Office Management of Early Pregnancy Loss

The management of early pregnancy loss used to be based largely in the hospital setting, but it has shifted to the outpatient setting, allowing women to remain under the care of their family physician throughout the miscarriage process. Up to 15 percent of recognized pregnancies end in miscarriage, and as many as 80 percent of miscarriages occur in the first trimester, with chromosomal abnormalities as the leading cause. In general, no interventions have been proven to prevent miscarriage; occasionally women can modify their risk factors or receive treatment for relevant medical conditions. Unless products of conception are seen, the diagnosis of miscarriage is made with ultrasonography and, when ultrasonography is not available or is nondiagnostic, with measurement of beta subunit of human chorionic gonadotropin levels. Management options for early pregnancy loss include expectant management, medical management with misoprostol, and uterine aspiration. Expectant management is highly effective for the treatment of incomplete abortion, whereas misoprostol and uterine aspiration are more effective for the management of an embryonic gestation and embryonic demise. Misoprostol in a dose of 800 meg administered vaginally is effective and well-tolerated. Compared with dilation and curettage in the operating room, uterine aspiration is the preferred procedure for early pregnancy loss; aspiration is equally safe, quicker to perform, more cost-effective, and amenable to use in the primary care setting. All management options are equally safe; thus, patient preference should guide treatment choice.