Early Pregnancy Loss · Expectant vs Medical vs Surgical

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] Hemodynamics/infection + preference/gestation
   Hemodynamically stable/any infection? Patient preference and gestation?
   • Hemodynamically unstable, heavy bleeding, or infection (septic) → Unstable/bleeding/sepsis → emergency evacuation
   • Stable, no infection — leaning non-surgical → Stable · expectant vs medical
   • Leaning surgical/surgical indication (comorbidity, unwilling to wait, medical failure) → Surgery (suction/MVA)
2. [Decision] Stable · expectant vs medical
   Expectant or medical? (Stable incomplete/missed miscarriage may be expectant or medical, by patient preference.)
   • Expectant management → Expectant management
   • Medical management → Medical (mifepristone + misoprostol)
3. [End] Expectant management
   Expectant management: suits stable, uninfected patients; allow time (often 1–2 weeks or longer) for spontaneous expulsion; failure or bleeding/infection → switch to medical/surgical; do not judge completion by endometrial thickness alone.
4. [End] Medical (mifepristone + misoprostol)
   Medical management: mifepristone 200 mg oral → 24 h later misoprostol 800 mcg vaginal (repeat if needed), higher complete expulsion than misoprostol alone (83.8% vs 67.1%) with less need for surgery; without mifepristone, misoprostol 600–800 mcg alone, repeat at ≥3 h intervals; give anti-D immunoglobulin if Rh-negative.
5. [End] Surgery (suction/MVA)
   Surgical management (suction curettage/manual vacuum aspiration MVA or curettage): comorbidity, bleeding, infection, medical failure or patient preference; quick completion, low complications; give anti-D if Rh-negative.
6. [End] Unstable/bleeding/sepsis → emergency evacuation
   Hemodynamically unstable/heavy bleeding/septic abortion → emergency surgical evacuation + resuscitation (fluids, transfusion if needed) + broad-spectrum antibiotics; address other issues once stable.

Source guidelines & references

• Early pregnancy loss management (ACOG Practice Bulletin 200; Schreiber NEJM 2018 mifepristone pretreatment)

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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