Miscarriage Classification and Management

Definition and Classification

Early pregnancy loss (EPL) is the preferred term for describing a pregnancy that may not progress, is in the process of expulsion, or has incompletely or completely passed, according to the American College of Obstetricians and Gynecologists 1
Incomplete Miscarriage is defined as the presence of intracavitary tissue, typically with internal vascularity, or a persistent gestational sac following pregnancy loss, as stated by the American College of Obstetricians and Gynecologists 1
Complete Miscarriage is characterized by no persistent gestational sac or intracavitary tissue following pregnancy loss, as defined by the American College of Obstetricians and Gynecologists 1
EPL in Progress describes a situation where the gestational sac is located in the lower uterine segment or endocervical canal and is in the process of expulsion, according to the American College of Obstetricians and Gynecologists 1
Missed Miscarriage, also termed "silent miscarriage," occurs when the embryo has died but has not been expelled from the uterus, corresponding to "diagnostic of EPL" in current terminology, as stated by the American College of Obstetricians and Gynecologists and Praxis Medical Insights 1, 2

Concerning for EPL: Embryonic crown-rump length (CRL) <7 mm with no cardiac activity, mean sac diameter (MSD) 16-24 mm with no embryo, or absence of embryo 7-13 days after visualization of gestational sac, as defined by Praxis Medical Insights 2
Diagnostic of EPL: CRL ≥7 mm with no cardiac activity, MSD ≥25 mm with no embryo, or absence of embryo ≥14 days after visualization of gestational sac, as stated by the American College of Obstetricians and Gynecologists and Praxis Medical Insights 1, 2
Anembryonic Pregnancy is a specific term for a gestational sac measuring 25 mm or larger without an embryo, or absence of an embryo on serial examinations obtained at discriminatory time intervals, as defined by the American College of Obstetricians and Gynecologists 1
Embryonic Demise refers to a specific scenario when the crown-rump length is 7 mm or longer and there is absence of cardiac activity, according to the American College of Obstetricians and Gynecologists 1

Pregnancy of Unknown Location (PUL) is a transient state referring to patients with a positive pregnancy test and no evidence of an ectopic pregnancy or an intrauterine pregnancy on transvaginal ultrasound, as defined by the American College of Radiology 3
Gestational Trophoblastic Disease is a rare condition where abnormal trophoblastic tissue grows in the uterus, including hydatidiform moles (complete or partial), as stated by the Journal of Clinical Oncology 4

Poor prognostic indicators include a calcified yolk sac and an enlarged amniotic cavity relative to the crown-rump length (expanded amnion sign), as stated by the American College of Obstetricians and Gynecologists 1

Management options for incomplete miscarriage include expectant management, medical management with misoprostol, or surgical evacuation (suction dilation and curettage), as recommended by Praxis Medical Insights 2
Surgical evacuation is preferably performed under ultrasound guidance to reduce the risk of uterine perforation, as stated by Praxis Medical Insights 2
Serial hCG monitoring is recommended until levels return to the non-pregnant state, as suggested by Praxis Medical Insights 2
Histopathologic examination of tissue is recommended to confirm intrauterine pregnancy and rule out gestational trophoblastic disease, as recommended by Praxis Medical Insights 2

The American College of Radiology recommends excluding ectopic pregnancy, heterotopic pregnancy, gestational trophoblastic disease, incomplete versus complete miscarriage, and cervical ectopic pregnancy or cesarean scar ectopic pregnancy when evaluating a patient with suspected miscarriage 5, 6

A negative serum β-hCG essentially excludes both intrauterine and ectopic pregnancy, according to the American College of Radiology 5, 6
Elevated β-hCG in a non-pregnant patient may indicate miscarriage, ectopic pregnancy, pituitary production, paraneoplastic production, or gestational trophoblastic disease, as stated by the American College of Radiology 5, 6

The American College of Radiology suggests considering gynecological causes such as hemorrhagic ovarian cysts, pelvic inflammatory disease, ovarian torsion, and placental abruption, as well as non-gynecological causes like appendicitis, inflammatory bowel disease, and urinary tract calculi, when miscarriage presents with acute pelvic pain 5, 6

The American College of Radiology recommends a thorough clinical evaluation correlating history, physical examination, and laboratory testing before choosing radiologic examination, and notes that serum β-hCG test is essential when a premenopausal patient presents with acute pelvic pain 5, 6

The American College of Obstetricians and Gynecologists recommends confirming pregnancy status and dating through systematic questioning about symptoms, timing, and risk factors, including last menstrual period, positive pregnancy test, and previous ultrasounds 7
Patients who have had previous miscarriages should be evaluated for recurrent miscarriage, defined as three or more consecutive losses, which requires specialized evaluation, according to the American Society for Reproductive Medicine 8
The Royal College of Obstetricians and Gynaecologists suggests that patients with a history of chronic medical conditions, such as diabetes mellitus, hypertension, or autoimmune diseases, should be assessed for potential complications 8

The American Psychological Association recommends screening for acute distress and providing emotional support to patients experiencing miscarriage, with a focus on coping mechanisms and available social support systems 9
Patients who have experienced domestic violence or intimate partner violence should be identified and provided with appropriate resources and support, according to the National Coalition Against Domestic Violence 9
The Society for Critical Care Medicine suggests that patients' cultural and spiritual beliefs regarding pregnancy loss should be respected and addressed, with options for chaplain or spiritual counselor support 10

The American College of Obstetricians and Gynecologists recommends documenting tissue passage, including size and appearance, to determine completeness of miscarriage and exclude gestational trophoblastic disease 7
Patients should be provided with information on warning signs that require immediate evaluation, such as soaking more than 2 pads per hour, severe abdominal pain, or fever above 100.4°F (38°C), according to the Centers for Disease Control and Prevention 9