Compare conditions

Put any two — or three — conditions side by side, adult or pediatric, to spot the look-alike differences fast, row by row.

Early Pregnancy Loss

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In one line

·A pregnancy that stops growing and ends before 20 weeks, most often because of a chromosome error the embryo could not survive.

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Normal physiology

·A sperm fertilizes an egg in the fallopian tube, and the new embryo travels down into the uterus and burrows into the lining (implantation). Cells divide in an exact pattern, hormones—especially human chorionic gonadotropin (hCG, the pregnancy hormone) and progesterone—rise steadily to support growth. The uterus stays relaxed, the cervix stays closed and firm, and blood vessels in the lining deliver oxygen and nutrients. By about 6 weeks, a heartbeat appears on ultrasound, and the embryo continues to grow week by week.

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What goes wrong

·The pregnancy stops growing. The embryo or early fetus dies, hormone levels drop, and the body begins to expel the tissue through cramping and bleeding.

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Hallmark signs

·Vaginal bleeding
·Cramping or pain low in the belly
·Passing clots or tissue from the vagina
·Pregnancy symptoms suddenly stop (breast tenderness goes away, nausea disappears)
·Ultrasound shows an empty gestational sac or a sac that is too small for the dates
·Beta-hCG hormone level stops rising normally or starts to drop
·No fetal heartbeat seen on ultrasound when the embryo is big enough to have one
·Heavy bleeding soaking through more than one pad per hour, or feeling dizzy and weak

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Red flags · escalate now

·Soaking through more than one thick pad per hour for two hours in a row—this can mean dangerous bleeding.
·Severe belly pain on one side, or pain in the shoulder tip—this can mean the pregnancy is in the fallopian tube (ectopic) and the tube may be tearing.
·Feeling very dizzy, weak, or like you might faint—this can mean you have lost too much blood and your body is going into shock.
·Fever (temperature over 100.4°F or 38°C) or foul-smelling vaginal discharge—this can mean an infection in the uterus that needs antibiotics right away.
·Severe, constant pain that does not ease up—this can mean tissue is stuck in the cervix (opening of the womb) or there is another serious problem.

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Workup

·Quantitative serum beta-hCG
·Transvaginal pelvic ultrasound
·Complete blood count (CBC)
·Rh blood type and antibody screen
·White blood cell count (WBC) and C-reactive protein (CRP) if infection suspected
·Blood type and screen (for transfusion readiness)

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Treatment

·Expectant management (waiting 1–4 weeks for the body to complete the miscarriage naturally)
·Misoprostol 800 mcg placed in the vagina (can repeat once after 24 hours if tissue does not pass)
·Suction dilation and curettage (D&C) under anesthesia
·Anti-D immunoglobulin (RhoGAM) 300 mcg intramuscular injection if mother is Rh-negative
·Broad-spectrum intravenous antibiotics (such as clindamycin plus gentamicin) if septic miscarriage suspected
·Pain control with ibuprofen 600–800 mg every 6–8 hours, or acetaminophen with codeine for severe cramping
·Counseling about recurrence risk and workup after two or more consecutive losses

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NCLEX trap

·Some bleeding in early pregnancy is threatened miscarriage (the pregnancy might survive), but many cases are already pregnancy loss (the pregnancy will not survive). Ultrasound plus bHCG trends tell you which one it is. Never guess — always check.
·Check the mother's Rh type first. Only Rh-negative mothers need anti-D to protect future babies. Rh-positive mothers do not need it and should not get it.
·Heavy bleeding and cramping in early pregnancy loss needs: (1) a blood count to check if she is anemic, (2) IV access ready in case she needs urgent D&C (a procedure to clean out the uterus), and (3) antibiotics only if she shows signs of infection (fever, foul-smelling discharge, uterus hurts when you press it). Safety first, then treat what you find.
·Offer three safe choices: (1) wait 1–4 weeks for the body to pass the tissue on its own (expectant), (2) take misoprostol medicine to speed it up (medical), or (3) have a D&C now (surgical). Each is safe when done right. Let the patient choose unless infection or heavy bleeding forces D&C right away.
·One early pregnancy loss does not raise the risk of losing the next pregnancy. After two or more losses in a row, check for antiphospholipid syndrome (sticky blood that causes clots) or uterus shape problems. One loss is bad luck, not a pattern yet.
·Ectopic pregnancy also causes bleeding and cramping and can have a low bHCG. Transvaginal ultrasound must find the pregnancy sac inside the uterus, not outside. If you see no sac inside when bHCG is high enough (above 1,500–2,000), think ectopic and act fast — it can rupture and cause life-threatening bleeding inside the belly.

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