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    1st Trimester Bleeding: Miscarriage – Treatment

    Obstetrics and Gynecology

    Last Updated Oct 27, 2021
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    Context

    • Early Pregnancy Loss (EPL): Intrauterine pregnancy (IUP) loss < 20 weeks Gestational Age (GA).
    • 80% occur in first 12 weeks GA.
    • 15-25% of all pregnancies.

    Recommended Treatment

    Overall treatment principles:

    • Hemodynamic stabilization.
    • Prevent alloimmunization if Rh negative.
    • Guidance and pain control.
    • If nonviable – expectant, medical, or surgical management usually OB/GYN input.

    A) Initial ED treatment (threatened, inevitable, incomplete, missed, and completed miscarriages):

    1. Treat complications:
    • Infection (endometritis and/or septic abortion) occurs in 2-3% of cases, irrespective of treatment.
    • Hemorrhage
    • Retained Products of Conception
    • OB/GYN consult, admission, fluid resuscitation, antibiotics
    1. Prevent Rh alloimmunization:
    • For Rh Negative patients, administer:
      • If < 12 weeks GA:
      • 50-120 mcg anti-D immunoglobulin within 72 hours (expectant, medical or surgical management).
      • 300 mcg dose is acceptable.
      • If >12 weeks GA: dose = 300 mcg IM.
    1. Symptom management:
    • Naproxen 500 mg q12h or Ibuprofen 800 mg q8h
    • Acetaminophen 1000 mg q6h
    • Heating pads
    • Consider antiemetics, especially if receiving medical management with misoprostol
    1. Address psychological concerns:
    • Acknowledge distress and grief
    • Reassure that they are not at fault
    • Reassure that they are not at increased risk of future miscarriages. Fewer than 5% of women will experience two miscarriages, and only 1% experience three or more.

    B) Treatment by Miscarriage Category:

    CLICK TO ENLARGE

    Incomplete, inevitable or missed miscarriage:

    • Consider OB/GYN consult to discuss surgical, medical, and expectant options.
    • The MIST trial found no difference in rates of infection between all three options, but an increased rate of unplanned admissions and surgical management with expectant and medical management.

    CLICK TO ENLARGE

    • If available F/U with OB/GYN for monitoring of miscarriage completion through expectant, medical, or surgical management often best.

    Threatened Miscarriage:

    • Viability confirmed: Return care to main OB provider.
    • Viability uncertain: see PECS Miscarriage – Diagnosis.
    • Provide anticipatory guidance on possibility of future miscarriage.

    Completed Miscarriage:

    • F/U with primary OB provider (or Early Pregnancy Assessment Clinic if in the Lower Mainland) to ensure resolution of bleeding (< 72 hours).

    C) Discharge planning:

    • Discharge Instructions: Return to ED if: significant increase in bleeding, pain, lightheadedness or fainting, fever, foul-smelling discharge.
    •  F/U with main OB provider within 72 hours.

    Counselling:

    Lower Mainland Resources for follow up:

    Criteria For Safe Discharge Home

    1. Bleeding controlled and hemodynamically stable.
    2. No infection – septic miscarriage (no fever, uterine tenderness, leukocytosis, foul-smelling discharge).
    3. Follow up arranged.
    4. Discharge counselling and instructions completed.

    Criteria For Hospital Admission

    Requiring urgent surgical management:

    1. Heavy bleeding and/or hemodynamic instability.
    2. Septic miscarriage.

    Criteria For Close Observation And/or Consult

    OB/GYN consult if:

    • Hemodynamic instability.
    • Septic miscarriage.
    • Incomplete, inevitable, or missed miscarriage for discussion of expectant vs. medical vs. surgical management and arrangement of timely follow up.
    • Unclear diagnosis of complete vs. incomplete miscarriage.

    Criteria For Transfer To Another Facility

    Indications: Anticipating surgical management not available at current facility.

    Quality Of Evidence?

    Justification

    Comparison of expectant vs. medical vs. surgical management.

    Moderate-High

    All women with 1st trimester miscarriage who are Rh negative should receive Rho-gam5. Based on expert opinion and extrapolation.

    Low

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    Additional topic reviews:

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