INTERIM UPDATE

ACOG PRACTICE BULLETIN

Clinical Management Guidelines for Obstetrician–Gynecologists
NUMBER 200 (Replaces Practice Bulletin Number 150, May 2015)

Committee on Practice Bulletins—Gynecology. This Practice Bulletin was developed by the ACOG Committee on Practice
Bulletins—Gynecology in collaboration with Sarah Prager, MD; Vanessa K. Dalton, MD, MPH; and Rebecca H. Allen, MD, MPH.

INTERIM UPDATE: This Practice Bulletin is updated as highlighted to reflect recent evidence regarding the use of mife-
pristone combined with misoprostol for medical management of early pregnancy loss. This Practice Bulletin also includes
limited, focused updates to align with Practice Bulletin No. 181, Prevention of Rh D Alloimmunization.

Early Pregnancy Loss

Early pregnancy loss, or loss of an intrauterine pregnancy within the first trimester, is encountered commonly in
clinical practice. Obstetricians and gynecologists should understand the use of various diagnostic tools to differentiate
between viable and nonviable pregnancies and offer the full range of therapeutic options to patients, including
expectant, medical, and surgical management. The purpose of this Practice Bulletin is to review diagnostic approaches
and describe options for the management of early pregnancy loss.

maternal age and a prior early pregnancy loss (7, 8).

Background The frequency of clinically recognized early pregnancy
Definition loss for women aged 20–30 years is 9–17%, and this
Early pregnancy loss is defined as a nonviable, intrauter- rate increases sharply from 20% at age 35 years to 40%
ine pregnancy with either an empty gestational sac or at age 40 years and 80% at age 45 years (7). Discussion
a gestational sac containing an embryo or fetus without of the many risk factors thought to be associated with
fetal heart activity within the first 12 6/7 weeks of ges- early pregnancy loss is beyond the scope of this docu-
tation (1). In the first trimester, the terms miscarriage, ment and is covered in more detail in other publications
spontaneous abortion, and early pregnancy loss are used (6, 7).
interchangeably, and there is no consensus on terminol-
ogy in the literature. However, early pregnancy loss is the Clinical Considerations
term that will be used in this Practice Bulletin. and Recommendations
Incidence < What findings can be used to confirm a diagnosis of
Early pregnancy loss is common, occurring in 10% of all early pregnancy loss?
clinically recognized pregnancies (2–4). Approximately
Common symptoms of early pregnancy loss, such as
80% of all cases of pregnancy loss occur within the first
vaginal bleeding and uterine cramping, also are common
trimester (2, 3).
in normal gestation, ectopic pregnancy, and molar preg-
nancy. Before initiating treatment, it is important to
Etiology and Risk Factors distinguish early pregnancy loss from other early pregnancy
Approximately 50% of all cases of early pregnancy loss complications. Treatment of an early pregnancy loss before
are due to fetal chromosomal abnormalities (5, 6). The confirmed diagnosis can have detrimental consequences,
most common risk factors identified among women who including interruption of a normal pregnancy, pregnancy
have experienced early pregnancy loss are advanced complications, or birth defects (9). Therefore, a thorough

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evaluation is needed to make a definitive diagnosis. In are considerably more conservative than past recommen-
combination with a thorough medical history and physical dations and also have stricter cutoffs than the studies on
examination, ultrasonography and serum b-hCG testing which they are based (14) (Table 1). The authors of the
can be helpful in making a highly certain diagnosis. guidelines report that the stricter cutoffs are needed to
Ultrasonography, if available, is the preferred modality account for interobserver variability; however, this
to verify the presence of a viable intrauterine gestation. In already was accounted for in the original study through
some instances, making a diagnosis of early pregnancy loss its use of multiple ultrasonographers (12, 15). Other
is fairly straightforward and requires limited testing or important limitations in the development of these guide-
imaging. For example, early pregnancy loss can be lines should be recognized. For example, there were few
diagnosed with certainty in a woman with an ultrasound- cases at or near the measurements ultimately identified as
documented intrauterine pregnancy who subsequently decision boundaries. Similarly, the time between observ-
presents with reported significant vaginal bleeding and an ing a gestational sac and expecting to see a yolk sac or
empty uterus on ultrasound examination. In other instances, embryo was increased from 7 days or more in the clinical
the diagnosis of early pregnancy loss is not as clear. study (13) to 14 days in the guidelines (14). The basis of
Depending on the specific clinical circumstances and how this recommendation is unclear.
much diagnostic certainty the patient desires, a single serum Obstetrician–gynecologists caring for women expe-
b-hCG test or ultrasound examination may not be sufficient riencing possible early pregnancy loss should consider
to confirm the diagnosis of early pregnancy loss. other clinical factors when interpreting the Society of
The use of ultrasound criteria to confirm the diagnosis Radiologists in Ultrasound guidelines, including the
of early pregnancy loss was initially reported in the early woman’s desire to continue the pregnancy; her willingness
1990s, shortly after vaginal ultrasonography became widely to postpone intervention to achieve 100% certainty of
available. Based on these early studies, a crown–rump pregnancy loss; and the potential consequences of waiting
length (CRL) of 5 mm without cardiac activity or an empty for intervention, including unwanted spontaneous passage
gestational sac measuring 16 mm in mean gestational sac of pregnancy tissue, the need for an unscheduled visit or
diameter have been used as diagnostic criteria to confirm procedure, and patient anxiety. It is important to include
early pregnancy loss (10, 11). Recently, two large pro- the patient in the diagnostic process and to individualize
spective studies have been used to challenge these cutoffs. these guidelines to patient circumstances.
In the first study, 1,060 women with intrauterine pregnan- Criteria that are considered suggestive, but not
cies of uncertain viability were followed up to weeks 11–14 diagnostic, of early pregnancy loss are listed in Table 1
of gestation (12). In this group of women, 55.4% received (14). Slow fetal heart rate (less than 100 beats per minute
a diagnosis of nonviable gestation during the observation at 5–7 weeks of gestation) (16) and subchorionic hemor-
period. A CRL cutoff of 5 mm was associated with an 8.3% rhage also have been shown to be associated with early
false-positive rate for early pregnancy loss. A CRL cutoff of pregnancy loss but should not be used to make a defini-
5.3 mm was required to achieve a false-positive rate of 0% tive diagnosis (17). These findings warrant further eval-
in this study (12). Similarly, the authors reported a 4.4% uation in 7–10 days (14).
false-positive rate for early pregnancy loss when using In cases in which an intrauterine gestation cannot be
a mean gestational sac diameter cutoff of 16 mm. A mean identified with reasonable certainty, serial serum b-hCG
gestational sac diameter cutoff of 21 mm (without an measurements and ultrasound examinations may be
embryo and with or without a yolk sac) on the first ultra- required before treatment to rule out the possibility of
sound examination was required to achieve 100% specific- an ectopic pregnancy. A detailed description of the rec-
ity for early pregnancy loss. In a second study of 359 ommended approach to ectopic pregnancy diagnosis and
women from the first study group, the authors concluded management is available in Practice Bulletin Number
that growth rates for the gestational sac (mean gestational 193, Tubal Ectopic Pregnancy (18).
sac diameter) and the embryo (CRL) could not predict
viability accurately (13). However, the authors concluded
< What are the management options for early preg-
nancy loss?
that if a gestational sac was empty on initial scan, the
absence of a visible yolk sac or embryo on a second scan Accepted treatment options for early pregnancy loss
performed 7 days or more after the first scan was always include expectant management, medical treatment, or
associated with pregnancy loss (13). surgical evacuation. Although these options differ
Based on these studies, the Society of Radiologists significantly in process, all have been shown to be
in Ultrasound Multispecialty Panel on Early First Tri- reasonably effective and accepted by patients. In
mester Diagnosis of Miscarriage and Exclusion of women without medical complications or symptoms
a Viable Intrauterine Pregnancy created guidelines that requiring urgent surgical evacuation, treatment plans

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Table 1. Guidelines for Transvaginal Ultrasonographic Diagnosis of Pregnancy Failure in
a Woman With an Intrauterine Pregnancy of Uncertain Viability*

Findings Suspicious for, but Not Diagnostic of,

Findings Diagnostic of Pregnancy Failure Pregnancy Failurey

Crown–rump length of 7 mm or greater and no heartbeat Crown–rump length of less than 7 mm and no heartbeat
Mean sac diameter of 25 mm or greater and no embryo Mean sac diameter of 16–24 mm and no embryo
Absence of embryo with heartbeat 2 weeks or more after Absence of embryo with heartbeat 7–13 days after a scan
a scan that showed a gestational sac without a yolk sac that showed a gestational sac without a yolk sac
Absence of embryo with heartbeat 11 days or more after Absence of embryo with heartbeat 7–10 days after a scan
a scan that showed a gestational sac with a yolk sac that showed a gestational sac with a yolk sac
Absence of embryo for 6 weeks or longer after last
menstrual period
Empty amnion (amnion seen adjacent to yolk sac, with no
visible embryo)
Enlarged yolk sac (greater than 7 mm)
Small gestational sac in relation to the size of the embryo
(less than 5 mm difference between mean sac diameter
and crown–rump length)
*Criteria are from the Society of Radiologists in Ultrasound Multispecialty Consensus Conference on Early First Trimester
Diagnosis of Miscarriage and Exclusion of a Viable Intrauterine Pregnancy, October 2012.
†
When there are findings suspicious for pregnancy failure, follow-up ultrasonography at 7–10 days to assess the pregnancy for
viability is generally appropriate.
Reprinted from Doubilet PM, Benson CB, Bourne T, Blaivas M, Barnhart KT, Benacerraf BR, et al. Diagnostic criteria for nonviable
pregnancy early in the first trimester. Society of Radiologists in Ultrasound Multispecialty Panel on Early First Trimester Diagnosis
of Miscarriage and Exclusion of a Viable Intrauterine Pregnancy. N Engl J Med 2013;369:1443–51.

can safely accommodate patient treatment preferences. Patients undergoing expectant management may
There is no evidence that any approach results in experience moderate-to-heavy bleeding and cramping.
different long-term outcomes. Patients should be Educational materials instructing the patient on when and
counseled about the risks and benefits of each option. who to call for excessive bleeding and prescriptions for
The following discussion applies to symptomatic and pain medications should be provided. It also is important
asymptomatic patients. to counsel patients that surgery may be needed if
complete expulsion is not achieved. Studies among
Expectant Management women with early pregnancy loss typically have used
Because of a lack of safety studies of expectant ultrasound criteria, patient-reported symptoms, or both,
management in the second trimester and concerns about to confirm complete passage of gestational tissue.
hemorrhage, expectant management generally should be Although there is no consensus in the literature, a com-
limited to gestations within the first trimester. With monly used criterion for complete expulsion of preg-
adequate time (up to 8 weeks), expectant management nancy tissue is the absence of a gestational sac and an
is successful in achieving complete expulsion in approx- endometrial thickness of less than 30 mm (23). However,
imately 80% of women (19). Limited data suggest that there is no evidence that morbidity is increased in asymp-
expectant management may be more effective in symp- tomatic women with a thicker endometrial measurement
tomatic women (those who report tissue passage or have (24). Surgical intervention is not required in asymptom-
ultrasound findings consistent with incomplete expul- atic women with a thickened endometrial stripe after
sion) than in asymptomatic women (20, 21). Further- treatment for early pregnancy loss. Thus, the use of ultra-
more, studies that included women with incomplete sound examination for any diagnostic purpose other than
early pregnancy loss tend to report higher success rates documenting the absence of the gestational sac is not
than those that included only women with missed or recommended. Other follow-up approaches, such as stan-
anembryonic pregnancy loss (22). dardized follow-up phone calls, urine pregnancy tests, or

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serial quantitative serum b-hCG measurements, may be
useful, especially for women with limited access to Box 1. Protocol for the Medical
follow-up ultrasound examination (25). However, these Management of Early Pregnancy Loss
approaches have not been studied sufficiently among
women with early pregnancy loss to provide meaningful
guidance. c Misoprostol 800 micrograms vaginally, with one
repeat dose as needed, no earlier than 3 hours
Medical Management after the first dose and typically within 7 days if
Medical management for early pregnancy loss can be there is no response to the first dose*
considered in women without infection, hemorrhage, c A dose of mifepristone (200 mg orally) 24 hours
severe anemia, or bleeding disorders who want to shorten before misoprostol administration should be
considered when mifepristone is available.†
the time to complete expulsion but prefer to avoid surgi-
cal evacuation. Compared with expectant management, c Prescriptions for pain medications should be
provided to the patient.
medical management of early pregnancy loss decreases
c Women who are Rh(D) negative and unsensitized
the time to expulsion and increases the rate of complete should receive Rh(D)-immune globulin within 72
expulsion without the need for surgical intervention (26). hours of the first misoprostol administration.
Misoprostol-based regimens have been extensively c Follow-up to document the complete passage of
studied for the medical management of early pregnancy tissue can be accomplished by ultrasound exam-
loss (26). Most studies suggest that a larger dose of mi- ination, typically within 7–14 days. Serial serum
soprostol is more effective than a smaller dose, and vag- b-hCG measurements may be used instead in
inal or sublingual administration is more effective than settings where ultrasonography is unavailable.
Patient-reported symptoms also should be con-
oral administration, although the sublingual route is asso- sidered when determining whether complete
ciated with more cases of diarrhea (26). The largest ran- expulsion has occurred.
domized controlled trial conducted in the United States c If medical management fails, the patient may opt
demonstrated complete expulsion by day 3 in 71% of for expectant management, for a time deter-
women with first-trimester pregnancy loss after one dose mined by the woman and her obstetrician–
of 800 micrograms of vaginal misoprostol (23). The suc- gynecologist or other gynecologic provider, or
suction curettage.
cess rate was increased to 84% after a second dose of 800
micrograms of vaginal misoprostol was administered if *Zhang J, Gilles JM, Barnhart K, Creinin MD, Westhoff C,
needed. Therefore, in patients for whom medical man- Frederick MM. A comparison of medical management with
misoprostol and surgical management for early pregnancy
agement of early pregnancy loss is indicated, initial treat- failure. National Institute of Child Health Human
ment using 800 micrograms of vaginal misoprostol is Development (NICHD) Management of Early Pregnancy
recommended, with a repeat dose as needed (Box 1). Failure Trial. N Engl J Med 2005;353:761–9.
†SchreiberCA, Creinin MD, Atrio J, Sonalkar S, Ratcliffe SJ,
The addition of a dose of mifepristone (200 mg
Barnhart KT. Mifepristone pretreatment for the medical
orally) 24 hours before misoprostol administration may management of early pregnancy loss. N Engl J Med
significantly improve treatment efficacy and should be 2018;378:2161–70.
considered when mifepristone is available (Box 1).
Although initial studies were unclear about the benefit
of mifepristone for the management of early pregnancy 0.21–0.68). Reports of bleeding intensity and pain as
loss (27), a 2018 randomized controlled trial showed that well as other adverse effects were generally similar for
a combined mifepristone–misoprostol regimen was the two treatment groups, and the occurrence of serious
superior to misoprostol alone for the management of adverse events was rare among all participants. These
early pregnancy loss (28). Among 300 women under- results are consistent with the demonstrated efficacy and
going medical management for early pregnancy loss, safety of the mifepristone–misoprostol combined regi-
those who received mifepristone (200 mg orally) fol- men for medication-induced abortion (29, 30). Currently,
lowed by misoprostol (800 micrograms vaginally) 24 the availability of mifepristone is limited by U.S. Food
hours later had significantly increased rates of complete and Drug Administration Risk Evaluation and Mitigation
expulsion (relative risk [RR], 1.25; 95% CI, 1.09–1.43) Strategy restrictions (31). The American College of Ob-
compared with women who received misoprostol alone stetricians and Gynecologists supports improving access
(800 micrograms vaginally) (28). The mifepristone– to mifepristone for reproductive health indications (32).
misoprostol regimen also was associated with A 2013 Cochrane review of limited evidence
a decreased risk of surgical intervention with uterine concluded that among women with incomplete preg-
aspiration to complete treatment (RR, 0.37; 95% CI, nancy loss (ie, incomplete tissue passage), the addition of

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misoprostol does not clearly result in higher rates of formed in an office setting with an electric vacuum
complete evacuation when compared with expectant source or manual vacuum aspirator, under local anes-
management (at 7–10 days, success rates were 80–81% thesia with or without the addition of sedation (37, 38).
versus 52–85%, respectively) (33). Therefore, at this Surgical management in the office setting offers sig-
time, there is insufficient evidence to support or refute nificant cost savings compared with the same pro-
the use of misoprostol among women with incomplete cedure performed in the operating room (38–40).
pregnancy loss. Patients often choose management in the office setting
As with expectant management of early pregnancy for its convenience and scheduling availability (38).
loss, women opting for medical treatment should be
counseled on what to expect while they pass pregnancy < How do the different management options for
tissue, provided information on when to call regarding early pregnancy loss compare in effectiveness
bleeding, and given prescriptions for pain medications. and risk of complications?
Counseling should emphasize that the woman is likely to
Studies have demonstrated that expectant, medical, and
have bleeding that is heavier than menses (and poten-
surgical management of early pregnancy loss all result in
tially accompanied by severe cramping). The woman
complete evacuation of pregnancy tissue in most patients,
should understand how much bleeding is considered too
much. An easy reference for the patient to use is the and serious complications are rare. As a primary
soaking of two maxi pads per hour for 2 consecutive approach, surgical evacuation results in faster and more
hours (34). The patient should be advised to call her predictable complete evacuation (22). The success of
obstetrician–gynecologist or other gynecologic provider surgical uterine evacuation of early pregnancy loss ap-
if she experiences this level of bleeding. As with proaches 99% (23). The largest U.S. trial reported that
expectant management, it also is important to counsel success rates after medical management of anembryonic
patients that surgery may be needed if medical manage- gestations (81%) was lower than with embryonic or fetal
ment does not achieve complete expulsion. death (88%) or incomplete or inevitable early pregnancy
Follow-up typically includes confirmation of com- loss (93%) (23). However, a subsequent multivariable
plete expulsion by ultrasound examination, but serial analysis of the same data revealed that only active bleed-
serum b-hCG measurement may be used instead in set- ing and nulliparity were strong predictors of success (41).
tings where ultrasonography is unavailable. Patient-
Therefore, medical management is a reasonable option
reported symptoms also should be considered when
for any pregnancy failure type.
determining whether complete expulsion has occurred.
Overall, serious complications after early preg-
Surgical Management nancy loss treatment are rare and are comparable
across treatment types. Clinically important intrauter-
Surgical uterine evacuation has long been the traditional
approach for women presenting with early pregnancy ine adhesion formation is a rare complication after
loss and retained tissue. Women who present with surgical evacuation. Hemorrhage and infection can
hemorrhage, hemodynamic instability, or signs of infec- occur with all of the treatment approaches. In the
tion should be treated urgently with surgical uterine Management of Early Pregnancy Failure Trial, women
evacuation. Surgical evacuation also might be preferable randomized to the misoprostol group were signifi-
in other situations, including the presence of medical cantly more likely to have a decrease in their hemo-
comorbidities such as severe anemia, bleeding disorders, globin levels greater than or equal to 3 g/dL than
or cardiovascular disease. Many women prefer surgical women in the vacuum aspiration group (23, 42). How-
evacuation to expectant or medical treatment because it ever, rates of hemorrhage-related hospitalization with
provides more immediate completion of the process with or without transfusion are similar between treatment
less follow-up. approaches (0.5–1%) (23, 43). Pelvic infection also
In the past, uterine evacuation often was per- can occur after any type of early pregnancy loss treat-
formed with sharp curettage alone. However, studies ment. One systematic review concluded that although
show that the use of suction curettage is superior to the infection rates appeared lower among those undergo-
use of sharp curettage alone (35, 36). Furthermore, the ing expectant management than among those undergo-
routine use of sharp curettage along with suction curet- ing surgical evacuation (RR, 0.29; 95% CI, 0.09–
tage in the first trimester does not provide any addi- 0.97), the overall rates of infection were low (1–2%)
tional benefit as long as the obstetrician–gynecologist (43). Because neither approach was clearly superior,
or other gynecologic provider is confident that the the reviewers concluded that patient preference should
uterus is empty. Suction curettage also can be per- guide choice of intervention (43).

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 The risk of infection after suction curettage for tions. Small observational studies show no benefit to
missed early pregnancy loss should be similar to that delayed conception after early pregnancy loss (51, 52).
after suction curettage for induced abortion. Therefore, Abstaining from vaginal intercourse for 1–2 weeks
despite the lack of data, antibiotic prophylaxis also after complete passage of pregnancy tissue generally
should be considered for patients with early pregnancy is recommended to reduce the risk of infection, but
loss (44, 45). The use of a single preoperative dose of this is not an evidence-based recommendation.
doxycycline is recommended to prevent infection after
surgical management of early pregnancy loss. Some ex- < How should patients be counseled regarding
perts have recommended administration of a single 200- the use of contraception after early preg-
mg dose of doxycycline 1 hour before surgical manage- nancy loss?
ment of early pregnancy loss to prevent postoperative
infection. The use of antibiotics based only on the diag- Women who desire contraception may initiate hormonal
nosis of incomplete early pregnancy loss has not been contraception use immediately after completion of early
found to reduce infectious complications as long as pregnancy loss (53). There are no contraindications to the
unsafe induced abortion is not suspected (46). The ben- placement of an intrauterine device immediately after sur-
efit of antibiotic prophylaxis for the medical management gical treatment of early pregnancy loss as long as septic
of early pregnancy loss is unknown. abortion is not suspected (53). The expulsion rate with
immediate intrauterine device insertion after suction curet-
< How do the different treatment approaches to tage in the first trimester is not clinically significantly dif-
early pregnancy loss differ with respect to cost?
ferent than placement 2–6 weeks postoperatively (5%
Studies have consistently shown that surgical man- versus 2.7% at 6 months) (54).
agement in an operating room is more costly than
expectant or medical management (47, 48). However, < How should patients be counseled regarding
surgical management in an office setting can be more prevention of alloimmunization after early
effective and less costly than medical management pregnancy loss?
when performed without general anesthesia and in Although the risk of alloimmunization is low, the
circumstances in which numerous office visits are consequences can be significant, and administration
likely or there is a low chance of success with medical of Rh D immune globulin should be considered in
management or expectant management (49). Findings cases of early pregnancy loss, especially those that
from studies comparing the cost-effectiveness of are later in the first trimester. If given, a dose of at
medical and expectant management schemes are least 50 micrograms should be administered. Because
inconsistent. However, a U.S. analysis of all three of the higher risk of alloimmunization, Rh D-negative
management approaches concluded that medical man- women who have surgical management of early preg-
agement with misoprostol was the most cost-effective nancy loss should receive Rh D immune globulin pro-
intervention (48). One limitation of the available phylaxis (55).
studies on cost of early pregnancy loss care is that
none of these studies can adequately consider clinical < What type of workup is needed after early
nuances or patient treatment preferences, which can pregnancy loss?
affect patient adherence to the primary treatment reg-
imen and, subsequently, the effectiveness of that No workup generally is recommended until after the
treatment. For instance, in one observational study, second consecutive clinical early pregnancy loss (7).
the effectiveness of medical management of early Maternal or fetal chromosomal analyses or testing for
pregnancy loss was far lower than rates reported in inherited thrombophilias are not recommended rou-
randomized clinical trials, which was due in large part tinely after one early pregnancy loss. Although throm-
to patients’ unwillingness to complete the treatment bophilias commonly are thought of as causes of early
regimen (50). pregnancy loss, only antiphospholipid syndrome con-
sistently has been shown to be significantly associated
< How should patients be counseled regarding in- with early pregnancy loss (56, 57). In addition, the use
terpregnancy interval after early pregnancy loss?
of anticoagulants, aspirin, or both, has not been shown
There are no quality data to support delaying concep- to reduce the risk of early pregnancy loss in women
tion after early pregnancy loss to prevent subsequent with thrombophilias except in women with antiphos-
early pregnancy loss or other pregnancy complica- pholipid syndrome (58, 59).

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< Are there any effective interventions to prevent The following recommendations are based primarily on
early pregnancy loss? consensus and expert opinion (Level C):

There are no effective interventions to prevent early < Accepted treatment options for early pregnancy loss
pregnancy loss. Therapies that have historically been include expectant management, medical treatment, or
recommended, such as pelvic rest, vitamins, uterine surgical evacuation. In women without medical com-
relaxants, and administration of b-hCG, have not been plications or symptoms requiring urgent surgical
proved to prevent early pregnancy loss (60–62). Like- evacuation, treatment plans can safely accommodate
wise, bed rest should not be recommended for the patient treatment preferences.
prevention of early pregnancy loss (63). A 2008 Co- < The use of a single preoperative dose of doxycycline
chrane review found no effect of prophylactic proges- is recommended to prevent infection after surgical
terone administration (oral, intramuscular, or vaginal) management of early pregnancy loss.
in the prevention of early pregnancy loss (64). For < Although the risk of alloimmunization is low, the
threatened early pregnancy loss, the use of progestins consequences can be significant, and administration
is controversial, and conclusive evidence supporting of Rh D immune globulin should be considered in
their use is lacking (65). Women who have experi- cases of early pregnancy loss, especially those that
enced at least three prior pregnancy losses, however, are later in the first trimester.
may benefit from progesterone therapy in the first tri- < Because of the higher risk of alloimmunization, Rh
D-negative women who have surgical management
mester (7).
of early pregnancy loss should receive Rh D immune
globulin prophylaxis.
Summary of
Recommendations References
and Conclusions 1. National Institute for Health and Clinical Excellence. Ectopic
pregnancy and miscarriage: diagnosis and initial manage-
The following recommendation and conclusion are based ment in early pregnancy of ectopic pregnancy and miscar-
on good and consistent scientific evidence (Level A): riage. NICE Clinical Guideline 154. Manchester (UK):
NICE; 2012. Available at: http://www.nice.org.uk/guidance/
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pregnancy loss is indicated, initial treatment using pdf. Retrieved January 20, 2015. (Level III)
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pregnancy. N Engl J Med 1988;319:189–94. (Level II-3)
a dose of mifepristone (200 mg orally) 24 hours
before misoprostol administration may significantly 3. Wang X, Chen C, Wang L, Chen D, Guang W, French J.
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nancy: a population-based prospective study. Fertil Steril
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< The use of anticoagulants, aspirin, or both, has not
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SG. Estimates of human fertility and pregnancy loss. Fertil
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5. Stephenson MD, Awartani KA, Robinson WP. Cytogenetic
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or inconsistent scientific evidence (Level B): carriage: a case-control study. Hum Reprod 2002;17:446–
51. (Level II-2)
< Ultrasonography, if available, is the preferred modality 6. Alijotas-Reig J, Garrido-Gimenez C. Current concepts and
to verify the presence of a viable intrauterine gestation. new trends in the diagnosis and management of recurrent
< Surgical intervention is not required in asymptomatic miscarriage. Obstet Gynecol Surv 2013;68:445–66. (Level III)
women with a thickened endometrial stripe after treat-
7. Evaluation and treatment of recurrent pregnancy loss:
ment for early pregnancy loss. a committee opinion. Practice Committee of the American
< The routine use of sharp curettage along with suction Society for Reproductive Medicine. Fertil Steril 2012;98:
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additional benefit as long as the obstetrician– 8. Nybo Andersen AM, Wohlfahrt J, Christens P, Olsen J,
gynecologist or other gynecologic provider is confi- Melbye M. Maternal age and fetal loss: population based
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