12-phase flow (12)

1. 1FRAME
   Early pregnancy loss / miscarriage = loss of a clinically recognised intrauterine pregnancy in the first trimester (< 13 wk). Affects ~ 10-20% of recognised pregnancies. Phenotypes: threatened (bleeding + closed cervix + viable IUP); inevitable (bleeding + dilated cervix); incomplete (partial passage of POC); missed (no cardiac activity but no symptoms; SRU criteria CRL ≥ 7 mm no cardiac OR sac ≥ 25 mm empty); complete (full passage of POC); septic (any of above + infection — surgical emergency). Management options for confirmed early loss: EXPECTANT (success ~ 80% at 8 wk for incomplete; ~ 50% for missed; 4-8 wk timeline); MEDICAL (mifepristone 200 mg PO + misoprostol 800 µg vaginally 24 h later per Schreiber 2018 NEJM PMID 29874535 — 83.8% expulsion vs 67.1% misoprostol alone); SURGICAL (MVA in office or D&C in OR; 99% success). All three are first-line per ACOG PB 200 (PMID 30157093) for stable patients.
   inputs: gestational_age_by_lmp_or_us
   advance: GA + phenotype documented; pretest probability + ectopic risk + management-arm framework set
2. 2ENTRY
   Recognise via first-trimester bleeding ± cramping ± passage of pregnancy tissue, OR surveillance US showing non-viable pregnancy (no cardiac activity at CRL ≥ 7 mm or empty sac ≥ 25 mm), OR abnormal β-hCG trajectory (failure to double in 48-72 h), OR febrile presentation with retained tissue (septic abortion). Differential: ectopic pregnancy (PUL, abnormal β-hCG, adnexal mass / free fluid); molar pregnancy (β-hCG markedly above expected, snowstorm pattern); subchorionic hemorrhage (US bleed identification with viable IUP — better prognosis); cervical/vaginal pathology (cervicitis, polyp, lesion).
   inputs: gestational_age_by_lmp_or_us
   advance: Phenotype suspected; ectopic ruled in/out via TVUS + β-hCG; bleeding severity graded
3. 3CONTEXT
   Capture prior pregnancy outcomes (≥ 2-3 losses → recurrent loss workup), Rh status (Rho(D) IG decision), IUD in place (mifepristone contraindication + ectopic risk), bleeding diathesis / anticoagulation (mifepristone contraindication; surgical preferred), chronic systemic corticosteroid use (mifepristone contraindication), prior cesarean / uterine surgery (misoprostol caution; uterine rupture risk), patient preference for management arm (shared decision-making is central).
   inputs: prior_pregnancy_outcomes_and_losses, maternal_rh_status, iud_in_place_or_recent_iud_removal, bleeding_diathesis_or_anticoagulation, chronic_systemic_corticosteroid_use, prior_cesarean_or_uterine_surgery
   advance: Risk-factor + contraindication context captured; management-arm options narrowed
4. 4RED_FLAGS
   Hemorrhagic shock (SBP < 90 / MAP < 65, tachycardia, hemoglobin drop) → IV access, crystalloid, type and crossmatch, surgical evacuation. Septic abortion (fever ≥ 38°C + foul discharge + uterine tenderness ± hypotension + leukocytosis) → broad-spectrum antibiotics IMMEDIATELY + parallel uterine evacuation + sepsis bundle (do not delay one for the other). Ectopic pregnancy until ruled out (PUL with abnormal β-hCG; adnexal mass or free fluid; clinical pain pattern) → route to ob.ectopic-pregnancy.v1. Retained POC > 1 wk without spontaneous passage → reassess management arm.
   inputs: maternal_bp, maternal_hr, maternal_temperature
   actions: protocol.septic_shock
   advance: Red-flag pathway activated; shock / sepsis / ectopic ruled in/out and routed appropriately
5. 5INITIAL_WORKUP
   TVUS (define phenotype — sac, yolk sac, fetal pole, cardiac activity, SRU non-viability criteria, subchorionic bleed); serum quantitative β-hCG (baseline + trend if PUL); CBC (hemoglobin for hemorrhage; WBC for sepsis); blood type and Rh; type and screen if surgical evacuation possible; STI screen if septic or high-risk; optional progesterone (low < 5 ng/mL favors non-viable, but not diagnostic). Document phenotype clearly to drive management arm.
   inputs: transvaginal_ultrasound_early_pregnancy, serum_quantitative_beta_hcg, cbc_with_diff, blood_type_and_rh
   actions: panel.cbc, workup.pelvic_pain
   advance: Phenotype confirmed; ectopic ruled out; Rh status known; management-arm decision ready
6. 6BRANCHING_WORKUP
   PUL with abnormal β-hCG → ectopic workup (ob.ectopic-pregnancy.v1; serial β-hCG, repeat US, methotrexate vs surgical per stability). Molar pregnancy suspicion (β-hCG markedly above expected, snowstorm pattern on US, theca lutein cysts) → GTD workup + uterine evacuation. Recurrent pregnancy loss (≥ 2-3 losses) → recurrent loss workup (antiphospholipid antibodies, karyotype, uterine cavity assessment) per ACOG/ASRM guidance (separate engine). Septic abortion → blood + cervical/endometrial cultures + broad-spectrum antibiotics + uterine evacuation in parallel.
   advance: Differential narrowed and routed; primary miscarriage management arm or alternative pathway selected
7. 7DIFFERENTIAL
   Ectopic pregnancy (PUL pattern, abnormal β-hCG, adnexal mass / free fluid; ob.ectopic-pregnancy.v1); molar pregnancy (β-hCG above expected, snowstorm US, theca lutein cysts); subchorionic hemorrhage (US bleed with viable IUP — better prognosis but counsel risk); cervical/vaginal pathology (cervicitis, polyp, lesion as bleeding source not from pregnancy); intrauterine infection / chorioamnionitis (later GA); gestational trophoblastic disease.
   advance: Differential confirmed; primary diagnosis anchored as miscarriage phenotype OR alternative diagnosis routed
8. 8RISK_STRATIFICATION
   Stratify by phenotype + hemodynamic stability + infection status + Rh status + patient preference. STABLE incomplete/missed/inevitable without sepsis → all three arms (expectant / medical / surgical) acceptable. UNSTABLE (hemorrhagic shock OR septic) → surgical evacuation + immediate IV access + antibiotics if septic. SEPTIC → mandatory antibiotic bundle + uterine evacuation in parallel. RH-NEGATIVE → Rho(D) IG within 72 h regardless of arm. Anticoagulated / bleeding diathesis / chronic steroids / IUD in place → surgical preferred over medical.
   inputs: maternal_bp, maternal_hr, maternal_temperature, maternal_rh_status
   advance: Management-arm decision documented with rationale; risk-stratified urgency assigned
9. 9TREATMENT
   EXPECTANT MANAGEMENT (non-pharm; success ~ 80% at 8 wk for incomplete, ~ 50% for missed; 4-8 wk timeline; ACOG PB 200 PMID 30157093 acceptable for stable patients). MEDICAL: mifepristone 200 mg PO ×1 followed by misoprostol 800 µg vaginally 24 h later — complete expulsion 83.8% per Schreiber 2018 PreFaiR NEJM (PMID 29874535) vs 67.1% misoprostol alone (RR 1.25, 95% CI 1.09-1.43); uterine aspiration 8.8% vs 23.5% — mifepristone pretreatment is now standard. SURGICAL: manual vacuum aspiration (MVA) in office under local OR D&C in OR with anesthesia; ~ 99% success; preferred if hemodynamic instability, septic abortion, medical failure, patient preference, or contraindications to medical (IUD, bleeding diathesis, anticoagulation, chronic steroids). RHO(D) IMMUNE GLOBULIN 300 µg IM ×1 within 72 h for all Rh-negative patients (ACOG PB 200; some protocols use 50 µg up to 12 wk if first trimester). SEPTIC ABORTION BUNDLE: broad-spectrum IV antibiotics (cefoxitin 2 g IV q6h OR ampicillin-sulbactam 3 g IV q6h ± gentamicin 5 mg/kg IV daily + clindamycin 900 mg IV q8h if polymicrobial or post-procedure) + uterine evacuation in parallel + sepsis bundle (lactate, blood cultures, fluid resuscitation per SSC 2026); do NOT defer evacuation pending antibiotic effect — source control is essential. Pain control (NSAIDs e.g. ibuprofen 600 mg PO q6h; opioids as needed).
   inputs: patient_preference_for_management_arm, maternal_rh_status, gestational_age_by_lmp_or_us
   advance: Management arm initiated (or surgical evacuation completed if septic/unstable); Rho(D) IG given if Rh-negative; antibiotics started if septic; pain control prescribed
10. 10DISPOSITION
    OUTPATIENT for stable patients on expectant or medical management with reliable follow-up + return precautions (heavy bleeding > 2 pads/h for 2 h, fever, severe pain, fainting). OUTPATIENT OFFICE-BASED SURGICAL (MVA) for stable patients with available trained provider. ED for hemorrhagic shock, suspected septic abortion, or acute heavy bleeding. INPATIENT for septic abortion with sepsis bundle, hemorrhagic instability requiring blood products, or surgical evacuation requiring anesthesia.
    inputs: maternal_bp
    advance: Level of care set; outpatient follow-up scheduled with return precautions OR admission for septic/unstable patients
11. 11MONITORING
    EXPECTANT: weekly clinical assessment + symptom tracking; US at 1-2 wk to confirm passage; β-hCG to negativity (typically 4-6 wk; longer if molar). MEDICAL: clinical assessment + US 1-2 wk after misoprostol; β-hCG to negativity. SURGICAL: US within 1-2 wk if any concern; β-hCG to negativity. ALL ARMS: monitor for hemorrhage (CBC if active bleeding), infection (fever, foul discharge), retained products (persistent bleeding > 2 wk; reassess); follow-up at 1-2 wk and 4-6 wk minimum. Rho(D) IG documentation in record.
    inputs: cbc_with_diff, serum_quantitative_beta_hcg
    actions: panel.cbc
    advance: Passage confirmed by US or β-hCG negative; no infection / hemorrhage / retained products
12. 12FOLLOWUP
    CONTRACEPTION counseling — patients can attempt conception again immediately or after 1-2 cycles per preference (no longer routine 2-3 cycle wait); IUD can be placed immediately post-procedure if desired; combined OCPs and other methods all acceptable. GRIEF support — many patients experience real grief at any GA; offer referral to perinatal loss support / counseling; partner often grieves too. STI screen if septic abortion. RECURRENT LOSS workup (antiphospholipid antibodies, karyotype, hysterosalpingogram or saline-infusion sonohysterogram, thrombophilia panel) if ≥ 2-3 losses (separate engine ob.recurrent-pregnancy-loss.v1, not built). Reassure 80-90% chance of subsequent successful pregnancy after one loss. Postpartum mental health screen (EPDS).
    advance: Contraception counseling delivered; grief support offered; recurrent loss workup initiated if indicated; subsequent-pregnancy plan documented