Triage and care for women with symptoms or diagnosis of pregnancy loss between 14 + 0 and 21 + 6 weeks' gestation

Mid-trimester pregnancy loss (MTL), defined as a pregnancy loss occurring between 14 + 0 and 21 + 6 weeks of gestation, causes significant physical and emotional distress to women and presents clinical challenges to healthcare professionals. It is acknowledged that in low-resource settings, this guideline might be applicable to births up to 28 weeks or babies weighing less than 1 kg. Risk factors for MTL include advanced maternal age, previous history of MTL, women of Black ethnicity, smoking, excessive alcohol consumption, obesity, and anatomical factors such as a short cervix, congenital uterine anomalies, and myomas. Medical risk factors include previous cervical trauma from loop electrosurgical excision procedure or Cesarean section in labor, placental dysfunction, infections, thrombophilias, endocrine disorders such as thyroid disease and polycystic ovary syndrome, and fetal chromosomal abnormalities. Early assessment and accurate diagnosis are fundamental to managing threatened and confirmed mid-trimester pregnancy loss. Our guideline emphasizes the importance of maternal vital signs monitoring, laboratory investigations, and ultrasound imaging to identify and manage those with threatened or confirmed mid-trimester pregnancy loss, as well as address potential maternal complications, including infection or hemorrhage. A multidisciplinary approach involving obstetricians, gynecologists, maternal-fetal medicine specialists, nurses, midwives, psychologists, and social workers is important for providing comprehensive care. The guideline advocates for personalized management plans tailored to individual women's preferences, medical history, and gestational age. Care for threatened MTL should be targeted to the likely cause and might include cervical cerclage, progesterone, and management of risk factors, for example antibiotics for urinary tract infections. Care for confirmed MTL might include expectant management, medical induction of labor, or surgical intervention such as dilation and evacuation. Acknowledging the profound emotional impact of mid-trimester pregnancy loss, our guideline underscores the importance of offering compassionate and culturally sensitive psychosocial support to women and their families. This includes providing access to bereavement care, counseling services, support groups, and resources for coping with grief and loss. Continued monitoring and follow-up care are essential components of managing mid-trimester pregnancy loss. Our guideline recommends regular postpartum assessments to evaluate physical recovery and emotional well-being and to address any ongoing medical or psychological concerns. Contraceptive counseling and future pregnancy planning should also be discussed as part of comprehensive care. It is important that, where possible, women receive continuity of care from healthcare professionals to help the coordination and provision of holistic and comprehensive care. Further research is needed to enhance our understanding of the etiology, risk factors, and optimal management strategies for threatened mid-trimester pregnancy loss. Additionally, education and training initiatives should be implemented to ensure healthcare professionals are equipped with the knowledge and skills necessary to deliver high-quality, woman-centered care to individuals and families experiencing this complication. Mid-trimester pregnancy loss represents a complex clinical scenario necessitating a holistic and compassionate approach to care. By adhering to the recommendations outlined in this clinical guideline, healthcare providers can strive to optimize outcomes and support individuals and their families through this challenging experience.