1. Office Management of Early Pregnancy Loss

2. Objectives Discuss the differential and the work-up needed for the patient with first trimester bleeding Compare the risks and benefits of expectant management vs. medical or surgical intervention for miscarriage Describe how to use vaginal misoprostol for medical management of miscarriage Explain the use of manual vacuum aspiration for early pregnancy loss

3. Epidemiology of Early Pregnancy Loss One in four women will experience EP Up to 15- 20% of diagnosed pregnancies

4. What are the clinical presentations of first trimester losses?

5. Causes of EPL Chromosomal abnormalities > 50% Infection Reproductive tract abnormalities Exposure to toxins Uncontrolled endocrine or autoimmunedisease

6. Jennifer 22 years old LMP was 7 weeks ago Positive urine pregnancy She is having some vaginal bleeding Additional history? And on physical?

7. Algorithm with Physical Exam

8. Diagnosis of Miscarriage: Ultrasound Anembryonic pregnancy Embryonic Demise A gestational sac should be visible in the uterus on vaginal sono if the HCG> 2000. If not: consider ectopic pregnancy.

9. Anembryonic Pregnancy Mean sac diameter 18-25 mm with no yolk sac or fetal pole, or no growth 7-14 days

10. Embryonic Demise when no FH

11. Back to Jennifer… What does she need to know?

12. Risk Factors Age Prior miscarriages Smoking Cocaine use Fever/Infection

13. Miscarriage Myths Air travel Blunt abdominal trauma Contraceptive use Exercise HPV vaccine Previous abortions Sexual activity

14. Three Options: 1.Expectant Management 2.Medication Management 3.Aspiration Procedure

15. Potential Risks of Expectant Management: All Rare Infection Need for emergent uterine aspiration Hemorrhage/blood transfusion Worth noting: These risks also exist for surgical or medical management and are not statistically different… Butler et al J Fam Pract 2005 54:889-90

16. What are the potential benefits of expectant management?

17. What would be the contraindications to expectant management?

18. Success of Expectant Management GroupNComplete Day 7 Complete Day 14 Success Day 49 Incomplete 221117 (53%)185 (84%)201 (91%) Missed 13841 (30%)81 (59%)105 (76%) Anembryonic 9223 (25%)48 (52%)61 (66%) TOTAL 451181 (40%)314 (70%)367 (81%) Luise C, et al. BMJ 2002; 324(7342):873-5.

19. What anticipatory guidance and help do we provide for expectant management?

20. Medical management of miscarriage: Misoprostol for early pregnancy loss

21. Misoprostol for Miscarriage Common protocols: 800mcg miso administered vaginally or buccally with repeat in 24 hours if incomplete, and Vacuum on Day 8 if still incomplete Alternatives: 600mcg oral, 400mcg SL Alternative: repeat q 24 vs q 3 hours Zhang et al. NEJM 8/25/05; 353(8)761-9.

22. Side Effects of Misoprostol Bleeding Cramping Fevers and/or chills Nausea and vomiting Diarrhea

23. Guidelines for Misoprostol Use for Early Pregnancy Loss Clear diagnosis 10 weeks or under by ultrasound Rule out ectopic pregnancy because medical treatment for ectopic pregnancy differs from miscarriage treatment Testing: Ultrasound, Rh screen, hematocrit, quantitative serum hCG (quant not always needed if ultrasound diagnosis is definitive)

24. Patient Instructions (same as for expectant management) Call for “heavy bleeding” Patient does NOT need to bring products of conception back to the provider Contact information for quickly reaching provider must be supplied Pain medications prescribed

25. Success Rates with Expectant Management vs Misoprostol Expectant Management (%)Misoprostol (%) By Day 7By Day 14By Day 46By Day 8 Incomplete53849193 Embryonic Demise30597688 Anembryonic Gestation25526681 Total40708184

26. What is done about the failure to pass tissue?

27. How is completion of the miscarriage diagnosed?

28. What do you need to start using misoprostol in your practice?

31. “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 Vacuum Aspiration (EVA) Cochrane Review 2001 (1)CD001993

32. Uterine Aspiration Electric Vacuum Aspirator Manual Vacuum Aspirator

33. MVA Instruments and Supplies

34. MVA in ED/Labor Ward vs. Suction D & C (EVA) in OR Waiting time reduced by 52% Mean procedure time reduced from 33 to 19 minutes Costs reduced by 41% ($1404 to $827, P <.01) Better yet - MVA in family medicine office Blumenthal PD, Remsburg RE. Int J Gynecol Obstet 1994, 45: 261-267.

35. Introducing MVA in your Practice Training: Easy to adopt if trained in “D and C” Equipment: MVA syringe ($30 reusable) and suction currettes ($1 each) Ultrasound: can be used for many purposes, and clearly saves patients many trips to the ER or to radiology Patient handouts/forms-many available online

36. Advantages to office MVA Avoid repeated exams that occur in hospital Cost Avoid cumbersome OR protocols (NPO requirements, discharge criteria) Reduced wait time Personalized care Convenience, privacy, patient autonomy

37. Cases for Review: Sonia LMP 8 weeks ago Started spotting 3 days ago Now having heavier cramping with bleeding Appears comfortable, normal vital signs

38. Sonia, Continued Your exam reveals the following: Abdomen: Soft, nontender Vaginal vault: Moderate amount of blood, Cervix: Os open, tissue at os noted Bimanual exam: Uterus slightly enlarged, approx. 6 weeks size, nontender Hemoglobin: 10.2 Urine pregnancy test: Positive What is your working diagnosis? Would you do further testing? How would you counsel her?

39. Sonia, Continued How do you explain to her what is happening?

40. Katie Presents for prenatal care LMP 8 weeks ago, certain of her dates The pregnancy has been uncomplicated except for a small amount of bleeding she had about 3 weeks ago On exam, you find that her uterine size is small, more consistent with a 4-6 week IUP, os is closed.

41. Katie, Continued Very small, irregular sac with sub-chorionic bleed visible

42. Katie, Continued After 6 days of watchful waiting, Katie returns with further spotting and cramping. You send a serum β-hCG, and get a repeat ultrasound. The ultrasound still shows a small irregular shaped gestational sac. The serum β-hCG level has dropped 30%. What is your assessment? What options do you offer her now?

43. Katie, Continued She decides to opt for treatment with medication. What regimen do you use and how do you advise her?

44. How is completion of the miscarriage diagnosed?

45. EBM for Office Management of Miscarriage 1) Women with first trimester miscarriage should have the choice of expectant management or an intervention (uterine aspiration or misoprostol) Nanda K, Lopez LM, Grimes DA, Peloggia A, Nanda G. Expectant care versus surgical treatment for miscarriage. Cochrane Database of Systematic Reviews 2012, Issue 3. Art. No.: CD003518. DOI: 10.1002/14651858.CD003518.pub3. A Cochrane Systematic review- Strength of recommendation = A 2) Vacuum aspiration is the surgical treatment of choice to evacuate incompelete abortion due to shorter operating time and less blood loss than sharp curretage Tunçalp Ö, Gülmezoglu AM, Souza JP. Surgical procedures for evacuating incomplete miscarriage. Cochrane Database of Systematic Reviews 2010, Issue 9. Art. No.: CD001993. DOI: 10.1002/14651858.CD001993.pub2. A Cochrane systematic review - Strength of recommendation = A 3) Vaginal misoprostol is highly effective for completing first trimester miscarriage when a choice is made to intervene in place of expectant management http://dynamed101.epnet.com/Detail.aspx?id=113658#misoprostol_400_mcg_vaginally_inc Level 1 (Dynamed)

46. Summary Management of first trimester pregnancy complications can be done in a Family Practice setting. Expectant management, medical treatment or aspiration procedure are appropriate with EPL: patient choice is key. Education and close follow-up are essential for medical & expectant management. Incomplete abortions are more likely to have successful expectant management than missed abortions/anembryonic pregnancies.

47. Practice Recommendations Care of women experiencing early pregnancy loss can be integrated into the family medicine office setting The options for treatment can be presented to patients with their likelihood of success in a patient-centered manner and without any need to rush to a decision Counseling patients and their partners that their routine activities did not bring on their miscarriage is an essential part of the treatment.

48. References Allison JL, Sherwood RS, Schust DJ. Management of first trimester pregnancy loss can be safely moved into the office. Rev Obstet Gynecol; 2011;4(1):5-14. Prine LW, MacNaughton H Office Management of Early Pregnancy Loss Am Fam Physician 2011;84(1);75-82 Deutchman M, Tubay AT, Turok First Trimester Bleeding Am Fam Physician 2009 Jun 1;79(11):985-94. Chen B, Creinin M, Contemporary Management of Early Pregnancy Failure Clin Obstet and Gynecol 2007 Volume 50, Number 1, 67–88 Dynamed Miscarriage accessed 5/25/13: http://web.ebscohost.com/dynamed/detail?vid=3&sid=b5a02ed2-dee1-4f94- b13f- ca26a177216a%40sessionmgr15&hid=24&bdata=JnNpdGU9ZHluYW1lZC1MSVZFJn Njb3BlPXNpdGU%3d#db=dme&AN=113658