| First Visit |
1. Assess desired pregnancy outcome and rule out contraindications
- Suspected ectopic pregnancy
- Hemodynamic instability, pelvic infection
- Caution: anemia, bleeding disorder or anticoagulated
- If medication management:
1. Allergy to medications used
2. An IUD in place (remove) |
2. Ultrasound if indications:
- No definitive intrauterine EPL confirmed by previous US
- Bleeding since last US
- Assess US findings suspicious vs. diagnostic of EPL (Doubilet 2013)
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3. Other diagnostic testing
- Pregnancy test /serum hCG if needed (See algorithm)
- Consider Rh (see Ch. 3)
- Hgb if hx or current symptoms
- STD risk assessment / testing per CDC SPR Guidelines
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4. Counseling & Consent
- Consider patient access to emergency services & follow-up
- Evaluate patient’s treatment priorities and discuss the risks, benefits, and alternatives
- Discuss expected symptoms and reasons to call for expectant and medication management
- Assess the patient’s social support, coping strategies, and emotional state, and offer support as appropriate
If >9 week embryo, discuss possible recognizable fetal tissue |
5. Management / Medications
- Offer NSAID +/- a mild opioid
- Administer Rh IG if indicated (See Ch 5 Rh-D Immunoglobulin)
If patient elects medication mgmt:
- Mifepristone + Misoprostol (or choose a medication regimen appropriate for the patient (see Table above))
If patient elects aspiration:
- See Ch 6 for additional guidance
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6. Establish follow-up and instructions
- Answer all questions, and provide 24-hour contact information for patient
- Review plans for the follow-up visit (via phone or in person) at 7-14 days
- Contraceptive counseling and initiation if patient is interested
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| Follow up visit(s) as needed |
Assess for completion
- History +/- physical
- Serial HCG levels (in all patients without a prior confirmed IUP)
- Serial hCG or US (in cases where Hx and physical are not consistent with a completed EPL)
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Findings consistent with completed miscarriage |
| History
Cramping, bleeding with or without clots or tissue (POC) followed by:
- Diminishing bleeding and resolving cramping
- Resolution of pregnancy symptoms
Physical exam if diagnosis remains unclear
- Uterus firm, small, nonpregnant size
- VS +/- orthostatics as clinically appropriate
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Serial hCG
Decline >50% in 2 days suggests completed EPL |
Ultrasound
- Absence of previously identified gestational sac
- Note: A thickened endometrial stripe and/or heterogeneous intrauterine material are typical after successful management, and without ongoing or abnormal bleeding should not indicate the need for aspiration
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| If miscarriage not completed |
If miscarriage is completed |
- Clinically stable patients may continue expectant management, consider 2nd dose of misoprostol and a 2nd follow-up, or opt for aspiration. Many providers dispense a 2nd misoprostol dose, to be taken after phone follow-up if no bleeding has occurred
- Uterine aspiration is recommended if there are signs of clinical instability or infection
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- If pregnancy not desired, offer patient-centered contraceptive counseling, initiate method, and offer emergency contraception for future use if interested
- If pregnancy is desired, patient can try to get pregnant whenever they feel ready. Discuss future fertility plans and address concerns, as appropriate
- Offer support and referral for additional counseling if needed
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