Early Pregnancy Loss and Pregnancy Complications
Early pregnancy loss
Early pregnancy loss (EPL) is a nonviable intrauterine pregnancy before 13 weeks. Use strict ultrasound criteria to avoid misdiagnosis: no cardiac activity at crown–rump length ≥7 mm, or mean sac diameter ≥25 mm without an embryo, or no embryo/heartbeat on repeat scan after an appropriate interval. Management options-expectant, medical (misoprostol 800 mcg vaginally, with or without mifepristone pretreatment), or surgical (manual vacuum aspiration)-are all acceptable; choice depends on hemodynamic stability, infection, bleeding, and patient preference. Give Rh immune globulin to Rh-negative patients. Septic abortion requires antibiotics and urgent evacuation.
Pregnancy complications
Always exclude ectopic pregnancy in any patient with bleeding, pain, or a pregnancy of unknown location. Methotrexate is an option for a stable, unruptured ectopic with hCG below about 5,000 mIU/mL, no fetal cardiac activity, and mass <3.5–4 cm; follow day 4 and 7 hCG and expect a decline. Molar pregnancy presents with markedly elevated hCG, bleeding, and a snowstorm appearance; treat with suction evacuation and follow hCG. For preeclampsia prevention, low-dose aspirin is started at 12–16 weeks in high-risk patients. Short interpregnancy intervals and short cervix are associated with preterm birth.
Traps: diagnosing EPL on a single borderline scan, giving methotrexate when fetal cardiac activity is present, and missing ectopic pregnancy after a presumed miscarriage.
Rule of thumb: when the diagnosis is uncertain, repeat ultrasound and hCG rather than intervene; when EPL is diagnosed, offer all three management options and contraception.