Office Management of Early Pregnancy Loss

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

Epidemiology of Early Pregnancy Loss

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

What are the clinical presentations of first trimester

losses?

Causes of EPL

• Chromosomal abnormalities > 50%

• Infection

• Reproductive tract abnormalities

• Exposure to toxins

• Uncontrolled endocrine or autoimmune disease

Jennifer

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

Additional history? And on physical?

Algorithm with Physical Exam

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.

Anembryonic Pregnancy

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

Embryonic Demise when no FH

Back to Jennifer…

What does she need to know?

Risk Factors

• Age

• Prior miscarriages

• Smoking

• Cocaine use

• Fever/Infection

Miscarriage Myths

• Air travel

• Blunt abdominal trauma

• Contraceptive use

• Exercise

• HPV vaccine

• Previous abortions

• Sexual activity

Three Options:

1. Expectant Management

2. Medication Management

3. Aspiration Procedure

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

What are the potential benefits of expectant management?

What would be the contraindications to expectant

management?

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.

What anticipatory guidance and help do we provide for expectant

management?

Medical management of miscarriage: Misoprostol for early

pregnancy loss

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 hoursZhang et al. NEJM 8/25/05; 353(8)761-9.

Side Effects of Misoprostol

• Bleeding

• Cramping

• Fevers and/or chills

• Nausea and vomiting

• Diarrhea

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)

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

Success Rates with Expectant Management vs Misoprostol

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

What is done about the failure to pass tissue?

How is completion of the miscarriage diagnosed?

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

“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

Uterine Aspiration

Electric Vacuum Aspirator

Manual Vacuum Aspirator

MVA Instruments and Supplies

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.

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

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

Cases for Review: Sonia

• LMP 8 weeks ago

• Started spotting 3 days ago

• Now having heavier cramping with bleeding

• Appears comfortable, normal vital signs

Sonia, ContinuedYour 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?

Sonia, Continued

How do you explain to her what is happening?

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.

Katie, Continued

Very small, irregular sac with sub-chorionic bleed visible

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?

Katie, Continued

She decides to opt for treatment with medication.

What regimen do you use and how do you advise her?

How is completion of the miscarriage diagnosed?

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)

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.

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.

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=JnNpdGU9ZHluYW1lZC1MSVZFJnNjb3BlPXNpdGU%3d#db=dme&AN=113658