Version May 2024
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 (EPL), which occurs in the first trimester, is the most common type. Individuals experiencing pregnancy loss are evaluated for conditions that require emergency treatment and then counseled regarding the different management options, which include expectant, medication, and surgical management.
This topic will review the treatment options available to patients with pregnancy loss up to 20 weeks of gestation. Related content on risk factors and etiology, clinical presentation, the role of ultrasound in diagnosis of pregnancy loss, management techniques, and stillbirth 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): Ultrasound diagnosis".)
●(See "Pregnancy loss (miscarriage): Description of management techniques".)
●(See "Stillbirth: Maternal care".)
In this topic, we will use the term "patient" to describe genetic females. We recognize that not all people capable of pregnancy identify as a woman or female and we encourage the reader to consider the specific counseling needs of transgender and gender-expansive individuals.
USE A PATIENT-CENTERED APPROACH — It is critical for clinicians to avoid inserting their personal biases when counseling patients regarding management of pregnancy loss. It is common for clinicians to have a strong opinion about the "best" option in any given clinical scenario. However, the best evidence indicates that all management options (expectant, medication, or surgical) are reasonable in a majority of cases, and patients are most satisfied when they are able to choose (ie, shared decision-making) [1,2]. Data suggest patients presenting to an emergency department for pregnancy loss care may not be offered all clinically appropriate options [3].
Elicit patient preferences — There are several questions clinicians can ask to elicit a patient's preferences in this setting:
•Have you had a previous pregnancy loss? If yes:
-Did it pass naturally (ie, spontaneously) or did you receive treatment?
-Did anything unexpected happen?
-Do you feel that you made the right decision?
•What worries you the most about this process? For instance, some individuals are concerned about having unpredictable bleeding that may occur with expectant management, while others are fearful of an invasive surgical procedure.
•Do you feel most comfortable having the pregnancy pass on its own, or do you prefer the idea of removing the pregnancy as soon as possible? Patients are also educated that the amount of time to achieve a completed miscarriage with expectant management varies based on the type of miscarriage. (See 'Expectant management' below.)
•How comfortable are you with minor procedures? What are your concerns about pain? For some patients, the pain control options available for a surgical procedure will factor into their decision.
Enable patient to choose treatment — Enabling patients to choose their treatment approach whenever medically safe is an important component of care. Studies consistently demonstrate that individuals often want to participate in treatment planning. It is not meaningful to talk about what proportion of individuals prefer a specific treatment option; rather, it is important to recognize that preferences vary, and patients report they want to participate in treatment decisions [4-8]. Patients who have had a prior pregnancy often use that experience to inform their treatment choice. Primigravid patients with a loss may seek more advice and input from their provider and trusted support persons [8]. A study of quality-of-life scores reported that individuals who were managed according to their own preferences had better outcomes [5].
PRESENT TREATMENT OPTIONS — There are three management options for pregnancy loss: expectant, medication, and surgical management. Expectant management is when patients prefer to "wait and see" without any intervention; medication management is when medications, not a procedure, are primarily used; surgical management refers to any management that is primarily procedure based. All three management options are available for pregnancy loss up to 20 weeks of gestation. The patient weighs the efficacy, degree of intervention, advantages, risks, and complications of each option to make a treatment plan.
Expectant management — Expectant management implies the patient waits for the pregnancy tissue to pass on its own. Patients may initially elect expectant management and then pursue surgical or medication management if the pregnancy has not passed in a reasonable time or if bleeding, infection, or other complications develop.
●Factors for consideration
•Patient preferences – Individuals may select expectant management because they prefer a less invasive or "more natural" approach, desire more time to consider treatment options, or want to avoid surgical procedures.
•Gestational age – In regions where active management is accessible, expectant management is generally discouraged after approximately 13 weeks of gestation because of increased risk of complications. If access to active management is limited, then expectant management is offered.
•Unpredictable onset, duration, and degree of heavy uterine bleeding and cramping – Patients who desire expectant management are counseled that they may experience heavy vaginal bleeding and/or uterine cramping [9]. There are no predictive factors that guide the patient as to when symptoms may begin. Instructions for when to contact the clinician should be provided. Patients should also understand that, although a less-invasive approach may be desired, surgical uterine aspiration may still be required for retained products of conception, infection, and/or bleeding or evidence of hemodynamic instability.
•Efficacy and variable amount of time needed to complete miscarriage – While approximately 70 to 80 percent of all patients with first-trimester pregnancy loss will have an empty uterus by 14 days of expectant management, the percentage of miscarriages completed spontaneously by 14 days is lower for individuals with prolonged loss without expulsion (eg, several weeks' discrepancy between ultrasonographic and menstrual period dating) and nonviable pregnancies with an empty gestational sac than it is for those with incomplete miscarriage. The amount of time for completed miscarriage does not vary based on how the pregnancy was conceived (eg, spontaneous, assisted reproductive technology).
A study that followed 1096 individuals with first-trimester pregnancy loss reported the following completion rates for expectant management by type of pregnancy loss [10]:
-Incomplete miscarriage – Seven-day completion of 53 percent (117 of 221); 14-day completion of 84 percent (185 of 221).
-Prolonged loss without expulsion – Seven-day completion of 30 percent (41 of 138); 14-day completion of 59 percent (81 of 138).
-Nonviable pregnancy with empty gestational sac – Seven-day completion of 25 percent (23 of 92); 14-day completion of 52 percent (48 of 92).
●Up to 12+6 weeks of gestation – Expectant management is approximately 70 to 80 percent effective in the first trimester table [10-12]. Patients may continue expectant management in the first trimester as long as they remain hemodynamically stable and without signs or symptoms of infection. The authors advise considering medication or surgical management if the pregnancy has not passed after approximately four weeks of expectant management in the first trimester; this is a general approach and is tailored to the desires and medical needs of each patient.
We also discuss that the longer the patient waits for spontaneous passage of the pregnancy, the risk of complications or difficulty increases, including infection, heavy bleeding and/or hemorrhage, and incomplete passage of tissue. Any of these may prompt the need for medication or surgical management despite the patient's initial desire for minimal intervention. Additionally, the patient may only experience partial passage of tissue. In a trial comparing the three treatment options for patients with first-trimester pregnancy loss, approximately one-third of patients had evidence of retained products of conception on follow-up ultrasound performed 10 to 14 days after tissue passage [12]. In this study, rates of infection were similar among patients managed expectantly (3 percent) versus medically or surgically (2 and 3 percent, respectively). However, unplanned hospital admissions and unplanned surgical procedures were higher in the expectant management group. Surgical procedures performed in emergency circumstances are generally considered to be of greater risk compared with planned procedures.
●13 to 19+6 weeks of gestation – Expectant management is more commonly used at later gestational ages in low- and middle-income countries; the American College of Obstetricians and Gynecologists advises against second-trimester expectant management because of lack of safety data [9]. There are few data on efficacy of expectant management in the second trimester. One older source indicated approximately 85 percent of individuals with an intrauterine fetal demise over 24 weeks of gestation would spontaneously labor within three weeks of diagnosis, but this is a different population from those with second-trimester loss [13].
In the second trimester, increasing time between diagnosis of pregnancy loss and management leads more rapidly to increased risks, including life-threatening ones such as disseminated intravascular coagulation. As a result of the increasing risk profile with expectant management in the second trimester, the authors advise immediate intervention (medication or surgical) in the second trimester. In some cases, with appropriate counseling and thorough understanding of the risks and benefits, patients may choose to wait two to four weeks before undergoing medication or surgical management. Oral analgesia should be offered to those choosing expectant management, and they should be counseled to come to a health facility/hospital if they experience severe cramping or heavy vaginal bleeding. The risks of expectant management are otherwise similar to those of medication management. (See "Pregnancy loss (miscarriage): Description of management techniques", section on 'Complications of medication management'.)
●≥20 weeks of gestation (stillbirth) – While the nomenclature and definitions of stillbirth, or late fetal death, vary, stillbirth commonly describes delivery of a fetus of ≥20 weeks of gestation with no signs of life. The issues around stillbirth and its management are presented separately.
•(See "Stillbirth: Incidence, risk factors, etiology, and prevention".)
•(See "Stillbirth: Maternal care".)
•(See "Stillbirth: Maternal and fetal evaluation".)
Medication management — Medication management typically involves the patient taking two different medications (mifepristone followed by misoprostol) over 24 to 48 hours to induce passage of the uterine contents [9,14,15]. In settings where mifepristone is not available, misoprostol-only protocols can also be used, but the efficacy is somewhat lower than that of the combined regimen. However, combination therapy is often not offered to US patients, despite improved efficacy compared with misoprostol-only, likely because of drug prescribing restrictions [16]. (See "Pregnancy loss (miscarriage): Description of management techniques", section on 'Medication management'.)
●Factors for consideration – Medication management approach offers patients more control over the timing of tissue passage, is highly effective, and generally does not require surgical intervention [17]. In addition, the patient chooses when to initiate the medication, the surroundings, and presence of support persons. While the efficacy of medication management is slightly lower compared with uterine aspiration (99.6 versus 99.8 percent, respectively, in one study of first-trimester abortion), some individuals are motivated to avoid a surgical procedure, if possible [18]. A large body of evidence demonstrates the safety of both medication and surgical approaches, and each individual's treatment preferences should drive management whenever clinically safe.
●Efficacy of combination versus single agent treatment – Combined treatment with mifepristone followed by misoprostol is preferred as it has higher efficacy compared with misoprostol-only therapy. Efficacy rates (ie, rate of empty uterus following treatment) of approximately 70 to over 90 percent have been reported; treatment efficacy varies with medication, gestational age, presence of uterine bleeding, and duration of follow-up [14,15,19,20]. Efficacy is on the higher end of the spectrum for individuals treated with combination therapy, gestational age less than nine weeks, and onset of uterine bleeding prior to treatment [14,19].
•Up to 12+6 weeks gestation – A trial comparing combination therapy with mifepristone and misoprostol with misoprostol-only for 300 individuals with pregnancy loss through 12+6 weeks of gestation reported the following [14]:
-Efficacy by day 8 – 87.8 versus 71.1 percent, respectively.
-Efficacy by day 30 – 91.2 versus 75.8 percent, respectively. These results included a small number of patients who received a second dose of misoprostol if the uterus was not completely empty at the first follow-up visit.
•13 to 19+6 weeks of gestation – Medication management efficacy data for second-trimester pregnancy loss are largely extrapolated from the second-trimester medication abortion literature [21-23]. Studies specific to second-trimester abortion report 24-hour expulsion rates of 73 to 97 percent following combined treatment with mifepristone and misoprostol [24-27]. One small trial of 64 patients undergoing medication abortion between 18 and 23 weeks of gestation reported higher rates of placental retention in subjects receiving misoprostol alone versus mifepristone and misoprostol (6.3 versus 3.1 percent) [26]. (See "Second-trimester pregnancy termination: Induction (medication) termination".)
●Mechanism of action – Mifepristone is an antiprogestin that binds competitively with the progestin receptor and results in decidual necrosis while priming the uterus and cervix for prostaglandin activity [28,29]. Misoprostol is a prostaglandin E1 analog and works as a uterotonic, making the uterus contract and expel the pregnancy tissue [30,31].
●Risks – General risks of medication management include retained tissue that requires surgical evacuation (8 to 9 percent), blood transfusion (2 percent), and pelvic infection (less than 1 percent) [14]. When patients elect for medication management, it is important they understand that aspiration for removal of retained tissue or the placenta is possible. Complications are presented in detail separately. (See "Pregnancy loss (miscarriage): Description of management techniques", section on 'Complications of medication management'.)
●Presence of medical comorbidities – Comorbidities that may favor a medication approach include uterine anomalies or cavity distortion (eg, fibroids). Medical conditions that might increase the risks associated with medication abortion, particularly the risk of hemorrhage, include bleeding dyscrasias, significant cardiopulmonary disease, and use of an anticoagulation medication; surgical management is preferred for these individuals. (See 'Surgical management' below.)
●Safety – Overall, the safety of medication management in the second trimester is reduced as compared with the safety of surgical management [32,33]. However, this is only true if there are clinicians trained and skilled at performing dilation and evacuation (D&E) for this gestational age range. In settings where there is a dearth of capable D&E providers, medication management becomes the primary method of pregnancy loss management in the second trimester.
Surgical management — Surgical management with vacuum aspiration of the uterus is performed with either manual or electric vacuum aspiration systems.
●Factors for consideration – Surgical management is predictable, highly efficacious, and offers rapid resolution of miscarriage [17]. The procedure typically occurs in a health care facility, where pain medication can be administered, and takes under 15 minutes to complete. Recovery can be as fast as 20 to 30 minutes for individuals who receive minimal or no sedation. Patients have the ability to schedule a specific date and time. Return to usual activities is typically the same day following procedures performed for first-trimester pregnancy loss. Individuals who want to minimize pain and/or bleeding and prefer a predictable course may prefer this route.
●Efficacy – The efficacy of early surgical management using vacuum aspiration is nearly 100 percent [1,18]. Although much of the efficacy data for surgical management come from the abortion literature, not studies evaluating early pregnancy loss (EPL) management, there is no reason to expect outcomes of surgical management to be different based on the diagnostic indication of abortion or EPL (as matched for other factors) [34,35].
●Risks – The risks of surgical management are mainly the risks related to the procedure and include incomplete evacuation, injury (eg, cervical laceration, perforation of the uterus), bleeding, infection, and formation of intrauterine adhesions. Rarely, an individual may require additional surgery as a result of surgical complications from uterine aspiration.
●Patient medical comorbidities – Surgical management is favored for individuals with anemia or bleeding abnormalities or those who require anticoagulant medication.
●Comparison with hysteroscopic resection – Hysteroscopic resection has been proposed as an alternative to vacuum aspiration for patients with retained products of conception (ie, incomplete spontaneous abortion). The rationale is that focal resection rather than aspiration of the entire cavity could reduce the risk of postoperative uterine adhesions and preserve fertility. However, in a trial comparing hysteroscopic resection (n = 282) with uterine aspiration (n = 281) for patients with retained pregnancy tissue, live birth rates at two years of follow-up were similar between the groups (62.8 versus 67.6 percent, absolute risk difference -4.8, 95% CI -13.0 to 3.0) [36]. The elapsed time to conception was similar as well (median 5.7 versus 4.9 months, absolute median difference 0.4, 95% CI -0.4 to 1.2). All included patients desired future pregnancy and pregnancy was defined as an intrauterine gestation of at least 22 weeks. Hysteroscopic resection also requires additional equipment and is less readily available compared with uterine aspiration. Routine hysteroscopic resection is therefore not advised.
●Additional considerations for 13 to 19+6 weeks of gestation – Surgical management in the second trimester typically requires both cervical preparation and cervical dilation. The combination may require an additional day of treatment prior to the procedure itself. (See "Pregnancy loss (miscarriage): Description of management techniques", section on 'Specific to 13 to 19+6 weeks of gestation'.)
REVIEW ADDITIONAL CARE POINTS
Pain management — Pain management should be offered to all patients experiencing pregnancy loss, regardless of mode of management. The degree of pain, and thus the need for pain medication or treatment, varies by the intervention and the gestational age of pregnancy. Pain management options are discussed by treatment in related content. (See "Pregnancy loss (miscarriage): Description of management techniques".)
Use of anti-D immune globulin — Use of anti-D immune globulin following pregnancy loss varies by gestational age at the time of loss. A discussion of various guidelines and the authors' approaches are presented in related content. (See "Pregnancy loss (miscarriage): Description of management techniques", section on 'Prevention of alloimmunization'.)
Timing of contraception initiation — Many individuals wish to delay their next pregnancy, and the need for contraception should be routinely assessed as part of the management of pregnancy loss. Ovulation can resume within days to weeks after early pregnancy loss (EPL). Patients wishing to use contraception may initiate any method, except for intrauterine devices (IUDs), after any pregnancy loss is diagnosed, either prior to or at the time of medication or surgical management.
●IUD – IUDs can be placed after expulsion of the pregnancy tissue, at the time of uterine evacuation, or at an interval (typically within four weeks). IUD expulsion rates are similar post-aspiration and interval insertion timing (5.0 versus 2.7 percent) when assessed six months following insertion.
●Vaginal contraceptives – Initiation of vaginal methods, such as the contraceptive ring or diaphragm, can safely be initiated after expulsion of gestational tissue, although some individuals may opt to wait until bleeding has subsided. If initiation of contraception is delayed more than seven days after complete expulsion, a back-up method should be used for seven days. (See "Contraception: Postabortion".)
Future pregnancy — Individuals experiencing pregnancy loss commonly ask about the odds of a future successful live birth, when they can safely attempt conception, and if there are any interventions to reduce the risk of future pregnancy loss.
Likelihood of live birth — Individuals with pregnancy loss, particularly EPL, are likely to have subsequent normal pregnancies. A study of over 53,000 parous individuals reported that 43 percent experienced one or more prior first-trimester pregnancy losses [37]. The likelihood of subsequent live birth does not appear to differ among patients electing medication or expectant management [38].
The rate of pregnancy loss is influenced by maternal age and history of prior pregnancy loss.
Timing of subsequent pregnancy — There are no high-quality data suggesting that delaying a subsequent pregnancy decreases the risk of a repeat pregnancy loss [39]. Patients are often advised to abstain from vaginal intercourse for one to two weeks to reduce the risk of infection, but this is not an evidence-based recommendation.
Although the World Health Organization advises a six-month delay before attempted conception [40], subsequent observational data suggest that there is not a benefit to delaying conception:
●A Norwegian population study of over 49,000 births after a pregnancy loss reported that interpregnancy interval <3 months compared with interpregnancy interval of 6 to 11 months was associated with reduced risk of small for gestational age (SGA) birth and gestational diabetes and similar risk of preterm birth, large for gestational age (LGA), and preeclampsia [39]. Adjusted confounders included maternal age, gravidity, year of birth, maternal smoking, and maternal prepregnancy body mass index. Likelihood of repeat pregnancy loss was not assessed.
●Data from a secondary analysis of over 1000 individuals with one to two prior pregnancy losses reported that those who tried to conceive within three months of loss were more likely to achieve live birth compared with those who waited more than three months (53 versus 36 percent) [41]. In addition, the shorter time interval for attempting conception was associated with a shorter time to pregnancy that resulted in live birth (adjusted fecundability odds ratio 1.71, 95% CI 1.30-2.25).
There may be some individual circumstances, such as planned fertility evaluations (eg, patients with recurrent pregnancy loss), that cannot be done during pregnancy and thus attempting conception is delayed. It is also important to advise patients to assess their own emotional readiness before reinitiating conception efforts.
Role of low-dose aspirin to reduce risk of pregnancy loss
Our approach — We suggest initiation of low-dose oral aspirin, 81 mg, prior to conception for individuals who have experienced one to two (or more) prior pregnancy losses. There is insufficient evidence to support use of preconception low-dose aspirin to prevent pregnancy loss for those who are nulliparous and/or who have not had a prior loss. While the available data conflict, this approach is based on limited supporting data combined with the low anticipated risk of aspirin based on its use in other pregnant populations. While the 2018 American College of Obstetricians and Gynecologists practice bulletin advises against using low-dose aspirin to prevent pregnancy loss, the publication was created prior to the 2021 per-protocol analysis presented below [42,43]. (See 'Review of data' below.)
Low-dose aspirin is suggested for individuals at high risk of preeclampsia or with antiphospholipid antibodies; timing of initiation varies by indication [44-46].
●(See "Preeclampsia: Prevention", section on 'Low-dose aspirin'.)
●(See "Antiphospholipid syndrome: Obstetric implications and management in pregnancy".)
Review of data — While the available data regarding the impact of low-dose aspirin on pregnancy loss conflict, concerns exist regarding limitations of the initial trials.
●Two trials that enrolled people with one to two prior pregnancy losses reported no impact of low-dose aspirin on risk of future loss, but the first trial started low-dose aspirin at 12 weeks of gestation, which is outside of the usual time period of pregnancy loss, and the multicenter trial was notable for treatment nonadherence [47,48].
●A post hoc per-protocol analysis of the above multicenter trial that compared low-dose aspirin with placebo for individuals with one to two prior pregnancy losses was performed to account for changes in treatment adherence over time. The post hoc analysis reported that, compared with placebo, low-dose aspirin started preconception and used throughout the entire follow-up period was associated with fewer pregnancy losses (risk ratio [RR] 0.69, 95% CI 0.50-0.95) and more live births (RR 1.33, 95% CI 1.08-1.64) [42]. The impact of aspirin on pregnancy loss and live birth was greater if aspirin was started prior to conception and continued throughout pregnancy and attenuated if the treatment was taken less than four of seven days per week. Study limitations included that participants were mostly well educated and living in households with high median incomes, which limits generalizability of the findings, and that adverse events, such as preterm birth and preeclampsia, were rare, which limits the ability to fully assess safety.
Recurrent pregnancy loss — While the definition of recurrent pregnancy loss is not universally agreed on, two to three prior losses are generally considered recurrent pregnancy loss [49,50]. Individuals who meet the criteria of recurrent loss represent a distinct population and their evaluation and management may differ. However, once an individual has been diagnosed with pregnancy loss, the options for treating the loss are the same regardless of the number of prior pregnancy losses.
●(See "Recurrent pregnancy loss: Definition and etiology".)
●(See "Recurrent pregnancy loss: Evaluation".)
●(See "Recurrent pregnancy loss: Management".)
Risk of depression and mood disorders — Individuals' responses to experiencing a pregnancy loss vary widely, and many patients report psychological distress, including symptoms of depression, anxiety, and post-traumatic stress disorder (PTSD), that can last for months [51-54]. Since one-quarter to one-third of individuals with pregnancy loss experience some adverse mental health outcome following pregnancy loss, and these medical conditions have available treatments, we suggest that all people diagnosed with pregnancy loss be screened for depression using a validated screening tool, such as the Edinburgh Postpartum Depression Scale. This can be done at the time of diagnosis, treatment, and/or follow-up visit to ensure this serious medical condition is not missed. When patients have a positive depression screen or demonstrate persistent elevated levels of distress or depression symptoms, clinicians can either offer treatment for depression or refer to a mental health care provider. Available community resources should be discussed as well. (See "Screening for depression in adults".)
Our approach is informed by the following data:
●A prospective cohort study reported that, compared with individuals with ongoing normal pregnancy, up to 29 percent of individuals with pregnancy loss experienced a significant mental health burden one month after loss and nearly 20 percent continued to have symptoms up to nine months after loss [52]. The study compared 492 individuals with pregnancy loss with 87 individuals with normal ongoing pregnancy. At one month, 29 percent reported symptoms meeting criteria for PTSD, 24 percent for anxiety, and 11 percent for depression, while individuals with normal ongoing pregnancy reported anxiety and depression rates of 13 and 2 percent, respectively. By nine months of follow-up, symptoms of PTSD, anxiety, and depression persisted but dropped to 18, 17, and 6 percent, respectively, for individuals with pregnancy loss.
●In a planned secondary analysis of a randomized trial comparing mifepristone-misoprostol with misoprostol alone for management of early pregnancy loss, 24 percent of participants were at risk for major depression 30 days after treatment [53]. After controlling for baseline depression, adverse childhood experience score, and parity, Black participants had more than double the risk for major depression 30 days after pregnancy loss treatment compared with non-Black participants (adjusted odds ratio 2.48, 95% CI 1.28-4.81).
By comparison, elevated rates of adverse mental health outcomes are not reported for most individuals undergoing pregnancy termination. (See "Pregnancy termination and potential psychiatric outcomes".)
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)" and "Society guideline links: Recurrent pregnancy loss".)
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
●Patient-centered approach – When counseling patients with pregnancy loss about their management options, it is critical for clinicians to avoid inserting their personal biases. Patients are asked about their preferences and encouraged to participate in decision-making. However, in situations in which certain treatment approaches would not be medically advisable, clinicians should make this clear. (See 'Use a patient-centered approach' above.)
●Treatment options – Pregnancy loss can be managed expectantly, with medication or with surgery. Each has unique advantages and potential risks, which are discussed with the patient. Evidence indicates that all management options (expectant, medication, or surgical) are reasonable in a majority of cases, and patients are most satisfied when they are able to choose. (See 'Present treatment options' above.)
●Additional care points – The additional care points below are discussed with patients as indicated by their clinical needs.
•Pain management – Pain management should be offered to all patients experiencing pregnancy loss, regardless of mode of management. Factors that impact pain include route of treatment and gestational age of loss. (See 'Pain management' above.)
•Contraception – All contraception can be initiated immediately following the completion of any pregnancy loss process. (See 'Timing of contraception initiation' above.)
•Future pregnancy – Individuals with pregnancy loss, particularly early pregnancy loss (EPL), are likely to have subsequent normal pregnancies. Earlier initiation of conception efforts after a pregnancy loss does not increase the risk of another pregnancy loss and may positively impact live birth rates. It is important for patients to be emotionally ready for pregnancy when they start trying to conceive. (See 'Likelihood of live birth' above and 'Timing of subsequent pregnancy' above.)
•Low-dose aspirin to reduce risk of future pregnancy loss – For individuals who have experienced one to two pregnancy losses, we suggest initiation of low-dose aspirin prior to conception (Grade 2C). This approach is informed by a post hoc analysis of a multicenter trial combined with the low anticipated risk of aspirin based on its use in other pregnant populations. For those who are nulliparous or who have not yet had a loss, there is insufficient evidence to support use of preconception low-dose aspirin at this time. Management of individuals with recurrent pregnancy loss is presented elsewhere. (See 'Role of low-dose aspirin to reduce risk of pregnancy loss' above and "Recurrent pregnancy loss: Management".)
•Risk of depression and mood disorders – Attention to the emotional and psychological health of the patient experiencing pregnancy loss is critical. Responses can range from relief to overwhelming grief and even depression. We use a validated screening tool to assess for depression in patients, such as the Edinburgh Postpartum Depression Scale. We also directly discuss the possibility of mood disorders with every patient, so they and their support persons can be alert for signs of depression. (See 'Risk of depression and mood disorders' 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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