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Management of Early Pregnancy Loss

Management of Early Pregnancy Loss. Judith Bliss, MD April 2009. Goals for Today. Discuss Practical Management of Abnormal First Trimester Pregnancy Discuss four management options for spontaneous abortion (miscarriage) Expectant Management Medication Management (Misoprostol)

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Management of Early Pregnancy Loss

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  1. Management of Early Pregnancy Loss Judith Bliss, MD April 2009

  2. Goals for Today • Discuss Practical Management of Abnormal First Trimester Pregnancy • Discuss four management options for spontaneous abortion (miscarriage) • Expectant Management • Medication Management (Misoprostol) • Manual Vacuum Aspiration in the clinic • Electric Vacuum Aspiration in the Operating Room

  3. 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

  4. 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%

  5. Terminology of Common Complications • Threatened Abortion • Missed Abortion anembryonic or embryonic • Inevitable Abortion • Incomplete Abortion • Complete Abortion • Ectopic Pregnancy • Molar Pregnancy

  6. Management Options for Safely Evacuating the Uterus • Expectant Management • Misoprostol • Mifepristone/Misoprostol • Methotrexate/Misoprostol • MVA • EVA

  7. 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

  8. 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

  9. Case A continued One week later HCG is 3000 Repeat ultrasound still shows possible sac versus pseudosac No pain, brownish vaginal discharge

  10. 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

  11. Success of expectant management in the first trimester Luise C, et al . BMJ 2002; 324

  12. 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

  13. 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.

  14. 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

  15. 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.

  16. 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

  17. 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

  18. 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%

  19. 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.

  20. Ultrasound post Medical Abortion

  21. Incomplete Abortion

  22. 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)

  23. 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

  24. 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.

  25. Logistics at CCRMC • Can be prescribed by any physician • Follow-up as for expectant management but expect sooner resolution on average than expectant managment

  26. Case C • 28 y/0 G2P1 presents at 13 weeks gestation. No fetal heart tones heard. • Ultrasound shows 8 weeks missed SAB • No symptoms

  27. 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.

  28. 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

  29. Logistics at CCRMC • Access in Reproductive Health Procedures Clinic (GYN Tomasulo) in Martinez (Linda Wise 4912) • Brentwood: Tomasulo, Sara Levin • Antioch: Nancy Palmer • Pittsburg: Feierabend • Concord: Tomasulo, Bliss • Richmond: Bliss, Lehman

  30. 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

  31. 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

  32. 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

  33. 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

  34. 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

  35. 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

  36. 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.

  37. Inexpensive Small Portable Quiet Specimen likely to be intact May require repeated reloading of suction MVA Instruments and Supplies

  38. Post MVA • Rhogam if indicated, iron if indicated • Doxycycline 100 bid for 2-14 doses • Ibuprofen • Contraception or folic acid • Follow-up appointment

  39. 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

  40. 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

  41. 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

  42. 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

  43. 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

  44. 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

  45. Website Resources • www.ansirh.org • www.rhedi.org • www.ipas.org • www.earlyoptions.org • www.prochoice.org

  46. 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!

  47. 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

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