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Objective: While a number of glossaries have been produced by various authorities in different countries, at present there is no internationally accepted common set of definitions for many terms used to describe pregnancy losses. The objective of the current study was to provide a standardized French/English terminology/glossary relating to pregnancy losses., Methods: Literature review, construction of a glossary and rating of proposals using a formal consensus method. The glossary was subject of a critical comprehensive review by a meeting of professionals (multidisciplinary panel)., Results: A miscarriage is a spontaneous evacuation of an intra-uterine pregnancy<22WG. A missed early miscarriage is when ultrasound (<14WG) shows no growth of intra-uterine sac/embryo and/or loss of fetal heart activity. An early miscarriage is when spontaneous evacuation of intra-uterine pregnancy occurs <14WG. A complete early miscarriage is when there is no retained products of conception (empty uterus on ultrasound) and no bleeding nor pain. Incomplete early miscarriage is when ultrasonography shows retained products of conception in the uterine cavity (including cervical canal). Repeat miscarriage or recurrent pregnancy loss is when the woman experiences 3 or more consecutive miscarriages <14WG. A late miscarriage is when there is spontaneous evacuation of pregnancy ≥14WG and <22WG. A threatened late miscarriage is when shortening/opening of the cervix±uterine contraction occur ≥14WG and <22WG. An intra-uterine fetal demise is when there is a spontaneous loss of fetal heart activity ≥14 WG., Conclusion: The final current terminology should be used by all healthcare professionals., (Copyright © 2014 Elsevier Masson SAS. All rights reserved.)

Objectives: Study of epidemiology of pregnancy loss., Materials and Method: A systematic review of the literature was performed using Pubmed and the Cochrane library databases and the guidelines from main international societies., Results: The occurrence of first trimester miscarriage is 12% of pregnancies and 25% of women. Miscarriage risk factors are ages of woman and man, body mass index greater than or equal to 25kg/m(2), excessive coffee drinking, smoking and alcohol consumption, exposure to magnetic fields and ionizing radiation, history of abortion, some fertility disorders and impaired ovarian reserve. Late miscarriage (LM) complicates less than 1% of pregnancies. Identified risk factors are maternal age, low level of education, living alone, history of previous miscarriage, of premature delivery and of previous termination of pregnancy, any uterine malformation, trachelectomy, existing bacterial vaginosis, amniocentesis, a shortened cervix and a dilated cervical os with prolapsed membranes. Fetal death in utero has a prevalence of 2% in the world and 5/1000 in France. Its main risk factors are detailed in the chapter., (Copyright © 2014 Elsevier Masson SAS. All rights reserved.)

Objective: To assess early and late benefits and harms of different management options for first trimester miscarriage and for induction of labor and obtaining of uterine vacuity in case of fetal death beyond of 14weeks of gestation., Methods: French and English publications were searched using PubMed and Cochrane Library., Results: Concerning missed miscarriage, expectant management is not recommended (LE1) because it increases the risk of failure, need of unplanned surgical procedure and blood transfusion (LE1). Surgical uterine evacuation remains more effective than medical treatment using misoprostol (LE1), but both techniques involve rare and comparable risks (EL1). When chosen, medical treatment should be a vaginal dose of 800μg of misoprostol, possibly repeated 24 to 48hours later (EL2). Administration of mifepristone prior to misoprostol is not recommended (EL2). In case of incomplete miscarriage, expectant management can be offered because it does not increase the risk of complications, neither haemorrhagic nor infectious (EL1). Medical treatment using misoprostol is not recommended (EL2) because it does not improve the evacuation rate when compared to our first option, and does not reduce the risk of complications (EL2). Surgical uterine evacuation leads to high evacuation rate (97-98%) and low risk of complications, haemorrhagic and infectious (<5%) (EL1). However, this option should not be the only one because of the good efficiency of the expectant management (more than 75% of evacuation) and comparably low risk of complications (EL1). Surgical aspiration should be favoured to curettage because it is quicker, less painful and leads to less bleeding (EL2). After a first trimester miscarriage future fertility is identical with each treatment (EL2). When a trophoblastic retention is suspected, a diagnostic hysteroscopy is recommended (EL2). In case of late intrauterine foetal death beyond 14weeks of gestation and without a past caesarean section, the most efficient protocol seems to be vaginal administration of misoprostol 200 to 400μg every 4 to 6hours (EL2). Twenty-four hours prior to misoprostol the administration of 200mg of mifepristone is recommended (EL3) because it improves the induction-expulsion time and diminishes the quantity of needed misoprostol (and so the complications linked to it) (EL3)., (Copyright © 2014 Elsevier Masson SAS. All rights reserved.)

Objectives: To define guidelines for the management of women diagnosed with threatened late miscarriage (TLM)., Materials and Methods: A systematic review of the literature was performed using Pubmed and the Cochrane library databases and the guidelines from main international societies., Results: Management of women diagnosed with threatened LM requires a complete history-taking searching for a previous history of LM and/or of premature delivery (Grade B). Speculum examination is required to diagnose membrane prolapse (Grade B) and vaginal ultrasound scan is recommended to measure the cervical length (Grade B). Finally, initial management should allow to rule out chorioamniotitis (Grade B). Vaginal progesterone therapy (90-200mg daily) is recommended for women diagnosed with a sole shortened cervix (<25mm) in mid-pregnancy (Grade A). Cerclage is only recommended in women with both history of previous premature delivery and/or previous LM and shortened cervical length diagnosed before 24 weeks of gestation (Grade A). Finally, cervical cerclage (Mc Donald technique) associated with systematic tocolytic therapy (indometacine) and antibiotics are to be recommended in women diagnosed with TLM with dilated cervical os eventually associated with membrane prolapse (GradeC)., (Copyright © 2014 Elsevier Masson SAS. All rights reserved.)

The objective of this review was to assess early and late benefits and harms of different management options for first-trimester miscarriage. Surgical uterine evacuation remains the most effective and the quickest method of treatment. Depending on the clinical situation, medical treatment using misoprostol (missed miscarriage) or expectative attitude (incomplete miscarriage) does not increase the risk of complications, neither haemorrhagic nor infectious. However, these alternatives generally require longer outpatient follow-up, which leads to more prolonged bleeding and not planned surgical procedures., (Copyright © 2014 Elsevier Masson SAS. All rights reserved.)

A first trimester miscarriage is most often painfully experienced by the patients. The practitioner should be able to offer appropriate, timely, efficient and safe medical management, allowing a shorter convalescence without effect on subsequent fertility. Each step of the process of the miscarriage results in clinical and ultrasonographic characteristics, and requires a specific therapeutic strategy. Vaginal ultrasound allows confirmation of early pregnancy failure (missed miscarriage) diagnosis and to estimate the complete or incomplete removal of trophoblastic material. However, the endometrial thickness does not appear to be predictive for the risk of persistent bleeding or secondary surgery. Surgical evacuation of the product of conception remains the most effective and the quickest method of treatment. Depending on the clinical situation, medical treatment with misoprostol (missed miscarriage) or expectative attitude (incomplete miscarriage) do not increase the risk of complications, particularly the infectious one. However, these alternatives generally require more prolonged outpatient follow-up leading to more frequent consultations and surgical emergencies.

Objectives: Medical treatment using misoprostol has been recommended as an alternative to surgical evacuation for spontaneous miscarriages in the first trimester, in order to avoid anesthesia, a surgical operation and hospitalization. Our aim was to assess the efficacy and the safety of vaginal misoprostol in out-patient management of early miscarriages., Material and Methods: We conducted a prospective cohort study including patients with a spontaneous miscarriage of less than 14 weeks gestation. Exclusion criteria were hemorrhagic miscarriages, gestational sac larger than 40 mm and/or cranio-caudal length of the embryo of more than 30 mm. Our protocol used 4 intravaginal tablets (800 microg) of misoprostol on Day 1, out-patient follow-up, clinical and ultrasound reassessment on Day 2. If the intra-uterine antero-posterior diameter on ultrasound examination was greater than 15 mm (or the gestational sac persisted), a second dose of misoprostol was administered or surgical evacuation was performed (failure of medical treatment)., Results: One hundred two patients were included, of whom 30 had an inevitable or threatened miscarriage and 72 had a missed abortion. The success rate defined by complete expulsion of the products of conception without resorting to surgical evacuation and without short-term complications, was 78.4% (80 patients). Two patients were lost to follow-up at 48 hours. Complete expulsion occurred within 2 days in 94% of cases. There were 13 emergency consultations, including 8 for expulsion pain and five surgical evacuations (3 for hemorrhagic expulsion, 2 for hemorrhagic retention). All together, there were 15 surgical evacuations for retention of the products of conception after 1 or 2 doses of misoprostol. There was one case of endometritis (1%). Thirty-four patients were hospitalized, 22 for surgical evacuation and 12 for expulsion pain., Conclusion: It is possible to use misoprostol as a single vaginal dose (800 microg) as out-patient treatment, since it gives satisfactory efficacy (80%) and is sufficiently safe (5% needing emergency surgery). However, out-patient management should only be performed after explaining the treatment and its risks clearly to the patient.

Introduction: First trimester miscarriages complicating 15 to 20% of pregnancies, are the leading cause of gynecology emergencies., Objectives and Methods: This review exhaustively summarized the French and English reports found on Medline data base about the management of first trimester miscarriage., Results: The treatment of reference remains surgical evacuation. It is generally used to avoid haemorrhage and intrauterine infection but is also required for women who wish an immediate termination of pregnancy. Recently, alternatives have been proposed, such as expectant management or medical treatment by misoprostol, to improve patient satisfaction and to reduce complications and costs generated by surgery. Expectant management allows to avoid curettage in most of incomplete miscarriages without any increase of the rate of complications or bleeding duration. Vaginal misoprostol allows complete expulsion in 70 to 90% of missed pregnancies without any increase of the rate of complications., Conclusion: Today, we can propose to motivated and informed patients an alternative to surgical treatment but large randomized studies still are needed to assess benefits and risks for each method.