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Management of Early Pregnancy Loss
Judith Bliss, MDApril 2009
Goals for Today
Discuss Practical Management of Abnormal First Trimester Pregnancy
Discuss four management options for spontaneous abortion (miscarriage)
1. Expectant Management2. Medication Management (Misoprostol)3. Manual Vacuum Aspiration in the clinic4. Electric Vacuum Aspiration in the Operating
Room
Goals of Treatment
Decrease blood loss and pain Address grief and provide education Provide patient-centered care
appropriate to her situation that is relatively convenient and efficient
Provide contraception or pre-conception counseling
Miscarriage 20% of pregnant women have
bleeding before 20 weeks 50% of these end in spontaneous
abortion Miscarriage uncommon after 10
weeks EGA When fetal heartbeat identified on
ultrasound the risk of SAB decreases to 3%
Terminology of Common Complications
Threatened Abortion Missed Abortion anembryonic or embryonic
Inevitable Abortion Incomplete Abortion Complete Abortion Ectopic Pregnancy Molar Pregnancy
Management Options for Safely Evacuating the Uterus
Expectant Management Misoprostol Mifepristone/Misoprostol Methotrexate/Misoprostol MVA EVA
Case A
30 y/o G3P0; one prior TAB age 16 and one prior SAB 8 months ago
Has been trying to get pregnant for one year
Presents with spotting, no pain LMP 4-5 weeks ago
HCG initially 500 with ultrasound showing empty uterus
HCG two days later 800
Interpretation of HCG
Should increase by at least 60 percent every 48 hours from 4 weeks to about 8 weeks EGA
Should see pregnancy on ultrasound at HCG 1500-6000
Peaks at 9 weeks and then declines Slowly declines after TAB, or
pregnancy loss
Case A continued
One week later HCG is 3000 Repeat ultrasound still shows possible
sac versus pseudosacNo pain, brownish vaginal discharge
Expectant Management
Use when: Condition stable and she has a desired
pregnancy with threatened abortion/possible ectopic and does not want to disrupt possible normal pregnancy
Known abnormal IUP and prefers expectant management and has support and access to medical care
Success of expectant management in the first trimester
Group N Complete day 7
Complete day 14
Success day 49
Incomplete 221 117 (53%) 185 (84%) 201 (91%)
Missed 138 41 (30%) 81 (59%) 105 (76%)
Anembryonic 92 23 (25%) 48 (52%) 61 (66%)
TOTAL 451 181 (40%) 314 (70%) 367 (81%)
Luise C, et al . BMJ 2002; 324
Expectant management
In the setting of incomplete abortion expectant management is successful 82-96% of the time
Average time to completion is 9 days Success rate is less for embryonic death or
anembryonic gestations (missed abortions) (25-76%)
First trimester miscarriages may be expectantly managed indefinitely if without hemorrhage or infections
Expectant Management
Prepare patient for SAB Expect on and off bleeding and cramping; heavy
bleeding for several hours; passage of tissue and clot. Will not see parts before 10 weeks (fetal pole size on sono).
Recommend support person OK to give vicodin, motrin, phenergan if known
abnormal IUP. To ER for bleeding more than 2 or more maxi
pads an hour for more than 2 hours, prolonged heavy bleeding, feeling faint
Generally don’t give antibiotic prophylaxis.
Could this be an Ectopic?
Until a gestational sac is verified in the uterus ALWAYS GIVE ECTOPIC PRECAUTION
Gestational sac should have yolk sac and/or fetal pole or be large, e.g. greater than 6 weeks size
Logistics at CCRMC
Follow-up in a few days to two weeks Follow-up site should have access to
next alternative option Ultrasound in clinic at follow-up can
be useful to verify passage if history unclear.
Case B
25 y/o G3P2 presents with spotting at 9 weeks EGA on Friday morning
HCG is 5000 Ultrasound shows 6 week fetal pole
without HR Uterus mildly tender with small
amount blood in vault
Medication Management
Decreased time to passage so shorter follow up time and potential for fewer visits
Infection rate similar to expectant and surgical
Expect 5-15% will need aspiration Some cases of missed abortion may
be at risk for greater blood loss
Misoprostol for miscarriageZhang et al NEJM 8/25/05
800mcg miso administered vaginally on Day 1 with repeat on Day 3 if incomplete and Vacuum on Day 8 if still incomplete
71% complete by Day 3 84% complete by Day 8 Anembryonic gestation success rate 81% Embryonic or fetal death 88% Incomplete or inevitable abortion 93%
Misprostol
Recommend 800mcg buccal followed by second dose in 24-72 hours if no obvious passage of tissue with first dose
Some use 400-600 orally or buccally more frequently. Best evidence is with vaginal misoprostol.
Don’t treat the ultrasound. Uterus does NOT have to be completely empty for success.
Ultrasound post Medical Abortion
Incomplete Abortion
Misoprostol Protocol
Planned Parenthood large prospective non-randomized data on medication abortion (not SAB) has shown a 93% decrease in serious infection rate (needed IV antibiotics/hospitalization) with two interventions:
Buccal instead of vaginal misoprostol Prophylactic antibiotics (doxy 100 bid for 7
days)
Misoprostol Counseling
Supportive companion Vicodin, motrin, phenergan—take early Make sure to have pads at home Expect several hours of heavy bleeding
starting several hours after dose Blood looks like more in the toilet bowl Antibiotic prophylaxis recommended Plan for contraception/ folic acid
Side effects of misoprostol
Bleeding – typically lasts up to 2 weeks with spotting till next period
Cramping – usually starts within the first few hours. NSAIDs can be used
Fevers and/or chills – common side effect. If lasts >24 hours, evaluate for infection
Nausea and vomiting – more common after oral misoprostol. Should resolve in 6 hours
Diarrhea – also more common after oral miso and should resolve in 24 hours.
Logistics at CCRMC
Can be prescribed by any physician Follow-up as for expectant
management but expect sooner resolution on average than expectant managment
Case C
28 y/0 G2P1 presents at 13 weeks gestation. No fetal heart tones heard.
Ultrasound shows 8 weeks missed SAB
No symptoms
Mifepristone and Misoprostol
Possibly viable undesired IUP up to 63 days
Undesired threatened abortion Used by some for blighted ovum or
missed abortion—may be higher success rate/less blood loss.
Protocol for Mife/Miso
Give 200mcg mifepristone in clinic Send home with four 200mcg pills of
misoprotol to use in 6-72 hours buccally
More extensive consent process and limited access to medication
Antibiotic prophylaxis
Logistics at CCRMC
Access in Reproductive Health Procedures Clinic (GYN Tomasulo) in Martinez (Linda Wise 4912)
1. Brentwood: Tomasulo, Sara Levin2. Antioch: Nancy Palmer3. Pittsburg: Feierabend4. Concord: Tomasulo, Bliss5. Richmond: Bliss, Lehman
Case D
40 y/o G5P1 ectopic 1, TAB 2 Presents with no LMP since before
depo shot 5 months ago Spotting, minimal pain HCG 1890 Sono 2 cm ovarian cyst, empty
uterus Does not want to be pregnant
Methotrexate/Misoprostol
Methotrexate alone used for known ectopic pregnancies
Methotrexate/Misoprostol can be used if Mifepristone not available (Mifeprisone must be ordered by physician and shipped directly to physician with account www.earlyoptions.org)
Methotrexate/Misoprostol can be used if treatment desired before ectopic ruled-out
Logistics at CCRMC
Generally available at larger sites and always at Martinez (may be sent to infusion clinic for injection)
Ectopic for helpful for calculating dose and structuring follow-up
May refer to any GYN clinic for follow-up
Case E
18 y/o G4P2 TAB 1 presents with spotting and cramping 10 weeks post LMP
Sono shows 7 week missed SAB Family does not know she is pregnant
again Wants resolved ASAP
Manual Vacuum Aspiration Advantages
Able to assess tissue and verify POC to rule-out ectopic pregnancy
Fewest return visits Trend towards least blood loss Most certain time course/clinician
with them during procedure Requires least amount of home
support May be able to place IUD at the same
time
Manual Vacuum Aspiration Disadvantages
Requires more equipment Very small risk of uterine perforation May have more infection risk Requires more clinic or emergency
room time and more nursing time Requires more physician training
Manual Vacuum Aspiration
Sharp curettage (D and C) no longer an acceptable option due to higher complication rates
Manual Vacuum Aspiration Equipment is inexpensive, there is very little noise, the procedure is well tolerated and can be performed in a clinic or ER situation with only a paracervical block.
MVA Instruments and Supplies
Inexpensive Small Portable Quiet Specimen likely
to be intact May require repeated reloading of
suction
Post MVA
Rhogam if indicated, iron if indicated Doxycycline 100 bid for 2-14 doses Ibuprofen Contraception or folic acid Follow-up appointment
Logistics at CCRMC
Reproductive Health Procedures Clinic: Monday and Wednesday am GYN MTZ Tomasulo, access Linda Wise 4912
GYN clinics: Schedule early in clinic and check with provider in clinic
ER: Works well when ER and Perinatal Unit not too busy
Case F
38 y/o with history of prior LEEP presents at 11 weeks with spotting
Sono shows 10 week missed SAB History of intolerance to pelvic
exams Hb of 8 Poorly controlled seizure disorder Weighs 342 lbs
Electric Vacuum Aspiration in an Operating Room
Best for woman who needs general anesthesia or more sedation then can be given in your clinic
May be more appropriate for significant respiratory, cardiac, or obesity co-morbidity
May be more appropriate for high risk bleeding situations or unstable patients
Disadvantages of EVA
Wait for OR and physician availability Expense NPO status IV Less privacy May have more anesthesia then
necessary/desired Most risk of procedure from anesthesia Less continuity with staff
Logistics at CCRMC
Consider direct scheduling in the OR Often times on Tuesday and
Thursday available but any day OK H and P and consent in clinic or can
be done in PACU prior to procedure if necessary
Call OB attending on call to make sure provider available
Contraception
Initiate Discussion Early even if was desired pregnancy
Start contraceptive early, usually while still bleeding
IUD or Implanon can be placed during MVA or EVA
Website Resources
www.ansirh.org www.rhedi.org www.ipas.org www.earlyoptions.org www.prochoice.org
Psychological Management Acknowledge, dispel guilt Legitimize grief Provide comfort, ongoing support Reassure about the future Counsel patient how to tell family, friends Warn of anniversary phenomenon Include partner in psychological care Assess level of grief and adjust counseling
accordingly Don’t forget – half of pregnancies are
unintended!
Conclusion
Provide medical and psychologic support—your job is not just to rule out ectopic
As family physicians we can make the situation not only safe, but also decrease pain, anxiety and inconvenience
Remember misoprostol,MVA, EVA in addition to expectant management