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Management of Early Pregnancy Loss

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Presentation on theme: "Management of Early Pregnancy Loss"— Presentation transcript:

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

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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