centred care discussions can help patients understand their pregnancy loss risk and make decisions about their management and follow-up, including time off for bereavement and mental health support.

Evidence

The following search terms were entered into PubMed from January 2021 to December 2024: early pregnancy loss, incomplete, spontaneous abortion, diagnosis, and management. The International Society of Ultrasound in Obstetrics and Gynecology (2021 and 2022), and Association of Early Pregnancy Units presentations and references were also used.

Validation Methods

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations).

Intended Audience

Health care providers who provide care to pregnant patients experiencing intrauterine early pregnancy loss.

Tweetable Abstract

Early pregnancy loss is a common experience that can be traumatic. Patient-centred care in an Early Pregnancy Assessment Clinic can help patients make informed decisions.

SUMMARY STATEMENTS

• 1.
  Early pregnancy bleeding and loss are common reasons for health care visits (high).
• 2.
  Most early pregnancy loss results from aneuploidy and is not preventable or treatable (high).
• 3.
  Early pregnancy loss has significant psychosocial consequences for patients and their families that can include depression, anxiety and Post-Traumatic Stress Disorder (PTSD) (high).
• 4.
  The establishment of multidisciplinary Early Pregnancy Assessment clinics across the country is recommended; they improve patient experience by expediting evaluation of early pregnancy bleeding and providing physical and emotional care specific to EPL, reducing visits to the emergency department and surgical wait times (high).
• 5.
  Care for early pregnancy should be prioritized to provide patient-centred, evidence based care, reduce complications and manage the mental health needs of patients and their families (high).
• 6.
  Social circumstances, access to care, and patient preference influence management decisions. When diagnostic uncertainty is present, desiredness of the pregnancy can influence patient decision-making (high).
• 7.
  Canada lacks race-based data about early pregnancy outcomes, although data from other countries show inequities; this should be a consideration when providing care and a focus of research in the future (high).
• 8.
  When early pregnancy loss is diagnosed, medically stable patients can review all available management options (expectant, medical, procedural (surgical)) with support to make the decision best for them (high).
• 9.
  Successful medical management may avoid the need for a surgical procedure and the associated surgical and anesthetic risks; mifepristone and misoprostol should be free for patients who choose medical management (moderate).
• 10.
  Current evidence indicates that the amount of fetal blood in the maternal circulation does not reach a level to induce alloimmunization under 12 weeks of pregnancy and guidelines suggest consideration of RhIg administration between 10-12 weeks on an individual basis, in the context of shared decision-making about the potential benefits and risks (moderate).
• 11.
  Providing antibiotics prior to procedural (surgical) management of early intrauterine pregnancy loss with uterine aspiration and avoiding sharp curettage may reduce the risks of infection and intrauterine adhesions (moderate).

RECOMMENDATIONS

• 1.
  Ultrasound criteria should be used to diagnose intrauterine early pregnancy loss. (strong, high)
• 2.
  Clinicians should avoid using hCG values alone to diagnose normal intrauterine pregnancy as there is overlap between non-viable intrauterine pregnancy, viable intrauterine pregnancy, and ectopic pregnancy. (strong, high)
• 3.
  Clinicians should screen patients diagnosed with pregnancy loss for depression and offer treatment or referral to a mental health care provider when they have symptoms of depression. (strong, moderate)
• 4.
  Patients with no prior history of early pregnancy loss should be counselled that no known treatment can change the outcome of a threatened early pregnancy loss. (strong, high)
• 5.
  Patient health history (anemia, bleeding disorders, etc.), and proximity to a health care facility that can manage urgent and emergent complications should be considered when counselling patients on management options. (strong, high)
• 6.
  For stable patients with EPL without signs of infection, all available management options (expectant, medical, procedural) should be discussed. (strong, high)
• 7.
  Patients who choose expectant or medical management of early pregnancy loss should be counselled about the potential need for urgent intervention and provided with instructions on when and where to present for medical assessment if excessive bleeding, pain or signs and symptoms of infection occur. (strong, high)
• 8.
  Clinicians should use mifepristone and misoprostol or multidose misoprostol alone for medical management of early pregnancy loss (gestational sac present). (strong, high)
• 9.
  Expectant management has high success rates for incomplete Early Pregnancy Loss (thickened endometrium with no gestational sac present) and should be a first choice when the patient does not have heavy bleeding, significant pain, or infection. (strong, moderate)
• 10.
  Clinicians should use a misoprostol-only regimen when patients request medical management of incomplete Early Pregnancy Loss (thickened endometrium with no gestational sac present). (strong, high)
• 11.
  A definite intrauterine early pregnancy loss managed expectantly or medically that results in heavy bleeding which resolves can be followed clinically. Ultrasound +/- hCG levels can be reserved for clinical concerns: ongoing heavy bleeding, suspected infection, spotting > 3 weeks or amenorrhea > 8 weeks. (strong, moderate)
• 12.
  Routine RhIg prophylaxis for early pregnancy loss at less than 12 weeks is not recommended (moderate). RhIg administration can be considered on an individual basis between 10-12 weeks in the context of a shared decision-making discussion about the potential benefits and risks. (conditional, moderate)
• 13.
  For surgical management, suction curettage is recommended. Sharp curettage should be minimized to reduce the risk of intrauterine adhesions (strong, moderate); antibiotic prophylaxis should be considered to reduce the risk of infection. (strong, moderate)
• 14.
  For a clinically complete Early Pregnancy Loss (heavy bleeding that has resolved), expectant management has a high success rate even if retained products are identified on ultrasound with no gestational sac present. (strong, moderate)
• 15.
  Pregnant patients who have experienced a prior early pregnancy loss should be offered a reassurance ultrasound at 7 weeks GA to confirm pregnancy location and viability. (strong, low)
• 16.
  Clinicians should create local health quality improvement initiatives to improve wait times for requested procedural management and reduce repeat visits to the emergency department. (strong, moderate)