1. Management of 1st Trimester Bleeding Jen Phillips, MD 4/5/2017

3. Thanks to Dr. Nicole Yonke and baby Anya

4. Objectives
Understand how to address early pregnancy bleeding and pregnancy of unknown location.
Learn how to diagnose abnormal intrauterine pregnancy vs ectopic vs early normal pregnancy.
Compare the risks and benefits of expectant management vs medical vs surgical intervention with miscarriage.
Understand how to use misoprostol for medical management of miscarriage .
Learn about the MVA.
Manual Vacuum Aspiration is a proven technology that is particularly appropriate for very early abortions and for treatment of incomplete abortion and has been used worldwide for almost 30 years (Greenslade, et al., 1993).
In this presentation we will:
• Identify uses for MVA and conditions requiring precaution
• Learn the steps in performing an MVA procedure
• Understand the importance of tissue inspection
• Identify possible complications of MVA
To achieve our objectives, we will review the history of MVA, give an overview of the uses for MVA, describe how to perform an MVA procedure, and describe the importance of and process for tissue inspection.
Source: Greenslade F, Leonard A, Benson J, Winkler J, Henderson V. Manual Vacuum
Aspiration: A Summary of Clinical & Programmatic Experience Worldwide. Carrboro,
North Carolina: IPAS, 1993.

5. pretest How often does spontaneous abortion occur?
What is a threatened vs incomplete vs inevitable vs missed abo?
What are the options for management of missed abortion?
How can we ‘rule out’ ectopic pregnancy?
How can MVA (manual vacuum aspiration) help?

6. Epidemiology of early pregnancy loss
One in four women will have a miscarriage during her lifetime.
May only form a gestational sac (blighted ovum or anembryonic pregnancy) or demise may occur after embryo forms. Usually under 10 weeks gestational age.
Spontaneous abortion occurs 8-20% of pregnancies.

7. Clinical presentation of early pregnancy failure
Missed abortion
Incomplete abortion
Inevitable abortion
Complete abortion
Spontaneous abortion
Missed abortion is clinically outdated but may be the best diagnosis code for asymptomatic women with anembryonic pregnancy or embryonic demise by ultrasound. Incomplete abortion is when some tissue has passed but not all. Spontaneous abortion is is pregnancy loss less than 20 weeks gestation. Complete abortion is when all tissue has passed. Inevitable abortion is when cervix is open, contractions have started but no tissue has yet passed.

9. 21 yo G1 at 6w by LMP
Presents with vaginal bleeding in OB triage x 1 day
What is the differential diagnosis?
Viable IUP pregnancy
Miscarriage
Ectopic pregnancy
Pregnancy of unknown location(PUL)
+hCG, but no IUP seen on US

10. What other history do you want?
Is this a desired pregnancy?
Has she had an US already
History
Ectopic pregnancy
SAB
PID/STIs
AMA
Known anatomic abnormalities
DM/Thyroid disease

11. our patient continued…
Ultrasound performed in triage
Small fluid collection in the uterus, no IUP
Sent to DI with same results on US
βhCG is 2200
No cramping or abdominal pain
Normal exam, scant brown blood in vaginal vault
Hct 41, vital signs are normal
Rh positive
What category does she fall into? How would you describe this situation?

12. PUL: Pregnancy unknown location
8-31% of women presenting with first trimester pain or vaginal bleeding will have a PUL
7-20% of these women ultimately diagnosed with ectopic pregnancy
40% of women with ectopic are not diagnosed at initial visit
Crochet JAMA 2013; 309:

13. What should we do with her?
Add her to the new MCH beta book
Call MCH fellow to discuss follow-up plan
Place patient phone number, PUL, hCG value and follow-up plan in the comments section

14. What if pregnancy is undesired?
Aspirate to rule out ectopic
Follow BhCG to make sure they are falling (confirms IUP)
Send POC to pathology to confirm IUP

15. She follows up for labs and ultrasound
Day 3 – BhCG 3520
Day 5 – BhCG 5632
Day 7 – repeat US gestational sac with yolk sac and embryo, no cardiac motion
What is her diagnosis now?
Has an IUP – unclear if it is viable
Rose by 60%

16. Previous criteria for diagnosing nonviable pregnancy were too “loose”
Did not address 19% variability in ultrasonographer measurements of gestational sac and fetal pole size
Small study sizes
Erroneous treatments with methotrexate causing adverse fetal outcomes and rising lawsuits
Risk of harming a normal pregnancy with old criteria
Doubilet PM et al. N Engl J Med 2013;369:

17. Doubilet PM et al. N Engl J Med 2013;369:1443-1451.
New Guidelines for TVUS Dx of an IUP of Uncertain Viability
Doubilet PM et al. N Engl J Med 2013;369:

18. She returns for another US one week later
CRL 7.5 mm, no cardiac motion
What is your diagnosis?

19. She asks, “How many women have a miscarriage?”
One in four women will have a miscarriage during her lifetime
Prine AFP 2011 Office Management of Early Pregnancy Loss

20. She asks, “How many pregnancies end in SAB?”
12-24% of women with a +PGU will have a pregnancy loss
True rate likely higher ~30% because many losses occur pre-clinically before a missed LMP
Usually under 10 weeks gestational age
How I counsel
Jurkovic BMJ 2013; 345

21. What is the most common cause of pregnancy loss?
Chromosomal abnormalities are the most common cause
Detected in 50-85% of pregnancy tissue specimens after a spontaneous abortion
Jurkovic BMJ 2013; 345

22. What are risk factors for early loss?
Advanced Maternal Age
Moderate alcohol use
Caffeine use
Cigarette Smoking
Chronic disease
Antiphospholipid Antibody Syndrome, PCOS, thyroid disease, DM
Obesity
Previous pregnancy loss
Reproductive tract abnormalities
Maternal infections – Syphilis, CT, toxo, vaginal mycoplasma or ureaplasma
Prine AFP 2011 Office Management of Early Pregnancy Loss

23. Recurrent pregnancy loss
Reasonable to perform evaluation after two consecutive losses based on patient desire and age
50-75% are unexplained after workup and 50% or more will still conceive
Uterine anatomy, parental karyotype, antiphospholipid antibodies, TSH, r/o diabetes, prolactin
Consider karyotype on POCs in this scenario
Evaluation and treatment of recurrent pregnancy loss: a committee opinion ;The Practice Committee of the American Society for Reproductive Medicine:Fertility and Sterility® Vol. 98, No. 5, November 2012

24. Treatment of Early Pregnancy Loss
Expectant Management (waiting)
Misoprostol (can be done in clinic, triage, CRH)
Aspiration procedure (D&C)
Patient Hand outs from Reproductive Access Website discuss options
Can give info in triage and then refer back to PCP or CRH if she is unsure on what she would like to do for management

25. Study of family medicine physicians
56% had seen women with EPL in last 6 months
18% only referred patients
59% only offered expectant management
24% offered aspiration
16% offered misoprostol medical management
Adds to >100% due to multiple modalities.
“Offered” means on their own not via referral
Wallace Fam Med 2013;45(3):173-9.)

26. What number of women experience first trimester bleeding?
Ranges from 15% to 25%.
Half of women with bleeding will have pregnancy loss by 20w gestation.
Risk of SAB may be related to amount of spotting
Connolly , Obs&Gyn Jan 2013
Prine AFP 2011 Office Management of Early Pregnancy Loss

27. How should we evaluate first trimester bleeding?
Physical Exam
Vital signs - is she stable?
Large blood loss requiring transfusion possible with SAB and ectopic pregnancies
Abdominal Exam
Peritoneal signs?
Pelvic Exam
How much blood do you see in the vaginal vault?
Is there active bleeding from the cervix? How much?
Is her cervix open?
Is she tender on bimanual exam?

28. Laboratory Tests βhCG Hematocrit ?
Rh negative: give Rhogam to all Rh negative women with first trimester bleeding regardless of how early in pregnancy

29. Barnhart KT, Obstet Gynecol 2004;104:50–5
Kirk Human Reproduction Update 2014;20:
Quantitative βhCG
Correlate with gestational age and ultrasound
2 measurements, 48 hours apart
Should increase by at least 53%, but may not “double”.
If rise not at least 53%, then 99% of time it is not viable IUP
A rise <35% considered safer definition of non-viable
Falling or plateaued serial quantitative HCGs can diagnose a failing pregnancy but not the location

30. Imaging
Ultrasound is primary and often only diagnostic approach needed
Do not need to wait for the βhCG to do an US
What if the MCH attending is not credentialed to do first trimester US?
MCH-OB back-up can do if available during daylight hours
Can ask OB team to perform first trimester US if not busy
If OB team is unavailable, send patient to Diagnostic Imaging
Many attendings credentialed – MCH-OB, Jen, Mary Lemon, Liz, Dave

31. ~ 5 weeks Does not confirm IUP Gestational Sac Slide from ALSO
Doubliet, 2014 Radiol Clin N Am;52:

32. Yolk Sac ~ 5.5 weeks Confirms IUP
Unless heterotopic – more on this later

33. Embryonic Pole Will usually see by 6w
Cardiac motion confirms viability
May still be viable even if cardiac motion is not identified (If < 7 mm)
Can repeat US in 1 week
Would not follow hCGs in this situation

34. Very early IUP
SAB
Ectopic
Empty Uterus

35. Free Fluid
Empty uterus with free fluid

36. Ultrasound Summary Yolk sac – diagnoses IUP
Heartbeat - diagnoses viable IUP
A yolk sac and/or embryo rule out ectopic…..unless heterotopic
“Gestational sac” without yolk sac or embryo
Does NOT rule out ectopic- may be pseudosac
Abdallah et al Ultrasound Obstet Gynecol 2011

37. Case 2
28-year-old G3 P1011 presents to OB triage with a positive pregnancy test at home and heavy vaginal bleeding with clots. Dating by last menstrual period of 9 weeks. Ultrasound shows an empty uterus. Pelvic exam shows an open cervical os and some tissue at the os. She is Rh-. What do you do? What is her probable diagnosis?

38. Transvaginal ultrasound diagnosis of miscarriage
Anembryonic pregnancy: Gestational sac of >25 mm without pole or yolk sac OR if < 25 mm with no change on rescan 7 days later.
Missed abortion:Fetal pole of >7 mm by CRL without heart beat or if <7 mm no change in rescan 7 days later.
No embryo w/ cardiac activity 11d after GS and YS seen.

39. Remember
Pregnancy dating and sonography are imperfect so diagnosis of spontaneous abortion in a woman with a wanted pregnancy may take two ultrasounds.
Be patient.

40. Case 3
32-year-old G1 P0 comes in to your primary care clinic with a little vaginal spotting when she wipes. She is really worried because this is a wanted pregnancy. On ultrasound you see:

41. Early Pregnancy Uterus outline Sub-chorionic Bleed Embryo Yolk Sac
Gestational Sac
Choriodecidual Reaction
Vaginal Ultrasound
Ultrasound can be useful in identifying an early intrauterine pregnancy. In pregnancies < 5 weeks, the gestational sac may be difficult to find. There will be a thick decidual shadow
The features to look for when performing a vaginal ultrasound to determine gestational age:
the presence of the gestational sac
the presence of an embryonic structure
the presence of the yolk sac
the presence of cardiac activity.

42. How to rule out ectopic
When no gestational sac is visible you must consider ectopic.
When no yolk sac is present in gestational sac you must consider ectopic. Pseudosac?
If pregnancy is unwanted an MVA could be performed in an attempt to get chorionic villi which would rule out ectopic.
History and physical alone will not usually confirm diagnosis of ectopic pregnancy. Differentiating an ectopic pregnancy from an early intrauterine pregnancy or spontaneous abortion usually requires a combination of serum quantitative hCG measurements, pelvic ultrasound and in some cases an MVA.

43. Ectopic Pregnancy 1-2% of pregnancies
Consider in all women with pain and bleeding
Women with h/o ectopic, tubal surgery, or tubal pathology are at increased risk
Increased risk if smoker or IVF
Most women do not have risk factors
Jurkovic BMJ 2011;342:d3397

44. Ectopic Presentation 10% of women have no symptoms
Amount of bleeding classically is spotting
Abdominal pain is often absent or late finding, likely due to earlier recognition
Majority of women with abdominal pain in early pregnancy don’t have an ectopic
Kirk Human Reproduction Update 2014;20:

45. Ectopic Diagnosis TVUS sensitivity 98.3% - but not on first US
20% may have pseudosac, but still more likely to be normal pregnancy so can’t diagnose by this alone
Free fluid on US
Ectopics have been identified with βhCG at levels < 100 and > 50,000
A single βhCG cannot confirm diagnosis
Ectopic may have normal rise in HCG
No single pattern to diagnose women with EP
Kirk Human Reproduction Update 2014;20:
Lozeau AFP 205;72:

46. Pseudosac vs ‘real sac’

47. PUL follow-up with serial BhCG
Review ectopic warning signs carefully
Repeat βhCG in 48 hours
βhCG drop by 13% in 48 hr
Risk of needing intervention is low and likely SAB or resolving ectopic.
Follow βhCG weekly until BhCG is 0.
May need to repeat βhCG again in another 48 hours
Normally rising βhCG – repeat TVUS when above discriminatory zone or on day 7.
Abnormally rising βhCG across 3 measurements or symptoms – needs evaluation and repeat US for ectopic

48. Heterotopic Pregnancy
Presence of simultaneous pregnancies at two different implantation sites
Usually intrauterine and ectopic
1 in 30,000
1 in 3,900 with ART
Complex adnexal mass and fluid in the pelvis

49. Heterotopic pregnancy
Intrauterine pregnancy
Right adnexal mass

50. What is the discriminatory zone?
Serum hCG at which US findings should be detected
Threshold level – refers to the lowest serum hCG at which a gestational sac or fetal pole can be detected
1,500-2,000 mIU/mL commonly used a hCG disriminatory zone in practice for seeing gestational sac
However, this is value is not conservative enough

51. Traditional HCG and Ultrasound Correlates
Gestational age by LMP
Transabdominal Landmarks
Transvaginal Landmarks
Serum hCG mIU/ml IRP
< 5 weeks
None
Possible gestational sac
1800
5 - 6 weeks
Gestational sac
Gestational sac, yolk sac
7 weeks
5-10 mm embryo
Same as transabdominal, with cardiac activity
>20,000

52. Discriminatory zone - reconsidered
Reviewed 690 1st tri pregnancies with vaginal bleeding and/or pelvic pain with HCG and TVUS
50% of the time a gestational sac could be seen when HCG >879
90% of the time GS seen when HCG >1918
99% discriminatory level was much higher than currently used
Connolly Obstet Gynecol 2013;121:65–70

53. Use Caution with Discriminatory Values
HCG >1500 would only detect 80% of viable pregnancies
HCG > 2000 may only diagnose 91% of viable pregnancies
Reasons for not visualizing – fibroids, polyps, obesity, adenomyosis
Use care when interpreting hCG discriminatory level in hemodynamically stable patients with PUL
The decision to intervene should not be based solely on a single hCG level in a stable patient.
Connolly Obstet Gynecol 2013;121:65–70
Ko J Ultrasound Med 2014; 33:

54. New Discriminatory Values
Connolly Obstet Gynecol 2013;121:65–70

55. If B-HCG below discriminatory level
Serial B-HCGs
If B-HCG in 48 hrs has gone up by 53% then this is a normal pregnancy with 99% confidence but repeat u/s is still indicated until fetal pole is seen and measured for dating.
A decreasing B-HCG is abnormal and is most likely a miscarriage.
In what cases could a decreasing b-hcg still produce a normal pregnancy?

56. Case 4
18-year-old G1 P0 comes into reproductive health. She thinks she 5-6 weeks pregnant. She is having a little bit of vaginal bleeding. She does not want to be pregnant and on ultrasound you see a small gestational sac with a double decidual ring reaction. There is no yolk sac.

57. With her consent you proceed with manual vacuum aspiration (MVA)to find:

58. On closer look

59. Case 4
24-year-old G3 P2 002 at 8 weeks by her last menstrual period comes in with vaginal bleeding and cramping. She has had a lot of nausea with this pregnancy. Her beta-hCG is 12,000 and her ultrasound shows a “starry night” or “cluster of grapes”.

60. Partial Hydatiform Mole
Sebire Gestational Trohoblastic disease in Management of Unintended and Abnormal Pregnancy: Comprehensive Abortion Care

61. With her consent you proceed with manual vacuum aspiration (MVA)to find: hydropic villi

62. Management of early pregnancy failure
Uterine curette introduced in 1843
D and C advocated in late 18th century to decrease hemorrhage and chance of sepsis
Dilation and curettage has been standard management for over 50 years
Edwards and Carson report prompts increased MVA use in USA in 1997
Misoprostol introduced for medical management of EPL in

63. Potential risks of expectant management
Infection
Need for emergent uterine aspiration
Hemorrhage/blood transfusion

64. Potential benefits of expectant management
Avoid risks (albeit uncommon) of uterine aspiration including perforation
Decrease risk of excess curettage (Asherman’s syndrome)
Patient preference
Cost

65. Contraindications to expectant management
Excess blood loss
Infection
Inability to access an emergent uterine aspiration
Patient choice

66. Myths of expectant management
Acceptable for limited time only
DIC
Infection likely
Preferred by most women

67. Success of expectant management
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

68. How well does miso work for miscarriage?
Day 1: 800 mcg miso administered vaginally
Day 3: Repeat misoprostol if incomplete % complete
Day 8: Aspiration if still incomplete % complete
Anembryonic gestation success rate 81%
Embryonic or fetal death 88%
Incomplete or inevitable abortion 93%
Zhang et al NEJM 8/25/05

69. UNM Misoprostol Management Protocol
On MCH Wiki
UNM Misoprostol Management Protocol
Candidates
Non-viable pregnancy up to 10 weeks gestation diagnosed by ultrasound
Ectopic pregnancy has been excluded
Dictate note & place patient in the beta book
Labs
Rh screen, Hct, quantitative serum βhCG
Procedure
800 mcg misoprostol vaginally or buccally
Give prescription for 1 dose with a second dose in case tissue does not pass with first dose
Ibuprofen 800 mg starting at time of misoprostol and then q 6 hr
Tylenol #3 1-2 tabs q 3-4 hr prn severe pain

70. Psychosocial factors in decision making: qualitative study
Women may need more time and information than usually provided after initial diagnosis to make decision
Women choosing surgery usually got adequate counseling
Women choosing expectant management needed more info about miscarriage process
Ogden . BJOG 2004; 111:463-7

71. 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 pump aspiration

72. Historical Perspective of MVA use
: Large US study documents safety of vacuum
aspiration
: US government funds research to develop non electric vacuum source
1972: First report on MVA use
1973: Non-profit organization (IPAS) created to
complete development of MVA and
distribute instruments worldwide
1980s: Several manufacturers market MVA
worldwide
1990s: MVA used in >100 countries
1997: Edwards and Carson report prompts
increased MVA use in US
Historical Perspective:
: Phase 1 of the Joint Program for the Study of Abortion (JPSA) documented the safety of vacuum aspiration. The three-part JPSA study analyzed 250,000 cases of induced abortion in the US and established vacuum aspiration as the method of choice for first trimester abortion.
1971: The need to make vacuum aspiration available in a broad range of clinical settings, particularly where electricity was an issue, led to the development and refinements of manual vacuum aspiration technologies. The United States Agency for International Development funded Battelle Laboratories to improve existing manual vacuum sources.
1972: Karman and Potts report their experience with MVA for uterine evacuation with a hand-held syringe vacuum source and flexible plastic cannulae with whistlecut design (Karman and Potts, 1972).
1973 – 1980s: After the Helms Amendment was passed prohibiting use of US foreign aid to support abortion services internationally, Ipas (a not-for-profit organization) was created to complete development of MVA technology. Ipas and other manufacturers began distributing MVA, and in the 1980s Ipas began sponsoring training in MVA.
1990s: By 1993, Ipas MVA instruments had been distributed in more than 100 countries. Numerous international studies have demonstrated the effectiveness of MVA for both treatment of incomplete abortion and for induced abortion.
1997: Edwards and Carson’s research on MVA (Edwards and Carson, 1997) and subsequent dissemination (Edwards and Creinin, 1997) initiated a resurgence of interest in using MVA for early abortion procedures in the United States.
Sources: Karman H, Potts M. Very Early Abortion Using a Syringe as a Vacuum Source. The Lancet 1972; 1:
Edwards J, Carson S. New Technologies Permit Safe Abortion at Less than Six Weeks’ Gestation and
Provide Timely Detection of Ectopic Gestation. American Journal of Obstetrics and Gynecology 1997;
176:
Edwards J, Creinin MD. Surgical Abortion for Gestation of Less than 6 Weeks. Current Problems in
Obstetrics, Gynecology, and Fertility 1997; 20 (1):11-19.

73. 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.

74. Manual Vacuum Aspiration (MVA) vs. Electric Vacuum Aspiration (EVA)
Inexpensive
Small
Portable
Quiet
Specimen likely to be intact
May require repeated reloading of suction
EVA
More costly but longer life
Bulky
Less portable
Noisy
Fragmentation of specimen possible
Constant suction
The choice of method—standard vacuum aspiration with an electric vacuum pump (EVA) or manual vacuum aspiration (MVA)—is a matter of provider preference and experience. Some providers prefer to utilize MVA throughout the first trimester; others reserve this equipment for use before 6 weeks’ gestation.1 In early pregnancy, both methods are equally fast for completion of the procedure. There are no randomized studies comparing the two methods.
Manual vacuum aspiration is a technique of uterine evacuation that uses a hand-held syringe to generate suction. In many ways, the technique is similar to that of standard suction curettage with a larger cannula. The key difference is the suction source: a hand-held syringe in the case of MVA and an electric suction pump with EVA. Flexible or rigid cannulas may be used with either technique.
MVA has certain advantages over EVA performed with larger-bore cannulas. MVA is less expensive, and the equipment used can be transported easily. Generally, it is quieter and may permit easier identification of gestational sacs from very early pregnancies.1 However, it should be noted that newer EVA machines are quieter than older models. One disadvantage of MVA is that with more-advanced gestations, the procedure may require repeated reloading of the suction; this is not necessary with EVA, as the machinery creates constant suction.
Experienced practitioners may offer MVA shortly after a pregnancy test turns positive. At this point in time, the gestational sac will not yet be visible by transvaginal ultrasound. Edwards and Creinin1 reported that the gestational sac was grossly visible in the tissue aspirate in 50% of cases when no sac was visible on preoperative ultrasonography.
The availability of the technique makes it possible for women to have abortions without significant delay, and the technique can also help diagnose ectopic pregnancies at an early stage in the gestation, enabling medical management with methotrexate.1
Ref:
1 Edwards J, Creinin MD. Surgical abortion for gestations of less than 6 weeks. Curr Problems Obstet Gynecol Fertil 1997;20:11-19.

75. MVA in ED/labor ward vs. suction D and C (EVA) in OR
Waiting time reduced by 52%
Procedure time reduced from mean 33 to 19 minutes
Costs reduced by 41% ($1404 to $827,
P < .01) for all three outcomes
Blumenthal PD, Remsburg RE. Int J Gynecol Obstet 1994, 45:

76. MVA for EPL (early pregnancy loss) at University of New Mexico
Women who present with an incomplete abortion, inevitable abortion or missed abortion with heavy bleeding are candidates for MVA in OB triage. Women with missed abortion without heavy bleeding may be scheduled for an outpatient clinic procedure at CRH ( / ad huc referral). .
An ultrasound from Diagnostic Imaging or Women’s Ultrasound may be used to make the diagnosis, as may an ultrasound by a credentialed physician from the departments of either Family Medicine or OB-GYN.

77. Misoprostol for early pregnancy loss
Candidates
Non-viable pregnancy up to 10 weeks gestation diagnosed by ultrasound
Ectopic pregnancy has been excluded
Labs
Rh screen, Hct, quantitative serum βhCG
Procedure
800 mcg misoprostol vaginally or buccally
Give prescription for 1 dose with a second dose in case tissue does not pass with first dose
Ibuprofen 800 mg starting at time of misoprostol and then q 6 hr
Tylenol #3 1-2 tabs q 3-4 hr prn severe pain

78. 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.

79. Failure to pass tissue
If no passage of tissue occurs (the patient has not bled as much as a period) within hours, the patient may use the second vaginal dose of 800 mcg misoprostol.
If no passage of tissue occurs by 1-2 weeks consider referral for MVA vs. D&C. May continue expectant management if desired.

80. Patient precautions
Call for “heavy bleeding” defined as soaking two pads every hour for more than 2 hours. The patient does not need to bring products of conception back to the provider and should not be instructed to do so. The provider seeing the patient should give her instructions for who to call.

81. Followup in one week to ensure completion
Diagnosis completion by either :
1) follow-up quantitative serum hCG following passage of tissue (a drop of 50%)
2) a transvaginal ultrasound with absence of sac. Note: if one of these criteria has been met, no further follow-up of serum hCGs is warranted

82. Which is better or safer: aspiration, medication or waiting?
Cochrane 2010
Compared miso to expectant and miso to aspiration and found each equal
Cochrane 2012
Aspiration to expectant management
More unplanned surgery & transfusions (1.4% vs. 0%) with expectant.
Infection and psychological outcomes similar and cost less with expectant

83. Antibiotics indicated
Yes for uterine aspiration
Doxycycline 200 mg the night before (up to 12 hrs) or one hour prior to procedure appears optimal
Metronidazole alternative if allergic
Antibiotics not needed for misoprostol or expectant management
SFP Guideline Contraception April 2011

84. Summary for EPL
Expectant management or medical or surgical intervention (MVA or EVA) are appropriate with EPL based on patient choice.
Appropriate education and close follow-up essential for expectant management.
Incomplete abortions are more likely to have successful expectant management than missed abortions/anembryonic pregnancies.
If expectant management unsuccessful by day 14 consider intervention.

85. Summary 1st trimester bleeding is common.
Early normal pregnancy, early abnormal pregnancy or ectopic can be the cause.
Ectopic must be ruled out!
Women have options of watchful waiting, misoprostol and MVA for EPL.

86. MCH Beta Book Guidelines
Help us manage women with miscarriage, pregnancies of unknown location, and ectopic pregnancies
Women evaluated in OB triage and continuity clinics
MCH fellows will manage this book under supervision of Nicole Yonke & Larry Leeman

87. Beta Book
“Beta Book” is a Care Team list, just like the MCH Care Team.
Patient should be added by the resident seeing her in triage or clinic
Include contact number, PUL or SAB
Initial BhCG and follow-up plan

88. Ectopic Pregnancies
All diagnosed or probable ectopics should be placed in the MCH and OB Beta Book.
Patient should have consult by the Ob/Gyn Family Planning Service

89. Questions?