COMPARING MANAGEMENT OPTIONS FOR EPL

Clinically stable patients can choose among the following management options to achieve completion of their EPL, or switch from one to another during the process:

• Expectant management (wait and watch)
• Medication management with misoprostol +/- mifepristone
• Aspiration in an outpatient or operating room setting.

Choosing from among these options is a preference-sensitive decision (Wallace 2010), as each option is safe and relatively effective, and patients report greater satisfaction when treated according to their preference.

Studies show a wide range of success rates for expectant and medication management, as success rates depend on type of EPL, clinical studies define success differently (based on US vs clinical endpoints), and there are inconsistencies as to when aspiration is offered to participants enrolled in expectant care. Studies suggest that expectant management has higher success rates when the process of expulsion has already begun, compared to other types of EPL. Providers should counsel patients about their chance of success with each method of management depending upon the type of pregnancy loss (see Comparison Table on next page) and the amount of time the patient is willing to wait until completion.

EXPECTANT MANAGEMENT

Clinically stable patients may choose to await natural completion of EPL. “Watchful waiting” may avoid intervention and attendant side effects or complications (See Table below; Nanda 2012).

An EPL can take days to weeks to complete without intervention. Patients can be managed expectantly for 6 weeks if they remain stable and amenable. Clinicians may reassess patients every 1-2 weeks and provide phone access between visits and, to monitor progression and check in to see if the patient prefers to continue expectant management vs. another management option for faster resolution.

Given slightly increased rates of bleeding with expectant vs. aspiration management, patients with anemia (some providers use hgb < 9) or other bleeding risks may be best managed with aspiration (Nanda 2012).

MANAGEMENT WITH MEDICATIONS

Medication management offers patients a more predictable time to completion, avoidance of uterine aspiration, and an outpatient option available through their primary care provider. Overall though, medication management is more cost-effective than the other two options (less follow-up than expectant care and fewer overall costs than aspiration).

Mifepristone and Misoprostol

Treatment with 200mg oral mifepristone followed by misoprostol results in a higher likelihood of successful management of EPL (specifically missed abortion) than treatment with misoprostol alone (relative risk 1.25), with significantly less likelihood of uterine aspiration (relative risk 0.37), and a trend toward less bleeding (Schreiber 2018, Dzuba 2015). The regimen may cost more than misoprostol alone, although fewer follow-up visits may be needed. Dosing and timing are similar to medication abortion with misoprostol dosed 24-48h after mifepristone. This regimen requires provider registration with a mifepristone manufacturer. (See Chapter 4: Medication Abortion).

^{*highest success rates when misoprostol taken between 7-20h after mifepristone (Flynn 2021)}

Misoprostol Alone

Misoprostol is effective and safe in treating EPL. Some studies show higher levels of bleeding and more follow-up with misoprostol compared to aspiration (Davis 2007, Zhang 2005), so patients with severe anemia (hgb <9) or risk factors for bleeding may be best managed with aspiration.

UTERINE ASPIRATION

Uterine aspiration offers the most definitive management of EPL and highest success rates. Patients may choose aspiration for rapid resolution, support through the entire process, or to avoid side effects of medication management. As with aspiration abortion, MVA for EPL can be performed safely for patients in most outpatient primary care settings and the ED. Costs and bleeding-related complications are greater in the operating room vs. office settings and may add unnecessary burdens to patients and families if options are available (Dalton 2006). If uterine aspiration is used to manage EPL, prophylactic antibiotics did not result in a significantly lower risk of pelvic infection, and are not recommended (Lissauer 2019, Prieto 2012). See Chapter 6 for MVA Steps.

COMPARISON OF MANAGEMENT OPTIONS FOR EPL