Patient handout

Early Pregnancy Loss / Miscarriage

PRODUCTION

1. Your condition

This handout is for early pregnancy loss / miscarriage. Your care team identified this based on: first-trimester vaginal bleeding (any amount) — most common entry to miscarriage workup (acog pb 200 pmid 30157093).

Other reasons your team may use this plan: passage of pregnancy tissue / products of conception with or without bleeding — inevitable/incomplete/complete spectrum; tvus without cardiac activity at crl ≥ 7 mm (doan/sru non-viability criterion) or empty gestational sac ≥ 25 mm — missed abortion/anembryonic gestation (acog pb 200 pmid 30157093); first-trimester pelvic pain or cramping with bleeding — threatened or inevitable miscarriage; rule out ectopic.

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
expectant waiting for spontaneous passage	—	—	—	PregCat: N/A — observation strategy. \| Lactation: N/A — pre-delivery scenario. \| ACOG PB 200 (PMID 30157093) supports expectant management for stable patients; success ~ 80% at 8 wk for incomplete miscarriage, ~ 50% for missed; counsel patient on timeline, return precautions (heavy bleeding > 2 pads/h for 2 h, fever, severe pain), and option to switch to medical or surgical at any time.

Plan: Miscarriage management pathways — expectant / medical (mifepristone + misoprostol per Schreiber 2018 PreFaiR NEJM PMID 29874535) / surgical (MVA / D&C) + Rho(D) IG per ACOG PB 200 PMID 30157093 + septic abortion antibiotic bundle

3. When to call your provider

Contact your care team if any of the following happen:

Heavy bleeding / hemodynamic instability → ED
Fever / signs of infection → ED for septic abortion bundle
No passage 1-2 wk after misoprostol → repeat misoprostol or surgical evacuation
Persistent retained products on US → surgical evacuation

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

Septic abortion — fever + foul discharge + uterine tenderness ± hypotension ± leukocytosis after pregnancy loss or procedure → IV broad-spectrum antibiotics (cefoxitin or ampicillin-sulbactam ± gentamicin + clindamycin) + uterine evacuation IN PARALLEL + sepsis bundle (SSC 2026) — source control essential, do NOT defer evacuation for antibiotic effect.(life-threatening)
Hemorrhagic shock from acute heavy bleeding with pregnancy loss — SBP < 90 / orthostatic collapse / tachycardia / hemoglobin drop → IV access x 2 + crystalloid + type and crossmatch + emergent surgical evacuation + blood products per CBC.(life-threatening)

5. Follow-up

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).

6. Sources

Guideline: ACOG Practice Bulletin 200 (2018) Early Pregnancy Loss + Schreiber 2018 NEJM PreFaiR RCT for mifepristone+misoprostol vs misoprostol alone