Thread by @GaryPayinda

Guideline summary for #ED docs on early pregnancy loss/miscarriage:
acog.org/clinical/clini…
10% of all #pregnancies end in #miscarriage, though the rate approaches 80% by maternal age 45yrs.
Half of early pregnancy loss (AKA miscarriages) are due to chromosomal abnormalities. 🧵

Crown-rump length (CRL) 7mm or greater and no heartbeat. Mean sac diameter (MSD) 25mm and no embryo.
Each one is an #ultrasound feature diagnostic of early pregnancy loss.
#POCUS
#medtwitter

80% of patients with early pregnancy loss can be safely managed with an expectant management (watch and wait) approach.
Relatively few miscarriages will require ED care; most of these will involve significant and symptomatic haemorrhage or infection.

One to two doses of misoprostol is effective at medical management of miscarriage in approximately 70-80% of cases in which it's used.
Repeat ultrasound 7 days later to confirm absence of gestational sac, serial b-hcg may be used by #OBGYN as followup.

Adding mifepristone to misoprostol significantly improved its efficacy.

How much vaginal bleeding is 'too much'?
No precise answer, but 2 maxi pads an hour for 2 hours is a good approximation.
Moderate to heavy bleeding, tissue passage, and severe pain may be an expected part of a miscarriage. Patient education and ability to access advice is key.

Suction curettage is an effective treatment option, and does not always need to be performed in operating theatre; clinic (or even ED) are options for some. Patient preference is key in determining a medical vs surgical treatment plan.

In a real-world study of medical treatment of miscarriage, the rates of completing a full course of treatment were much lower than in big RCTs. Drs shouldn't underestimate the cramping and vomiting side effects of miscarriage meds when discussing medical vs surgical options.

If no infection is suspected, IUDs can be placed at the time of surgical treatment of early pregnancy loss.
@threadreaderapp unroll

Don't forget to check Rh status and manage alloimmunisation risk with Rh immunoglobulin prophylaxis.

How to help patients with early pregnancy loss:
1) Give the news gently, be supportive of what for some is a tremendous loss, discuss social work/other support options.
2) Ask the patient how they feel, if they see it as a loss or potential loss, treat it as what it is: a loss.

3) Ask the patient how they would like their early pregnancy loss to be treated: options include expectant, medication, and uterine aspiration.
4) Work with your O&G colleagues to form a treatment plan in accordance with patient wishes.

"There are no effective treatments to prevent miscarriage (early pregnancy loss)."
Help patients understand that there isn't anything they could have done 'better' or 'differently' to prevent the miscarriage.
medpagetoday.com/opinion/second…

Managing miscarriages sensitively, safely, accurately, and competently is challenging.
Helping patients understand that miscarriages occur in 10% (or more) of pregnancies, and that they didn't cause the miscarriage might help some patients. Every individual will be different.

As with all things in emergency med, communication is key: it's important that the patient feels comfortable talking to you.
Sit down. Take time. Listen.
They may have gone from one of the happiest, most hopeful times of their life to the saddest in the space of a few hours.