EARLY PREGNANCY LOSS (EPL)

EPL, often referred to as miscarriage, includes all intrauterine pregnancy loss before 20 weeks of gestation. EPL is common, occurring among 10-20% of clinically recognized pregnancies (Ho 2022, ACOG 2018). Nearly half of all EPLs are the result of random genetic errors (with the most common risk factors being age >35 years and prior EPL) while other factors such as environmental exposures, socioeconomic, and immunologic factors are also implicated (Lens 2021, ACOG 2018). It is rarely possible to determine the cause of EPL.

People with EPL often present with vaginal bleeding and/or abdominal cramping. An EPL can also be an incidental finding on routine US or absent cardiac activity in an asymptomatic person. EPL can be classified based on clinical exam and US findings as outlined in the table below.

^{1 For patients prioritizing a definitive EPL diagnosis, use upper range, and for those prioritizing expedited pregnancy resolution, such as those experiencing an undesired pregnancy, use lower range. SRU/AGOG guidelines suggest diagnosing EPL when there is a CRL of 7 mm and no embryonic cardiac motion, despite evidence that a 5.3 mm threshold gave 100% diagnostic certainty (SFP 2024). Similarly, an empty GS with a mean-sac diameter of 25 mm was also recommended as a diagnostic threshold for EPL, despite research showing that 21 mm was adequate for diagnostic certainty.}

Avoid terms that lack specificity and clarity such as “pregnancy failure,” “spontaneous abortion,” and “blighted ovum”; many people prefer the term “miscarriage” or “early pregnancy loss” (Clement 2019). The term “miscarriage” may carry an implication that they are somehow at fault (i.e. for not “carrying” the pregnancy correctly).

Recurrent pregnancy loss (RPL) is defined as two or more pregnancy losses. While nearly half of RPL cases lack a clear etiology, potential causes can be broadly categorized as genetic, anatomic, endocrine, auto-immune (e.g. antiphospholipid antibody syndrome), and environmental factors (Pillarisetty 2023). The most common causes include fetal chromosomal abnormalities and idiopathic RPL. Evidence on the effectiveness of progesterone for preventing EPL remains mixed, with increased potential benefit for people with 3 or more RPLs (Coomarasamy 2020).

EPL in stable patients is rarely a medical emergency, thus management commonly and appropriately occurs in the outpatient setting, which is safe, efficient, and cost-effective, while also providing more options. While some emergency departments (EDs) are building capability to actively manage EPL (Access Bridge), most still offer expectant management, unless a person is unstable. Initial expectant management in the ED may lead to higher rates of needing to return to the ED emergently for a procedure or blood transfusion (Benson 2023, Torre 2012). Management in the outpatient setting leads to higher satisfaction rates compared to EPL initially managed in the ED (Miller 2019).

Maintaining Legal Safety

Abortion restrictions impact people experiencing EPL and result in dangerous delays in care, particularly in the setting of hemodynamic instability. Those from marginalized communities living in restrictive environments are at higher risk of criminalization of pregnancy outcomes (including EPL and stillbirth) and may avoid seeking care due to fear and risk of being reported to law enforcement.

Additionally, clinicians at some religiously affiliated institutions and in restricted settings face added barriers to managing EPL or ectopic pregnancies when there is fetal cardiac activity (Freedman 2008, Wingo 2020). Clinicians should be aware of local resources and consider all opportunities to prevent criminalization and avoid putting individuals seeking care at risk, including never asking people presenting with symptoms of EPL if they used abortion pills, and if this information is offered, never documenting it in the chart (Pregnancy Justice). For more, see Ch 2: Preventing Criminalization.