1 / 31

Management of Early Pregnancy Loss (EPL)

Management of Early Pregnancy Loss (EPL). Sarah Prager, MD, MAS Department of ob/gyn University of Washington September 29, 2008. Outline. Background information Expectant management Medical management Methotrexate Misoprostol (+/- mifepristone) Surgical management. Background.

lew
Download Presentation

Management of Early Pregnancy Loss (EPL)

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Management of Early Pregnancy Loss (EPL) Sarah Prager, MD, MAS Department of ob/gyn University of Washington September 29, 2008

  2. Outline • Background information • Expectant management • Medical management • Methotrexate • Misoprostol (+/- mifepristone) • Surgical management

  3. Background • Spontaneous Abortion (SAb) is the most common complication of early pregnancy. • 8-20% clinically recognized pregnancies • 13-26% all pregnancies • 80% SAbs occur in the first trimester

  4. Age Prior SAb Smoking Alcohol Caffeine (high intake) Maternal weight BMI < 18.5 or > 25 Celiac disease (untreated) Alcohol Cocaine NSAIDs High gravidity Fever Low folate levels Risk factors

  5. Etiology • 33% anembryonic • 50% due to chromosomal abnormalities • Autosomal trisomies 52% • Monosomy X 19% • Polyploidies 22% • Other 7% • Host factors • Structural abnormalities • Maternal infection/endocrinopathy/coagulopathy • Unexplained

  6. Clinical presentation • Bleeding • Pain/cramping • Falling or abnormally rising BhCG • Ultrasound findings: • Absent fetal cardiac activity with CRL > 5 mm • Absent fetal pole if mean sac diameter > 25 mm (TA) or 18 mm (TV) • No/abnormal yolk sac (95% PPV) • No/abnormal fetal heart rate • Small sac size • Subchorionic hematoma

  7. Management options • Expectant management • Medical management • Surgical management Sotiriadis A, Obstet Gynecol 2005; Nanda K, Cochrane Database Syst Rev 2006

  8. Expectant management • Requirements for therapy: • Less than 13 weeks gestation • Stable vital signs • No evidence of infection • What to expect: • Most expulsions occur in the first 2 weeks after diagnosis • Prolonged follow-up may be needed • Acceptable and safe to wait up to 4 weeks post-diagnosis

  9. Outcomes • Overall success rate of 81% • Success rates vary by type of miscarriage • 91% for incomplete/inevitable abortion • 76% with missed abortion • 66% with anembryonic pregnancies Luise C, Ultrasound Obstet Gynecol 2002

  10. What is success? • ≤15 mm endometrial thickness (ET) • 3 days to 6 weeks after diagnosis • No vaginal bleeding • Negative urine hCG

  11. Problems with ET measurements • No clear rationale for this cut off • In a study of 80 women with successful medical abortion: • Mean ET at 24 hours 17.5 mm (7.6 – 29 mm) • At one week: 15% with ET > 16 mm • Study of medical management after miscarriage: • 86% success rate if use absence of gestational sac • 51% success rate if use ET ≤15 mm Harwood B, Contraception 2001; Reynolds A, Eur. J Obstet Gynecol Reproduct. Biol 2005

  12. When to intervene • Vaginal bleeding and pos. UPT can continue for 2-4 weeks, so not good measures of success • Continued gestational sac • Clinical symptoms • Patient preference • Time (?)

  13. Medical management • Misoprostol • Mifepristone plus Misoprostol • Methotrexate plus Misoprostol • There is no medical regimen for management of early pregnancy loss that is FDA approved.

  14. Medical management • Requirements for therapy: • Less than 13 weeks gestation • Stable vital signs • No evidence of infection • *No allergies to medications used

  15. Misoprostol • Prostoglandin E1 analogue • FDA approved for prevention of gastric ulcers • Used off-label for many ob/gyn indications • Labor induction • Cervical ripening • Medical abortion (with mifepristone) • Prevention/treatment of post-partum hemorrhage • Can be administered by oral, buccal, sublingual, vaginal and rectal routes Chen B, Clin Obstet Gynecol 2007

  16. Why misoprostol? • Do something while still avoiding surgery • Cost effective • Few side effects (especially with vaginal) • Stable at room temperature • Readily available

  17. Dosing Regimens • Creinin: 400 mcg po vs 800 pv 25% vs. 88% • Ngoc: 800 mcg po vs 800 pv: 89% vs. 93% (NS) • Tang: 600 mcg SL vs 600 pv q 3 hrs x 3 doses: 87.5% • SL had more side effects (diarrhea 70% vs 27.5%) • Phupong: 600 mcg po x 1 vs. q 4 hrs x 2 doses: 82% vs 92% (NS) • Repeat dosing increased diarrhea (40% vs 18%) • Gilles: 800 mcg pv saline-moistened vs. dry: 83% vs 87% (NS) Creinin MD, Obstet Gynecol 1997; Ngoc NTN, Int.J Gynaecol Obstet 2004; Tang OS, Hum Reproduct 2003; Phupong V, Contraception 2005; Gilles JM, Am J Obstet Gynecol 2004

  18. Outcomes • Single dose 400 – 800 mcg misoprostol • 25 – 88% success rate • Repeat dose x 1 if incomplete at 24 hours • 80 – 88% success rate • Placebo success rates: • 16 – 60% • Success rate depends on type of miscarriage: • 100% with incomplete abortion • 87% for all others Wood SL, Obstet Gynecol 2002; Bagratee JS, Hum Reproduct 2004; Blohm F, BJOG: Int J Obstet Gynecol 2005

  19. Side effects and complications • Misoprostol vs. placebo: • Nausea, vomiting and diarrhea: no difference • Pain: more pain and analgesics in one study • Hemoglobin concentration: no difference • Infection: 0 for placebo vs. 2 - 4.7% for misoprostol • No benefit with repeat dosing within 3-4 hrs. • Improved outcome with one repeat dose at 24 hrs. if incomplete • 90% found medical management acceptable and would elect same treatment again Wood SL, Obstet Gynecol 2002; Bagratee JS, Hum Reproduct 2004; Blohm F, BJOG: Int J Obstet Gynecol 2005

  20. Misoprostol bottom line • 800 mcg. per vagina (or buccal) • Repeat x 1 at 12-24 hours if incomplete • Measure success as with expectant management • Intervene with surgical management if: • Continued gestational sac • Clinical symptoms • Patient preference • Time (?)

  21. Mifepristone and misoprostol • Mifepristone: progestin antagonist that binds to progestin receptor • Used with elective medical abortion to “destabilize” the implantation site • Current evidence-based regimen: 200 mg Mifepristone and 800 mcg misoprostol • Success rates for mifepristone and misoprostol in EPL: • 52 – 84% (observational trials using non-standard dosing) • 90 – 93% ( with standard dosing) • No direct comparison b/w misoprostol alone and mifepristone/misoprostol with standard dosing • Mifepristone may help, data still pending Gronlund A, Acta Obstet Gynaecol 1998; Nielsen S, Br J Obstet Gynaecol 1997; Niinimaki M, Fertility Sterility 2006; Schreiber CA, Contraception 2006

  22. Methotrexate and misoprostol • Methotrexate: folic acid antagonist • Cytotoxic to the trophoblast • Used in medical management for ectopic pregnancy • Introduced in 1993 in combination with misoprostol to treat elective abortion medically. • Success rates up to 98% (misoprostol administered 7 days after methotrexate) • No data for use in early pregnancy loss Creinin MD, Contraception 1993

  23. Surgical management • Suction dilation and curettage (D&C) • Who should have surgical management? • Unstable • Significant medical morbidity • Infected • Very heavy bleeding • Anyone who wants immediate therapy

  24. Surgical Management • Benefits: • Convenient timing • Observed therapy • High success rates: (93 – 100%) • Risks: • Infection (1/200) • Perforation (1/2000) • Cervical trauma • Uterine synechiae (very rare)

  25. Infection prophylaxis • Periabortal antibiotics reduce infection risk 42% • No strong evidence on what to use • Doxycycline • 2 -14 doses • Metronidazole • Bacterial vaginosis • Trichomoniasis • Suspicious discharge Sawaya GF, Obstet Gynecol 1996; Prieto JA, Obstet Gynecol 1995

  26. Where to perform? • Canada: • 92.5% women with SAb presenting to hospital have D&C • 51% women with SAb presenting to family physician have D&C • Manual vacuum aspiration (MVA) in outpatient setting can decrease hospital costs by 41% Weibe E, Fam Med 1998; Finer LB, Perspect Sexu Reproduct Health 2003; Blumenthal PD, Int J Gynaecol Obstet 1994

  27. Outcome comparison • Risk of incomplete abortion: • Expectant > surgical • Expectant ≥ medical • Resolution within 48 hours: surgical>medical>expectant management • Risk of Infection: 2-3% • Expectant = Medical = Surgical Nanda K, Cochrane Database Syst Rev 2006; Nielsen S, Br J Obstet Gynaecol 1999; Shelly JM, Aust. NZ J Obstet Gynaecol 2005; Sotiriadis A, Obstet Gynecol 2005; Tinder J, (MIST) BMJ, 2006

  28. Cost analysis • Medical management most cost effective • 2 studies • Misoprostol vs. expectant vs. surgical: • 1000 vs. 1172 vs. 2007 dollars • Expectant management most cost effective • MIST trial • Expectant vs. medical vs. surgical: • 1086 vs. 1410 vs. 1585 pounds Doyle NM, Obstet. Gynecol 2004; You JH, Hum Reprod 2005; Petrou S, BJOG 2006

  29. Postmiscarriage care • Rhogam at time of diagnosis or surgery • Pelvic rest for 2 weeks • No evidence for delaying conception • Initiate contraception upon completion of procedure (even IUDs!) • Expect light-moderate bleeding for 2 weeks • Menses return after 6 weeks • Negative BhCG values after 2-4 weeks • Appropriate grief counseling Goldstein R, Am J Obstet. Gynecol 2002; Wyss P, J Perinat Med 1994; Grimes D, Cochrane Database Syst Rev 2000

  30. Future miscarriage risk • Increased risk of miscarriage in future pregnancy • 20% after 1 SAb • 28% after 2 SAbs • 43% after 3+ SAbs

  31. Thank You! • Questions? • pragers@u.washington.edu • O: (206) 731-6292 • P: (206) 540-6077

More Related