What are the recommended steps for diagnosing early pregnancy loss in a primary care setting?

Recommended steps for diagnosing early pregnancy loss in primary care:

• Assess women presenting with pain and/or bleeding in early pregnancy clinically, including history and symptoms, to determine urgency and need for referral.
• For women with bleeding but no pain and pregnancy less than 6 weeks gestation without risk factors, consider expectant management with advice to return if symptoms worsen and to repeat a urine pregnancy test after 7 to 10 days. A negative test confirms miscarriage; a positive test requires further assessment.
• Refer women with pain, bleeding at or beyond 6 weeks gestation, or uncertain gestation to an early pregnancy assessment service (EPAS) or out-of-hours gynaecology service for further evaluation within 24 hours if clinically indicated.
• Explain to women the reasons for referral and what to expect at the EPAS, including ultrasound scanning and possible blood tests.
• At the EPAS, a transvaginal ultrasound scan is offered to identify pregnancy location and viability (presence of fetal pole and heartbeat). If transvaginal scan is unacceptable, a transabdominal scan may be offered with explanation of limitations.
• Serum human chorionic gonadotrophin (hCG) measurements are used to assess trophoblastic activity and guide management, not to locate the pregnancy. Two hCG measurements approximately 48 hours apart are taken to assess trends.
• Women with decreasing hCG levels (>50% decrease) are likely miscarrying but require follow-up with a urine pregnancy test 14 days after the second hCG test to confirm resolution.
• Women with increasing hCG levels (>63% increase) are likely to have a developing intrauterine pregnancy but require ultrasound follow-up to confirm location and viability.
• Women with hCG changes that do not meet these thresholds require urgent clinical review within 24 hours.
• Provide women with written information on when and how to seek urgent help if symptoms worsen or new symptoms develop, including 24-hour contact details.

These steps ensure timely and sensitive diagnosis of early pregnancy loss and appropriate referral for specialist assessment and management in line with NICE guideline NG126 ¹.