1. New approaches for management of 1 st trimester pregnancy complications (You can do it!!) Emily Godfrey MD MPH Larry Leeman MD MPH Panna Lossy MD

2. Early Pregnancy Complications Miscarriage (1 in 5 recognized pregnancies) –Missed abortion –Incomplete abortion –Complete abortion Ectopic Pregnancy (2 in 100 pregnancies) Molar Pregnancy (1 in 1000 pregnancies) Unintended Pregnancy (1 in 2 pregnancies)

3. 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%

4. Miscarriage treatment options for hemodynamically stable women Expectant management Misoprostol Manual Vacuum Aspiration (MVA) Aspiration by Electric Vacuum (EVA)

5. 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

6. Success of expectant management GroupNComplete day 7 Complete day 14 Success day 49 Incomplete221117 (53%)185 (84%)201 (91%) Missed13841 (30%)81 (59%)105 (76%) Anembryonic9223 (25%)48 (52%)61 (66%) TOTAL451181 (40%)314 (70%)367 (81%) Luise C, et al. BMJ 2002; 324

7. Misoprostol for miscarriage Zhang 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%

8. 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.

9. Surgical options Sharp curettage (D and C) no longer an acceptable option due to higher complication rates Vacuum aspiration includes manual vacuum aspiration (MVA) vs. electrical pump aspiration

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

11. Why deal with this in the ED or Office? Can’t we just send everyone home or to the OR? MVA in ED/labor ward vs. suction D and C (EVA) in OR Waiting time reduced by 52% Procedure time reduced from mean 33 to 19 minutes Costs reduced by 41% ($1404 to $827, P <.01) for all three outcomes Blumenthal PD, Remsburg RE. Int J Gynecol Obstet 1994, 45: 261-267

12. Diagnosis of Ectopic Failure of  hCG to increase by at least 65% in 48 hours is concerning for ectopic or failing IUP Ultrasound (transvaginal) –IUP rules out ectopic except rare heterotopic –No gestational sac +  hCG>1800 highly suggestive –Gestational sac / embryo outside of uterus confirms ectopic –Pitfalls: pseudogestational sac, ruptured corpus luteum Laparoscopy – gold standard

13. Ectopic Pregnancy – Extrauterine Mass Uterus Extrauterine mass

14. Expectant Management Criteria include: –Minimal pain or bleeding –Reliable follow-up –No evidence of tubal rupture –  hCG <1000 and falling –Best when pregnancy not seen on TVUS

15. Medical Management: methotrexate Safe, effective, less costly than surgery Success rate 86-94% Equal or better fertility preservation Criteria for use: –Stable vital signs, few symptoms –No contraindication to drug –Unruptured ectopic –Absence of embryonic cardiac activity –Ectopic mass <3 cm –  hCG levels <5000 mIU/ml (relative)

16. Methotrexate Dosing Single dose IM regimen with 50mg/m2 Obtain serum  hCG 7th day post- treatment –Follow until level reaches 10mIU/ml (3-4 wks) If there is not >25% decrease in hCG from Day 0 till Day 7, repeat dose of MTX Increase in hCG before Day 4 and mild abdominal pain are common Alternative is planned multidose regimen

17. Is this happening because I played basketball, ate green chile, missed sleep, or had sex? Universal seeking of explanation Self blame common Concerned that physicians could do something to prevent miscarriage

18. 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!

19. Conclusions First trimester complications are common Family medicine doctors have the skills to manage the majority of these complications Misoprosol and MVA are excellent tools for primary care providers Psychological issues may be best managed by the primary care doctor