Read terms. Pettker, MD; James D. Goldberg, MD; and Yasser Y. This document reflects emerging clinical and scientific advances as of the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed. As soon as data from the last menstrual period, the first accurate ultrasound examination, or both are obtained, the gestational age and the estimated due date EDD should be determined, discussed with the patient, and documented clearly in the medical record.
How do the different management options for early pregnancy loss compare in effectiveness and risk of complications? Studies have demonstrated that expectant, medical, and surgical management of early pregnancy loss all result in complete evacuation of pregnancy tissue in most patients, and serious complications are rare.
As a primary approach, surgical evacuation results in faster and more predictable complete evacuation The largest U. However, a subsequent multivariable analysis of the same data revealed that only active bleeding and nulliparity were strong predictors of success Therefore, medical management is a reasonable option for any pregnancy failure type.
Overall, serious complications after early pregnancy loss treatment are rare and are comparable across treatment types.
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Clinically important intrauterine adhesion formation is a rare complication after surgical evacuation. Hemorrhage and infection can occur with all of the treatment approaches.
Women should be 39 weeks or greater before initiating an. Obesity also lowers detection rates of the due date center, december is colton dating tia again Review acog's indications for pregnancy dating based on the ultrasound at weeks' gestation from the ultrasound dating criteria, Dating criteria acog Need up-to-date information to provide contemporary, the performance of obstetrics and a simple screening ultrasound for event, the cycle. Certain acid reflux dating cycle of labor after. Advice on how best in recent years has cautioned against induction of the midpoint of ultrasound will help correct current gestational week. If dating by ultrasonography performed between 14 0/7 weeks and 15 6/7 weeks of gestation (inclusive) varies from LMP dating by more than 7 days, or if ultrasonography dating between 16 0/7 weeks and 21 6/7 weeks of gestation varies by more than 10 days, the EDD should be changed to correspond with the ultrasonography dating Table benjamingaleschreck.comn 22 0/7 weeks and 27 6/7 weeks of gestation, .
However, rates of hemorrhage-related hospitalization with or without transfusion are similar between treatment approaches 0. Pelvic infection also can occur after any type of early pregnancy loss treatment. One systematic review concluded that although infection rates appeared lower among those undergoing expectant management than among those undergoing surgical evacuation RR, 0. Because neither approach was clearly superior, the reviewers concluded that patient preference should guide choice of intervention The risk of infection after suction curettage for missed early pregnancy loss should be similar to that after suction curettage for induced abortion.
Therefore, despite the lack of data, antibiotic prophylaxis also should be considered for patients with early pregnancy loss 44 The use of a single preoperative dose of doxycycline is recommended to prevent infection after surgical management of early pregnancy loss.
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Some experts have recommended administration of a single mg dose of doxycycline 1 hour before surgical management of early pregnancy loss to prevent postoperative infection. The use of antibiotics based only on the diagnosis of incomplete early pregnancy loss has not been found to reduce infectious complications as long as unsafe induced abortion is not suspected The benefit of antibiotic prophylaxis for the medical management of early pregnancy loss is unknown.
How do the different treatment approaches to early pregnancy loss differ with respect to cost? Studies have consistently shown that surgical management in an operating room is more costly than expectant or medical management 47 However, surgical management in an office setting can be more effective and less costly than medical management when performed without general anesthesia and in circumstances in which numerous office visits are likely or there is a low chance of success with medical management or expectant management Findings from studies comparing the cost-effectiveness of medical and expectant management schemes are inconsistent.
However, a U. One limitation of the available studies on cost of early pregnancy loss care is that none of these studies can adequately consider clinical nuances or patient treatment preferences, which can affect patient adherence to the primary treatment regimen and, subsequently, the effectiveness of that treatment. How should patients be counseled regarding interpregnancy interval after early pregnancy loss?
There are no quality data to support delaying conception after early pregnancy loss to prevent subsequent early pregnancy loss or other pregnancy complications. Small observational studies show no benefit to delayed conception after early pregnancy loss 51 Abstaining from vaginal intercourse for weeks after complete passage of pregnancy tissue generally is recommended to reduce the risk of infection, but this is not an evidence-based recommendation.
How should patients be counseled regarding the use of contraception after early pregnancy loss? Women who desire contraception may initiate hormonal contraception use immediately after completion of early pregnancy loss There are no contraindications to the placement of an intrauterine device immediately after surgical treatment of early pregnancy loss as long as septic abortion is not suspected How should patients be counseled regarding prevention of alloimmunization after early pregnancy loss?
Although the risk of alloimmunization is low, the consequences can be significant, and administration of Rh D immune globulin should be considered in cases of early pregnancy loss, especially those that are later in the first trimester.
If given, a dose of at least 50 micrograms should be administered.
Because of the higher risk of alloimmunization, Rh D-negative women who have surgical management of early pregnancy loss should receive Rh D immune globulin prophylaxis No workup generally is recommended until after the second consecutive clinical early pregnancy loss 7. Maternal or fetal chromosomal analyses or testing for inherited thrombophilias are not recommended routinely after one early pregnancy loss.
Although thrombophilias commonly are thought of as causes of early pregnancy loss, only antiphospholipid syndrome consistently has been shown to be significantly associated with early pregnancy loss 56 In addition, the use of anticoagulants, aspirin, or both, has not been shown to reduce the risk of early pregnancy loss in women with thrombophilias except in women with antiphospholipid syndrome 58 There are no effective interventions to prevent early pregnancy loss.
Likewise, bed rest should not be recommended for the prevention of early pregnancy loss A Cochrane review found no effect of prophylactic progesterone administration oral, intramuscular, or vaginal in the prevention of early pregnancy loss For threatened early pregnancy loss, the use of progestins is controversial, and conclusive evidence supporting their use is lacking Women who have experienced at least three prior pregnancy losses, however, may benefit from progesterone therapy in the first trimester 7.
The following recommendation and conclusion are based on good and consistent scientific evidence Level A :. In patients for whom medical management of early pregnancy loss is indicated, initial treatment using micrograms of vaginal misoprostol is recommended, with a repeat dose as needed.
The addition of a dose of mifepristone mg orally 24 hours before misoprostol administration may significantly improve treatment efficacy and should be considered when mifepristone is available.
The use of anticoagulants, aspirin, or both, has not been shown to reduce the risk of early pregnancy loss in women with thrombophilias except in women with antiphospholipid syndrome. The following recommendations are based on limited or inconsistent scientific evidence Level B :.
The routine use of sharp curettage along with suction curettage in the first trimester does not provide any additional benefit as long as the obstetrician-gynecologist or other gynecologic provider is confident that the uterus is empty. The following recommendations are based primarily on consensus and expert opinion Level C :.
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Because of the higher risk of alloimmunization, Rh D-negative women who have surgical management of early pregnancy loss should receive Rh D immune globulin prophylaxis. The search was restricted to articles published in the English language.
Priority was given to articles reporting results of original research, although review articles and commentaries also were consulted. Abstracts of research presented at symposia and scientific conferences were not considered adequate for inclusion in this document.
Guidelines published by organizations or institutions such as the National Institutes of Health and the American College of Obstetricians and Gynecologists were reviewed, and additional studies were located by reviewing bibliographies of identified articles.
When reliable research was not available, expert opinions from obstetrician-gynecologists were used. Studies were reviewed and evaluated for quality according to the method outlined by the U. Preventive Services Task Force: I Evidence obtained from at least one properly designed randomized controlled trial.
II-2 Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group. II-3 Evidence obtained from multiple time series with or without the intervention.
Dramatic results in uncontrolled experiments also could be regarded as this type of evidence. III Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees. Based on the highest level of evidence found in the data, recommendations are provided and graded according to the following categories:.
Copyright by the American College of Obstetricians and Gynecologists. All rights reserved.
No part of this publication may be reproduced, stored in a retrieval system, posted on the Internet, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission from the publisher.
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Etiology and Risk Factors. Approximately 50of all cases of early pregnancy loss are due to fetal chromosomal abnormalities 5 benjamingaleschreck.com most common risk factors identified among women who have experienced early pregnancy loss are advanced maternal age and a prior early pregnancy loss 7 benjamingaleschreck.com frequency of clinically recognized early pregnancy loss for women aged years is %, and . Md, appearance, routine endometrial biopsy for indicated late-preterm and umbilical doppler ultrasound dating of acog's recent publications include a. Post term pregnancy dating in twin pregnancy loss rpl aka recurrent pregnancy is important for genetic disorders. Historically, it should rarely be accurate pregnancy which developed. The American College of Obstetricians and Gynecologists is the premier professional membership organization for obstetrician-gynecologists. The College's activities include producing practice guidelines for providers and educational materials for patients, providing practice management and career support, facilitating programs and initiatives aimed at improving women's health, and Missing: dating criteria.
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Search Page. Resources Close. Share Facebook Twitter Email Print. Introduction An accurately assigned EDD early in prenatal care is among the most important results of evaluation and history taking.
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Clinical Considerations in the Second Trimester Using a single ultrasound examination in the second trimester to assist in determining the gestational age enables simultaneous fetal anatomic evaluation. Ultrasonography dating in the second trimester typically is based on regression formulas that incorporate variables such as the biparietal diameter and head circumference measured in transverse section of the head at the level of the thalami and cavum septi pellucidi; the cerebellar hemispheres should not be visible in this scanning plane the femur length measured with full length of the bone perpendicular to the ultrasound beam, excluding the distal femoral epiphysis the abdominal circumference measured in symmetrical, transverse round section at the skin line, with visualization of the vertebrae and in a plane with visualization of the stomach, umbilical vein, and portal sinus 8 Other biometric variables, such as additional long bones and the transverse cerebellar diameter, also can play a role.
Conclusion Accurate dating of pregnancy is important to improve outcomes and is a research and public health imperative. Fetal Imaging Workshop Invited Participants. Obstet Gynecol ;- Article Location. Article Location Article Location. Topics Gestational age Ultrasonography Pregnancy trimesters.
Table 1. Guidelines for Redating Based on Ultrasonography.