| First Visit |
1. Rule out contraindications
- Suspected ectopic pregnancy
- Hemodynamic instability, pelvic infection
- Caution: anemia, bleeding disorder or taking anticoagulants
- 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
- See Chapter 3 for US findings suspicious vs. diagnostic of EPL
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3. Other diagnostic testing
- Pregnancy test /serum hCG if needed (See algorithm)
- Rh
- Hgb / Hct (if home mgmt, heavy/ persistent bleeding or if anemia suspected)
- STD risk assessment / testing per CDC Guidelines
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4. Counseling and informed 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 misoprostol 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 and a mild opioid
- Administer Rh IG if Rh negative
(50mcg for EPL <13 weeks)
If patient elects medication mgmt:
- Misoprostol (see Table above)
- Incomplete AB 600 mcg PO
or 400 mcg SL
8000 mcg PV
- Dispense 1-2 doses with instructions to take 2nd dose if no bleeding by follow up.
If patient elects aspiration:
- See Chap 5 for additional guidance & follow-up.
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6. Establish follow-up and instructions
- Answer all questions, and provide 24-hour contact information for patient
- Review plans for the follow-up visit at 7-14 days
- Make a contraceptive plan if appropriate
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| Follow up visit(s) as needed |
Assess for completion of miscarriage
- 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)
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Findings consistent with completed miscarriage |
| History
Cramping, bleeding with or without clots or tissue (POC) with:
- Diminishing bleeding
- No ongoing pregnancy symptoms
Physical exam if diagnosis remains unclear
- Uterus firm and smaller size consistent with aborted pregnancy
- VS +/- orthostatics as clinically appropriate
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Serial hCG
Decline >50% in 2 days suggests completed EPL |
Ultrasound
- Absence of previously identified gestational sac
- Note: A thickened endometrial stripe and heterogeneous intrauterine material are typical after successful management, does not indicate failure, and without ongoing bleeding should not indicate the need for aspiration
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| 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
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- Confirm contraceptive plans and offer emergency contraception if pregnancy is not desired
- Patient can try to get pregnant when emotionally ready. Discuss future fertility plans and address concerns, as appropriate
- Offer support and referral for additional counseling if needed
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