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Things I Do But Should I: Post Miscarriage

Vanessa Cardy, MD and Adrien Selim, MD
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Discuss management of that patient who has suffered a spontaneous miscarriage with focus on confirming that the miscarriage has completed as well as how long patients should wait post miscarriage before attempting conception again.

Pearls:

  • Confirmed complete first trimester miscarriage after expectant, medical or surgical management does not require serial beta-HCG.

  • You can confirm a miscarriage by ultrasound or one week HCG.

  • Situations where serial HCG may be needed include: ectopic pregnancy, gestational trophoblastic neoplasia, and retained products of conception.

  • Women do not need to wait 3 months post miscarriage to attempt conception. They may begin when physically and emotionally ready.

 

  • You have a patient who you think has had a miscarriage. Are serial beta-HCGs until zero necessary?

    • For confirmed complete first trimester miscarriage after expectant, medical, or surgical management, seral beta-HCs are not needed.

  • How do you confirm a completed miscarriage?

    • ACOG recommends ultrasound to see an empty uterus.

    • AAFP recommends either ultrasound or HCG one week later to see a reduction by 80% of the beta-HCG value.

  • What are the situations where you will need serial beta-HCGs?

  1. Ectopic pregnancy: if still in differential (ie: never confirmed intrauterine pregnancy).

  2. Gestational trophoblastic neoplasia (GTN): group of diseases that occur most commonly following molar pregnancy but can also occur after miscarriage or term pregnancy. May often present as abnormal uterine bleeding (AUB) following term pregnancy or miscarriage. Want follow serial HCGs until negative.

  3. Retained products of conception: persistent pain or bleeding post miscarriage. HCG may also be negative if products are necrotic so test of choice is ultrasound. If ultrasound is inconclusive, serial HCG that increases or plateaus suggest retained products, ectopic, GTN, or ongoing pregnancy.

  • Do you recommend waiting 3 months to conceive after a miscarriage?

    • No evidence delaying conception post miscarriage will prevent any complications.

    • Women can begin again as soon as emotionally and medically ready.

    • Even though ACOG recommends abstaining from vaginal intercourse for 1-2 weeks post miscarriage, it is not evidence based.

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