Office%20Management%20of%20Early%20Pregnancy%20Loss

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Office Management of Early Pregnancy Loss
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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

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Epidemiology of Early Pregnancy Loss

• One in four women will experience EP
• Up to 15- 20 of diagnosed pregnancies

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What are the clinical presentations of first
trimester losses?
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Causes of EPL

• Chromosomal abnormalities gt 50
• Infection
• Reproductive tract abnormalities
• Exposure to toxins
• Uncontrolled endocrine or autoimmune disease

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Jennifer

• 22 years old
• LMP was 7 weeks ago
• Positive urine pregnancy
• She is having some vaginal bleeding

Additional history? And on physical?
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Algorithm with Physical Exam
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Diagnosis of Miscarriage Ultrasound

• Anembryonic pregnancy
• Embryonic Demise
• A gestational sac should be visible in the uterus
  on vaginal sono if the HCGgt 2000. If not
  consider ectopic pregnancy.

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Anembryonic Pregnancy

• Mean sac diameter 18-25 mm with no yolk sac or
  fetal pole, or no growth 7-14 days

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Embryonic Demise when no FH
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Back to Jennifer
What does she need to know?
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Risk Factors

• Age
• Prior miscarriages
• Smoking
• Cocaine use
• Fever/Infection

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Miscarriage Myths

• Air travel
• Blunt abdominal trauma
• Contraceptive use
• Exercise
• HPV vaccine
• Previous abortions
• Sexual activity

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Three Options

1. Expectant Management
2. Medication Management
3. Aspiration Procedure

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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 54889-90
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What are the potential benefits of expectant
management?
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What would be the contraindications to expectant
management?
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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(7342)873-5.
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What anticipatory guidance and help do we provide
for expectant management?
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Medical management of miscarriage Misoprostol
for early pregnancy loss
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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.
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Side Effects of Misoprostol

• Bleeding
• Cramping
• Fevers and/or chills
• Nausea and vomiting
• Diarrhea

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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)

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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

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Success Rates with Expectant Management vs
Misoprostol
Expectant Management () Expectant Management () Expectant Management () Misoprostol ()
By Day 7 By Day 14 By Day 46 By Day 8
Incomplete 53 84 91 93
Embryonic Demise 30 59 76 88
Anembryonic Gestation 25 52 66 81
Total 40 70 81 84
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What is done about the failure to pass tissue?
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How is completion of the miscarriage diagnosed?
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What do you need to start using misoprostol in
your practice?
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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
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Uterine Aspiration
Manual Vacuum Aspirator
Electric Vacuum Aspirator
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MVA Instruments and Supplies
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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 lt .01)
• Better yet - MVA in family medicine office

Blumenthal PD, Remsburg RE. Int J Gynecol Obstet
1994, 45 261-267.
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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

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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

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Cases for Review Sonia

• LMP 8 weeks ago
• Started spotting 3 days ago
• Now having heavier cramping with bleeding
• Appears comfortable, normal vital signs

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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?
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Sonia, Continued

• How do you explain to her what is happening?

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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.

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Katie, Continued

• Very small, irregular sac with sub-chorionic
  bleed visible

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Katie, Continued

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

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Katie, Continued

• She decides to opt for treatment with medication.
• What regimen do you use and how do you advise
  her?

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How is completion of the miscarriage diagnosed?
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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?id113658
  misoprostol_400_mcg_vaginally_inc
• Level 1 (Dynamed)

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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.

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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.

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References

• Allison JL, Sherwood RS, Schust DJ. Management of
  first trimester pregnancy loss can be safely
  moved into the office. Rev Obstet Gynecol
  20114(1)5-14.
• Prine LW, MacNaughton H Office Management of
  Early Pregnancy Loss Am Fam Physician
  201184(1)75-82
• Deutchman M, Tubay AT, Turok First Trimester
  Bleeding Am Fam Physician 2009 Jun
  179(11)985-94.
• Chen B, Creinin M, Contemporary Management of
  Early Pregnancy Failure Clin Obstet and Gynecol
  2007 Volume 50, Number 1, 6788
• Dynamed Miscarriage accessed 5/25/13
  http//web.ebscohost.com/dynamed/detail?vid3sid
  b5a02ed2-dee1-4f94-b13f-ca26a177216a40sessionmgr1
  5hid24bdataJnNpdGU9ZHluYW1lZC1MSVZFJnNjb3BlPXN
  pdGU3ddbdmeAN113658