Early miscarriage treatment: 3 options

Early miscarriage (early pregnancy loss or spontaneous miscarriage) is defined as a the loss of an intrauterine pregnancy within the first 12 6/7 weeks of pregnancy. It is usually diagnosed with ultrasound (either an empty gestational sac or a gestational sac containing an embryo or fetus without fetal heart activity).

When early pregnancy loss occurs, patients are usually eager to know why it happened and what the prognosis is for future pregnancies. But first, it's important to take the right steps to treat to the early miscarriage itself.

What are the treatment options?

The accepted treatment options for early pregnancy loss include:

• Expectant management
• Medical treatment or
• Surgical evacuation

All three options are reasonably effective. Patients should be counseled about the advantages and disadvantages of each of these options.

Expectant management

Expectant management is also known as "watchful waiting." 80% of women will miscarry spontaneously within 8 weeks of receiving a diagnosis of early pregnancy loss. The chances are greater in patients who have already started passing tissue (or ultrasound findings showing incomplete expulsion) when they have been diagnosed.

Patients being managed expectantly may experience moderate-to-heavy bleeding and cramping. They should be counseled that they might need surgery if complete expulsion (ultrasound showing absence of a gestational sac with the uterine lining thickness of less than 30 mm) is not achieved.

Medical management

The drug that is commonly used for medical management of early pregnancy loss is Misoprostol (Cytotec) a prostaglandin E1 analogue. Cytotec will shorten the time to complete expulsion and at the same time it will make it possible to avoid surgery. Cytotec is not recommended in patients with infection, bleeding, severe anemia or bleeding disorders. It should also be avoided in patients allergic to the medication.

The recommended initial dose of of Cytotec is 800 micrograms vaginally. One repeat dose may be used as needed, no earlier than 3 hours after the first dose and typically within 7 days if there is no response to the first dose.

71% of women will miscarry within 3 days of the first dose of Cytotec. The success rate increases to 84% when the second dose was administered if needed.

Patients should be counseled that they will experience bleeding heavier than menses (can be accompanied by severe cramping). Patients should contact the doctor if there is heavy bleeding (more than the soaking of two maxi pads per hour for two consecutive hours). Surgery may be needed if medical management does not achieve complete expulsion.

Follow up to document complete expulsion includes ultrasound examination within a week or two. Serial hCG levels and patient symptoms can also be used to assess for complete expulsion.

Women who are Rh(D) negative and unsensitized should receive Rh(D)-immune globulin within 72 hours of the first misoprostol administration.

Surgical management

Surgical uterine evacuation has long been the traditional approach for women presenting with early pregnancy loss and retained tissue. This is the preferred route in patients that are bleeding heavily, have lost a lot of blood or those with signs of infection. It is also preferred in patients with severe anemia, bleeding disorders or heart disease. It has the advantage of more immediate completion of the process with fewer follow-ups. At InVia, we will recommend this route to patients where we would like to send the tissue for chromosomal evaluation.

Using a suction curette is preferred to using a sharp curette. Possible complications of surgery include making a hole in the uterus (perforation), infection, bleeding, risk of anesthesia and scar tissue formation. A single dose of an antibiotic (e.g. Doxycycline, Ancef) can be used to prevent infection.

Which is the best treatment option?

All three approaches work and serious complications are rare. Surgery has the highest success rate (99%).

Can early pregnancy loss be prevented?

Unfortunately, there are no effective interventions to prevent early pregnancy loss. Treatments that have historically been recommended include pelvic rest, vitamins, uterine relaxants and booster hCG shots. Bed rest should not be recommended for the prevention of early pregnancy loss. The use of progesterone is controversial. Women with a history of recurrent pregnancy loss may benefit from progesterone therapy in the first trimester.

To see a fertility specialist with a strong success rate diagnosing and treating fertility issues, make an appointment at one of InVia's four Chicago area fertility clinics.