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Recognizing and Responding to Signs of Miscarriage
Early miscarriage is common, the most common complication in pregnancy. How do we think about our options to manage this?
About one million American women experience early pregnancy failure each year. This is the loss of a pregnancy in the first 12 weeks. Before the common use of early pregnancy tests and ultrasounds, women often didn't even know they were pregnant for several months. Now, women know that they're pregnant if they want to within two weeks after fertilization, and an ultrasound of five to six weeks from the last menstrual period, four weeks after fertilization can show early fetal development and whether the pregnancy is developing as it should.
As many as 60% of eggs that are fertilized don't lead to live births. Most of those aren't even recognized as a pregnancy. But for women who've had a positive pregnancy test, 15% to 25% of those pregnancies will not proceed past the first trimester, the first 12 weeks.
Early pregnancy loss is common, and it may be recognized as cramping and bleeding early in pregnancy, signs that the pregnancy is probably going to end in a spontaneous abortion without any medical intervention.
The Role of Ultrasound in Detecting Pregnancy Failure
All over the world women miscarry early, and most do not get or need medical intervention. However, with the use of early ultrasound at six weeks from the last menstrual period, we can see if the pregnancy is going to fail. If there's a sac without a heartbeat or a fetus, or if there's a tiny area that might have been an early fetus that doesn't have a heartbeat, that pregnancy will probably miscarry. However, it may take weeks to months for that to happen on its own.
Some women are willing to wait for nature to take its course -- have their miscarriage, pass their tissue, or may just be heavy bleeding. They won't really see a fetus because one hasn't developed. But some women want to get on with their reproductive lives, and end this pregnancy so they can start again if they want to.
In the U.S. in past years, women who had access to early pregnancy care and found that they didn't have a heartbeat were recommended to have a D&C. This is a procedure in the operating room with anesthesia. The cervix is stretched open with a dilator, and a tube is passed into the uterus to aspirate the sac and the early placenta. This is expensive -- it can cost thousands of dollars -- and time-consuming.
Techniques that have evolved over the last 20 years include using a syringe with a suction device and a little tube to remove the failed pregnancy, and this can be done in about five minutes in the office under local anesthesia. Many physicians are familiar and comfortable with this option, and they counsel this option for the patient. But many are not and are most likely to counsel going to the operating room.
Medication Options for Managing Early Pregnancy Loss
Over the past 15 years, medications have been studied that can cause the uterus to cramp and push out the pregnancy. One of these medications, Misoprostol is widely available and has been used especially in women who've already started to cramp and bleed as they begin to miscarry early. One large study found that this oral medication is as successful in women experiencing early pregnancy failure as a surgical procedure if they've already started cramping and bleeding. The risk of heavy bleeding and infection was not any different in the surgical procedure than in the medical one.
If women have an early pregnancy that isn't growing, doesn't have a heartbeat or an ultrasound, but hasn't started cramping and bleeding yet, taking this medication is less successful than if women have already started the process.
A recent study published in "The New England Journal of Medicine" compared women who took the cramping medicine called uterotonic Misoprostol with women who were given the same combination of drugs as women use when they are choosing a medical abortion. This combination has been used safely by millions of women around the world for the past 20 years, and it combines a medication called Mifepristone followed by Misoprostol.
This randomized trial showed that women who were given just the cramping medicine when they had a failed early pregnancy demonstrated by ultrasound, were successful in completing a miscarriage at home within 4 days and about 67% of the time. Women who were given the two medications were successful in ending the failed pregnancy, but in 4 days 84% at the time. Women who hadn't completed a miscarriage in four days were offered another dose of medication. Some women who didn't complete their miscarriage had a suction procedure to finish the miscarriage.
Most women were satisfied with the process and said that they would recommend it to a friend and they would choose this way of ending an early pregnancy loss if it happened to them again. Now, not all physicians are familiar with these medications, and not all pharmacies carry them. But these options can become important choices for some women.
Choosing the Right Management Option for You
So how do you use this information? Early pregnancy failure can be devastating to women who've been hoping for a baby. Once the ultrasound findings that there's no growing fetus are explained, a woman may choose to wait until nature takes its course, knowing that this might take days to weeks. Some women want it all over with as soon as possible and are comfortable with the surgical procedure and are not comfortable with what can be significant cramping and bleeding that can come with spontaneous abortion or with the medication.
Emotional and Physical Considerations
Some women want the timeliness of taking the medication rather than waiting, but want the privacy of being at home, knowing that they can call their physician if they're having any difficulties. However you and your clinician come to manage this problem, it's often an emotional roller coaster, a big loss, as well as a physical loss. Make the choices that work the best for you and get the information that will help you move forward. And thanks for joining us on The Scope.
updated: November 4, 2024
originally published: September 20, 2018
Early Pregnancy Assessment Clinic (EPAC)
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