ob.miscarriage.v1PRODUCTION

ob.miscarriage.v1

Early Pregnancy Loss / Miscarriage

obstetricsacutesubacuteadultpregnancy

Hard-required inputs

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Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

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

Actions

Advance rule

Set

Advance when

GA + phenotype documented; pretest probability + ectopic risk + management-arm framework set

Patient inputs (16)

prior_pregnancy_outcomes_and_losses*history • CONTEXT

not present

Prior loss(es) count; ≥ 2-3 losses triggers recurrent pregnancy loss workup (separate engine) and influences emotional support

maternal_rh_status*history • CONTEXT

Rh-negative + first-trimester pregnancy loss → Rho(D) immune globulin 300 µg IM within 72 h per ACOG PB 200 (PMID 30157093)

bleeding_diathesis_or_anticoagulation*history • CONTEXT

not present

Bleeding diathesis or anticoagulation is a contraindication to mifepristone medical management; surgical evacuation preferred

prior_cesarean_or_uterine_surgery*history • CONTEXT

not present

Prior cesarean / uterine surgery raises uterine rupture risk with misoprostol; cautious dosing or surgical preference

gestational_age_by_lmp_or_us*demographic • FRAME

GA dictates US findings (gestational sac size, CRL, cardiac activity expectations); SRU non-viability criteria CRL ≥ 7 mm or sac ≥ 25 mm

serum_quantitative_beta_hcg*lab • INITIAL_WORKUP

Trend β-hCG (doubling 48-72 h vs plateau/fall); discriminatory zone for IUP visibility (~ 3500 mIU/mL TVUS); PUL workup

cbc_with_diff*lab • INITIAL_WORKUP

Hemoglobin for hemorrhage severity; leukocytosis for septic abortion suspicion

blood_type_and_rh*lab • INITIAL_WORKUP

Rh status drives Rho(D) IG decision; type and screen for crossmatch readiness if surgical

transvaginal_ultrasound_early_pregnancy*imaging • INITIAL_WORKUP

not present

Defining imaging — IUP confirmation (gestational sac + yolk sac + fetal pole + cardiac activity); SRU criteria for non-viability (CRL ≥ 7 mm no cardiac OR sac ≥ 25 mm empty); subchorionic hemorrhage; ectopic exclusion

maternal_bp*vital • RED_FLAGS

Hypotension → hemorrhagic shock; orthostatic vitals to grade volume status

maternal_hr*vital • RED_FLAGS

Tachycardia → volume depletion / sepsis / pain

maternal_temperature*vital • RED_FLAGS

Fever > 38°C raises septic abortion concern; mandates broad-spectrum antibiotics + uterine evacuation

patient_preference_for_management_arm*history • TREATMENT

not present

Shared decision-making: expectant vs medical vs surgical; all three are first-line for stable patients with confirmed early pregnancy loss

iud_in_place_or_recent_iud_removalhistory • CONTEXT

not present

IUD in place is a contraindication to mifepristone and raises ectopic risk; document and counsel

chronic_systemic_corticosteroid_usehistory • CONTEXT

not present

Chronic systemic corticosteroid use is a contraindication to mifepristone

std_screen_if_septic_or_high_risklab • INITIAL_WORKUP

Chlamydia/gonorrhea/HIV/syphilis if septic abortion concern; baseline STI history

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (6)

6 need judgement

informationallife_threateningmiscarriage_septic_abortion_emergency
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.
Trigger could not be auto-evaluated — needs clinician judgement.
informationallife_threateningmiscarriage_hemorrhagic_shock_emergency
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.
Trigger could not be auto-evaluated — needs clinician judgement.
informationalmoderatemiscarriage_medical_management_first_line
Stable patient choosing medical management with no contraindications → mifepristone 200 mg PO ×1 then misoprostol 800 µg vaginally 24 h later (Schreiber 2018 PreFaiR NEJM PMID 29874535); 83.8% complete expulsion vs 67.1% misoprostol alone (RR 1.25, 95% CI 1.09-1.43); clinical/US assessment 1-2 wk.
Trigger could not be auto-evaluated — needs clinician judgement.
informationalmoderatemiscarriage_recurrent_loss_workup
Recurrent pregnancy loss ≥ 2-3 losses → workup includes antiphospholipid antibodies, karyotype, hysterosalpingogram or saline-infusion sonohysterogram, thrombophilia panel; route to ob.recurrent-pregnancy-loss.v1 (separate engine, not built in this wave).
Trigger could not be auto-evaluated — needs clinician judgement.
informationalmildmiscarriage_stable_outpatient_shared_decision
Stable patient with confirmed early pregnancy loss + no infection + no hemodynamic instability + no contraindications → shared decision-making among expectant / medical (mifepristone + misoprostol per Schreiber 2018 PMID 29874535) / surgical (MVA or D&C) per ACOG PB 200 (PMID 30157093); Rho(D) IG if Rh-negative.
Trigger could not be auto-evaluated — needs clinician judgement.
informationalmildmiscarriage_rh_negative_alloimmunisation_prophylaxis
Rh-negative maternal blood type + any first-trimester pregnancy loss (spontaneous or after procedure) → Rho(D) immune globulin 300 µg IM ×1 within 72 h per ACOG PB 200 (PMID 30157093); some protocols accept 50 µg if confirmed first trimester only.
Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

This dossier does not reference any calculators.

Recommended regimen

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

axis: miscarriage_management_pathwaysstep expectant_management - Expectant management — wait for spontaneous passage (ACOG PB 200 PMID 30157093)

Selected step "Expectant management — wait for spontaneous passage (ACOG PB 200 PMID 30157093)" — Hemodynamically stable, no signs of infection, patient prefers expectant approach, willing to accept 4-8 wk timeline, reliable follow-up

expectant waiting for spontaneous passage
first line
observation_strategy
triggers: stable_patient_with_confirmed_early_pregnancy_loss_preferring_expectant
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.

outpatient playbook — drug actions (4)

1. mifepristone PO once
rxcui 6964
200 mg PO • PO • single dose
trigger: Medical management chosen, no contraindications
Schreiber 2018 PreFaiR PMID 29874535
2. misoprostol vaginal 24 h later
rxcui 42331
800 µg vaginally • vaginal • 24 h after mifepristone
trigger: Medical management 24 h after mifepristone
Schreiber 2018 PreFaiR; counsel heavy bleeding + cramping 4-24 h post-dose
3. Rho(D) immune globulin
rxcui 35465
300 µg IM • IM • single dose within 72 h
trigger: Rh-negative blood type
ACOG PB 200 PMID 30157093
4. ibuprofen PRN for cramping
600 mg PO q6h PRN • PO • q6h PRN
trigger: Cramping pain
NSAID first-line; counsel can be used during medical management

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: First-trimester vaginal bleeding (any amount) — most common entry to miscarriage workup (ACOG PB 200 PMID 30157093); 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).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Early Pregnancy Loss / Miscarriage** (ob.miscarriage.v1).
Phenotype framing: 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.
Scope: 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.

No severity triggers fired against current inputs.

Plan

Regimen axis: **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** — step "Expectant management — wait for spontaneous passage (ACOG PB 200 PMID 30157093)".
1. expectant waiting for spontaneous passage (observation_strategy, first line) — 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.

Setting playbook (outpatient) — Manage stable patients with confirmed early pregnancy loss via shared decision-making among expectant / medical / surgical arms; deliver Rho(D) IG if Rh-negative; arrange follow-up + grief support
2. mifepristone PO once 200 mg PO PO single dose — Medical management chosen, no contraindications (Schreiber 2018 PreFaiR PMID 29874535)
3. misoprostol vaginal 24 h later 800 µg vaginally vaginal 24 h after mifepristone — Medical management 24 h after mifepristone (Schreiber 2018 PreFaiR; counsel heavy bleeding + cramping 4-24 h post-dose)
4. Rho(D) immune globulin 300 µg IM IM single dose within 72 h — Rh-negative blood type (ACOG PB 200 PMID 30157093)
5. ibuprofen PRN for cramping 600 mg PO q6h PRN PO q6h PRN — Cramping pain (NSAID first-line; counsel can be used during medical management)

Non-pharmacologic actions:
- Counsel return precautions (heavy bleeding > 2 pads/h x 2 h, fever, severe pain, fainting)
- Schedule clinical + US follow-up 1-2 wk
- Offer grief support resources + perinatal loss counseling
- Contraception counseling for subsequent pregnancy planning

AVOID / contraindication checks:
- Mifepristone contraindicated IUD in place chronic systemic corticosteroids hemorrhagic disorder anticoagulation allergy (FDA labeling; Schreiber 2018 PMID 29874535)
- Misoprostol caution prior cesarean or uterine surgery uterine rupture risk
- Surgical evacuation mandatory for hemodynamic instability or septic abortion regardless of patient preference (ACOG PB 200 PMID 30157093)
- Rho(D) IG within 72h for all Rh negative patients with pregnancy loss (ACOG PB 200)
- Septic abortion requires parallel antibiotics AND uterine evacuation source control not antibiotics alone (ACOG PB 200)
- Do not delay uterine evacuation pending antibiotic effect in septic abortion
- Counsel return precautions heavy bleeding greater than 2 pads per hour x 2 h fever severe pain fainting after expectant or medical management

Monitoring

Regimen monitoring:
- Expectant: weekly clinical assessment + US at 1-2 wk
- Medical: clinical + US 1-2 wk after misoprostol; β-hCG to negativity
- Surgical: clinical 1-2 wk post-procedure; US if any concern; β-hCG to negativity
- CBC if active bleeding
- Temperature + signs of infection at each follow-up
- Rho(D) IG documentation in record
- β-hCG trended to undetectable (typically 4-6 wk; longer if molar)

Setting (outpatient) monitoring:
- Symptom diary + bleeding pattern
- Follow-up US at 1-2 wk
- β-hCG to negativity over 4-6 wk

Follow-up plan: 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).
- Close-out criterion: Contraception counseling delivered; grief support offered; recurrent loss workup initiated if indicated; subsequent-pregnancy plan documented

Monitoring phase: 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.

Disposition

Current setting: outpatient — Manage stable patients with confirmed early pregnancy loss via shared decision-making among expectant / medical / surgical arms; deliver Rho(D) IG if Rh-negative; arrange follow-up + grief support

Disposition criteria:
- Successful passage confirmed + β-hCG trending to negative + no infection / hemorrhage → routine follow-up + contraception + grief support

Escalation triggers (move to higher acuity):
- 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

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] 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.
- [MODERATE] Stable patient choosing medical management with no contraindications → mifepristone 200 mg PO ×1 then misoprostol 800 µg vaginally 24 h later (Schreiber 2018 PreFaiR NEJM PMID 29874535); 83.8% complete expulsion vs 67.1% misoprostol alone (RR 1.25, 95% CI 1.09-1.43); clinical/US assessment 1-2 wk.

Citations

- ACOG Practice Bulletin 200 (2018) Early Pregnancy Loss + Schreiber 2018 NEJM PreFaiR RCT for mifepristone+misoprostol vs misoprostol alone [PMID:29874535](https://pubmed.ncbi.nlm.nih.gov/29874535/)
- Cited evidence (PMID 30157093) [PMID:30157093](https://pubmed.ncbi.nlm.nih.gov/30157093/)

Last reconciled with current guidelines: 2026-05-26.

References

ACOG Practice Bulletin 200 (2018) Early Pregnancy Loss + Schreiber 2018 NEJM PreFaiR RCT for mifepristone+misoprostol vs misoprostol alone — PMID:29874535
Cited evidence (PMID 30157093) — PMID:30157093