Management of Early Pregnancy Loss Judith Bliss, MD April 2009
Goals for Today • Discuss Practical Management of Abnormal First Trimester Pregnancy • Discuss four management options for spontaneous abortion (miscarriage) • Expectant Management • Medication Management (Misoprostol) • Manual Vacuum Aspiration in the clinic • Electric Vacuum Aspiration in the Operating Room
Goals of Treatment • Decrease blood loss and pain • Address grief and provide education • Provide patient-centered care appropriate to her situation that is relatively convenient and efficient • Provide contraception or pre-conception counseling
Miscarriage • 20% of pregnant women have bleeding before 20 weeks • 50% of these end in spontaneous abortion • Miscarriage uncommon after 10 weeks EGA • When fetal heartbeat identified on ultrasound the risk of SAB decreases to 3%
Terminology of Common Complications • Threatened Abortion • Missed Abortion anembryonic or embryonic • Inevitable Abortion • Incomplete Abortion • Complete Abortion • Ectopic Pregnancy • Molar Pregnancy
Management Options for Safely Evacuating the Uterus • Expectant Management • Misoprostol • Mifepristone/Misoprostol • Methotrexate/Misoprostol • MVA • EVA
Case A • 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 • Presents with spotting, no pain LMP 4-5 weeks ago • HCG initially 500 with ultrasound showing empty uterus • HCG two days later 800
Interpretation of HCG • 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 1500-6000 • Peaks at 9 weeks and then declines • Slowly declines after TAB, or pregnancy loss
Case A continued One week later HCG is 3000 Repeat ultrasound still shows possible sac versus pseudosac No pain, brownish vaginal discharge
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 • Known abnormal IUP and prefers expectant management and has support and access to medical care
Success of expectant management in the first trimester Luise C, et al . BMJ 2002; 324
Expectant management • In the setting of incomplete abortion expectant management is successful 82-96% of the time • Average time to completion is 9 days • 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
Expectant 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 person • 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 • Generally don’t give antibiotic prophylaxis.
Could this be an Ectopic? • 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
Logistics at CCRMC • Follow-up in a few days to two weeks • 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.
Case B • 25 y/o G3P2 presents with spotting at 9 weeks EGA on Friday morning • HCG is 5000 • Ultrasound shows 6 week fetal pole without HR • Uterus mildly tender with small amount blood in vault
Medication Management • Decreased time to passage so shorter follow up time and potential for fewer visits • Infection rate similar to expectant and surgical • Expect 5-15% will need aspiration • Some cases of missed abortion may be at risk for greater blood loss
Misoprostol for miscarriageZhang 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 • 71% complete by Day 3 • 84% complete by Day 8 • Anembryonic gestation success rate 81% • Embryonic or fetal death 88% • Incomplete or inevitable abortion 93%
Misprostol • Recommend 800mcg buccal followed by second dose in 24-72 hours if no obvious passage of tissue with first dose • Some use 400-600 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.
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: • Buccal instead of vaginal misoprostol • Prophylactic antibiotics (doxy 100 bid for 7 days)
Misoprostol Counseling • Supportive companion • Vicodin, motrin, phenergan—take early • Make sure to have pads at home • Expect several hours of heavy bleeding starting several hours after dose • Blood looks like more in the toilet bowl • Antibiotic prophylaxis recommended • Plan for contraception/ folic acid
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.
Logistics at CCRMC • Can be prescribed by any physician • Follow-up as for expectant management but expect sooner resolution on average than expectant managment
Case C • 28 y/0 G2P1 presents at 13 weeks gestation. No fetal heart tones heard. • Ultrasound shows 8 weeks missed SAB • No symptoms
Mifepristone and Misoprostol • Possibly viable undesired IUP up to 63 days • Undesired threatened abortion • Used by some for blighted ovum or missed abortion—may be higher success rate/less blood loss.
Protocol for Mife/Miso • Give 200mcg mifepristone in clinic • Send home with four 200mcg pills of misoprotol to use in 6-72 hours buccally • More extensive consent process and limited access to medication • Antibiotic prophylaxis
Logistics at CCRMC • Access in Reproductive Health Procedures Clinic (GYN Tomasulo) in Martinez (Linda Wise 4912) • Brentwood: Tomasulo, Sara Levin • Antioch: Nancy Palmer • Pittsburg: Feierabend • Concord: Tomasulo, Bliss • Richmond: Bliss, Lehman
Case D • 40 y/o G5P1 ectopic 1, TAB 2 • Presents with no LMP since before depo shot 5 months ago • Spotting, minimal pain • HCG 1890 • Sono 2 cm ovarian cyst, empty uterus • Does not want to be pregnant
Methotrexate/Misoprostol • 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 www.earlyoptions.org) • Methotrexate/Misoprostol can be used if treatment desired before ectopic ruled-out
Logistics at CCRMC • 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 • May refer to any GYN clinic for follow-up
Case E • 18 y/o G4P2 TAB 1 presents with spotting and cramping 10 weeks post LMP • Sono shows 7 week missed SAB • Family does not know she is pregnant again • Wants resolved ASAP
Manual Vacuum Aspiration Advantages • Able to assess tissue and verify POC to rule-out ectopic pregnancy • Fewest return visits • Trend towards least blood loss • Most certain time course/clinician with them during procedure • Requires least amount of home support • May be able to place IUD at the same time
Manual Vacuum Aspiration Disadvantages • Requires more equipment • Very small risk of uterine perforation • May have more infection risk • Requires more clinic or emergency room time and more nursing time • Requires more physician training
Manual Vacuum Aspiration • 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.
Inexpensive Small Portable Quiet Specimen likely to be intact May require repeated reloading of suction MVA Instruments and Supplies
Post MVA • Rhogam if indicated, iron if indicated • Doxycycline 100 bid for 2-14 doses • Ibuprofen • Contraception or folic acid • Follow-up appointment
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
Case F • 38 y/o with history of prior LEEP presents at 11 weeks with spotting • Sono shows 10 week missed SAB • History of intolerance to pelvic exams • Hb of 8 • Poorly controlled seizure disorder • Weighs 342 lbs
Electric Vacuum Aspiration in an Operating Room • 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 high risk bleeding situations or unstable patients
Disadvantages of EVA • Wait for OR and physician availability • Expense • NPO status • IV • Less privacy • May have more anesthesia then necessary/desired • Most risk of procedure from anesthesia • Less continuity with staff
Logistics at CCRMC • Consider direct scheduling in the OR • 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 • Call OB attending on call to make sure provider available
Contraception • Initiate Discussion Early even if was desired pregnancy • Start contraceptive early, usually while still bleeding • IUD or Implanon can be placed during MVA or EVA
Website Resources • www.ansirh.org • www.rhedi.org • www.ipas.org • www.earlyoptions.org • www.prochoice.org
Psychological Management • Acknowledge, dispel guilt • Legitimize grief • Provide comfort, ongoing support • Reassure about the future • Counsel patient how to tell family, friends • Warn of anniversary phenomenon • Include partner in psychological care • Assess level of grief and adjust counseling accordingly • Don’t forget – half of pregnancies are unintended!
Conclusion • Provide medical and psychologic support—your 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 • Remember misoprostol,MVA, EVA in addition to expectant management