Miscarriage (Mis)management part 2: Management and Counselling

This is a guest post by Dr. Julia Dmytryshyn.

This is the second post in a two-part review on miscarriage management in the ED. Part one covered evaluation and diagnosis of miscarriage. This post will review the effectiveness of different management options, the controversy on when and if to administer Rhogam, counselling regarding activity/bed rest post-discharge, and the importance of sensitive disclosure, expectation setting, and clear discharge instructions in miscarriage management.

Once a patient is diagnosed with a confirmed loss, currently available management options include expectant management, medical management with mifepristone and misoprostol, or surgical management. As per the most recent guidelines published by the American College of Obstetricians and Gynecologists (ACOG), all options are reasonably effective, with no difference in long-term outcomes (1). A paper published in the Lancet in 2021 developed management recommendations based on appraisal of guidelines, expert group discussions, and a literature review and meta-analysis that included 78 trials with 17,795 participants. They recommend expectant management as first line in patients presenting with incomplete miscarriage (provided there is no excessive bleeding or signs of infection), as they have a greater than 90% chance of completing their miscarriage without any medical intervention (2). Overall, expectant management is successful in achieving complete expulsion in about 80% of patients. However, this can take up to 8 weeks, and if the patient prefers a shorter process, then medical management can be considered in women without infection, hemorrhage, severe anemia, or bleeding disorders. Many patients also prefer surgical management because it provides immediate completion with less follow-up (1). The Lancet review states that all active interventions were more likely to result in the completion of miscarriage when compared to expectant management or placebo. They conclude that the most effective method was suction aspiration with cervical preparation, with the ACOG guidelines reporting surgical treatment success rates approaching 99%. There were no important differences amongst management options for adverse outcomes of death, uterine perforation, need for hysterectomy, blood transfusion, or ICU admission. Taking this all into account, in the absence of medical complications or symptoms requiring emergent surgical management, patients should be presented with all available options and supported to choose the management that best suits their needs and preferences (1, 2).

A quick word on medical management regimens: there has been some debate as to whether combination therapy with mifepristone followed by misoprostol is superior to misoprostol alone. Mifepristone is a competitive progesterone and glucocorticoid receptor antagonist that blocks the actions of progesterone and initiates passing of the pregnancy, whereas misoprostol is a synthetic prostaglandin E1 analogue that causes cervical softening and uterine contractions. A study published in the New England Journal of Medicine in 2018 showed that pre-treatment with mifepristone led to a statistically significant increase in efficacy and a decrease in surgical intervention to complete treatment (3), and a subsequent large, placebo-controlled, double-blind, randomized trial published in the Lancet in 2020 also showed significantly improved completion rates with mifepristone pre-treatment (4). Therefore, we recommend combination therapy with mifepristone and misoprostol if a patient is opting for medical management.

Another aspect of miscarriage management is consideration of anti-D immune globulin (Rhogam) to prevent alloimmunization in RhD-negative individuals. Much controversy exists on the gestational age (GA) at which this is indicated in early pregnancy loss, and on whether this is required for these patients at all. I had some trouble finding current Canadian guidelines, but I’ll present the various recommendations I came across and how this translates into clinical practice. The most recent official guidelines published by the Society for Obstetricians and Gynaecologists of Canada (SOGC) in 2018 recommend Rhogam after incomplete or threatened miscarriage at any GA (5). In 2020 they reported new evidence that supports withholding Rh testing and Rhogam for medically treated miscarriages in GA up to 8 weeks, given the very low probability that Rh antigen is expressed on fetal cells at this stage (Rh antigen has been detected as early as 7 weeks + 3 days after LMP) (6). The Royal College of Obstetricians and Gynaecologists, based out of the UK, state that Rhogam is not required for medical management of miscarriage in GA up to 13 + 6 weeks. In terms of surgical management, they recommend Rh testing after 10 weeks GA and only considering Rh testing in GA less than 10 weeks (7). Historically, surgically managed patients have been considered to be at higher risk for alloimmunization, however, it has since been demonstrated that that fetal red blood cell concentrations are insufficient to cause Rh sensitization with uterine aspiration in the first trimester (8).

The most clear-cut and recent recommendations I could find come from the World Health Organization (WHO) Abortion Care Guideline published in March 2022:

• At below 12 weeks GA, routine Rh testing and Rhogam administration is not required for pregnancy loss regardless of treatment modality chosen (not required in expectant, medical or surgical management).
• At 12 GA or later, Rh testing should be conducted and Rhogam administered to RhD-negative individuals experiencing pregnancy loss (9).

All this said, alloimmune hemolytic disease poses serious health risks for mother and baby. I’ll mention a clinical summary posted by the BC Emergency Medicine Network, which raises a valid point that although evidence for benefit of Rhogam in early pregnancy is decreasing, the risks of Rhogam administration are very low. Therefore, they still recommend Rhogam for incomplete and threatened miscarriage at all gestational ages (10). So how do we translate this all into our clinical practice? There is no clear right answer. The most recent SOGC guidelines still do recommend Rhogam for all miscarriages and threatened abortions during the first 12 weeks (5). However, the future guidelines will likely recommend that it is safe to forego Rh testing and immunoglobulin in all early pregnancy loss and bleeding under 8 weeks GA, in keeping with practices in many other countries and the evidence reported by the SOGC in 2020 (6, 9). Keeping the WHO guidelines in mind, you shouldn’t be faulted in holding off on Rh testing and Rhogam administration when patients present before 12 weeks gestational age, but considering the consequences of alloimmunization, maybe better to air on the side of caution until the guidelines are all in agreement.

The last matter of debate I’ll cover is counselling regarding activity/bed rest post-discharge. Anecdotally, about half the patients referred in with a threatened miscarriage have been told they need to avoid exercise, be off work, or be on strict bed rest. There is no conclusive evidence that bed rest prevents miscarriage. The etiology of miscarriage is not related to an excess of activity, so it doesn’t make much sense to recommend strict activity restrictions to prevent pregnancy loss. The ACOG 2021 guidelines state that there are no effective interventions to prevent early pregnancy loss and bed rest should not be recommended (1). The 2023 ACOG guidelines on physical activity and exercise during pregnancy cite several reviews that have determined there is no credible evidence that bed rest prevents preterm labour. Bed rest increases the risk of venous thromboembolism, back pain and deconditioning, and there are numerous studies documenting the negative effects of activity restriction in pregnancy, including psychosocial effects on the mother and family (11).

A BMJ report on the management of threatened miscarriage reviews the very few studies evaluating bed rest in threatened miscarriage (12). They include a retrospective study of 226 women who were hospitalized with threatened miscarriage, which found no significant difference in miscarriage rate between the bed rest group (16% miscarried) and the no treatment group (20% miscarried) (13). In contrast, they cite another retrospective analysis of 230 women with threatened miscarriage and subchorionic hematomas, which found 9.9% of patients in the bed rest group miscarried versus 23.3% in those who continued their usual activities (P= 0.006) (14). The BMJ report concludes that there is no definite evidence that bed rest affects the course of a pregnancy, but that abstinence from an active environment can help women feel safer and provide emotional relief (12). However, evidence also suggests that women may experience self-blame if they fail to comply to recommended restrictions and subsequently have a miscarriage (15). I think it’s fair to suggest avoiding vigorous exercise until a patient’s condition stabilizes and they can be followed up by their obstetrical provider, but bed rest should not be recommended.

I’d like to conclude with some reflective advice on disclosing a miscarriage diagnosis, setting patient expectations, and providing clear follow-up instructions. About 1 in 5 pregnancies end in early loss. A recent study in Ontario showed that over 80% of patients with first trimester bleeding or abdominal pain sought treatment in the emergency department (16). This inherently leads to disclosure in a crowded and rushed environment. As experienced providers, we become somewhat desensitized to this, but I will never forget standing in the corner of the room as a medical student, observing an emergency medicine physician disclose a miscarriage diagnosis for the first time. Healthcare providers often underestimate the psychological impact of miscarriage (17). I’d be amiss to not advocate for clinicians to slow down, reflect on their patient’s emotional state, and take a few extra minutes to provide the compassionate care these women need. A study examining what creates experiences of marginalization in women diagnosed with miscarriage in the ED found that a lack of discharge education and clarity regarding follow-up was a main contributor (18). ACOG guidelines advise that women should be counselled on what to expect while they pass pregnancy tissue, provided specific information on when and who to call for excessive bleeding, and given prescriptions for pain medications (1). In light of the current staffing and resource crisis, all of this might not always be possible during those chaotic shifts (which is quickly becoming every shift). This is exactly why countries such as the United Kingdom and Sweden have streamlined access to early pregnancy clinics to minimize distressing ED visits and reduce workload in the ED (18). Although these clinics exist here, they are often not easily accessible, and this highlights the need for us to advocate for early pregnancy clinics as a standard of care. In the meantime, we’ll continue to manage miscarriage in the ED, and hopefully resources such as this will continue to improve provider knowledge on this important topic.

References

1. American College of Obstetricians and Gynecologists. (2018). ACOG Practice Bulletin No. 200: early pregnancy loss. Obstetrics and gynecology, 132(5), e197-e207.
2. Coomarasamy, A., Gallos, I. D., Papadopoulou, A., Dhillon-Smith, R. K., Al-Memar, M., Brewin, J., … & Quenby, S. (2021). Sporadic miscarriage: evidence to provide effective care. The Lancet, 397(10285), 1668-1674.
3. Schreiber, C. A., Creinin, M. D., Atrio, J., Sonalkar, S., Ratcliffe, S. J., & Barnhart, K. T. (2018). Mifepristone pretreatment for the medical management of early pregnancy loss. New England Journal of Medicine, 378(23), 2161-2170.
4. Chu, J. J., Devall, A. J., Beeson, L. E., Hardy, P., Cheed, V., Sun, Y., … & Coomarasamy, A. (2020). Mifepristone and misoprostol versus misoprostol alone for the management of missed miscarriage (MifeMiso): a randomised, double-blind, placebo-controlled trial. The Lancet, 396(10253), 770-778.
5. Fung, K. F. K., & Eason, E. (2018). No. 133-prevention of Rh alloimmunization. Journal of Obstetrics and Gynaecology Canada, 40(1), e1-e10.
6. Costescu, D., Guilbert, E., Wagner, M. S., Dunn, S., Norman, W. V., Black, A., … & Trouton, K. (2020). Induced abortion: updated guidance during pandemics and periods of social disruption. Society of Obstetricians and Gynaecologists of Canada.
7. RCOG, RCM, BSACP, & FSRH. (2020). Coronavirus (COVID-19) infection and abortion care. Information for healthcare professionals.
8. Horvath, S., Tsao, P., Huang, Z. Y., Zhao, L., Du, Y., Sammel, M. D., … & Schreiber, C. A. (2020). The concentration of fetal red blood cells in first-trimester pregnant women undergoing uterine aspiration is below the calculated threshold for Rh sensitization. Contraception, 102(1), 1-6.
9. World Health Organization. (2022). Abortion care guideline.
10. Marsden, J., & Treissman, J. (2021). Anti-D immunoglobulin prophylaxis to optimize prevention of rhesus (Rh) alloimmunization in women. BC Emergency Medicine Network Point-of-Care Emergency Clinical Summaries.
11. Syed, H., Slayman, T., & Thoma, K. D. (2021). ACOG committee opinion no. 804: Physical activity and exercise during pregnancy and the postpartum period. Obstetrics & Gynecology, 137(2), 375-376.
12. Sotiriadis, A., Papatheodorou, S., & Makrydimas, G. (2004). Threatened miscarriage: evaluation and management. Bmj, 329(7458), 152-155.
13. Giobbe, M., Fazzio, M., & Boni, T. (2001). Current role of bed-rest in threatened abortion. Minerva ginecologica, 53(5), 337-340.
14. Ben-Haroush, A., Yogev, Y., Mashiach, R., & Meizner, I. (2003). Pregnancy outcome of threatened abortion with subchorionic hematoma: possible benefit of bed-rest?. IMAJ-RAMAT GAN-, 5(6), 422-424.
15. Qureshi, N. S. (2009). Treatment options for threatened miscarriage. Maturitas, 65, S35-S41.
16. Varner, C. E., Park, A. L., Little, D., & Ray, J. G. (2020). Emergency department use by pregnant women in Ontario: a retrospective population-based cohort study. Canadian Medical Association Open Access Journal, 8(2), E304-E312.
17. Kong, G. W., Lok, I. H., Lam, P. M., Yip, A. S., & Chung, T. K. (2010). Conflicting perceptions between health care professionals and patients on the psychological morbidity following miscarriage. Australian and New Zealand Journal of Obstetrics and Gynaecology, 50(6), 562-567.
18. MacWilliams, K., Hughes, J., Aston, M., Field, S., & Moffatt, F. W. (2016). Understanding the experience of miscarriage in the emergency department. Journal of Emergency Nursing, 42(6), 504-512.

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