CHAPTER 8 TEACHING POINTS: EARLY PREGNANCY LOSS MANAGEMENT

EXERCISE 8.1: Purpose: To review key steps in early pregnancy loss evaluation, counseling and management.

1. A 25-year-old patient you have been seeing for 5 years presents for an urgent visit. Their past history includes irregular periods, which you have managed with OCPs. They report not having had a period for 7 weeks, and now are having abdominal cramping and moderately heavy bleeding, up to a pad every hour. Urine hCG is positive.
   1. How would you proceed with evaluation?
      • Differential diagnosis includes threatened abortion with normally developing IUP, incomplete or inevitable abortion, resolving EPL, and ectopic pregnancy.
      • First consider and ensure hemodynamic stability (i.e. symptoms, vitals, Hgb as needed).
      • Then assess how the person feels about the pregnancy, acknowledging and understanding that this can be dynamic and may need to be revisited throughout the workup and management.
      • Proceed with thorough history taking (i.e. assess for loss of pregnancy symptoms, quantify bleeding, pelvic pain location) followed by bimanual and/or speculum exam, hCG and/or US, and Rh type (if unknown and >12 weeks) (see Ch 3: Health Evaluation Prior to Aspiration).
      • Management:
        • Desired pregnancy:
          • PUL on US: hCG now and in 48-72 hours, ectopic precautions, advise when needs emergency treatment
          • Confirmed IUP, no signs of EPL: no interventions will change outcome. Offer or refer to prenatal care, advise when to seek urgent or emergent care
        • Undesired pregnancy:
          • Options counseling
          • Can offer MAB or procedure for definitive treatment (in case of PUL: need to follow hCGs until zero)
        • Probable or confirmed EPL: manage based on Clinical Protocol above
        • Possible ectopic:
          • For unstable or one-sided pain, send the person to the ED.
          • Stable: hCG now and after 48-72 hours; ectopic precautions, advise when needs emergency treatment; see Clinical Protocol for Ectopic Diagnosis and Management in General Settings for guidance (Access Bridge).
   2. How would you counsel her while waiting for results?
      • The uncertainty of waiting for results may be stressful.
      • Keep them fully informed.
      • Inform that in > 50% of first trimester bleeding with confirmed IUP, the pregnancy continues.
      • Ask if they have a support person in this potentially difficult time.
   3. If an ultrasound reveals an intrauterine pregnancy with the presence of fetal cardiac activity, how would you discuss the result?
      • With fetal cardiac activity on US, > 85% go on to full term pregnancies.
      • No evidence for limiting activities.
      • If bleeding or cramping continues or begins again, repeat the evaluation.
      • If > 12 weeks, determine Rh status and give Rh IG as appropriate.
      • If a termination is desired, offer abortion services or a referral.
   4. How would your counseling differ if the person travelled to see you from somewhere with abortion bans?
      • Place of origin should not change treatment. Treatment options are determined based on where the practice is located, not the patient’s residence. Given potential travel constraints, offer same-day services whenever possible: counseling, treatment (expectant, medication, or procedural), and contraception if desired. People have the legal right to emergency medical care everywhere.
      • Inform about follow up care options (see INeedAnA.com for vetted options).
      • Provide information about If/When/How’s Repro Legal Helpline for guidance on their rights and information sources on what to do if they need hospital care.
      • Acknowledge the emotional and logistical burdens they’ve faced, validate their experience, and provide nonjudgmental care—especially if they were denied treatment or delayed in receiving care.
      • Given potential travel constraints, offer same-day counseling, treatment options (expectant, medication, or procedural), and contraception if desired.
      • Additional financial and logistical resources include NAF Hotline and AbortionFunds.org.

Return To Exercises

2. A person at 8 weeks by LMP is seeing you in clinic for vaginal bleeding for 5 days, now decreasing. They are sexually active and use condoms intermittently. Urine pregnancy test is positive. They bring in tissue with a gestational sac and chorionic villi.
   
   1. How would you proceed with evaluation?
      • Finding a gestational sac with chorionic villi rules out ectopic pregnancy, and suggests a complete EPL, especially given decreasing bleeding, except in the extremely rare case of heterotopic pregnancy.
      • Assess for hemodynamic stability, anemia, and infection with physical exam and labs, as needed.
      • If continued heavy bleeding and/or significant pain, an US may be helpful to evaluate uterine contents.
   2. How would you respond to the following questions:
      • “Was this miscarriage my fault?”
        • Avoid preconceived notions about the person’s feelings about this pregnancy. For example, even though they had a small infant at home, do not assume that this pregnancy was undesired.
        • Tell them an EPL is common, unlikely to occur in subsequent pregnancies, and not their fault, even though many people feel guilty.
        • After discussing the results, await their response and consider open-ended questions about their expectations, such as “How are you feeling about what is happening?” or “How do you feel about what I have told you?”
      • “Will this happen again?”
        • EPL is common, and in the majority of cases one or two previous EPLs does not predict subsequent EPL. About 65% of people with unexplained recurrent pregnancy loss have a successful next pregnancy (ACOG 2016).
        • If a person is seeking to conceive or pregnancy is desired, encourage a follow-up visit to discuss ways to support healthy pregnancies, such as actively managing chronic medical conditions, and minimizing smoking, alcohol or drug intake. Making a plan to access high quality preconception and prenatal care provides an opportunity to mitigate racial/ethnic and socioeconomic disparities in care.
        • Following three consecutive EPLs (or two for those with advanced age), it is appropriate to initiate or refer for evaluation for conditions such as chromosomal abnormalities, anatomic problems, luteal phase defects, or immunologic disorders such as anti- phospholipid syndrome potentially contributing to recurrent EPL.
   3. What other evaluation or management would you initiate? When can they attempt to conceive again?
      • Address contraceptive goals, methods and use. In most cases the person can attempt to conceive when they feel emotionally and physically ready.
      • For this gestational duration, Rh testing and RhIG are not indicated.
      • Offer a follow-up visit (phone or in-clinic) for continuity and support.

Return To Exercises

3. A person is 6 weeks by LMP with vaginal spotting for 2 days but no abdominal pain or passage of tissue. They have been trying to get pregnant with their partner. Urine hCG is positive.
   1. Does this person need an ultrasound? How would you assess them without ultrasound?
      • It is unclear if this is a normally developing IUP.
      • With a stable patient, you can either obtain US and/or serial hCG levels.
      • US (if available) may provide answers more quickly. See Chapter 3: PUL for evaluation of bleeding in the setting of PUL.
      • If unavailable, begin evaluation with a physical exam and hCG level.
      • Examination should include vital signs,assess for hemodynamic stability, pelvic exam to assess for an open os and/or tissue, uterine size, and assessment for adnexal masses or tenderness.
      • Unless US is performed and identifies an IUP, inform of the possibility of ectopic pregnancy, and give ectopic precautions pending further results.
   2. On exam, you find a closed cervical os, no gestational tissue, and a nontender uterus consistent with 6-week gestation in size without adnexal tenderness or enlargement. A transvaginal ultrasound shows an intrauterine gestational sac with a MSD of 16 mm with a YS and no embryo. How do you interpret these results? What are the next steps in evaluation?
      • The person’s pregnancy is confirmed to be intrauterine because of the presence of a gestational sac and a yolk sac within the uterus.
      • Differential diagnosis includes:
        • Early IUP, thus the embryo is not visualized
        • Concerning for EPL given MSD of 16-24mm, no embryo, and absence of embryo at ≥ 6 weeks since LMP
      • Since we can see an IUP on US and the patient is stable, we do not need to draw serial hCG levels. Given the desired pregnancy, we can repeat the US in 7-10 days (note: while 7-10 days may be a person-centered timeframe, waiting 11 days may be needed to meet US diagnostic criteria).
      • If unable to obtain an US at this visit, draw an hCG level before the person leaves the office, if possible. This can expedite the workup if an off-site US is inconclusive.
      • In people with desired pregnancies, diagnosis based on a more conservative, or slower, rate of hCG increase is preferred, as it can help avoid misclassification of a desired IUP as EPL.
      • With an IUP, the hCG change over 2 days can range from an increase of 35% to the traditionally expected doubling. Using an increase of > 53% in 2 days you will detect 99% of normally developing IUPs (Larraín 2024).
      • For people experiencing EPL, a decline in hCG level is expected. An hCG decline of >50% in 2 days supports a diagnosis of resolving EPL.
   3. An initial hCG is 4000, and 3200 48 hours later. What is the next step?
      • Even without an US, the information from these hCG results is consistent with a probable EPL. Assuming that we are unable to obtain an US at this visit, we can get information from the hCG levels drawn. Based on their examination and initial hCG level, this person is likely experiencing an EPL. The second hCG level declined, which is not expected for a normal developing IUP, which would have a minimum increase of 35%. People can be referred for an US and/or serial hCGs to rule out an ectopic pregnancy. Use shared decision-making if serial hCGs are cost-prohibitive: over the counter urine pregnancy tests will turn negative when the hCG level is 10-25, depending on the test.
      • How to calculate hCG trends:
        • This hCG calculator will do the calculations for you.
        • To calculate expected rise (for example: minimum expected hCG rise for a normally developing IUP): baseline hCG multiplied by 1.XX (XX is minimum expected rise).
          • Example: 4,000 x 1.35 = 5,400 minimum hCG on day 2 for normal IUP
        • To calculate trends over time (when evaluating for risk of ectopic):
          • (Baseline hCG minus repeat hCG) divided by baseline hCG
          • Example: (4,000 – 3000)/4000 = 25% decrease
          • For more information on ectopic diagnosis and management, see Ectopic Diagnosis and Management Clinical Protocol (Access Bridge)
   4. A repeat US 12 days after the initial US shows a MSD of 26 mm with a YS and no embryo. How do you interpret these results?
      • The initial US results were suspicious for EPL, though not diagnostic. The repeat US shows a mean sac diameter greater than 25 mm with no embryo and the absence of an embryo 11 days or more after a scan that showed a gestational sac with a yolk sac. These findings are diagnostic for EPL. Refer to EPL Diagnostic Criteria.
      • Next steps include explaining results, providing supportive counseling, and answering all questions. Management options include expectant management, medication, and aspiration procedure.
   5. If EPL is confirmed and completed, what kind of person-centered support may be of use?
      
      • Reminding them that EPL is not their fault and should not affect future fertility may address unspoken fears.
      • Useful resources for support include family and community, or counseling resources such as a miscarriage support group.
      • With desired pregnancies, giving space to grieve is crucial. You can encourage them to take time or find a grieving practice. Set up additional follow-up appointments as needed.
   6. How would your counseling be different if this person had 3 prior miscarriages?
      • Approach people with RPL in a sensitive manner and appreciate their needs, concerns, and preferences.
      • Address any treatable risk factors, as appropriate, in a non-judgmental way. Consider initiating further work-up for people who have had 2-3 EPLs (see recurrent pregnancy loss resources listed earlier in the chapter), or for those> 35 who have had 2 EPLs.

Return To Exercises

4. A person at 10 weeks by LMP calls in for a telehealth visit for vaginal bleeding. They had a positive pregnancy test and intend to continue the pregnancy, but their bleeding concerns them for EP given weekly cocaine use. They want to know if they should obtain an ultrasound, but have fears about legal consequences of their substance use during this pregnancy. How would you advise this person?

• • Medical management includes all principles of EPL management: establish hemodynamic stability, offer in-person visit or referrals for serial hCG testing and US, discuss options including expectant management, medication management, or uterine aspiration if EPL is confirmed.
  • Be aware of local resources and consider all opportunities to prevent criminalization and avoid putting individuals seeking care at risk (Pregnancy Justice 2024)
  • Leading U.S. medical organizations oppose policies criminalizing individuals for conduct allegedly harmful in pregnancy (ACOG 2020, AMA 2023, AAFP 2019). This is in recognition that confidentiality and trust are paramount to the patient-provider relationship, that criminalization of pregnant people violates medical ethics and HIPAA. Policies criminalizing pregnant people prevent many from seeking out health care services and other forms of assistance (see Ch 1: US Law and Policy Updates).
  • People of color and low-income people are more likely to be targeted and have been disproportionately criminalized by these policies (Riley 2022).
  • Advice will depend on your practice setting, institutional policies, and state mandated reporting requirements. Consider advising the person to seek medical care while consulting a legal aid agency (see Ch 9: Legal Resources) table regarding their legal protections and rights. Reassure safety of seeking care through your practice if possible, and discuss support you can offer in management.
  • Consider working within your institution to develop person-centered policies so that everyone can implement these best practices in caring for people with substance use disorders, prioritizing assistance in access to treatment over reporting people to law enforcement.
  • If appropriate, expectant management and/or self-managed miscarriage care may be preferred in this case to minimize risk of criminalization see Ch 2: Self Managed Abortion.