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Pregnancy loss (miscarriage): Description of management techniques

Pregnancy loss (miscarriage): Description of management techniques
Literature review current through: Jan 2024.
This topic last updated: Oct 13, 2023.

INTRODUCTION — Pregnancy loss, also referred to as miscarriage or spontaneous abortion, is generally defined as a nonviable intrauterine pregnancy up to 20 weeks of gestation. Early pregnancy loss, which occurs in the first trimester, is the most common type. For treatment, individuals experiencing pregnancy loss can choose expectant, medication, or surgical management. The advantages and risks vary across the options and by gestational age of the nonviable pregnancy, but all are generally safe.

This topic will review the details of each management option for patients with pregnancy loss up to 20 weeks of gestation. Related content on risk factors, clinical presentation and evaluation, and discussion of counseling individuals regarding treatment options is presented separately.

(See "Pregnancy loss (miscarriage): Terminology, risk factors, and etiology".)

(See "Pregnancy loss (miscarriage): Clinical presentations, diagnosis, and initial evaluation".)

(See "Pregnancy loss (miscarriage): Counseling and comparison of treatment options and discussion of related care".)

In this topic, we will use the term "patient" to describe genetic females and the words "woman/en" as used in the studies presented. We encourage the reader to consider the specific counseling needs of transmasculine and gender-expansive individuals.

TREATMENT TERMINOLOGY — The actual definitions of the terms below often differ from how they are commonly used both by medical professionals and lay persons. Confusion is further increased when billing codes are attached to diagnoses or procedures that are as imprecisely defined or use outdated definitions. Additionally, some of the gestational age cut-offs vary when these approaches are used for individuals with pregnancy loss compared with pregnancy termination. (See "Overview of pregnancy termination".)

Medication

Medication management – Primary use of medication (and not procedures) to evacuate the uterus. We recommend using the term "medication," not "medical," since medication more specifically indicates use of a medicine. Having a surgery or procedure can also be considered "medical." Medication management can also be used for pregnancy termination but the maximal gestational age differs from that of pregnancy loss.

-(See "First-trimester pregnancy termination: Medication abortion".)

-(See "Second-trimester pregnancy termination: Induction (medication) termination".)

Induction – The term typically used to indicate medication management at ≥20 weeks of pregnancy.

Surgical – Surgical management of pregnancy loss implies using instruments to remove pregnancy-related tissue from the uterus.

Uterine aspiration – Uterine aspiration refers to any procedure that primarily uses suction to remove the uterine contents. Although the technique can be used at a broad range of gestational ages, it is most commonly performed in the first trimester. We use "uterine aspiration" when referring to a procedure up to 13+6 weeks of gestation. Any necessary preceding cervical dilation is assumed.

Additional terminology that applies to uterine aspiration includes:

-Manual vacuum aspirator (MVA) – MVA typically refers to the device used to perform uterine aspiration. It is a syringe instrument with an attached cannula to aspirate the uterus. The act of manual uterine aspiration using an MVA is often also called "MVA" or manual vacuum aspiration procedure.

-Manual uterine aspiration (MUA) – This phrase more accurately describes the act of aspirating a uterus using an MVA. It can also be used to differentiate the action from the device.

-Electric vacuum aspirator (EVA) – EVA is commonly used to describe the electricity-powered machine that provides suction for a uterine aspiration procedure. Similar to MVA, the act of using an EVA is often also called "EVA" or electric vacuum aspiration.

Cervical dilation with uterine aspiration – Cervical dilation with uterine aspiration, also referred to as dilation and curettage (D&C), refers to any procedure in which a clinician first dilates the cervix and then uses a curette (usually a suction cannula) to remove tissue from the uterus. In practice, sharp curettes have generally been replaced with suction cannula when the procedure is performed related to pregnancy. To reduce misunderstanding, the authors prefer the wording "uterine aspiration" for D&C procedures that use suction cannula because this terminology correctly identifies the technique. (See "Dilation and curettage".)

-Avoidance of sharp curettage in pregnancy – Many professional organizations, including the World Health Organization (WHO), American College of Obstetricians and Gynecologists, and Society of Family Planning, advise that sharp curettage not be performed during D&C procedures in pregnancy because of the risks of perforation, blood loss, increased pain, intrauterine adhesion formation, and the need for greater cervical dilation compared with suction cannula [1,2]. (See "Intrauterine adhesions: Clinical manifestation and diagnosis", section on 'Etiology and risk factors'.)

Dilation and evacuation (D&E) – Any procedure to empty the uterus that uses both cervical dilation and any other method of uterine evacuation. We use "D&E" when referring to a procedure at or above 14 weeks, though it is important to note that the definition of D&E for billing and coding purposes may differ.

Uterine evacuation – While this terminology refers to any procedure that empties the uterus, it usually refers to the evacuation of pregnancy-related tissue.

EXPECTANT MANAGEMENT — Expectant management refers to for watchful waiting for the pregnancy tissue to pass on its own. In the first trimester, efficacy rates of 70 to 80 percent have been reported for this approach [3]. (See "Pregnancy loss (miscarriage): Counseling and comparison of treatment options and discussion of related care", section on 'Expectant management'.)

Clinical issues – Clinical issues that we consider and discuss with the patient include :

Gestational age of pregnancy loss – When selected, expectant management is most commonly used for management of first-trimester pregnancy loss. Beyond 13 weeks of gestation, we advise either medication management in a health facility or surgical management. By contrast, many low- and middle-income countries continue expectant management into later gestational ages and instruct patients to present to a health facility if labor commences.

Frequency and nature of follow-up care (eg, plan for repeat ultrasound or serum pregnancy testing) – We determine a follow-up plan based on the individual patient's clinical and emotional needs. Typically, follow-up evaluation occurs every one to two weeks until completion. If the pregnancy has not passed in >4 weeks of expectant management, alternate treatment options are advised.

Antibiotic are not indicated – Antibiotics are not indicated for expectant management of first-trimester pregnancy loss.

Confirmation of completed pregnancy loss – This can be done using ultrasound, urine or serum hCG levels, patient symptoms, or a combination thereof.

Need to change to different treatment option – The time at which the patient and clinician should consider a different treatment option if the pregnancy does not pass, and symptoms that require prompt evaluation.

Pain management – Patients experiencing spontaneous passage of pregnancy loss can expect significant uterine cramping. Patients in the first trimester are typically offered nonsteroidal anti-inflammatory drugs (NSAIDs) for pain. Some patients may require additional pain medication (non-narcotic or opioid), especially at gestational ages beyond the first trimester. Treatment varies by drug availability and geographic region.

Follow-up – Consensus on the need for follow-up and confirmation of complete passage of gestational tissue for patients who elect expectant management is lacking [4]. To confirm complete expulsion of tissue, studies have used criteria including ultrasound parameters, patient-reported symptoms, or both. Based on a trial comparing misoprostol-only medication management with uterine aspiration, one commonly used ultrasound criterion is absence of a gestational sac [5]. Ultrasound measurement of endometrial thickness does not appear to be helpful to confirm complete emptying of the uterus and the authors do not use it in their practices [6].

Complications – Any of the complications below warrant timely patient evaluation and likely progression to medication or surgical management depending on the problem and hemodynamic stability of the patient.

Incomplete uterine emptying – Patients who desire expectant management may experience incomplete passage of pregnancy tissue (ie, retained tissue). Medically stable patients may require uterine aspiration or medication therapy to empty the uterus of all pregnancy-related tissue. Medication management is not an option for patients with evidence of heavy bleeding or infection.

-(See 'Medication management' below.)

-(See 'Surgical management (uterine aspiration)' below.)

Need for uterine aspiration – Patients who desire expectant management are counseled that they may still require uterine aspiration if they develop heavy bleeding and/or infection. Patients with retained products of conception (POCs) may also warrant uterine aspiration.

Infection – Infection risk increases with duration of retained nonviable pregnancy. Patients who present with uterine infection may require antibiotics and uterine aspiration, sometimes as emergency treatment. Once infection is identified, further expectant or medication management is contraindicated. (See "Pregnancy loss (miscarriage): Clinical presentations, diagnosis, and initial evaluation", section on 'Septic abortion'.)

Bleeding – Patients passing a nonviable pregnancy can expect heavy bleeding and cramping, but both should improve after expulsion of the majority of tissue. Some patients will continue to bleed heavily, possibly as a result of uterine atony, infection, laceration/injury, or other causes. These individuals may require emergency evaluation and uterine aspiration. (See "Pregnancy loss (miscarriage): Clinical presentations, diagnosis, and initial evaluation", section on 'Hemorrhage'.)

Disseminated intravascular coagulation (DIC) – Prolonged expectant management with fetal demise can also lead to DIC, though it is a rare event unless the pregnancy remains in the uterus for several weeks [7]. At four weeks postdiagnosis, the risk of DIC is approximately 10 percent and increases with further delayed management [8]. DIC is a very serious condition that requires careful and prompt management to prevent significant morbidity and mortality.

MEDICATION MANAGEMENT — Medication management for pregnancy loss is similar to the medication regimens used for pregnancy termination. An overview and detailed discussions of medication pregnancy termination are presented elsewhere.

(See "Overview of pregnancy termination".)

(See "First-trimester pregnancy termination: Medication abortion".)

(See "Second-trimester pregnancy termination: Induction (medication) termination".)

Combined mifepristone and misoprostol regimen

Improved efficacy with combined therapy — For medication management of first-trimester pregnancy loss, we recommend combination therapy with mifepristone followed by misoprostol, if mifepristone is available, because of the higher efficacy rates compared with misoprostol-only in both trial and cohort studies (efficacy rates of 80 to >90 percent versus 75 percent, respectively) [9-13]. Efficacy rates vary with gestational age. However, lack of access to mifepristone should not be used as a reason to deny medication management to a patient who desires it. Detailed discussion of efficacy and additional counseling points for the two regimens are presented in related content. (See "Pregnancy loss (miscarriage): Counseling and comparison of treatment options and discussion of related care", section on 'Medication management'.)

Of note, the above recommendation is based on the body of evidence, including relevant major clinical trials, and consistent with the American College of Obstetricians and Gynecologists and World Health Organization (WHO) but differs from those of the National Institute for Health and Care Excellence (NICE) [2,4,14]. The NICE guideline advises misoprostol-only regimens for individuals with confirmed pregnancy loss (with or without symptoms) [14].

First trimester (up to 12+6 weeks gestation) — For patients who elect medication management of pregnancy loss, we take the following approach:

Drugs, dose, and regimen – Up to 12+6 weeks of gestation, the evidence-based protocol for medication management of pregnancy loss is mifepristone 200 mg orally followed in 24 hours by misoprostol 800 micrograms given vaginally, buccally, or sublingually (typically given as four 200 microgram tablets) [9-11]. However, an observational study including 139 patients with early pregnancy loss reported highest rates of gestational sac expulsion in those who took misoprostol 7 to 20 hours after mifepristone compared with those who took it 0 to 6 hours or 21 to 48 hours later (expulsion rates of 97, 55, and 88 percent, respectively) [15]. Until more supporting data are available, the authors continue to advise patients to take their misoprostol between 10 to 24 hours after mifepristone. Medication management may be initiated the same day as the diagnosis of pregnancy loss after appropriate counseling and consent.

Efficacy – Combined treatment with mifepristone followed by misoprostol results in successful medical treatment of early pregnancy loss in 80 to 90 percent of patients [9-11]. Efficacy estimates are impacted by gestational age, duration of follow-up, and patient symptoms. Increasing gestational age may lower efficacy rates while longer duration of follow-up interval and presence of vaginal bleeding appear to increase efficacy rates. In an observational study of patients treated in a pregnancy loss clinic but outside of a research protocol (ie, real-world experience), 76 of 85 patients (89 percent) had successful medical management, including two patients who required a second misoprostol dose [16]. Median gestational age was 49 days (range 30 to 80) as measured with ultrasound.

Alternative regimens – There are regimens for medication abortion that involve using misoprostol at the standard doses six hours apart or even simultaneously with mifepristone (95.8 and 95.1 percent successful, respectively) [17,18]. These regimens have not been studied in the setting of pregnancy loss but would likely have similar efficacies as for medication abortion.

Antibiotic prophylaxis – Antibiotics are not recommended for routine medication management of first-trimester pregnancy loss.

Pain management – There is no universal approach to pain reduction for medication management of pregnancy loss. We instruct patients to take a nonsteroidal anti-inflammatory drug (NSAID) prior to using misoprostol, though the timing of this has not been studied. Typically, medication management of early pregnancy loss is associated with less pain compared with uterine aspiration. That said, medication management is still a painful process for most people. Routine use of narcotics is not generally necessary.

Repeat misoprostol dosing – After nine weeks of gestation, there is significant improvement in outcomes with the addition of a repeat dose of misoprostol. Misoprostol 800 mcg administered buccally, vaginally, or sublingually after the initial treatment with mifepristone and misoprostol [4,19,20]. A repeat dose of misoprostol is also given to patients who experience minimal or no bleeding after 24 hours from the initial misoprostol dose.

Discussions specific to medication termination are presented elsewhere. (See "First-trimester pregnancy termination: Medication abortion".)

Second trimester (13 to 19+6 weeks of gestation) — Data from second-trimester medication abortion is extrapolated to individuals with second-trimester pregnancy loss. Beyond the first trimester, addition of mifepristone improves outcomes compared with misoprostol alone [21-23]. Several treatment regimens are available (table 1).

Medication protocols – There are multiple approaches to dosing and timing of mifepristone and misoprostol for second-trimester pregnancy loss (table 1).

Treating with mifepristone prior to misoprostol in the midtrimester reduces the pregnancy tissue expulsion time by approximately 40 to 50 percent [24-36]. Studies included a range of gestational ages from 13 to 24 weeks and used protocols that varied the misoprostol dose by the gestational age. The protocols are the same as those used for second-trimester pregnancy termination, which are reviewed in detail separately. (See "Second-trimester pregnancy termination: Induction (medication) termination", section on 'Medical society protocols'.)

Up to 20 weeks gestational age, we recommend using mifepristone 200 mg orally 24 hours prior to misoprostol administration. The misoprostol dosing is 800 micrograms buccally, sublingually, or vaginally every three hours until expulsion of the pregnancy tissue. Above 20 weeks, or in situations in which there is at least one prior uterine scar, smaller doses of misoprostol should be used, still at three-hour intervals. These medication regimens are based on data from pregnancy termination and discussed in detail in related content. (See "Second-trimester pregnancy termination: Induction (medication) termination".)

Additional points include:

Route of misoprostol administration – Different routes of administration have been evaluated, and the consensus is that vaginal or sublingual routes are preferred over oral/buccal administration as they lead to decreased time between initiation of misoprostol and fetal expulsion [27,37]. Data are extrapolated from studies evaluating pregnancy termination protocols.

Timing of misoprostol initiation – Data from studies on medication abortion indicate the optimal time to initiate misoprostol is between 24 and 48 hours after administration of mifepristone. Some studies have suggested improved outcomes with administration after 36 to 48 hours. The regimens recommended by the WHO, the American College of Obstetricians and Gynecologists, and the Society of Family Planning all provide the range of 24 to 48 hours [24,38,39]. Anecdotally, the authors' experience indicates a benefit, though not as significant, with an interval even shorter than 24 hours. If your clinical setting or the specific situation does not allow for a delay between administration of the two medications, one should still consider providing mifepristone prior to initiating misoprostol (table 1).

Location for treatment – It is generally advised that patients undergo medication management of second-trimester pregnancy loss within a health care facility and not as outpatients. The rationale is that these patients generally have increased need for pain medication and increased risks of bleeding, infection, retained tissue, and other complications.

Side effects – The side effects of mifepristone and misoprostol with later pregnancy are similar to those when used for first-trimester loss, though the multiple doses of misoprostol may increase the incidence of nausea and vomiting.

Pain management – The authors discuss pain management options with each patient and arrive at a reasonable plan. Treatment options are extrapolated from the limited available data on pregnancy termination. Studies of pain management for patients undergoing second-trimester medication termination have reported using oral analgesics (eg, NSAIDs and/or narcotics), intravenous or patient-controlled analgesia with fentanyl or morphine, intramuscular diclofenac, paracervical blockade, and regional anesthesia [30-32].

Relative contraindications – There are certain circumstances in which medication management of pregnancy loss between 13 and 20 weeks should be avoided or undertaken with more care. If a patient has one prior uterine scar, data suggest no changes in management need to be made as long as abnormal placentation (eg, placenta previa and/or placenta accreta) is not suspected. In the presence of more than one scar, the risk of uterine rupture is increased, and the authors advise eliminating a loading dose of misoprostol and halving the dose of misoprostol (200 mcg every three hours instead of 400 mcg every three hours).

In a situation where placenta previa or other abnormal placentation is suspected, surgical management should be considered first-line management if it is at all available.

(See "Placenta previa: Epidemiology, clinical features, diagnosis, morbidity and mortality".)

(See "Placenta accreta spectrum: Clinical features, diagnosis, and potential consequences".)

Misoprostol only — If mifepristone is not available and a patient prefers medication management, a misoprostol-only regimen is completely acceptable after appropriate counseling on the reduced efficacy (efficacy rates of 71 to 76 percent at 8 and 30 days, respectively, up to 12 weeks gestation) [9,14,39]. (See "Pregnancy loss (miscarriage): Counseling and comparison of treatment options and discussion of related care", section on 'Medication management'.)

First trimester

Our approach – We treat patients with a single dose of misoprostol 800 mcg per vagina (typically given as four 200 mcg tablets) [9,12].

-Patients are counseled that approximately two-thirds will have complete expulsion after a single treatment and nearly one-quarter will require subsequent uterine aspiration.

-For patients who do not have complete expulsion after a single dose, a second 800 mcg dose can be given after 12 to 24 hours.

World Health Organization – The WHO advises 800 mcg by any route (buccal, sublingual, or vaginal), without specifying maximum number of doses, to allow for potential need for repeat dosing [2].

Second trimester – Based on data from studies of medication termination in the second trimester, misoprostol alone can be given to complete pregnancy loss. We largely follow the approach endorsed by the American College of Obstetricians and Gynecologists that offers two different regimens and is presented in related content [38]. Our approach differs in that we do not restrict the number of misoprostol doses to five, as there are no data indicating a lack of safety using six or more doses. (See "Second-trimester pregnancy termination: Induction (medication) termination", section on 'Medical society protocols'.)

Medication side effects — While patients report more side effects with medication management versus uterine aspiration, studies have reported high satisfaction with both methods when individuals are able to choose their treatment [5]. We counsel patients on possible side effects and allow them to choose their preferred management, as medically indicated.

Mifepristone – While nausea and/or vomiting has been reported after mifepristone use, most individuals have very few, if any, side effects [40].

Misoprostol – Misoprostol is more likely than mifepristone to cause various side effects; gastrointestinal complaints are most common [5]. We offer patients receiving misoprostol an antiemetic, especially if they have preexisting nausea and vomiting related to pregnancy. Ondansetron is commonly prescribed because it is low cost and can be given as a dissolvable tablet and thus reduces the risk of having the medication vomited.

In a trial comparing misoprostol with vacuum aspiration, patients receiving misoprostol reported the following side effects [5]:

Nausea – 53 percent

Vomiting – 20 percent

Diarrhea – 24 percent

Abdominal pain – 99 percent

Pyrexia – 3 percent

Complications of medication management — Complications common to medication management for gestational ages up to 20 weeks include retained products of conception (POCs), infection, hemorrhage, and (rarely) death. The risk of complications generally rises with increasing gestational age.

For all gestational ages

Retained products of conception – Between 5 and 20 percent of individuals using medication management will require additional treatment for retained POCs [4]. By some estimates, the risk of retained POCs is as much as 8 percent after medication management regimens including mifepristone in the second trimester [33-35]. Use of mifepristone increases the likelihood of complete expulsion over misoprostol alone. Management of retained POCs includes repeating misoprostol or surgical aspiration, depending on the clinical context and the patient's preferences.

Infection – Rates of infection following medication management of early pregnancy loss are low (1 to 2 percent) [4], but when it does occur, retained POCs should be considered. Antibiotic prophylaxis is not recommended for routine medication management of pregnancy loss at any gestational age.

Hemorrhage requiring transfusion – In one trial of 300 individuals with pregnancy loss between 5 and 12 completed weeks of gestation, 2 percent of patients had bleeding requiring transfusion following treatment with mifepristone and misoprostol [9]. Hemorrhage requiring transfusion associated with medication management in the second trimester is estimated to be approximately 0.7 percent, similar to dilation and evacuation (D&E) [34,38,41]. This difference between first- and second-trimester transfusion rates is likely due to several factors. The 2 percent rate in the first trimester is from just one study of 300 subjects whereas the second-trimester studies included many more subjects (over 1000 in one). Additionally, medication management in the second trimester occurred in a hospital setting in the studies cited, allowing for more rapid assessment and management of bleeding, which could lead to a reduced need for transfusion.

Hemorrhage-related hospitalizations with or without transfusion are uncommon following medication management of pregnancy loss (0.5 to 1.0 percent) and are not clinically more likely than following surgical aspiration [5].

Death – There are no published data on risk of death from medication management of pregnancy loss less than 13 weeks of gestation. In the absence of untreated hemorrhage or infection, the risk is negligible.

There are limited data on the risk of maternal death after second-trimester medication management of pregnancy loss. Most of the data are extrapolated from maternal mortality associated with medication management of second-trimester abortion. However, these statistics are not accurate representations of the risk associated with medication management of pregnancy loss as there is less stigma surrounding presentation and treatment for pregnancy loss compared with abortion. Even in countries where abortion is illegal (and therefore associated with a much higher maternal mortality), most patients will still be able to receive treatment for pregnancy loss.

Specific to 13 to 19+6 weeks of gestation

Uterine rupture – Data are lacking on the rate of uterine rupture with medication management in the second trimester (and there are none specific to pregnancy loss management). One case series identified one uterine rupture out of 1002 consecutive second-trimester medication abortions [34]. Other studies estimate a risk of uterine rupture to be 0.04 percent with no uterine scar versus 0.28 percent with one uterine scar (not statistically significantly different) [36]. In a systematic review of cervical ripening agents in second-trimester abortion of scarred uteri, the risk with more than one prior uterine scar is statistically higher than no scar, although the absolute risk remains small (2.5 versus 0.08 percent, risk ratio 17.55, 95% CI 3-103) [42]. Given the low absolute risk and if the patient does not want a D&E or if no skilled D&E provider is available, it is reasonable to proceed with medication management for patients with more than one uterine scar. Defaulting to hysterotomy is not appropriate based only on prior uterine scar(s) given the higher maternal mortality as compared with medication management or D&E (60/100,000, 9.6/100,000, and 4.9/100,000, respectively) [43].

Cervical trauma – The reported risk of cervical laceration associated with both D&E and medication management in the second trimester is similar, at approximately 3.3 percent [38,44]. Risk factors for cervical laceration include mechanical dilation, nulliparity, advanced gestational age, and provider inexperience.

Follow-up care — The need for and type of follow-up after medication management of pregnancy loss depend on both the patient's wishes and the gestational age. While some individuals with pregnancy loss may be candidates for remote or no follow-up, we offer in-person follow-up to any patient who desires such.

First-trimester pregnancy loss – For patients choosing outpatient medication management of early pregnancy loss (ie, ≤12+6 weeks gestation), some form of follow-up is advised; this can be in person, by phone or telemedicine, and with or without confirmatory ultrasound or urine/blood human chorionic gonadotropin (hCG) testing [45].

In-person care – Typical follow-up care is for the patient return in one to two weeks after management for an ultrasound to confirm passage of the gestational sac and other obvious pregnancy tissue. The ultrasound does not need to demonstrate a completely empty uterine cavity as some blood and clot are often still present [46,47]. If the patient's history is consistent with completion and the ultrasound shows absence of a gestational sac, the pregnancy loss should be considered completed.

Virtual care – If preferred, remote follow-up appears to be acceptable based on data from studies of medication abortion care [48-53]. Individuals may not require a follow-up visit of any type if they receive, and understand, adequate information on what to expect, possible complications, and contraception [54]. Patients with concerns about a continuing pregnancy or other issues based on phone or telemedicine follow-up are then evaluated in person.

Serum hCG as marker of treatment success – In situations where ultrasonography is not available, serial serum hCG levels may be an alternate method for confirming completed pregnancy loss [4]. However, absolute levels or relative changes in serum hCG that confirm successful medication management are not yet known. In a planned secondary analysis of serum hCG levels for individuals with early pregnancy loss treated with mifepristone/misoprostol or misoprostol only, threshold hCG levels, absolute hCG drop, or percent hCG change (as measured from baseline to one to four days following misoprostol administration) that predicted treatment success were not found [55]. Based on data extrapolated from medication abortion, serum hCG measurements performed at least seven days after treatment may be better able to delineate treatment success or failure; however, the high variability in hCG values in the setting of early pregnancy loss may limit the precision of this test to diagnose completed treatment.

Second-trimester pregnancy loss – After inpatient medication management of pregnancy loss, when completion of the process is presumed confirmed before discharge, follow-up should be as it is for aspiration or D&E. (See "Overview of second-trimester pregnancy termination", section on 'Postprocedure considerations'.)

SURGICAL MANAGEMENT (UTERINE ASPIRATION)

For all gestational ages — Surgical management of pregnancy loss, at all gestational ages, is similar to surgical management of pregnancy termination. Detailed discussions specific to first- and second-trimester surgical aspiration, as well as cervical preparation, are presented separately; the following text will review nuances specific to patients with pregnancy loss.

(See "First-trimester pregnancy termination: Uterine aspiration".)

(See "Second-trimester pregnancy termination: Dilation and evacuation".)

(See "Pregnancy termination: Cervical preparation for procedural abortion".)

Key points specific to surgical management of pregnancy loss include:

Type of uterine aspiration – For patients who desire surgical management, aspiration with either manual uterine aspiration (MUA) using a manual vacuum aspiration (MVA) device or electric vacuum aspiration (EVA) is the preferred technique for treatment of first-trimester pregnancy loss. Uterine aspiration is safer, more efficacious, and better tolerated by awake patients compared with uterine curettage. Sharp curettage should not be used as a means to evacuate the uterus.

Efficacy – Based on evaluation of patients undergoing first-trimester uterine aspiration, MVA and EVA have similar efficacy [56]. Many providers prefer to switch from MVA to EVA after 8 to 10 weeks of gestation. Generally, after 8 to 10 weeks, MVA requires slightly more time to empty the uterus than EVA.

Gestational age – Some providers continue to use MVA into the second trimester for the aspiration component of the dilation and evacuation (D&E). In the United States, most use EVA for the aspiration component of the D&E. There are no published data comparing one modality of aspiration with the other in the second trimester.

Volume of material removed – The volume of material that the MVA can aspirate at a time is 60 mL versus approximately 2000 mL for EVA (which empties into a jar). The other main difference is that the suction generated by MVA only continues as long as the cannula is within the uterine cavity. If it is removed, the suction mechanism needs to be reset (which is easy and brief) before it can be used again. If one highly desires continuous suction (such as when anticipating more bleeding, for instance, as with a molar pregnancy), then EVA may be the preferred modality.

Cervical preparation – Cervical preparation refers to treatment of the cervix prior to the procedure. The need and approach to cervical preparation vary by the measured size of the pregnancy. This is reviewed in detail elsewhere. (See "Pregnancy termination: Cervical preparation for procedural abortion".)

For patients with pregnancy loss, the measured pregnancy size can be highly discordant from the gestational age as measured from the last menstrual period (LMP). A patient may be 16 weeks by LMP but measure eight weeks by ultrasound dating. Such a patient would then be considered to have an eight-week pregnancy loss and would be managed as such (ie, would not need cervical preparation).

Prior to 13 weeks, routine cervical preparation is generally not needed before uterine evacuation. Thus, depending on the desires and needs of the patient, a procedure can occur on the same day as the diagnosis of the pregnancy loss after informed consent is obtained.

For patients with pregnancy loss of 13 weeks of gestation or greater, cervical preparation is typically performed. However, some protocols do not routinely include cervical preparation prior to 14 weeks of gestation in individuals with prior vaginal deliveries [57].

-Choice of protocol – When cervical preparation is planned, there are same-day and two-day protocols for the combination of dilator placement and D&E. The duration of time between cervical preparation and second-trimester D&E depends on the type of cervical preparation used and gestational age (table 2) [58].

-Use of medication – Cervical ripening medications, such as misoprostol or mifepristone, may be used as well, particularly for gestations above 19 weeks, although the data are derived from studies of pregnancy termination and not pregnancy loss [58-61]. In the authors' experience, mifepristone is generally not needed because the cervix is often easier to dilate in the setting of fetal demise compared with pregnancy termination. Using mifepristone followed by misoprostol for cervical preparation prior to D&E increases the rate of fetal expulsion prior to the procedure and thus is not routinely recommended [58]. (See "Pregnancy termination: Cervical preparation for procedural abortion", section on 'Cervical preparation modalities'.)

Mechanical dilation of the cervix – Cervical dilation refers to the use of mechanical dilators at the time of the procedure to open the cervical os. The primary risk factor for incomplete uterine aspiration is inadequate cervical dilation. (See "Pregnancy termination: Cervical preparation for procedural abortion", section on 'Role of mechanical dilation'.)

If the cervix is already open, mechanical dilation may not be necessary. If the cervix is 1 cm dilated, the clinician may use a 10 mm cannula to empty the uterus most quickly, even if the gestational age of the pregnancy loss is less than 10 weeks.

If the cervix is not dilated, mechanical dilation will often be needed before evacuation, and this can be done with serial use of mechanical dilators up to the needed dilation. There is no set amount of dilation needed for each gestational age, but a general rule is to dilate the cervix to the same size in millimeters as the gestational age in weeks (ie, if it is an eight-week pregnancy loss, dilate to 8 mm).

If the cervix is difficult to dilate to the desired width, one can use a smaller cannula (ie, use a 6 mm cannula with an eight-week pregnancy loss). It may take slightly longer to empty the uterus, but this is preferable to potentially causing cervical trauma.

Selection of cannula size – Most clinicians use a cannula size that is equal to the gestational age of the pregnancy or 1 mm smaller. The smallest cannula most providers use for uterine evacuation is a 6 to 7 mm cannula, even at very early gestations. This is to maximize the opportunity to identify even a very small gestational sac, which is less likely to be intact/identifiable with a smaller cannula. (See "First-trimester pregnancy termination: Uterine aspiration", section on 'Procedure'.)

Tissue evaluation – Tissue evaluation after surgical management of pregnancy loss should be performed, just as after surgical management of abortion (picture 1). One important distinction is that the tissue will correspond to the ultrasound measurement of the pregnancy and not the LMP dating (as they can be quite discordant, depending on the timing of diagnosis of pregnancy loss). It may also be more difficult to identify fetal parts since they can become macerated if there is significant time between demise and management. (See "First-trimester pregnancy termination: Uterine aspiration", section on 'Tissue evaluation'.)

Pain management – Most patients experience moderate to severe cramping during the uterine aspiration procedure; cramping and pain also typically occur with cervical preparation techniques. Some individuals may opt for minimal or no pain management, while others prefer higher levels of anesthesia. The decision to use pain medication is complex and takes into account patient desires, the clinical setting for the procedure, comorbidities, and the availability of pain management agents. Patients are more likely to desire or require higher levels of analgesia/anesthesia with increasing gestational age, though this is highly variable. Pain management options with second-trimester D&E are the same as with first-trimester uterine aspiration procedures, with the addition of regional anesthesia. General anesthesia is rarely required and is typically not recommended if other adequate options are available [62].

Pain management options and administration are reviewed elsewhere. (See "First-trimester pregnancy termination: Uterine aspiration", section on 'Pain management'.)

Patient care setting – Uterine aspiration can be safely performed in both outpatient and operating room settings. Selection is based on available resources and patient preferences (in terms of sedation/pain management, timing of procedure, and other factors). Outside of North America, the majority of uterine aspiration procedures occur in outpatient settings [63], while in North America, uterine aspiration procedures for miscarriage are often managed in the operating room, though not because of safety concerns [64,65]. Some studies have reported that many patients prefer to have their management outside of the operating room because it can often occur more quickly and easily in an outpatient setting and is less expensive but still allows the patient many pain management options [66]. Typically, deep sedation and general anesthesia are available in an operating room, though some outpatient clinics are able to offer conscious sedation.

Antimicrobial prophylaxis – We and others recommend that antimicrobial prophylaxis be given prior to uterine aspiration for pregnancy loss of any gestational age [4,38,67-69]. Multiple drugs have demonstrated efficacy at reducing infection compared with placebo; the optimal antibiotic regimen has not been established [69].

We give a single dose of doxycycline 200 mg one hour prior to the procedure (table 3) [4,68].

Outpatients and/or those without IV access receive oral doxycycline while patients with IV access receive the same dose intravenously.

Some practices administer azithromycin at the time of osmotic dilator placement as well (table 4).

This approach is informed by studies of uterine aspiration for pregnancy termination as well as pregnancy loss [69,70]. Specific to patients with pregnancy loss, a trial of over 3400 patients in low-resource countries with pregnancy loss up to 22 weeks of gestation reported similar overall rates of pelvic infection between antibiotic and placebo groups (4.1 versus 5.3 percent) [71]. However, analysis by procedure type reported reduced infection risk for patients receiving antibiotics compared with patients receiving placebo prior to MVA (1.3 versus 4.1 percent). As aspiration is the preferred method of surgical uterine aspiration, we give antibiotics prior to uterine aspiration for pregnancy loss. (See "First-trimester pregnancy termination: Uterine aspiration", section on 'Antibiotic prophylaxis'.)

There are no studies of preoperative antibiotics specific to patients with pregnancy loss between 13 and 20 weeks of gestation. Given the later gestational age and recommended use of prophylactic antibiotics prior to dilation and evacuation [38], the authors also recommend their use when treating patients with pregnancy loss. (See "Second-trimester pregnancy termination: Dilation and evacuation", section on 'Prophylactic antibiotics'.)

Side effects – There are very few side effects to the uterine aspiration procedure. One may experience the usual side effects to the various pain medications used. Some patients may experience a vasovagal event with any manipulation of their cervix. This can appear alarming and even resemble seizure-like activity. However, with rare exceptions, it is a benign occurrence, and will resolve quickly with supportive measures and time. Vasovagal events are characterized by hypotension accompanied by bradycardia. Mental status changes with hypotension and tachycardia should raise the suspicion for hemorrhagic shock or other complications.

Avoidance of sharp curettage – Sharp curettage is actively discouraged because it is associated with reduced efficacy and increased rates of complication. We highly encourage all providers to eliminate any use of sharp curettage as a primary mechanism of uterine evacuation for pregnancy loss or abortion.

Specific to 13 to 19+6 weeks of gestation

Preprocedure laboratory studies – After approximately 15 weeks (by ultrasound), the risk of disseminated intravascular coagulation (DIC) increases with increasing gestational age of pregnancy loss. There are no strong data on when/if clinicians should check laboratory values in cases of prolonged fetal demise. If the demise occurred more than three weeks prior to management and the gestational age is 15 weeks and above, or if the clinician has increased concern for DIC for any reason, we advise providers to check preoperative complete blood count, coagulation studies, and fibrinogen. Due to the risk of DIC and excess bleeding, some outpatient clinics do not offer management of pregnancy loss after 13 to 15 weeks. (See "Evaluation and management of disseminated intravascular coagulation (DIC) in adults".)

Procedure technique – There are a variety of operative techniques that can be employed to surgically manage pregnancy loss in the second trimester. Up to approximately 16 weeks, complete evacuation can often be achieved with a larger cannula (up to 16 mm). After 16 weeks, suction in combination with the use of grasping forceps is typically used to evacuate the uterus [62]. By convention, surgical uterine evacuation procedures in the second trimester are referred to as D&Es.

(See 'Treatment terminology' above.)

(See "Second-trimester pregnancy termination: Dilation and evacuation".)

Role of hysterotomy or hysterectomy – There may be special circumstances in which hysterotomy or even hysterectomy might be the safest approach to managing pregnancy loss in the second trimester, though before 20 weeks, those situations would be rare (ie, invasive placenta and/or large fibroids preventing access through the cervix). In the setting of an abdominal cerclage, some degree of cervical dilation is typically possible but hysterotomy may be required if adequate dilation for D&E is not obtained. In the absence of some other risk factor, presence of one or more prior uterine scars is not an indication for avoiding D&E or even medication management. (See "Peripartum hysterectomy for management of hemorrhage".)

Complications — The overall risk of complication from uterine aspiration is relatively low but increases with increasing gestational age. Common complications include retained products of conception (POCs), bleeding, and infection.

Retained POCs or need for repeat surgical evacuation – Approximately 1 percent of individuals undergo repeat suction evacuation for suspected retained POCs or hematometra [5]. The risk is similar following second-trimester D&E procedures [38,72,73]. Patient presentation, diagnosis, and management are discussed elsewhere. (See "First-trimester pregnancy termination: Uterine aspiration", section on 'Incomplete or failed abortion' and "First-trimester pregnancy termination: Uterine aspiration", section on 'Hematometra'.)

Atony and/or hemorrhage – Uterine atony at the time of uterine aspiration can lead to hemorrhage. Hemorrhage after first-trimester uterine aspiration is uncommon, ranging between 0 and 3 per 1000 cases [74,75]. Uterine atony with resultant bleeding occurs approximately 2.6 percent of the time with D&E [76]. Both increasing maternal age and gestational age are independent risk factors.

Management includes uterine massage and uterotonics such as misoprostol (up to 1000 mcg administered rectally or buccally), carboprost, and methylergonovine. While there are no specific data for using tranexamic acid in the setting of hemorrhage after surgical management of pregnancy loss, it is now a first-line agent for managing hemorrhage after delivery and can also be utilized in this setting [77]. Bleeding as a result of abnormal placentation is sometimes refractory to uterotonics; an intrauterine Foley balloon is often effective in this setting. The possibility of perforation should always be considered during hemorrhage, especially when uterotonics fail.

(See "First-trimester pregnancy termination: Uterine aspiration", section on 'Hemorrhage'.)

(See "Second-trimester pregnancy termination: Dilation and evacuation", section on 'Hemorrhage'.)

(See "Overview of postpartum hemorrhage".)

Cervical trauma – Cervical lacerations or other trauma may occur, especially with traction on the cervix during dilation. The reported risk of cervical laceration associated with both D&E and medication management in the second trimester is similar, at approximately 3.3 percent [38,44]. Risk factors for cervical laceration include mechanical dilation, nulliparity, advanced gestational age, and provider inexperience. Occasionally, sutures are required to achieve hemostasis. (See "Second-trimester pregnancy termination: Dilation and evacuation", section on 'Cervical laceration'.)

To prevent cervical trauma, cervical priming with misoprostol should be considered when difficult dilation is expected (eg, individuals who are primigravid, adolescent, or of advanced gestational age). (See 'For all gestational ages' above.)

Perforation – Perforation at the time of uterine aspiration is a rare complication (<1 percent), even with second-trimester procedures [41,72,78-80]. Perforation can occur with either cervical dilation or uterine aspiration. The primary risk factor for perforation is inadequate cervical dilation. Recognition is important to prevent subsequent complications. Signs include sudden ability to advance instruments further, sudden increased pain in an awake patient, hemorrhage, or suspicious findings on ultrasound, such as a broad ligament hematoma. When suspected, further evaluation may be warranted, especially if there is any possibility that suction was applied in the peritoneal cavity. In those circumstances, laparoscopy or other means can be used to evaluate for bowel or other injury. (See "Uterine perforation during gynecologic procedures".)

Infection – Infection after uterine aspiration (sometimes referred to as endometritis) is uncommon, occurring in <1 percent of first-trimester cases based on data from first-trimester aspiration abortion. For second-trimester D&E, reported infection rates range between 0.1 to 4 percent [41,72,78]. Patients typically present with pelvic pain and uterine tenderness on examination and, occasionally, purulent discharge and other systemic signs of infection. If infection is suspected, ultrasound should be performed to assess for retained tissue. Re-aspiration is needed if there is retained tissue.

(See "First-trimester pregnancy termination: Uterine aspiration", section on 'Infection'.)

(See "Second-trimester pregnancy termination: Dilation and evacuation", section on 'Infection'.)

For patients with no evidence of sepsis and who can reasonably contact the clinician if problems develop, treatment with oral antibiotics is reasonable. For patients who are septic, intravenous antibiotics may be indicated. Choice of antibiotics is similar to treatment of pelvic inflammatory disease. (See "Pelvic inflammatory disease: Treatment in adults and adolescents".)

Intrauterine adhesions – While the incidence of intrauterine adhesions (IUAs) after expectant, medication, and surgical management for pregnancy loss is not known because asymptomatic individuals are not evaluated, limited data suggest that surgical management, specifically with sharp curettage, may be associated with increased risk of IUA formation. In a trial that randomly assigned 82 patients with retained POCs after pregnancy loss to observation (expectant management), misoprostol (medication management), or curettage (surgical management), only those in the surgical treatment group (2 patients, 7.7 percent) had IUAs at the time of hysteroscopy at six months, although the difference was not statistically significant [81]. Limitations include the small number of trial participants, that the IUAs diagnosed by hysteroscopy in this study may not have been clinically significant, and the reality that some individuals who elect for noninvasive management will still require a procedure for retained POCs or heavy bleeding. Additionally, retained POCs are known to be associated with a higher baseline risk of infection, which is then associated with a higher risk of IUAs. This study is reassuring that the percent of individuals with IUAs was small overall. The diagnosis and management of IUAs is presented in related content.

(See "Intrauterine adhesions: Clinical manifestation and diagnosis".)

(See "Intrauterine adhesions: Treatment and prevention".)

Blood transfusion – Hemorrhage requiring transfusion is rare (<1 percent) after first- and second-trimester uterine aspiration and can be due to uterine atony, abnormal placentation, or perforation [72]. For second-trimester procedures, atony is the most common cause (52 percent), followed by abnormal placentation (17 percent), cervical laceration (12 percent), uterine perforation (7 percent), lower uterine segment bleeding without atony (5 percent), and DIC (5 percent) [82]. Uterotonics are again the first-line therapy, as discussed in the bullet above.

Death – Death is a rare occurrence of pregnancy loss at any gestational age as long as pregnancy loss is recognized and managed appropriately. Delayed diagnosis and/or management can lead to increased risks of hemorrhage and infection, the two leading causes of major morbidity and mortality with pregnancy loss [83]. The risk of DIC also increases with prolonged intrauterine demise prior to uterine aspiration. (See "Disseminated intravascular coagulation (DIC) during pregnancy: Clinical findings, etiology, and diagnosis".)

Amniotic fluid embolus is another very rare complication, occurring in 1 out of 10,000 to 1 out of 80,000 procedures; however, it is approximately 80 percent fatal [84,85]. Management includes rapid recognition, cardiopulmonary support, and treatment of DIC, which is often present [86]. (See "Amniotic fluid embolism".)

Postprocedure follow-up — Follow-up after a uterine aspiration or D&E should be offered for all patients but should not be required [54]. In an asymptomatic patient, there is no indication for further tests or examinations. However, many patients value having the opportunity to check in with their provider, review any questions they have about pregnancy loss or the procedure, and discuss next steps regarding future pregnancy or contraception. Additionally, it is an opportunity for providers to evaluate the mental state of their patients and make sure that patients are coping appropriately with the loss. Social work services and referral for other mental health care should be offered as needed. (See "Pregnancy loss (miscarriage): Counseling and comparison of treatment options and discussion of related care", section on 'Review additional care points'.)

PREVENTION OF ALLOIMMUNIZATION — The guidance for giving RhD immune globulin is rapidly shifting based on emerging data demonstrating that not all RhD-negative individuals with pregnancy loss require RhD immune globulin to prevent alloimmunization [87].

Less than 12 weeks of gestation – While an international consensus is lacking, we take the approach advocated by the World Health Organization (WHO) Abortion Care Guideline and other societies and forego routine Rh testing and RhD immune globulin administration for patients experiencing pregnancy loss (expectant, medication, or surgical management) or abortion (induced or surgical) below 12 weeks of gestation (ie, less than 84 days from last menstrual period) [2,88-90]. Two authors (SP and EM) feel very comfortable not testing for Rh status or treating RhD-negative individuals with pregnancy loss at less than 12 weeks of gestation. One author (VD) does not advise against this approach but does not use it [4].

This is a change from prior guidelines in which RhD-negative patients undergoing surgical management were advised to receive RhD immune globulin, regardless of gestational age, because of the concern for higher risk of alloimmunization with uterine aspiration [4,91-93]. However, subsequent data demonstrated that the concentration of fetal red blood cells is insufficient to cause Rh sensitization in first-trimester pregnant patients undergoing uterine aspiration [94,95]. In an observational study of 506 patients undergoing abortion (medication or procedural) at less than 12 weeks gestation, none of the patients had newly elevated fetal red blood cell (fRBC) counts above the estimated sensitization threshold of 125 fRBCs/5 million total RBCs using high throughput flow cytometry [95]. One patient had fRBC levels that exceeded the threshold both before and after the intervention (ie, the fRBC elevation was not a result of the intervention).

12 weeks of gestation or later We take the approach of the World Health Organization (WHO) Abortion Care Guideline and other societies and advise Rh testing for pregnant patients who are 12 weeks of gestation (ie, 84 days) or more from the last menstrual period and experiencing pregnancy loss or induced abortion; patients who are RhD-negative should be offered RhD immune globulin to prevent Rh alloimmunization [2,4,88,90]. However, guideline variation exists, in part because some data were extrapolated from studies using outdated techniques. At least one national guideline advises offering RhD immunoglobulin to Rh-negative patients who are >70 days gestational age and another organization advises treating patients who are >77 days gestational age [89,96].

When RhD immunoglobulin is administered in the setting of pregnancy loss or abortion, the dose varies by gestational age:

12 to 18 weeks gestation – RhD immunoglobulin 100 mcg (500 international units). If the 100 mcg dose is not available, then two 50 mcg (250 international units) doses can be given [89].

>18 weeks gestation – RhD immunoglobulin 300 mcg (1500 international units) [89].

Additional discussions on the mechanism and prevention of alloimmunization are provided separately.

(See "RhD alloimmunization in pregnancy: Overview".)

(See "RhD alloimmunization: Prevention in pregnant and postpartum patients", section on 'Indications'.)

(See "Overview of pregnancy termination", section on 'Alloimmunization prevention'.)

ROLE OF TELEMEDICINE — There are many reasons why a patient or provider/practice may opt for remote treatment or follow-up: a patient may live far away from the clinic/provider, the clinic may not have on-site ultrasound and/or blood draw capabilities, other social barriers may prevent easy access to in-person visits (lack of transportation, childcare issues, difficulty getting time off work), or health crises necessitating social distancing may be in effect. When using remote visits, any concern by the patient or provider that there is an ongoing issue necessitates some sort of in-person evaluation. One example of a remote-care protocol was developed in response to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) crisis of 2020 [97,98]. While the protocol is for medication abortion, it applies to medication management of pregnancy loss of the same gestational age.

RESOURCES FOR PATIENTS AND CLINICIANS

World Health Organization (WHO) Abortion care guideline

National Institute for Health and Care Excellence NICE guideline [NG126] Ectopic pregnancy and miscarriage: diagnosis and initial management

American College of Obstetricians and Gynecologists

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Pregnancy loss (spontaneous abortion)".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topics (see "Patient education: Pregnancy loss (The Basics)" and "Patient education: Bleeding in early pregnancy (The Basics)")

Beyond the Basics topics (see "Patient education: Pregnancy loss (Beyond the Basics)")

PATIENT PERSPECTIVE TOPIC — Patient perspectives are provided for selected disorders to help clinicians better understand the patient experience and patient concerns. These narratives may offer insights into patient values and preferences not included in other UpToDate topics. (See "Patient perspective: Pregnancy loss".)

SUMMARY AND RECOMMENDATIONS

Treatment options for individuals with pregnancy loss include expectant, medication, and surgical management (table 1). The advantages and risks vary across the options and by gestational age of the nonviable pregnancy, but all are generally safe. (See 'Introduction' above.)

Expectant management consists of watchful waiting for pregnancy tissue to pass.

Clinical issues – Clinical issues that need to be addressed include frequency of follow-up, confirmation of an empty uterus, the time at which the patient and clinician should consider a different treatment option if the pregnancy does not pass, and symptoms that require prompt evaluation. (See 'Expectant management' above.)

Need for additional intervention – Complications, including incomplete emptying, hemorrhage, and infection warrant timely patient evaluation and likely progression to medication or surgical management depending on the problem and hemostatic stability of the patient. (See 'Expectant management' above.)

Medication management – For individuals who select medication management, we recommend treatment with mifepristone and misoprostol rather than misoprostol alone (Grade 1B). Combined treatment with mifepristone and misoprostol results in higher rates of emptying the uterus when compared with misoprostol alone. However, use of misoprostol alone is acceptable if it is not possible to access mifepristone and the patient prefers medication over other management options. (See 'Medication management' above and "Pregnancy loss (miscarriage): Counseling and comparison of treatment options and discussion of related care", section on 'Medication management'.)

Uterine aspiration during the first trimester can safely and acceptably occur in an outpatient or emergency department setting, while second-trimester uterine aspiration (dilation and evacuation) more often occurs in an operative setting. As appropriate, offering management in these locations provides more options for the patient and may improve the patient experience. (See 'Surgical management (uterine aspiration)' above.)

Cervical preparation – For patients with pregnancy loss of 13 weeks of gestation or greater, cervical preparation is typically performed. However, some protocols do not routinely include cervical preparation prior to 14 weeks of gestation in individuals with prior vaginal deliveries. (See 'For all gestational ages' above.)

Antibiotic prophylaxis – For patients undergoing surgical vacuum aspiration, we recommend that antimicrobial prophylaxis be given 60 minutes prior to the procedure (Grade 1B). While much of the supporting data come from trials of patients undergoing pregnancy termination rather than treatment for pregnancy loss, there is no reason to believe the response would differ. The choice of drug and duration of treatment are, in part, determined by the gestational age and concomitant use of cervical dilators. (See 'For all gestational ages' above.)

Additional considerations include pain management, prevention of anti-D antibodies and potential hemolytic disease of the newborn, and role of telemedicine to facilitate care.

Pain management – Pain management should be offered to all patients experiencing pregnancy loss, regardless of mode of management. Pain management needs and options vary by gestational age and type of treatment. (See 'Expectant management' above and 'Medication management' above and 'For all gestational ages' above.)

RhD negative – While an international consensus is lacking, we take the approach advocated by the World Health Organization (WHO) Abortion Care Guideline and other societies (see 'Prevention of alloimmunization' above):

-Less than 12 weeks of gestation – We forego routine Rh testing and RhD immune globulin administration for patients experiencing pregnancy loss (expectant, medication, or surgical management) or abortion (induced or surgical). (See 'Prevention of alloimmunization' above.)

-12 weeks of gestation or greater – We advise Rh testing; patients who are RhD-negative should be offered RhD immune globulin to prevent Rh alloimmunization. The dose of RhD immune globulin varies with gestational age. (See 'Prevention of alloimmunization' above.)

Telemedicine – Telemedicine provides new options for patients to access care and obtain follow-up. Any concern on the part of the patient or clinician should prompt an in-person evaluation. (See 'Role of telemedicine' above.)

ACKNOWLEDGMENTS — The UpToDate editorial staff acknowledges Togas Tulandi, MD, MHCM, and Haya M Al-Fozan, MD, who contributed to an earlier version of this topic review.

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Topic 128965 Version 20.0

References

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