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%
15% pregnancies end in SAB. About 300 pregnancies per year for our volume. ER saw around 600 patients with chief complaint of bleeding and pregnant last year.

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
Peaks at 9 weeks and then declines
Slowly declines after TAB, or pregnancy loss
85% increase by >66% Lowest documented in viable pregnancy is 53%.

9. Case A continued One week later HCG is 3000
Repeat ultrasound still shows possible sac versus pseudosac
No pain, brownish vaginal discharge
OK to management expectantly with SAB instuctions and ECTOPIC precautions

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
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

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
Griebel C, Halvorsen J, Golemon T and Day A, Management of Spontaneous Abortion, AFP October

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.
Expectant management is not do nothing.

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 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%
Incomplete = persistent sac OR endometrial lining >30mm

19. Misprostol
Recommend 800mcg buccal followed by second dose in hours if no obvious passage of tissue with first dose
Some use 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
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. MVA Instruments and Supplies
Inexpensive
Small
Portable
Quiet
Specimen likely to be intact
May require repeated reloading of suction
MVA Instruments and Supplies
This slide shows MVA instruments and cannulae from several manufacturers. The MVA technique described in this slide presentation uses a double valve syringe, shown here in the upper right. Refer to directions for use with each manufacturer’s product.
Necessary equipment includes:
MVA syringe
Cannulae
Speculum
Tenaculum
Dilators or misoprostol.

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
Linda Wise has agreed to provide this service. Outside TAB social workers have not.

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

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