How is early pregnancy loss treated in the emergency department (ED)?

Updated: Nov 05, 2018
  • Author: Slava V Gaufberg, MD; Chief Editor: Jeter (Jay) Pritchard Taylor, III, MD  more...
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Answer

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.

The American College of Obstetricians and Gynecologists (ACOG) recommends generally limiting expectant management to gestations within the first trimester owing to potential hemorrhage as well as a lack of safety studies of expectant management in the second trimester. [1] An estimated 80% success rate in achieving complete expulsion when adequate time is allowed (≤8 weeks). For women who wish to reduce the time to complete expulsion but do not wish to undergo surgical evacuation, treatment with misoprostol may be considered. [1]

Nadarajah et al found no statistically significant difference in the success rate between 360 women who underwent expectant or surgical management of early pregnancy loss, nor was there any difference in the types of miscarriage. [17] With expectant management, 74% patients had a complete spontaneous expulsion of products of conception. Of these patients, 106 (83%) miscarried within 7 days. However, the rates of unplanned admissions (18.1%) and unplanned surgical evacuations (17.5%) in the expectant group, were significantly higher than those in the surgical group (7.4% and 8% respectively). [17]


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