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)
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
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
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
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)
Findings consistent with completed miscarriage

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
Serial hCG

Decline >50% in 2 days suggests completed EPL


  • 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
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
  • 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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