INTERIM UPDATE

ACOG PRACTICE BULLETIN SUMMARY

Clinical Management Guidelines for Obstetrician–Gynecologists
NUMBER 200 (Replaces Practice Bulletin Number 150, May 2015)

For a comprehensive overview of these recommendations, the full-text Scan this QR code
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Practice Bulletin.

Committee on Practice Bulletins—Gynecology. This Practice Bulletin was developed

by the ACOG Committee on Practice Bulletins—Gynecology in collaboration with Sarah Prager, MD; Vanessa K. Dalton, MD,
MPH; and Rebecca H. Allen, MD, MPH.

INTERIM UPDATE: This Practice Bulletin is updated as highlighted to reflect recent evidence regarding the use of mife-
pristone combined with misoprostol for medical management of early pregnancy loss. This Practice Bulletin also includes
limited, focused updates to align with Practice Bulletin No. 181, Prevention of Rh D Alloimmunization. For complete details
on these updates, please see the full-text version.

Early Pregnancy Loss

Early pregnancy loss, or loss of an intrauterine pregnancy within the first trimester, is encountered commonly in
clinical practice. Obstetricians and gynecologists should understand the use of various diagnostic tools to differentiate
between viable and nonviable pregnancies and offer the full range of therapeutic options to patients, including
expectant, medical, and surgical management. The purpose of this Practice Bulletin is to review diagnostic approaches
and describe options for the management of early pregnancy loss.

Clinical Management Questions

< What findings can be used to confirm a diagnosis of early pregnancy loss?
< What are the management options for early pregnancy loss?
< How do the different management options for early pregnancy loss compare in effectiveness and risk of
complications?
< How do the different treatment approaches to early pregnancy loss differ with respect to cost?
< How should patients be counseled regarding interpregnancy interval after early pregnancy loss?
< How should patients be counseled regarding the use of contraception after early pregnancy loss?
< How should patients be counseled regarding prevention of alloimmunization after early pregnancy loss?
< What type of workup is needed after early pregnancy loss?
< Are there any effective interventions to prevent early pregnancy loss?

VOL. 132, NO. 5, NOVEMBER 2018 OBSTETRICS & GYNECOLOGY 1311

Copyright ª by the American College of Obstetricians

and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
Recommendations
and Conclusions
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
800 micrograms of vaginal misoprostol is recom-
mended, with a repeat dose as needed. The addition
of a dose of mifepristone (200 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):
< Ultrasonography, if available, is the preferred
modality to verify the presence of a viable intrauterine
gestation.
< Surgical intervention is not required in asymptomatic
women with a thickened endometrial stripe after
treatment for early pregnancy loss.
< 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 confi-
dent that the uterus is empty.
The following recommendations are based primarily on
consensus and expert opinion (Level C):
< Accepted treatment options for early pregnancy loss
include expectant management, medical treatment, or
surgical evacuation. In women without medical
complications or symptoms requiring urgent surgical
evacuation, treatment plans can safely accommodate
patient treatment preferences.
1312 Practice Bulletin No. 200 Summary
Copyright ª by the American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
< The use of a single preoperative dose of doxycycline
is recommended to prevent infection after surgical
management of 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.
< 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.
Studies were reviewed and evaluated for quality according
to the method outlined by the U.S. Preventive Services
Task Force. Based on the highest level of evidence found
in the data, recommendations are provided and graded
according to the following categories:
Level A—Recommendations are based on good and
consistent scientific evidence.
Level B—Recommendations are based on limited or
inconsistent scientific evidence.
Level C—Recommendations are based primarily on
consensus and expert opinion.
Full-text document published online on August 29, 2018.
Copyright 2018 by the American College of Obstetricians
and Gynecologists. All rights reserved. No part of this
publication may be reproduced, stored in a retrieval system,
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otherwise, without prior written permission from the
publisher.
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directed to Copyright Clearance Center, 222 Rosewood Drive,
Danvers, MA 01923, (978) 750-8400.
American College of Obstetricians and Gynecologists
409 12th Street, SW, PO Box 96920, Washington, DC 20090-6920
Official Citation
Early pregnancy loss. ACOG Practice Bulletin No. 200.
American College of Obstetricians and Gynecologists. Obstet
Gynecol 2018;132:e197–207.
OBSTETRICS & GYNECOLOGY
This information is designed as an educational resource to aid clinicians in providing obstetric and gynecologic care, and use
of this information is voluntary. This information should not be considered as inclusive of all proper treatments or methods of
care or as a statement of the standard of care. It is not intended to substitute for the independent professional judgment of the
treating clinician. Variations in practice may be warranted when, in the reasonable judgment of the treating clinician, such
course of action is indicated by the condition of the patient, limitations of available resources, or advances in knowledge or
technology. The American College of Obstetricians and Gynecologists reviews its publications regularly; however, its
publications may not reflect the most recent evidence. Any updates to this document can be found on www.acog.org or by
calling the ACOG Resource Center.
While ACOG makes every effort to present accurate and reliable information, this publication is provided “as is” without any
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this published product.

VOL. 132, NO. 5, NOVEMBER 2018 Practice Bulletin No. 200 Summary 1313

Copyright ª by the American College of Obstetricians

and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.