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

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Presentation on theme: "Management of Early Pregnancy Loss Judith Bliss, MD April 2009."— 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 Practical Management of Abnormal First Trimester Pregnancy Discuss four management options for spontaneous abortion (miscarriage) Discuss four management options for spontaneous abortion (miscarriage) 1. Expectant Management 2. Medication Management (Misoprostol) 3. Manual Vacuum Aspiration in the clinic 4. Electric Vacuum Aspiration in the Operating Room

3 Goals of Treatment Decrease blood loss and pain Decrease blood loss and pain Address grief and provide education Address grief and provide education Provide patient-centered care appropriate to her situation that is relatively convenient and efficient Provide patient-centered care appropriate to her situation that is relatively convenient and efficient Provide contraception or pre- conception counseling Provide contraception or pre- conception counseling

4 Miscarriage 20% of pregnant women have bleeding before 20 weeks 20% of pregnant women have bleeding before 20 weeks 50% of these end in spontaneous abortion 50% of these end in spontaneous abortion Miscarriage uncommon after 10 weeks EGA Miscarriage uncommon after 10 weeks EGA When fetal heartbeat identified on ultrasound the risk of SAB decreases to 3% When fetal heartbeat identified on ultrasound the risk of SAB decreases to 3%

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

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

7 Case A 30 y/o G3P0; one prior TAB age 16 and one prior SAB 8 months ago 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 Has been trying to get pregnant for one year Presents with spotting, no pain LMP 4-5 weeks ago Presents with spotting, no pain LMP 4-5 weeks ago HCG initially 500 with ultrasound showing empty uterus HCG initially 500 with ultrasound showing empty uterus HCG two days later 800 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 increase by at least 60 percent every 48 hours from 4 weeks to about 8 weeks EGA Should see pregnancy on ultrasound at HCG Should see pregnancy on ultrasound at HCG Peaks at 9 weeks and then declines Peaks at 9 weeks and then declines Slowly declines after TAB, or pregnancy loss 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 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 Known abnormal IUP and prefers expectant management and has support and access to medical care

11 Success of expectant management in the first trimester GroupN Complete day 7 Complete day 14 Success day 49 Incomplete (53%) 185 (84%) 201 (91%) Missed (30%) 81 (59%) 105 (76%) Anembryonic92 23 (25%) 48 (52%) 61 (66%) TOTAL (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 % of the time In the setting of incomplete abortion expectant management is successful % of the time Average time to completion is 9 days Average time to completion is 9 days Success rate is less for embryonic death or anembryonic gestations (missed abortions) (25-76%) 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 First trimester miscarriages may be expectantly managed indefinitely if without hemorrhage or infections

13 Expectant Management Prepare patient for SAB 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). 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 Recommend support person OK to give vicodin, motrin, phenergan if known abnormal IUP. 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 To ER for bleeding more than 2 or more maxi pads an hour for more than 2 hours, prolonged heavy bleeding, feeling faint Generally dont give antibiotic prophylaxis. Generally dont give antibiotic prophylaxis.

14 Could this be an Ectopic? Until a gestational sac is verified in the uterus ALWAYS GIVE ECTOPIC PRECAUTION 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 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 in a few days to two weeks Follow-up site should have access to next alternative option 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. 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 25 y/o G3P2 presents with spotting at 9 weeks EGA on Friday morning HCG is 5000 HCG is 5000 Ultrasound shows 6 week fetal pole without HR Ultrasound shows 6 week fetal pole without HR Uterus mildly tender with small amount blood in vault 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 Decreased time to passage so shorter follow up time and potential for fewer visits Infection rate similar to expectant and surgical Infection rate similar to expectant and surgical Expect 5-15% will need aspiration Expect 5-15% will need aspiration Some cases of missed abortion may be at risk for greater blood loss 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 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 71% complete by Day 3 84% complete by Day 8 84% complete by Day 8 Anembryonic gestation success rate 81% Anembryonic gestation success rate 81% Embryonic or fetal death 88% Embryonic or fetal death 88% Incomplete or inevitable abortion 93% Incomplete or inevitable abortion 93%

19 Misprostol Recommend 800mcg buccal followed by second dose in hours if no obvious passage of tissue with first dose 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. Some use orally or buccally more frequently. Best evidence is with vaginal misoprostol. Dont treat the ultrasound. Uterus does NOT have to be completely empty for success. Dont 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: 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 Buccal instead of vaginal misoprostol Prophylactic antibiotics (doxy 100 bid for 7 days) Prophylactic antibiotics (doxy 100 bid for 7 days)

23 Misoprostol Counseling Supportive companion Supportive companion Vicodin, motrin, phenergantake early Vicodin, motrin, phenergantake early Make sure to have pads at home Make sure to have pads at home Expect several hours of heavy bleeding starting several hours after dose Expect several hours of heavy bleeding starting several hours after dose Blood looks like more in the toilet bowl Blood looks like more in the toilet bowl Antibiotic prophylaxis recommended Antibiotic prophylaxis recommended Plan for contraception/ folic acid Plan for contraception/ folic acid

24 Side effects of misoprostol Bleeding – typically lasts up to 2 weeks with spotting till next period Bleeding – typically lasts up to 2 weeks with spotting till next period Cramping – usually starts within the first few hours. NSAIDs can be used 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 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 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. Diarrhea – also more common after oral miso and should resolve in 24 hours.

25 Logistics at CCRMC Can be prescribed by any physician Can be prescribed by any physician Follow-up as for expectant management but expect sooner resolution on average than expectant managment 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. 28 y/0 G2P1 presents at 13 weeks gestation. No fetal heart tones heard. Ultrasound shows 8 weeks missed SAB Ultrasound shows 8 weeks missed SAB No symptoms No symptoms

27 Mifepristone and Misoprostol Possibly viable undesired IUP up to 63 days Possibly viable undesired IUP up to 63 days Undesired threatened abortion Undesired threatened abortion Used by some for blighted ovum or missed abortionmay be higher success rate/less blood loss. Used by some for blighted ovum or missed abortionmay be higher success rate/less blood loss.

28 Protocol for Mife/Miso Give 200mcg mifepristone in clinic Give 200mcg mifepristone in clinic Send home with four 200mcg pills of misoprotol to use in 6-72 hours buccally Send home with four 200mcg pills of misoprotol to use in 6-72 hours buccally More extensive consent process and limited access to medication More extensive consent process and limited access to medication Antibiotic prophylaxis Antibiotic prophylaxis

29 Logistics at CCRMC Access in Reproductive Health Procedures Clinic (GYN Tomasulo) in Martinez (Linda Wise 4912) Access in Reproductive Health Procedures Clinic (GYN Tomasulo) in Martinez (Linda Wise 4912) 1. Brentwood: Tomasulo, Sara Levin 2. Antioch: Nancy Palmer 3. Pittsburg: Feierabend 4. Concord: Tomasulo, Bliss 5. Richmond: Bliss, Lehman

30 Case D 40 y/o G5P1 ectopic 1, TAB 2 40 y/o G5P1 ectopic 1, TAB 2 Presents with no LMP since before depo shot 5 months ago Presents with no LMP since before depo shot 5 months ago Spotting, minimal pain Spotting, minimal pain HCG 1890 HCG 1890 Sono 2 cm ovarian cyst, empty uterus Sono 2 cm ovarian cyst, empty uterus Does not want to be pregnant Does not want to be pregnant

31 Methotrexate/Misoprostol Methotrexate alone used for known ectopic pregnancies 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 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 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) 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 Ectopic for helpful for calculating dose and structuring follow-up May refer to any GYN clinic for 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 18 y/o G4P2 TAB 1 presents with spotting and cramping 10 weeks post LMP Sono shows 7 week missed SAB Sono shows 7 week missed SAB Family does not know she is pregnant again Family does not know she is pregnant again Wants resolved ASAP Wants resolved ASAP

34 Manual Vacuum Aspiration Advantages Able to assess tissue and verify POC to rule-out ectopic pregnancy Able to assess tissue and verify POC to rule-out ectopic pregnancy Fewest return visits Fewest return visits Trend towards least blood loss Trend towards least blood loss Most certain time course/clinician with them during procedure Most certain time course/clinician with them during procedure Requires least amount of home support Requires least amount of home support May be able to place IUD at the same time May be able to place IUD at the same time

35 Manual Vacuum Aspiration Disadvantages Requires more equipment Requires more equipment Very small risk of uterine perforation Very small risk of uterine perforation May have more infection risk May have more infection risk Requires more clinic or emergency room time and more nursing time Requires more clinic or emergency room time and more nursing time Requires more physician training Requires more physician training

36 Manual Vacuum Aspiration Sharp curettage (D and C) no longer an acceptable option due to higher complication rates 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. 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 Inexpensive Small Small Portable Portable Quiet Quiet Specimen likely to be intact Specimen likely to be intact May require repeated reloading of suction May require repeated reloading of suction

38 Post MVA Rhogam if indicated, iron if indicated Rhogam if indicated, iron if indicated Doxycycline 100 bid for 2-14 doses Doxycycline 100 bid for 2-14 doses Ibuprofen Ibuprofen Contraception or folic acid Contraception or folic acid Follow-up appointment 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 38 y/o with history of prior LEEP presents at 11 weeks with spotting Sono shows 10 week missed SAB Sono shows 10 week missed SAB History of intolerance to pelvic exams History of intolerance to pelvic exams Hb of 8 Hb of 8 Poorly controlled seizure disorder Poorly controlled seizure disorder Weighs 342 lbs 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 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 significant respiratory, cardiac, or obesity co-morbidity May be more appropriate for high risk bleeding situations or unstable patients May be more appropriate for high risk bleeding situations or unstable patients

42 Disadvantages of EVA Wait for OR and physician availability Wait for OR and physician availability Expense Expense NPO status NPO status IV IV Less privacy Less privacy May have more anesthesia then necessary/desired May have more anesthesia then necessary/desired Most risk of procedure from anesthesia Most risk of procedure from anesthesia Less continuity with staff Less continuity with staff

43 Logistics at CCRMC Consider direct scheduling in the OR Consider direct scheduling in the OR Often times on Tuesday and Thursday available but any day OK 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 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 Call OB attending on call to make sure provider available

44 Contraception Initiate Discussion Early even if was desired pregnancy Initiate Discussion Early even if was desired pregnancy Start contraceptive early, usually while still bleeding Start contraceptive early, usually while still bleeding IUD or Implanon can be placed during MVA or EVA IUD or Implanon can be placed during MVA or EVA

45 Website Resources

46 Psychological Management Acknowledge, dispel guilt Acknowledge, dispel guilt Legitimize grief Legitimize grief Provide comfort, ongoing support Provide comfort, ongoing support Reassure about the future Reassure about the future Counsel patient how to tell family, friends Counsel patient how to tell family, friends Warn of anniversary phenomenon Warn of anniversary phenomenon Include partner in psychological care Include partner in psychological care Assess level of grief and adjust counseling accordingly Assess level of grief and adjust counseling accordingly Dont forget – half of pregnancies are unintended! Dont forget – half of pregnancies are unintended!

47 Conclusion Provide medical and psychologic supportyour job is not just to rule out ectopic Provide medical and psychologic supportyour 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 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 Remember misoprostol,MVA, EVA in addition to expectant management


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