Address desire for future pregnancy or contraception
No additional workup is necessary after EPL unless a patient is experiencing recurrent pregnancy loss. We do recommend discussing plans for future conception. If a patient wants to conceive again as soon as possible, she can start trying when she feels emotionally ready (even before her next menstrual period). One study found that the ability to conceive and those pregnancy outcomes were the same when patients were randomly assigned to start trying immediately versus waiting 3 months after EPL.32
Alternatively, a patient may want to prevent pregnancy after EPL, and this information should be explicitly elicited and addressed with comprehensive contraception counseling as needed. All forms of contraception can be initiated immediately on successful management of EPL. All contraceptive methods, including an intrauterine device, can be initiated immediately following uterine aspiration.1,33,34
Patients should be reminded that if they delay contraception initiation by more than 7 days, they are potentially at risk for pregnancy.35 Most importantly, clinicians should not make assumptions about future pregnancy desires and should ask open-ended questions to provide appropriate patient counseling.
Finally, patients may feel additional anxiety in a subsequent pregnancy. It is helpful to acknowledge this and perhaps even offer earlier and more frequent visits in early pregnancy to help reduce anxiety. EPL is commonly experienced, and unfortunately it is sometimes poorly addressed by clinicians.
We hope this guidance will help you provide excellent, evidence-based, and sensitive care that will not only manage your patient’s EPL but also make the experience as positive as possible. ●
Key takeaways
- Early pregnancy loss (EPL) is common, occurring in up to 15% to 20% of clinically recognized pregnancies.
- EPL can be managed expectantly, with medication, or by uterine aspiration.
- There are virtually no contraindications to uterine aspiration.
- Contraindications to expectant or medication management include any situation in which heavy, unsupervised bleeding might be dangerous.
- In the absence of contraindications, patient preference should dictate the management approach.
- Mifepristone-misoprostol is more effective than misoprostol alone.
- Manual uterine aspiration in the outpatient setting is the most cost-effective approach to uterine evacuation.
- Rh testing is not necessary at less than 8 weeks’ gestation if choosing uterine aspiration, or at less than 10 weeks’ gestation if choosing expectant or medication management.
- Antibiotic prophylaxis is indicated for uterine aspiration, but not for expectant or medication management.
- Ultrasonography follow-up should focus on presence or absence of gestational sac.
- There are viable telemedicine and phone follow-up options that do not require repeat ultrasonography or in-person evaluation.
- There is no need to delay future conception once EPL management is confirmed to be complete.
- It is okay to initiate any contraceptive method immediately on completed management of EPL.
- Feelings toward EPL can be complex and varied; it is helpful to normalize your patients’ experiences, ask open-ended questions, and provide support as needed.