• 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.

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

2. 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.

3. 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

4. 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:

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

Created by Ella Barrett-Chan, MSI UBC 2023

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:

• Miscarriage and Bleeding in Early Pregnancy – Patient Information Sheet

Lower Mainland Resources for follow up:

• For TVUS, miscarriage management, grief/loss counselling, <13 weeks GA
  • Early Pregnancy Assessment Clinic at BC Women’s Hospital
  • Early Pregnancy Assessment Clinic at Surrey Memorial Hospital
• If a patient has had two or more losses:
  • Recurrent Pregnancy Loss Clinic, BC Women’s Hospital

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.

Requiring urgent surgical management:

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

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.

Indications: Anticipating surgical management not available at current facility.

Clinical Resources:

• Discharge teaching for patients with early pregnancy loss:
  • Miscarriage and Bleeding in Early Pregnancy Patient Information Sheet.
  • Discharge instructions: Threatened miscarriage Video (YouTube: Sunnybrook Hospital).
  • Discharge Teaching for Patients Experiencing an Early Pregnancy Loss (Provincial Council for Maternal and Child Health).
• Patient resource comparing expectant, medical, and surgical management (BC Women’s Early Pregnancy Assessment Clinic).

Additional topic reviews:

• Miscarriage – Diagnosis PECS.
• EM Rounds Blog (St John’s Hospital) on early pregnancy and PUL.
• Emergency Medicine Cases blog and podcast on early pregnancy complications.
• Breaking Bad News (Provincial Council for Maternal and Child Health).
• Communicating with Families Experiencing Pregnancy Loss (Provincial Council for Maternal and Child Health).

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2. American Society of Reproductive Medicine. Evaluation and treatment of recurrent pregnancy loss: a committee opinion. Fertil Steril. 2012;98(5):1103-1111.

   
   

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9. World Health Organization (WHO). Safe Abortion: Technical and Policy Guidance for Health Systems, 2nd Edition.; 2012.

   
   

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