Early Pregnancy loss in emergency medicine Author: Slava V Gaufberg, MD; Chief Editor: Pamela L Dyne,

Background
The term "abortion" is commonly used to mean all forms of early pregnancy loss; however, due to the polarizing social stigma assigned to this term, the term "miscarriage" is used here to indicate all forms of spontaneous early pregnancy loss or potential loss. One of the common complications of pregnancy is spontaneous miscarriage, which occurs in an estimated 5-15% of pregnancies. Spontaneous miscarriages are categorized as threatened, inevitable, incomplete, complete, or missed, and can be further classified as sporadic or recurrent (>3 occurrences).

Pathophysiology
The pathophysiology of a spontaneous miscarriage may be suggested by its timing. Chromosomal defects are commonly seen in spontaneous miscarriages, especially those that occur during 4-8 weeks' gestation. Genetic etiologies are common in early first-trimester loss but may be seen throughout gestation. Trisomy chromosomes are the most common chromosomal anomaly. Insufficient or excessive hormonal levels usually result in spontaneous miscarriage before 10 weeks' gestation. Infectious, immunologic, and environmental factors are generally seen in first-trimester pregnancy loss. Anatomic factors are usually associated with secondtrimester loss. Factor XIII deficiency and a complete or partial deficiency of fibrinogen are associated with recurrent spontaneous miscarriage.[1] A spontaneous miscarriage is a process that can be divided into 4 stages, as follows: threatened, inevitable, incomplete, and complete.

Threatened miscarriage: Vaginal bleeding, abdominal/pelvic pain of any degree, or both during early pregnancy represents a threatened miscarriage. Approximately a fourth of all pregnant women have some degree of vaginal bleeding during the first 2 trimesters. About half of these cases progress to an actual miscarriage.[2] Bleeding and pain accompanying threatened miscarriage is usually not very intense. Threatened miscarriage rarely presents with severe vaginal bleeding. On vaginal examination, the internal cervical os is closed and no cervical motion tenderness or tissue is found. Diffuse uterine tenderness, adnexal tenderness, or both may be present. Threatened miscarriage is defined by the absence of passing/passed tissue and the presence of a closed internal cervical os. These findings differentiate threatened miscarriage from later stages of a miscarriage. Inevitable miscarriage: Vaginal bleeding is accompanied by dilatation of the cervical canal. Bleeding is usually more severe than with threatened miscarriage and is often associated with abdominal pain and cramping. Incomplete miscarriage: Vaginal bleeding may be intense and accompanied by abdominal pain. The cervical os may be open with products of conception being passed, or the

internal cervical os may be closed. Ultrasonography is used to reveal whether some products of conception are still present in the uterus. Complete miscarriage: Patients may present with a history of bleeding, abdominal pain, and tissue passage. By the time the miscarriage is complete, bleeding and pain usually have subsided. Ultrasonography reveals a vacant uterus. Diagnosis may be confirmed by observation of the aborted fetus with the complete placenta, although caution is recommended in making this diagnosis without ultrasonography because it can be difficult to determine if the miscarriage is complete.

Epidemiology
Frequency
United States Many pregnancies are not viable. According to estimates, 50% of pregnancies terminate spontaneously before the first missed menstrual period; these miscarriages usually are not clinically recognized. Spontaneous miscarriage is typically defined as a clinically recognized (ie, by blood test, urine test, or ultrasonography) pregnancy loss before 20 weeks' gestation. Approximately 5-15% of diagnosed pregnancies result in spontaneous miscarriage. International Some European investigators quote the rate of spontaneous miscarriage to be as low as 2-5%.

Mortality/Morbidity
Surveillance data suggest that spontaneous miscarriages and induced abortions accounted for about 4% of pregnancy-related deaths in the United States.[3]

Race
Surveillance data for pregnancy-related deaths demonstrate more deaths due to ectopic pregnancy, spontaneous miscarriage, and induced abortion among African American women than among white women. Eight percent of pregnancy-related deaths among black women were due to ectopic pregnancies; 7% were due to miscarriages. Among white women, data show that 4% of pregnancy-related deaths were due to ectopic pregnancies; 4% were due to miscarriages.[3,
4]

Age

Age and increased parity affect a woman's risk of miscarriage. In women younger than 20 years, miscarriage occurs in an estimated 12% of pregnancies. In women older than 20 years, miscarriage occurs in an estimated 26% of pregnancies.

Age primarily affects the oocyte. When oocytes from young women are used to create embryos for transfer to older recipients, implantation and pregnancy rates mimic those seen in younger women. The number of miscarriages and chromosomal anomalies decreases, suggesting that the uterus is not responsible for poor outcomes in women of advanced reproductive age.

Background
The term "abortion" is commonly used to mean all forms of early pregnancy loss; however, due to the polarizing social stigma assigned to this term, the term "miscarriage" is used here to indicate all forms of spontaneous early pregnancy loss or potential loss. One of the common complications of pregnancy is spontaneous miscarriage, which occurs in an estimated 5-15% of pregnancies. Spontaneous miscarriages are categorized as threatened, inevitable, incomplete, complete, or missed, and can be further classified as sporadic or recurrent (>3 occurrences).

Pathophysiology
The pathophysiology of a spontaneous miscarriage may be suggested by its timing. Chromosomal defects are commonly seen in spontaneous miscarriages, especially those that occur during 4-8 weeks' gestation. Genetic etiologies are common in early first-trimester loss but may be seen throughout gestation. Trisomy chromosomes are the most common chromosomal anomaly. Insufficient or excessive hormonal levels usually result in spontaneous miscarriage before 10 weeks' gestation. Infectious, immunologic, and environmental factors are generally seen in first-trimester pregnancy loss. Anatomic factors are usually associated with secondtrimester loss. Factor XIII deficiency and a complete or partial deficiency of fibrinogen are associated with recurrent spontaneous miscarriage.[1] A spontaneous miscarriage is a process that can be divided into 4 stages, as follows: threatened, inevitable, incomplete, and complete.

Threatened miscarriage: Vaginal bleeding, abdominal/pelvic pain of any degree, or both during early pregnancy represents a threatened miscarriage. Approximately a fourth of all pregnant women have some degree of vaginal bleeding during the first 2 trimesters. About half of these cases progress to an actual miscarriage.[2] Bleeding and pain accompanying threatened miscarriage is usually not very intense. Threatened miscarriage rarely presents with severe vaginal bleeding. On vaginal examination, the internal cervical os is closed and no cervical motion tenderness or tissue is found. Diffuse uterine tenderness, adnexal tenderness, or both may be present. Threatened miscarriage is defined by the absence of passing/passed tissue and the presence of a closed internal cervical os. These findings differentiate threatened miscarriage from later stages of a miscarriage. Inevitable miscarriage: Vaginal bleeding is accompanied by dilatation of the cervical canal. Bleeding is usually more severe than with threatened miscarriage and is often associated with abdominal pain and cramping.

Incomplete miscarriage: Vaginal bleeding may be intense and accompanied by abdominal pain. The cervical os may be open with products of conception being passed, or the internal cervical os may be closed. Ultrasonography is used to reveal whether some products of conception are still present in the uterus. Complete miscarriage: Patients may present with a history of bleeding, abdominal pain, and tissue passage. By the time the miscarriage is complete, bleeding and pain usually have subsided. Ultrasonography reveals a vacant uterus. Diagnosis may be confirmed by observation of the aborted fetus with the complete placenta, although caution is recommended in making this diagnosis without ultrasonography because it can be difficult to determine if the miscarriage is complete.

Epidemiology
Frequency
United States Many pregnancies are not viable. According to estimates, 50% of pregnancies terminate spontaneously before the first missed menstrual period; these miscarriages usually are not clinically recognized. Spontaneous miscarriage is typically defined as a clinically recognized (ie, by blood test, urine test, or ultrasonography) pregnancy loss before 20 weeks' gestation. Approximately 5-15% of diagnosed pregnancies result in spontaneous miscarriage. International Some European investigators quote the rate of spontaneous miscarriage to be as low as 2-5%.

Mortality/Morbidity
Surveillance data suggest that spontaneous miscarriages and induced abortions accounted for about 4% of pregnancy-related deaths in the United States.[3]

Race
Surveillance data for pregnancy-related deaths demonstrate more deaths due to ectopic pregnancy, spontaneous miscarriage, and induced abortion among African American women than among white women. Eight percent of pregnancy-related deaths among black women were due to ectopic pregnancies; 7% were due to miscarriages. Among white women, data show that 4% of pregnancy-related deaths were due to ectopic pregnancies; 4% were due to miscarriages.[3,
4]

Age

Age and increased parity affect a woman's risk of miscarriage. In women younger than 20 years, miscarriage occurs in an estimated 12% of pregnancies. In women older than 20 years, miscarriage occurs in an estimated 26% of pregnancies. Age primarily affects the oocyte. When oocytes from young women are used to create embryos for transfer to older recipients, implantation and pregnancy rates mimic those seen in younger women. The number of miscarriages and chromosomal anomalies decreases, suggesting that the uterus is not responsible for poor outcomes in women of advanced reproductive age.

History

Patients with spontaneous miscarriage usually present to the ED with vaginal bleeding, abdominal pain, or both. o Vaginal bleeding may vary from slight spotting to a severe life-threatening hemorrhage. The patient's history should include the number of pads or tampons used. Hasan et al found that heavy bleeding in the first trimester, particularly when associated with abdominal pain, is associated with higher risk of miscarriage.[5] o Presence of blood clots or tissue may be an important sign indicating progression of spontaneous miscarriage. o Abdominal pain is usually located in the suprapubic area or in one or both lower quadrants. o Pain may radiate to the lower back, buttocks, genitalia, and perineum. The patient's history should also include the following: o Date of last menstrual period (LMP) o Estimated length of gestation o Sonogram results, if previously performed o Bleeding disorders o Previous miscarriage or elective abortions Other symptoms, such as fever or chills, are more characteristic of a septic miscarriage or abortion. Consider any woman of childbearing age with vaginal bleeding pregnant until proven otherwise.

Physical

Pelvic examination should focus on determining the source of bleeding. o Blood from cervical os o Intensity of bleeding o Presence of clots or tissue fragments o Cervical motion tenderness (presence increases suspicion for ectopic pregnancy) o Status of internal cervical os: open indicates inevitable or possibly incomplete miscarriage; closed indicates threatened miscarriage. o Uterine size and tenderness, as well as adnexal tenderness or masses Signs of threatened miscarriage:

Vital signs should be within reference ranges unless infection is present or hemorrhage has caused hypovolemia. o The abdomen usually is soft and nontender. o Pelvic examination reveals a closed internal cervical os. The bimanual examination is unremarkable. Signs of incomplete miscarriage: o The cervix may appear dilated and effaced, or it may be closed. o Bimanual examination may reveal an enlarged and soft uterus. o On pelvic examination, products of conception may be partially present in the uterus, may protrude from the external os, or may be present in the vagina. Bleeding and cramping usually persist. Complete miscarriage: On pelvic examination, the cervix should be closed, and the uterus should be contracted. Missed miscarriage: o Vital signs usually are within reference ranges. Abdominal examination may or may not reveal a palpable uterus. If palpable, the uterus usually is small for the presumed gestational age. o Fetal heart tones are inaudible or unseen on sonogram. o The cervical os is closed upon pelvic examination. The uterus may feel soft and enlarged.

Causes
Causes of first- and second-trimester miscarriage

Embryonic abnormalities account for 80-90% of first-trimester miscarriages. o Chromosomal abnormalities are the most common cause of spontaneous miscarriage. More than 90% of cytogenic and morphologic errors are eliminated through spontaneous miscarriage. o Chromosomal abnormalities have been found in more than 75% of fetuses that miscarry in the first trimester. o The rate of chromosomal abnormalities increases with age, with a steep increase in women older than 35 years. o Trisomy chromosomes commonly are encountered, with trisomy 16 accounting for approximately a third of chromosomal abnormalities in early pregnancy. Maternal factors account for the majority of second-trimester miscarriages. o Chronic maternal health factors: Maternal insulin-dependent diabetes mellitus (IDDM): As many as 30% of pregnancies in women with IDDM result in spontaneous miscarriage, predominantly in patients with poor glucose control in the first trimester. Severe hypertension Renal disease Systemic lupus erythematosus (SLE) Hypothyroidism and hyperthyroidism o Acute maternal health factors:

Infections (eg, rubella, cytomegalovirus [CMV], and mycoplasmal, ureaplasmal, listerial, toxoplasmal infections) Trauma Severe emotional shock

Other factors that may contribute to miscarriage

Exogenous factors: o Alcohol o Tobacco o Cocaine and other illicit drugs Anatomic factors: Congenital or acquired anatomic factors are reported to occur in 1015% of women who have recurrent spontaneous miscarriages. o Congenital anatomic lesions include mllerian duct anomalies (eg, septate uterus, diethylstilbestrol [DES]-related anomalies). Mllerian duct lesions usually are found in second-trimester pregnancy loss. o Anomalies of the uterine artery with compromised endometrial blood flow are congenital. o Acquired lesions include intrauterine adhesions (ie, synechiae), leiomyoma, and endometriosis. o Other diseases or abnormalities of the reproductive system that may result in miscarriage include congenital or acquired uterine defects, fibroids, cervical incompetence, abnormal placental development, or grand multiparity. Endocrine factors: o Endocrine factors potentially contribute to recurrent miscarriage in 10-20% of cases. o Luteal phase insufficiency (ie, abnormal corpus luteum function with insufficient progesterone production) is implicated as the most common endocrine abnormality contributing to spontaneous miscarriage. o Hypothyroidism, hypoprolactinemia, poor diabetic control, and polycystic ovarian syndrome are contributive factors in pregnancy loss. Infectious factors: o Presumed infectious etiology may be found in 5% of cases. o Bacterial, viral, parasitic, fungal, and zoonotic infections are associated with recurrent spontaneous miscarriage. Immunologic factors: o Immunologic factors may contribute in up to 60% of recurrent spontaneous miscarriages. o Both the developing embryo and the trophoblast may be considered immunologically foreign to the maternal immune system. o Antiphospholipid antibody syndrome generally is responsible for more secondtrimester pregnancy losses than first-trimester losses. Miscellaneous factors: o Miscellaneous factors may account for up to 3% of recurrent spontaneous miscarriages.

Other contributing factors implicated in sporadic and recurrent spontaneous abortions include environment, drugs, placental abnormalities, medical illnesses, and male-related causes. Gestational exposure to nonaspirin NSAIDs may increase the risk for miscarriage. Nakhai-Pour et al identified 4705 women who had spontaneous abortions by 20 weeks gestation. Each case was matched to 10 control subjects (n=47,050) who did not have a spontaneous abortion. In the women who had a miscarriage, 352 (7.5%) were exposed to a nonaspirin NSAID, whereas NSAID exposure was lower (1213 exposed [2.6%]) in women who did not have a miscarriage.[6]

Laboratory Studies

Qualitative urine pregnancy test, to confirm pregnancy Complete blood count with differential Blood type and Rh factor o Blood type must be documented for every pregnant patient with vaginal bleeding. o If Rh-negative, administer RhoGAM to prevent hemolytic disease of the newborn in this pregnancy and subsequent pregnancies. Hemoglobin and hematocrit: These studies establish baseline and detect hemorrhagic anemia. Quantitative human chorionic gonadotropin-beta o The discriminatory level of beta-hCG is approximately 1500 mIU/mL above which there should be sonographic evidence of early intrauterine pregnancy, if present. o Beta-hCG level rises at rate of doubling approximately every 48 hours for 85% of intrauterine pregnancies. The remaining 15% may rise with a different slope or be plateaued. o A higher likelihood of ectopic pregnancy or subsequent miscarriage exists if hCG blood level is lower than predicted by estimated gestational age (GA) based on the last menstrual period (LMP). o The possibility of molar pregnancy exists if beta-hCG is very high and out of proportion to predicted gestational age. This pregnancy occurs with or without evidence of early normal trophoblast growth and function, as indicated by adequately rising beta-hCG levels. Factor XIII and fibrinogen, if indicated per history

Imaging Studies
Ultrasonography is used widely and is the imaging study of choice. Advantages of ultrasonography include bedside use, availability, low cost, and noninvasiveness. Disadvantages include operator dependency. Ultrasonography aids identification of retained products of conception, fetal demise, incomplete miscarriage, ectopic pregnancy, or empty uterus; therefore, it provides a clinically relevant classification of early pregnancy loss. Following spontaneous first-trimester complete miscarriage, endovaginal ultrasonography has been found to be 81% sensitive and 94% specific in detection of retained products of conception.[7] Ultrasonography is

the most accurate diagnostic modality in the confirmation of a viable pregnancy during the first trimester.[7] Indications for ultrasonography in the ED include abdominal or pelvic pain, vaginal bleeding, persistently open cervical os, adnexal mass or fullness, cervical motion tenderness, discrepancy between uterine size and last menstrual period (LMP), and discrepancy between expected and measured beta-hCG levels. Seymour et al sought to determine whether a physical examination was necessary in pregnant patients presenting with pregnancy-related complaints and a viable pregnancy as shown on bedside ultrasonography. Fifty patients were enrolled in the study; each patient received a pelvic examination before ultrasonography. In all patients, findings on physical examination were the same as those found by ultrasonography. Bedside ultrasonography provided all the information needed to determine immediate management of these patients. Few findings on pelvic examination are likely to alter this management.[8] The findings of the study by Seymour et al also complement the findings of Close et al, who found there was very little inter-examiner reliability of the bimanual pelvic examination for identifying masses or uterine size,[9] which are principally the physical findings being evaluated in the early pregnant patient in the ED setting. Taken together, these studies highlight the impact that advances in technology has on the practice of medicine, but, at this time, the findings are unlikely to change current practice. A high-resolution vaginal ultrasound probe can detect pregnancy at 3-4 weeks' gestation and fetal heart activity at 5 and a half weeks. The presence of fetal cardiac activity in women with bleeding in early pregnancy has been noted to have a sensitivity of 97% and a specificity of 98% for fetal survival to the 20th week of pregnancy.[7] Fetal studies are limited in the first trimester due to small fetal size. Ultrasonography usually provides information in 3 major areas: location of pregnancy, pregnancy size, and absence or presence of fetal cardiac activity. An apparently empty uterus revealed by ultrasonography in a pregnant woman (ie, positive betahCG findings, LMP within last 20 wk) suggests a very early pregnancy (ie, < 3 wk GA), a completed miscarriage, or an ectopic pregnancy. (See Bedside Ultrasonography, First-Trimester Pregnancy.)

Sonographic signs suggestive of a nonviable pregnancy include the following: o Irregular gestational sac (ie, gestational sac >25-mm mean sac diameter [MSD] on transabdominal sonogram; >16-mm MSD on endovaginal sonogram without a detectable embryo) o Nonliving embryo (embryo without a heartbeat)

Presence of abnormal hyperechoic material within the uterine cavity, as depicted

in the sonogram below This endovaginal longitudinal view demonstrates fluid within the uterus (Ut). Echogenic debris also is present within the endometrial cavity. This image shows a large pseudogestational sac of an ectopic pregnancy. Consider the sonographic diagnosis of early pregnancy failure in relationship to developmental stage. o Subclinical or preclinical loss: This occurs within the first 2 weeks after conception. Sonographic evidence of pregnancy does not exist at this stage. o Loss at 5-6 weeks: Loss at this stage is based upon gestational sac characteristics. Abnormal gestational sac size is the most reliable indicator of abnormal outcome. Gestational sacs should be 5-mm mean sac diameter (MSD) by the fifth gestational week. An abnormally large gestational sac, as determined by highfrequency endovaginal sonography (HFEVS), is observed when the MSD is more than 8 mm without a demonstrable yolk sac or is more than 16 mm without a demonstrable embryo. o Loss at 7-8 weeks: Sonographic evidence is based upon demonstration of an abnormal embryo or gestational sac. o Loss at 9-12 weeks: Sonographic diagnosis of embryonic demise is usually made on demonstration of an abnormal fetus. Sonographic evidence of a fetus lacking cardiac activity is the most specific indicator of embryonic demise. This is

depicted in the sonogram below. This endovaginal ultrasonogram reveals an irregular gestational sac with an amorphic fetal pole. No fetal cardiac activity was noted. This image represents a missed miscarriage or fetal demise. Caution is advised in the diagnosis of embryonic demise. Determination of whether the viewed structure is the embryo is critical, as no other morphologically recognizable structures, other than a heartbeat, exist at this stage of development. The embryo must be scanned thoroughly for evidence of a heartbeat. o Most recommendations call for 2 independent examiners to view the embryo, either concurrent with the ED visit or at follow-up.

Most sonographers recommend repeating the scan within 3-7 days to determine if normal development is occurring. o On follow-up, a falling beta-human chorionic gonadotropin (hCG) level, as well as abnormal fetal development, confirms embryonic demise. Sonography can identify presence of a subchorionic hematoma or hemorrhage (ie, bleeding between the endometrium and the gestational sac). o A subchorionic hemorrhage is the most commonly identified source of firsttrimester bleeding, appearing on sonography as a crescent-shaped hypoechoic area next to the gestational sac. o Subchorionic hemorrhage encompasses a spectrum of sonographic findings. Subchorionic fluid can be classified in relation to gestational sac size and length of gestation. Subchorionic bleeding is present when pulsation of the subchorionic fluid is noted. o Size of the subchorionic hemorrhage should be taken into consideration, as greater size relates to an increased risk of spontaneous miscarriage. A large subchorionic hematoma (ie, surrounding greater than 50% of the gestational sac) is a poor prognostic indicator for the pregnancy outcome. A subchorionic

hemorrhage is depicted below. This endovaginal ultrasonographic image demonstrates a subchorionic hemorrhage (SH) less than half the gestational sac size. o Subchorionic bleeding can be demonstrated using color Doppler imaging. o Endovaginal ultrasonography should be applied whenever possible to limit image distortion due to patient habitus or an overdistended bladder. An incomplete miscarriage may demonstrate a variety of sonographic findings as follows: o The gestational sac may be misshaped or collapsed, or it may be intact, containing a nonliving embryo. In addition, an irregular complex mass within the endometrial or endocervical canal may be present. Sonogram of an incomplete

miscarriage is shown below. This image shows an endovaginal longitudinal view of a low-lying gestational sac (GS) within the uterus (Ut), representing an incomplete miscarriage.

Echogenic material or debris within the endometrial canal may represent retained products of conception or clotted blood. o First-trimester molar pregnancies may simulate an incomplete miscarriage, with echogenic material within the endometrial cavity that has no characteristic vesicles or cysts. o Intrauterine fluid collections may represent pseudogestational sacs found in ectopic pregnancies. o Studies suggest no statistically significant relationship between the initial presence of a gestational sac or endometrial thickness and the success rate of expectant management. A complete miscarriage may demonstrate the following sonographic findings: o An empty uterus noted on endovaginal sonogram suggests a complete miscarriage; however, sonographic diagnosis includes ectopic pregnancy and early intrauterine pregnancy. o Careful scanning for adnexal masses and/or free fluid is advised.

No single ultrasonographic measurement of the different anatomical features in the first trimester has demonstrated a high predictive value for determining early pregnancy outcome. Recent research suggests the finding of blood flow in the intervillous space in cases of first-trimester miscarriage using color Doppler ultrasonography as useful in the prediction of successful expectant management. Miscarriages with intervillous space blood flow were 4 times more likely to complete with expectant management.

Procedures

Transabdominal ultrasonography of the pelvis provides an overall view of the pelvic structures. A full bladder is required as a sonographic window. Endovaginal ultrasonography gives a detailed view of the endometrium of the uterus, ovaries, adnexa, and cul-de-sac. An empty bladder is required for optimal imaging.

Prehospital Care

Maintain routine universal precautions in view of potentially heavy vaginal bleeding. Emergency medical services (EMS) personnel should be aware of the potential for hemorrhagic shock and should treat any hemodynamic instability. o Obtain vital signs and establish an intravenous line in all pregnant patients who have abdominal pain and vaginal bleeding. o If the patient is hypotensive, an intravenous bolus of normal saline (NS) is indicated for hemodynamic stabilization. o Administer oxygen. Encourage the patient to bring any passed tissue to the hospital for evaluation.

Emergency Department Care

Treat all patients with vaginal bleeding of any etiology as follows:

Determine hemodynamic stability and treat instability. If the patient is in hemorrhagic shock, treatment includes the Trendelenburg position, oxygen, aggressive fluid resuscitation (at least 2 large-bore IV lines with lactated Ringer [LR] solution or normal saline, wide open), and hemotransfusion. Determine pregnancy status (qualitative and quantitative). Make laboratory determination of hematocrit (Hct) level and Rh status. Perform a pelvic examination to determine the rate of bleeding; presence of blood clots or products of conception; and condition of cervical os, cervix, uterus, and adnexa. Perform pelvic ultrasonography to determine intrauterine and/or extrauterine contents (fetal heart activity) and/or to clinically classify spontaneous miscarriage.

Diagnostic specific management

Inevitable miscarriage

The goal of treatment is evacuation of the uterus to prevent complications (eg, further hemorrhage, infection).

Incomplete miscarriage

If tissue, blood clots, or products of conception are found in the cervical os, remove them with ring forceps to facilitate uterine contractions and hemostasis. For the same reason, use oxytocin in cases of severe bleeding (10-20 mcg/L of NS, wide open). Administer RhoGAM to a gravid patient who is Rh-negative and is experiencing vaginal bleeding. Consider hemotransfusion in the case of severe bleeding, hemodynamic instability, or both. Consider treatment with misoprostol to facilitate completion of the miscarriage.

Complete miscarriage

Treatment of a patient who has had a complete miscarriage varies depending on the degree of certainty of the diagnosis. Diagnosing complete miscarriage in the ED can be difficult, unless an intact gestational sac was expelled. If pelvic examination produces fetal tissue (or material of similar appearance), send it to the laboratory for identification of possible products of conception.

Missed miscarriage

Treatment may vary depending on gestational age as follows: o First trimester Most patients pass the products of conception spontaneously. Coagulation defects secondary to a dead fetus are rare. [10] Expectant management, suction curettage, or misoprostol for medical management to facilitate passage of products of conception may be performed.

Second trimester The uterus is emptied by dilatation and evacuation. Alternatively, the uterus is emptied by induction of labor.

Consultations
Consultation with an obstetrician/gynecologist is indicated in all patients with the diagnosis of inevitable or incomplete miscarriage; patients with severe hemorrhage or patients who are hemodynamically unstable require immediate consultation for assistance with definitive treatment. Definitive treatment may be to evacuate the products of conception from the uterus with curettage. Depending on hospital policy, curettage may be performed in the ED with subsequent observation of patients for 4-6 hours after curettage, and then discharge if no complications occur. Curettage is generally reserved for those patients who are at risk for hemodynamic instability due to the briskness of bleeding or for those in whom endometritis is a concern. However, most patients with inevitable or incomplete miscarriage are candidates for medical management with misoprosto