CHAPTER 8 TEACHING POINTS: EARLY PREGNANCY LOSS MANAGEMENT

Purpose: To practice person-centered management in early pregnancy loss.

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: Threatened abortion with viable IUP, incomplete or inevitable abortion, resolving early pregnancy loss, and ectopic pregnancy.
      • First consider and ensure hemodynamic stability.
      • Then assess how the patient 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 speculum exam, bimanual exam, hCG and/or US, and Rh type as needed (see Ch 3).
      • If the hCG is above the discriminatory zone, an US is important to determine the location of the pregnancy unless the patient has a previously diagnosed IUP or EPL. Alternatively, serial hCGs can be obtained.
      • If initial value is below the discriminatory zone, serial hCGs can be obtained.
      • If US is non-diagnostic, proceed with an hCG now. If initial value is above the discriminatory zone, proceed with a second hCG in 48-72 hours.
      • If the pregnancy is undesired, the patient can choose to proceed directly to uterine aspiration (without waiting for hCG results) or medication abortion with ectopic precautions. This enables the patient to receive treatment without delay, and if opts for aspiration, may enable immediate confirmation of IUP vs. ectopic (if membranes and villi are confirmed).
   2. How would you counsel her while waiting for results?
      • The uncertainty of waiting for results can be stressful if a pregnancy is desired. Keep them fully informed.
      • Inform that in > 50% of first trimester bleeding, the pregnancy continues.
      • Ask if the patient has 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 her?
      • Over 85% of patients with fetal cardiac activity on US go on to have full term pregnancies.
      • Mention a lack of evidence to support the need to limit activities.
      • If bleeding or cramping continues or begins again, repeat the evaluation.
      • Determine Rh status and need for Rhogam as appropriate.
      • If a termination is desired, you can offer abortion services or a referral.

Return To Exercises

2. A 38-year-old G2 P1 patient is seeing you in clinic for vaginal bleeding. They are sexually active with a partner that makes sperm, and has been using condoms intermittently. They began having vaginal bleeding about 5 days ago, and it is now decreasing. Their last menstrual period was 8 weeks ago. Their urine pregnancy test is positive. They bring in tissue and you see gestational sac and chorionic villi.
   
   1. How would you proceed with evaluation?
      • Finding gestational sac and chorionic villi means it was not an ectopic pregnancy, except in the rare case of heterotopic pregnancy.
      • History suggests a complete EPL, especially given decreasing bleeding.
      • As with all cases, it is essential to assess for hemodynamic stability, or need for evaluation for anemia or infection. These concerns would prompt a physical exam and labs.
      • If their bleeding and cramping are ongoing, an US is optional to evaluate the contents of the uterus.
      • If the overall picture is consistent with an incomplete abortion, the patient should be offered expectant, medication, or aspiration management.
   2. How would you respond to the following questions:
      • “Was this miscarriage my fault?”
        • Avoid preconceived notions about her feelings about this pregnancy. For example, even though she has a small infant at home, do not assume that this pregnancy was undesired.
        • Tell her an early pregnancy loss is common, unlikely to occur in subsequent pregnancies, and not a woman’s fault, even though many women feel guilty.
        • After discussing the results, await her response and consider open-ended questions about her 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 patients with unexplained recurrent pregnancy loss have a successful next pregnancy (ACOG 2016)
        • If a patient 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 patients with advanced age), it is appropriate to initiate 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 age, Rh testing and Rhogam are not indicated.
      • Offer a follow-up visit (phone or in-clinic) for continuity and support.

Return To Exercises

3. A 24 yo G1P0 patient with vaginal spotting for 2 days. They are in a relationship with one partner and are interested in becoming pregnant. The last menstrual period was 6 weeks 2 days ago and the urine hCG is positive. They deny abdominal pain or passage of tissue. The patient is tearful and distraught.
   1. Does this patient need an ultrasound? How would you assess them without the use of ultrasound?
      • It is unclear if this is an IUP or if the pregnancy is viable.
      • 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 for evaluation of bleeding in the setting of pregnancy of unknown location.
      • If unavailable, begin evaluation with a physical exam and hCG level.
      • Examination should assess for hemodynamic stability, an open os and/or tissue, uterine size, and assessment for adnexal masses or tenderness.
      • Inform of the possibility of ectopic pregnancy, and give ectopic precautions pending further results.
   2. On examination, 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. You are able to obtain a transvaginal ultrasound, which shows Mean sac diameter of 16mm with a yolk sac and no embryo. How do you interpret these results? What are the next steps in evaluation?
      • The patient’s pregnancy is confirmed to be intrauterine because of the presence of a gestational sac and a yolk sac, though the viability is uncertain.
      • Differential diagnosis includes:
        • Early IUP, thus the embryo is absent
        • EPL given mean sac diameter of 16-24mm and no embryo and absence of embryo for 6 weeks or greater since the last menstrual period
      • Since we can see this pregnancy on US and the patient is stable, we do not need to draw serial hCG levels, instead we can repeat the US in 7-10 days.
      • If unable to obtain an US at this visit, plan to draw an hCG level before the patient leaves the office. This can expedite the workup if an off-site US is inconclusive.
      • In patients with desired pregnancies, diagnosis based on a more conservative, or slower, rate of increase is preferred, as it can help avoid misclassification of a desired IUP as EPL.
      • With a viable 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 viable IUPs (Barnhart 2009).
      • For patients 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 hCG level drawn at the initial evaluation is 4000. The hCG done 48 hours later is 3200
      • Assuming that we are unable to obtain an US at this visit we can get information from hCG level drawn. Based on their examination and initial hCG level, this patient could be experiencing EPL. The second hCG level declined, which is not expected for a viable IUP. For patients with a desired pregnancy, you may use a cut off of an increase of 35% in order to avoid misclassification of an IUP as an EPL or ectopic.
      • For example considering that this is a desired pregnancy:
        • Initial hCG = 4000
        • Repeat hCG done on day 2
        • Initial hCG x minimal expected % rise on day 2 = minimal expected rise (for a desired pregnancy)
          • 4000 x 0.35 = 1400
        • Initial hCG + expected rise = minimum expected 2nd hCG
          • 4000 + 1400 = 5400 (by day 2 should be > 5400)
      • If this was a non-desired pregnancy, the following calculations could be used if diagnostic aspiration is negative for POC and you are considering ectopic management
        • Initial hCG x expected % rise on day 2 = expected rise
          • 4000 x 0.53 = 2120
        • Initial hCG + expected rise = minimum expected 2nd hCG
          • 4000 + 2120 = 6120 (by day 2 should be > 6120)
   4. A repeat ultrasound was done 12 days after the initial ultrasound showed a Mean sac diameter was 26mm with a yolk sac and no embryo. How do you interpret these results? What are your next steps?
      • 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 Ch 3 Diagnostic Criteria.
   5. If EPL is confirmed and completed, what kind of patient support may be of use?
      
      • Reminding them that EPL is not their fault may address unspoken fears.
      • They have now had 2 spontaneous abortions, so there is a > 70% chance of successful future pregnancy. Further work-up is recommended at this time, as described in Teaching Points for Exercise 8.2.b.
      • Useful resources for support include family and community, or counseling resources such as a miscarriage support group.

Return To Exercises

4. A 29 yo patient at 10 weeks by LMP calls in for a telehealth visit for vaginal bleeding. The patient had a visit 3 weeks ago confirming a viable intrauterine pregnancy, and intends to continue the pregnancy. Upon reviewing medical history, the patient discloses weekly cocaine use, and wants to know if they should go to the emergency room to see if this is an early pregnancy loss, but has fears about legal consequences of their substance use during this pregnancy. How would you manage and advise this patient?

• • Medical management includes all principles of EPL management. Establish hemodynamic stability. Offer in-person visit or referrals for serial hCG testing and US. Discuss management options including expectant management, medication management, or uterine aspiration.
  • Leading medical organizations oppose policies criminalizing individuals for conduct allegedly harmful in pregnancy (ACOG 2020). This is in recognition that confidentiality and trust are paramount to the patient-provider relationship, that criminalization of pregnant people violates medical ethics and HIPPA. Policies criminalizing pregnant people prevent many from seeking out health care services.
  • As of 2022, 24 states and District of Columbia consider substance use during pregnancy to be child abuse under civil child-welfare statutes, while only 19 states have created treatment programs for those pregnant patients (Guttmacher 2022).
  • People of color and low-income people are more likely to be targeted and have been disproportionately criminalized by these policies.
  • Advising this patient will depend on your practice setting, institutional policies, and state mandated reporting requirements. Consider advising the patient to seek medical care while consulting a legal aid agency (see Ch. 9 Legal Resources) 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 in your institution to develop patient-centered policies so that every provider can implement these best practices in caring for people with substance use disorders, prioritizing assistance in access to treatment over reporting patients to law enforcement.