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Pregnancy loss in the first trimester has traditionally been treated with one of two methods: expectant care or operating room dilatation and curettage.
A nonviable intrauterine pregnancy up to 20 weeks of gestation is commonly described as pregnancy loss, often known as a miscarriage or spontaneous abortion is the most prevalent type of pregnancy loss that occurs in the first trimester. Women who have lost a pregnancy have three options for treatment: expectant, pharmacological, or surgical therapy. The benefits and dangers of each method differ depending on the gestational age of the nonviable pregnancy, but they are all generally safe.
Pregnancy loss in the first trimester has traditionally been treated with one of two methods: expectant care or operating room dilatation and curettage. Women now have more options in the outpatient setting, which are less expensive and can be done in more private settings. Pregnancy loss happens spontaneously in about 15-20% of pregnancies before 14 weeks of gestation. Because of the lack of established terminology, describing first trimester losses can be unclear. The word “blighted ovum” has mostly been phased out. However, there is still disagreement over phrases like “anembryonic pregnancy” and “missed abortion,” which are still widely used.
There are three options for managing a spontaneous pregnancy loss: expectant, medicinal, or surgical. Gestational age, whether the pregnancy loss is delayed or complete, maternal hemodynamic stability, the presence of infection, and, most significantly, patient preference all play a role in determining the best course of action.
When a woman undergoes spontaneous pregnancy loss, expectant management is frequently the first therapy option. Women who chose this route should be advised that total expulsion could take up to one month. Approximately 50% of women desire surgical management by day seven after diagnosis, and 70% by day 14. The emotional cost of delaying the end of the pregnancy loss process might be substantial. Making a quick intervention is often a more wise option.
Medical management may be a good option for women who have experienced a delayed pregnancy loss and want as little intervention as possible. Misoprostol, a prostaglandin E1 analogue, is commonly used as the first line of treatment. In around 80% of women with incomplete or delayed pregnancy loss in the first trimester, misoprostol completes pregnancy evacuation. The advantage of Medical termination is that it is economical and does not involve anesthesia. The disadvantage is that the process may get prolonged and one may still need surgical evacuation.
Sharp curettage, electronic vacuum aspiration (EVA), manual vacuum aspiration (MVA), a combination of vacuum aspiration, or sharp curettage can be some options to treat spontaneous first-trimester pregnancy loss. The standard approach is EVA. It is done with an electric suction device and a stiff curette in the operating room, and it usually involves general, intravenous, or spinal anesthesia. Its effectiveness and side effects have been well researched. MVA is conducted with a flexible curette attached to a 60-mL syringe capable of applying negative pressure equivalent to EVA. It is safe to use MVA devices in less than a 12-week pregnancy. If performed improperly it may lead to damage to uterus and injury to bowel and blood vessels.
Doctors should prioritize the preference of the well-informed patients in the management of first-trimester pregnancy loss. For hemodynamically stable women with incomplete pregnancy loss, having an expectant or medicinal management may be the best option. The use of vaginal misoprostol, 800 mg, is one of the most effective regimens for medical management of delayed loss, with completion rates of 80%. Surgical management should be explored in patients who chose it as their primary treatment option. Also, those who have failed to respond to anticipated or medicinal treatment can opt for surgery. MVA is less expensive and more efficient than EVA in the operating room, especially, when performed in the office while maintaining or improving safety and efficacy.