ACOG Releases New Recommendations on Early Pregnancy Loss

April 21, 2015

Washington, DC — Early pregnancy loss, or miscarriage, is a tragic yet common event, occurring in approximately ten percent of all clinically recognized pregnancies. Because of this, obstetrician-gynecologists must be prepared to care for patients and offer the full range of options for the management of early pregnancy loss, according to new guidelines from the American College of Obstetricians and Gynecologists (the College). The recommendations on “Early Pregnancy Loss” are presented in a Practice Bulletin released today by the College.

Most pregnancy losses occur in the first trimester, hence the importance of the new guidelines. According to the Practice Bulletin, approximately 50 percent of all cases of early pregnancy loss are due to fetal chromosomal abnormalities, and the most common risk factors are advanced maternal age and prior early pregnancy loss. The risk for miscarriage for women aged 20 to 30 years is between nine and 17 percent; this rate increases sharply from 20 percent at age 35 years to 40 percent at age 40 years and 80 percent at age 45 years.

“These recommendations serve to help guide providers in making appropriate decisions, as well as aide in counselling our patients. This Practice Bulletin, in particular, will help ob-gyns in better dealing with a common and yet emotionally devastating situation for pregnant women—early pregnancy loss,” stated Jeffrey M. Rothenberg, MD, Chair of the College’s Committee on Practice Bulletins—Gynecology, the Committee responsible for the new document.

Since there is overlap of common symptoms of early pregnancy loss with other obstetric conditions, including normal gestation, ectopic pregnancy, and molar pregnancy, it is important to distinguish early pregnancy loss from other early pregnancy complications prior to initiating treatment. The Practice Bulletin recommends a combination of a thorough medical history, physical examination, ultrasound and a pregnancy hormone blood test in order to make a highly certain diagnosis.

Once an early pregnancy loss is diagnosed, there are three accepted management options: expectant management, medical treatment or surgical evacuation. Studies have demonstrated that all three options result in complete evacuation of pregnancy tissue in most patients and serious complications are rare. Patients should be counseled about the risks and benefits of each option. In women without medical complications or symptoms requiring urgent surgical evacuation, treatment plans can safely accommodate patient preferences.

“Research has shown that women have strong and diverse preferences for how their early pregnancy loss is managed and report higher satisfaction when treated in accordance with these preferences. We believe clinicians who are prepared to offer all management options to their patents provide higher quality care,” said Jody Steinauer, MD, MAS, Professor of Obstetrics, Gynecology and Reproductive Services at the University of California, San Francisco, and Director of the Managing Early Pregnancy Loss initiative, an educational website that provides e-learning, online resources, practice integration tools, and patient education material for evidence-based, patient-centered early pregnancy loss management.

Practice Bulletin #150, “Early Pregnancy Loss” is published in the May issue of Obstetrics & Gynecology.

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The following recommendations are also published in the May issue of Obstetrics & Gynecology:

Committee Opinion #631 “Screening for Perinatal Depression” (Revised)

ABSTRACT: Perinatal depression, which includes major and minor depressive episodes that occur during pregnancy or in the first 12 months after delivery, is one of the most common medical complications during pregnancy and the postpartum period, affecting one in seven women. It is important to identify pregnant and postpartum women with depression because untreated perinatal depression and other mood disorders can have devastating effects on women, infants, and families. Several screening instruments have been validated for use during pregnancy and the postpartum period. Although definitive evidence of benefit is limited, the American College of Obstetricians and Gynecologists recommends that clinicians screen patients at least once during the perinatal period for depression and anxiety symptoms using a standardized, validated tool. Although screening is important for detecting perinatal depression, screening by itself is insufficient to improve clinical outcomes and must be coupled with appropriate follow-up and treatment when indicated; clinical staff in obstetrics and gynecology practices should be prepared to initiate medical therapy, refer patients to appropriate behavioral health resources when indicated, or both.

Committee Opinion #632 “Endometrial Intraepithelial Neoplasia” (NEW!)

ABSTRACT: Endometrial hyperplasia is of clinical significance because it is often a precursor lesion to adenocarcinoma of the endometrium. Making the distinction between hyperplasia and true precancerous lesions or true neoplasia has significant clinical effect because their differing cancer risks must be matched with an appropriate intervention to avoid undertreatment or overtreatment. Pathologic diagnosis of premalignant lesions should use criteria and terminology that clearly distinguish between clinicopathologic entities that are managed differently. At present, the endometrial intraepithelial neoplasia schema is tailored most closely to this objective, incorporating modified pathologic criteria based upon evidence that has become available since the creation of the more widely used 1994 four-class World Health Organization schema (in which atypical hyperplasia is equated with precancerous behavior). The accuracy of dilation and curettage compared with endometrial suction curette in diagnosing precancer and excluding concurrent carcinoma is unclear. Hysteroscopy with directed biopsy is more sensitive than dilation and curettage in the diagnosis of uterine lesions. When clinically appropriate, total hysterectomy for endometrial intraepithelial neoplasia provides definitive assessment of a possible concurrent carcinoma and effectively treats premalignant lesions. Systemic or local progestin therapy is an unproven but commonly used alternative to hysterectomy that may be appropriate for women who are poor surgical candidates or who desire to retain fertility.

The American College of Obstetricians and Gynecologists (The College), a 501(c)(3) organization, is the nation’s leading group of physicians providing health care for women. As a private, voluntary, nonprofit membership organization of approximately 58,000 members, The College strongly advocates for quality health care for women, maintains the highest standards of clinical practice and continuing education of its members, promotes patient education, and increases awareness among its members and the public of the changing issues facing women’s health care. The American Congress of Obstetricians and Gynecologists (ACOG), a 501(c)(6) organization, is its companion organization.

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