Early Pregnancy Failure

Early pregnancy failure is the loss of a pregnancy before 12 weeks in which the embryo has died or never developed, with the products retained in the uterus. It includes embryonic demise and anembryonic pregnancy. Most are due to chromosomal abnormality. It affects about 10 to 15 percent of clinically recognised pregnancies and matters because management choices exist and retained tissue can bleed or become infected.

• Risk factors: maternal age above 35 years, previous miscarriage, smoking, diabetes, thyroid disease.
• Usually found at scan or after pregnancy symptoms fade.
• About 80 percent of miscarriages occur before 12 weeks.

Women may have brown discharge, loss of nausea or breast tenderness, or no symptoms. Examination shows a closed os and a uterus smaller than dates.

• Often asymptomatic and found on routine scan.
• Pain and heavy bleeding appear when expulsion starts.
• Differential diagnosis: threatened miscarriage, ectopic pregnancy, molar pregnancy, wrong dates, low viability pregnancy.
• Complications: haemorrhage, infection, retained products, anaemia, psychological distress, coagulopathy if retained for weeks.

The diagnosis is made on transvaginal ultrasound.

• Crown rump length 7 mm or more with no cardiac activity, or mean sac diameter 25 mm or more with no embryo, confirms failure.
• Findings between suspicious and diagnostic need a repeat scan after 7 to 10 days.
• Haemoglobin, blood group and Rhesus status; platelets and clotting tests if heavy bleeding or retention of more than 4 weeks.
• Send tissue for histology to exclude molar pregnancy.

The principle is to offer expectant, medical or surgical management after confirming failure and excluding infection.

• Supportive: counsel on options and grief; analgesia; safety netting; expectant care for up to 14 days if stable and no infection.
• Pharmacological: misoprostol 800 micrograms vaginally, repeat once after 3 hours if no bleeding; if no tissue passes by 24 hours repeat the full course once; mifepristone 200 mg oral then misoprostol 800 micrograms vaginally 24 to 48 hours later where available; paracetamol 1 g oral 6-hourly (maximum 4 g in 24 hours); ibuprofen 400 mg oral 8-hourly with food for 3 days; metoclopramide 10 mg oral 8-hourly for nausea with cramps.
• Procedures: manual vacuum aspiration up to 12 weeks size under paracervical block with lignocaine 1 percent, 20 mL; sharp curettage under anaesthesia for larger uteri.
• Special groups: Rhesus negative women give anti-D immunoglobulin 250 IU IM within 72 hours; women with infection give ampicillin 2 g IV 6-hourly plus gentamicin 5 mg/kg IV once daily plus metronidazole 500 mg IV 8-hourly before evacuation.
• Red flags: heavy bleeding, fever above 38 degrees Celsius, offensive discharge, severe pain, collapse.
• Follow-up: urine pregnancy test at 3 weeks; review histology; contraception counselling; investigate after 3 consecutive losses.