Early Pregnancy Loss

Managing, Counseling, and Diagnosis

Research shows that people have strong and diverse preferences for how their miscarriage is managed. Patients report higher satisfaction when offered all management options and are treated according to their personal priorities and preferences.

Early pregnancy loss is designed to teach clinical learners to recognize people have strong and diverse preferences for how their miscarriage is managed. Patients report higher satisfaction when offered all management options and are treated according to their personal priorities and preferences.  Thus, learners will consider how to provide patient-centered pregnancy loss care to meet the individual needs of patients regardless of provider preferences.

Course Development

Led by Robin Wallace, MD, MPH (she/her)  Early Pregnancy Loss is a result of transdisciplinary research supported by The Bixby Center for Global Reproductive Health and curriculum development support from the staff of Innovating Education in Reproductive Health.

If you would like to be able to assign this content to learners and track their progress, you can request a login for RHEcourse, our free online platform for SRH education, which offers additional features for users who want to engage more deeply. If you are a learner who would like to enroll in these courses for self-paced learning, you can request a RHEcourse login for self-paced learning.

IERH acknowledges the importance of inclusive language as a component of patient-centered care and we are working to improve our content. Read more here.

Learning Objectives

Learning Objectives

The following videos include didactic narratives, provider testimonials, and live video and animation demonstrating a step-by-step method for surgical early pregnancy loss management.

After watching these video lectures, learners will:

  • Evaluate and diagnose abnormal pregnancy (anembryonic gestation, embryonic demise, fetal demise, incomplete miscarriage, ectopic pregnancy)
  • Understand the safety and efficacy of treatment options for EPL
  • Counsel patients about management options of EPL: expectant care, medication management, and uterine aspiration
  • Counsel patients about management options for second-trimester fetal demise: induction vs. D&E

Module 1: Evaluation, Diagnosis, and Counseling

Early Pregnancy Loss – Evaluation and Diagnosis

Presented by Robin Wallace, MD, MAS
Planned Parenthood South Atlantic

Citations for this course are available on the course page.

Counseling and Decision-making for EPL Management

Presented by Robin Wallace, MD, MAS
Planned Parenthood South Atlantic

Citations for this course are available on the course page.

Module 2: Management of Early Pregnancy Loss

Overview of EPL Management Options

Presented by Robin Wallace, MD, MAS
Planned Parenthood South Atlantic

Citations for this course are available on the course page.

Early Pregnancy Loss – Medication Management

Presented by Robin Wallace, MD, MAS
Planned Parenthood South Atlantic

Citations for this course are available on the course page.

Please review the ACOG Practice Advisory for Updated Mifepristone REMS Requirements.

 

Early Pregnancy Loss – At-home Care Principles

Presented by Robin Wallace, MD, MAS
Planned Parenthood South Atlantic

Citations for this course are available on the course page.

Uterine Aspiration Procedure for EPL

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Supplemental Videos

Second Trimester Pregnancy Loss

Presented by Robin Wallace, MD, MAS
Planned Parenthood South Atlantic

Citations for this course are available on the course page.

Practice Integration of EPL Management Services

Hear from real providers about how they integrated Early Pregnancy Loss services into their routine practice. Suggestions for implementation and evaluation of new services are presented.

 

EPL Management in Low Resource Settings

Low resource settings present unique challenges to the evaluation, diagnosis and management of EPL. Using Mulago Hospital in Uganda as one example, adaptations and alterations of clinical protocols are reviewed.

Addtional Resources

Counseling Decision Tool

Experiencing a miscarriage can be extremely difficult for many patients. This Counseling Decision Tool is intended to help the patient and provider choose a treatment that best fits the patient’s priorities and preferences.

Training, Education and Advocacy in Miscarriage Management (TEAMM)

TEAMM trains providers and support staff to integrate comprehensive early pregnancy loss care into their office-based and emergency medicine settings.

Reproductive Health Access Project

Miscarriage Care Resources:  offers clinical guidance and protocols for primary care providers to offer patient-centered EPL care. They also have a library of patient education materials in several languages.

Miscarriage Care Initiative

The Miscarriage Care Initiative is an effort by the Reproductive Health Access Project (RHAP) to expand access to evidence-based, patient-centered miscarriage care in primary care settings. Our vision is to support family physicians and clinic administrators to integrate all three forms of miscarriage management—expectant, medication, and manual vacuum aspiration (MVA) management—into their clinical practice.

Citations

American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins—Gynecology. ACOG Practice Bulletin No. 200: Early Pregnancy Loss. Obstet Gynecol. 2018;132(5):e197-e207. doi:10.1097/AOG.0000000000002899

American College of Obstetricians and Gynecologists. Improving access to mifepristone for reproductive health indications. Position Statement. Washington, DC: American College of Obstetricians and Gynecologists; 2018. (Level III)

Consensus Statement: Instructions for Us–Misoprostol for Treatment of Incomplete Abortion and Miscarriage. Expert Meeting on Misoprostol sponsored by Reproductive Health Technologies Project and Gynuity Health Projects. June 9, 2004. New York, NY.

Dzuba IG, Castillo PW, Bousiéguez M, Margarita Lugo Hernández E, Juan Castañeda Vivar J, Sanhueza Smith P. A repeat dose of misoprostol 800mcg following mifepristone for outpatient medical abortion at 64-70 and 71-77 days of gestation: A retrospective chart review [published online ahead of print, 2020 May 28]. Contraception. 2020;S0010-7824(20)30160-8.

Flink-Bochacki R, Hamm ME, Borrero S, Chen BA, Achilles SL, Chang JC. Family Planning and Counseling Desires of Women Who Have Experienced Miscarriage. Obstet Gynecol. 2018;131(4):625-631. doi:10.1097/AOG.0000000000002520

Flynn AN, Roe AH, Koelper N, McAllister A, Sammel MD, Schreiber CA. Timing and efficacy of mifepristone pretreatment for medical management of early pregnancy loss. Contraception. 2021;103(6):404-407. doi:10.1016/j.contraception.2021.01.007

Henkel A, Shaw KA. Advances in the management of early pregnancy loss. Curr Opin Obstet Gynecol. 2018;30(6):419-424. doi:10.1097/GCO.0000000000000501

Mark A, Foster AM, Grossman D, Prager SW, Reeves M, Velásquez CV, et al. Foregoing Rh testing and anti-D immunoglobulin for women presenting for early abortion: a recommendation from the National Abortion Federation’s Clinical Policies Committee. Contraception. 2019;99(5):265-66].

Nagendra D, Koelper N, Loza-Avalos SE, et al. Cost-effectiveness of Mifepristone Pretreatment for the Medical Management of Nonviable Early Pregnancy: Secondary Analysis of a Randomized Clinical Trial. JAMA Netw Open. 2020;3(3):e201594. doi:10.1001/jamanetworkopen.2020.1594

The Practice Committee of the American Society for Reproductive Medicine. Evaluation and treatment of recurrent pregnancy loss: a committee opinion. Fertil Steril 2012;98:1103–11.

Roe AH, McAllister A, Sammel MD, Schreiber CA. Pregnancy intentions and contraceptive uptake after miscarriage. Contraception. 2020;101(6):427-431. doi:10.1016/j.contraception.2020.03.002

Schreiber CA, Creinin MD, Atrio J, Sonalkar S, Ratcliffe SJ, Barnhart KT. Mifepristone pretreatment for the medical management of early pregnancy loss. N Engl J Med 2018; 378:2161–70. (Level I)

Shorter JM, Atrio JM, Schreiber CA. Management of early pregnancy loss, with a focus on patient centered care. Semin Perinatol. 2019;43(2):84-94. doi:10.1053/j.semperi.2018.12.005

Wallace R, DiLaura A, Dehlendorf C. “ ‘Every person’s just different’: Women’s Experiences with Counseling for Early Pregnancy Loss Management.” Women’s Health Issues, 2017; 27-4: 456-462.

Wiebe E, Campbell M, Aiken A, Albert A. Can we safely stop testing for rh status and immunizing rh-negative women having early abortions? A comparison of Rh alloimmunization in Canada and the Netherlands. Contraception: X. 2019;100001;

Zhang J, Gilles JM, Barnhart K, Creinin MD, Westhoff C, Frederick MM. A comparison of medical management with misoprostol and surgical management for early pregnancy failure. National Institute of Child Health Human Development (NICHD) Management of Early Pregnancy Failure Trial. N Engl J Med 2005;353:761–9.