A small proportion of patients who present with EPL will need urgent intervention – including those with hemorrhage, hemodynamic instability or evidence of infection. But 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)
- Medical management with misoprostol +/- mifepristone
- Aspiration in an outpatient or operating room setting.
Choosing from among these options is a preference-sensitive decision, as each of these options are safe and relatively effective, and patients report greater satisfaction when they are treated according to their own preference. As providers, we can provide patient-centered EPL care by supporting our patients in choosing the treatment method that is most in line with their own values and priorities for management.
It is helpful to understand that studies show a wide range of success rates for expectant and medical management, partly due to variability in defining endpoints (based on ultrasound versus clinical scenario) and inconsistencies in when aspiration is offered to participants enrolled in expectant care. And success rates may depend on the type of EPL. Studies suggest that expectant management has higher success rates with incomplete abortion, perhaps because 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) and the amount of time the patient is willing to wait until completion.
Clinically stable patients may choose to wait for the natural completion of EPL. “Watchful waiting” may avoid medical and surgical intervention and attendant side effects or complications, although subsequent aspirations are higher (See Table below; Nanda 2012).
Allowed to proceed on its own, an EPL can take days to weeks to complete, but a patient can be managed expectantly for 6 weeks if they remain stable and amenable. Many clinicians provide phone access between visits and reassess their patients every 1-2 weeks, both to monitor progression of the EPL as well as to check in with the patient to see if they would like to continue current management or prefer to switch to another management option for faster resolution.
There is a trend toward increased bleeding with expectant vs. aspiration management, so patients with severe anemia or risk factors for bleeding 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.
Mifepristone and Misoprostol
Pretreatment with mifepristone followed by treatment with misoprostol results in a higher likelihood of successful management of first-trimester pregnancy loss than treatment with misoprostol alone, with significantly less likelihood of uterine aspiration (relative risk 0.37), and a trend toward less bleeding (Schreiber 2018). Although the regimen may cost more, fewer follow-up visits may be required. Dosing and timing is similar to medication abortion.
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 or risk factors for bleeding may be best managed with aspiration. Overall though, there are cost savings from medication management over the other two options due to less follow-up than expectant care, and fewer overall costs than aspiration. See Steps Table below for additional contraindications.
|Misoprostol Dosing for Miscarriage Management (ACOG 2015, Gynuity)|
|Incomplete miscarriage||600 mcg orally (PO) or
400 mcg sublingually (SL)
|All other types of EPL||800 mcg vaginally (PV)
with optional repeat dose 24-48 hours later if no initial response
Methotrexate 50 mg/m2 has the advantage of being effective in treating early ectopic in situations wherein the diagnosis of EPL vs. ectopic is indeterminate. Efficacy is determined with serial hCG testing, clinical exams and progression of signs and symptoms (Seeber 2006).
UTERINE ASPIRATION FOR MISCARRIAGE MANAGEMENT
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 (Dalton 2006). Following pregnancy loss, antibiotics are indicated only if infection is suspected (Prieto 2012). See Chapter 5 for MVA Steps.
EPL OPTIONS COUNSELING
Options counseling for EPL can begin by reviewing all management options, including advantages, disadvantages, and outcomes, as discussed in the Comparison Table above. Consider a shared decision making approach to counseling – after providing the relevant medical information, elicit the patient’s priorities for treatment through discussion, or use of the checklist below. Then together you can agree on a management decision that honors the patient’s preferences and values for care.
Once the patient has chosen a management method, formulate a treatment and follow-up plan. For expectant or medication management, providers can follow a protocol such as outlined in the Step-by-Step Approach below, and for aspiration management, please see Chapter 7: What to Expect after an Abortion or Miscarriage for additional guidance.