Presentation on theme: "Management of Early Pregnancy Loss"— Presentation transcript:
1Management of Early Pregnancy Loss Judith Bliss, MDApril 2009
2Goals for TodayDiscuss Practical Management of Abnormal First Trimester PregnancyDiscuss four management options for spontaneous abortion (miscarriage)Expectant ManagementMedication Management (Misoprostol)Manual Vacuum Aspiration in the clinicElectric Vacuum Aspiration in the Operating Room
3Goals of Treatment Decrease blood loss and pain Address grief and provide educationProvide patient-centered care appropriate to her situation that is relatively convenient and efficientProvide contraception or pre-conception counseling
4Miscarriage 20% of pregnant women have bleeding before 20 weeks 50% of these end in spontaneous abortionMiscarriage uncommon after 10 weeks EGAWhen 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.
5Terminology of Common Complications Threatened AbortionMissed Abortion anembryonic or embryonicInevitable AbortionIncomplete AbortionComplete AbortionEctopic PregnancyMolar Pregnancy
6Management Options for Safely Evacuating the Uterus Expectant ManagementMisoprostolMifepristone/MisoprostolMethotrexate/MisoprostolMVAEVA
7Case A30 y/o G3P0; one prior TAB age 16 and one prior SAB 8 months agoHas been trying to get pregnant for one yearPresents with spotting, no pain LMP 4-5 weeks agoHCG initially 500 with ultrasound showing empty uterusHCG two days later 800
8Interpretation of HCGShould increase by at least 60 percent every 48 hours from 4 weeks to about 8 weeks EGAShould see pregnancy on ultrasound at HCGPeaks at 9 weeks and then declinesSlowly declines after TAB, or pregnancy loss85% increase by >66% Lowest documented in viable pregnancy is 53%.
9Case A continued One week later HCG is 3000 Repeat ultrasound still shows possible sac versus pseudosacNo pain, brownish vaginal dischargeOK to management expectantly with SAB instuctions and ECTOPIC precautions
10Expectant Management Use when: Condition stable and she has a desired pregnancy with threatened abortion/possible ectopic and does not want to disrupt possible normal pregnancyKnown abnormal IUP and prefers expectant management and has support and access to medical care
11Success of expectant management in the first trimester GroupNComplete day 7Complete day 14Success day 49Incomplete221117 (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
12Expectant managementIn the setting of incomplete abortion expectant management is successful 82-96% of the timeAverage time to completion is 9 daysSuccess 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 infectionsGriebel C, Halvorsen J, Golemon T and Day A, Management of Spontaneous Abortion, AFP October
13Expectant 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 personOK 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 faintGenerally don’t give antibiotic prophylaxis.Expectant management is not do nothing.
14Could this be an Ectopic? Until a gestational sac is verified in the uterus ALWAYS GIVE ECTOPIC PRECAUTIONGestational sac should have yolk sac and/or fetal pole or be large, e.g. greater than 6 weeks size
15Logistics at CCRMC Follow-up in a few days to two weeks Follow-up site should have access to next alternative optionUltrasound in clinic at follow-up can be useful to verify passage if history unclear.
16Case B25 y/o G3P2 presents with spotting at 9 weeks EGA on Friday morningHCG is 5000Ultrasound shows 6 week fetal pole without HRUterus mildly tender with small amount blood in vault
17Medication Management Decreased time to passage so shorter follow up time and potential for fewer visitsInfection rate similar to expectant and surgicalExpect 5-15% will need aspirationSome cases of missed abortion may be at risk for greater blood loss
18Misoprostol 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 incomplete71% complete by Day 384% complete by Day 8Anembryonic gestation success rate 81%Embryonic or fetal death 88%Incomplete or inevitable abortion 93%Incomplete = persistent sac OR endometrial lining >30mm
19MisprostolRecommend 800mcg buccal followed by second dose in hours if no obvious passage of tissue with first doseSome 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.
22Misoprostol ProtocolPlanned 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 misoprostolProphylactic antibiotics (doxy 100 bid for 7 days)
23Misoprostol Counseling Supportive companionVicodin, motrin, phenergan—take earlyMake sure to have pads at homeExpect several hours of heavy bleeding starting several hours after doseBlood looks like more in the toilet bowlAntibiotic prophylaxis recommendedPlan for contraception/ folic acid
24Side effects of misoprostol Bleeding – typically lasts up to 2 weeks with spotting till next periodCramping – usually starts within the first few hours. NSAIDs can be usedFevers and/or chills – common side effect. If lasts >24 hours, evaluate for infectionNausea and vomiting – more common after oral misoprostol. Should resolve in 6 hoursDiarrhea – also more common after oral miso and should resolve in 24 hours.
25Logistics at CCRMC Can be prescribed by any physician Follow-up as for expectant management but expect sooner resolution on average than expectant managment
26Case C28 y/0 G2P1 presents at 13 weeks gestation. No fetal heart tones heard.Ultrasound shows 8 weeks missed SABNo symptoms
27Mifepristone and Misoprostol Possibly viable undesired IUP up to 63 daysUndesired threatened abortionUsed by some for blighted ovum or missed abortion—may be higher success rate/less blood loss.
28Protocol for Mife/Miso Give 200mcg mifepristone in clinicSend home with four 200mcg pills of misoprotol to use in 6-72 hours buccallyMore extensive consent process and limited access to medicationAntibiotic prophylaxis
29Logistics at CCRMCAccess in Reproductive Health Procedures Clinic (GYN Tomasulo) in Martinez (Linda Wise 4912)Brentwood: Tomasulo, Sara LevinAntioch: Nancy PalmerPittsburg: FeierabendConcord: Tomasulo, BlissRichmond: Bliss, Lehman
30Case D 40 y/o G5P1 ectopic 1, TAB 2 Presents with no LMP since before depo shot 5 months agoSpotting, minimal painHCG 1890Sono 2 cm ovarian cyst, empty uterusDoes not want to be pregnant
31Methotrexate/Misoprostol Methotrexate alone used for known ectopic pregnanciesMethotrexate/Misoprostol can be used if Mifepristone not available (Mifeprisone must be ordered by physician and shipped directly to physician with accountMethotrexate/Misoprostol can be used if treatment desired before ectopic ruled-out
32Logistics at CCRMCGenerally 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-upMay refer to any GYN clinic for follow-up
33Case E18 y/o G4P2 TAB 1 presents with spotting and cramping 10 weeks post LMPSono shows 7 week missed SABFamily does not know she is pregnant againWants resolved ASAP
34Manual Vacuum Aspiration Advantages Able to assess tissue and verify POC to rule-out ectopic pregnancyFewest return visitsTrend towards least blood lossMost certain time course/clinician with them during procedureRequires least amount of home supportMay be able to place IUD at the same time
35Manual Vacuum Aspiration Disadvantages Requires more equipmentVery small risk of uterine perforationMay have more infection riskRequires more clinic or emergency room time and more nursing timeRequires more physician training
36Manual Vacuum Aspiration Sharp curettage (D and C) no longer an acceptable option due to higher complication ratesManual 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.
37MVA Instruments and Supplies InexpensiveSmallPortableQuietSpecimen likely to be intactMay require repeated reloading of suctionMVA Instruments and SuppliesThis 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 syringeCannulaeSpeculumTenaculumDilators or misoprostol.
38Post MVA Rhogam if indicated, iron if indicated Doxycycline 100 bid for 2-14 dosesIbuprofenContraception or folic acidFollow-up appointment
39Logistics at CCRMCReproductive Health Procedures Clinic: Monday and Wednesday am GYN MTZ Tomasulo, access Linda Wise 4912GYN clinics: Schedule early in clinic and check with provider in clinicER: Works well when ER and Perinatal Unit not too busyLinda Wise has agreed to provide this service. Outside TAB social workers have not.
40Case F38 y/o with history of prior LEEP presents at 11 weeks with spottingSono shows 10 week missed SABHistory of intolerance to pelvic examsHb of 8Poorly controlled seizure disorderWeighs 342 lbs
41Electric Vacuum Aspiration in an Operating Room Best for woman who needs general anesthesia or more sedation then can be given in your clinicMay be more appropriate for significant respiratory, cardiac, or obesity co-morbidityMay be more appropriate for high risk bleeding situations or unstable patients
42Disadvantages of EVA Wait for OR and physician availability Expense NPO statusIVLess privacyMay have more anesthesia then necessary/desiredMost risk of procedure from anesthesiaLess continuity with staff
43Logistics at CCRMC Consider direct scheduling in the OR Often times on Tuesday and Thursday available but any day OKH and P and consent in clinic or can be done in PACU prior to procedure if necessaryCall OB attending on call to make sure provider available
44Contraception Initiate Discussion Early even if was desired pregnancy Start contraceptive early, usually while still bleedingIUD or Implanon can be placed during MVA or EVA
46Psychological Management Acknowledge, dispel guiltLegitimize griefProvide comfort, ongoing supportReassure about the futureCounsel patient how to tell family, friendsWarn of anniversary phenomenonInclude partner in psychological careAssess level of grief and adjust counseling accordinglyDon’t forget – half of pregnancies are unintended!
47ConclusionProvide medical and psychologic support—your job is not just to rule out ectopicAs family physicians we can make the situation not only safe, but also decrease pain, anxiety and inconvenienceRemember misoprostol,MVA, EVA in addition to expectant management