Ectopic, Early Pregnancy Loss, or Normal Pregnancy?
Diagnosis and Management of First‐Trimester Bleeding
JodySteinauer,MD,MASJuly,2015
Disclosures
July10,2015Ihavenodisclosures.
Objectives
1. Toreviewtheworkupofbleedinginthefirsttrimester.2. Toapplyevidence‐basedprinciplesto:
1. ectopicpregnancy(EP)andearlypregnancyloss(EPL)diagnoses,and
2. EPandEPLmanagementoptions.
Patient Case: Presentation
• Mayaisa26yo G1P0presentingtotheemergencyroom.
• HowdowecareforMaya?
“I’m 2 months pregnant and I’m bleeding and cramping. Am I going to lose the baby?”
Patient Case: H&P
• Maya’ssureLMPwas9weeksago.• ShehadapositiveUPT2weeksago.• Thisisadesiredpregnancy.• Herfirstprenatalcarevisitisscheduledfornextweek.• Herbleedingislikea“lightperiod”forthepast3days.• ShehasnohistoryofSTIsorotherriskfactorsforectopicpregnancy.
• Onexamhercervicalos isclosed.• SheisRh‐negative.
WhatcanwetellMayarightnow?
Symptomatic Early Pregnancy Evaluation
Symptomatic Early Pregnancy
• Ectopicpregnancymustberuledout,butwemustbecarefultonotdiagnoseadesiredIUPasabnormal.
• TherearenewguidelinesforhCG discriminatoryzone,aswellasEPLultrasounddiagnosticcut‐offs.
• Choiceofmanagementisapreference‐sensitivedecision.
Symptomatic Early Pregnancy: Presentation
• Urgentoremergencycarevisit– Vaginalbleeding– Abdominalorpelvicpainorcramping– Passageofpregnancytissuefromthevagina– Lossofpregnancy‐relatedsymptoms– Hemodynamicinstability
• Incidentalclinicalfinding– BimanualexaminconsistentwithLMP– Ultrasoundsuggestiveofabnormalpregnancy
Bleeding in Early Pregnancy
• Keepthepatientinformed.– Providereassurancethatnotallvaginalbleeding&crampingsignifiesanabnormality,butavoidguaranteesthat“everythingwillbeallright.”
– Assureyouareavailablethroughouttheprocess.
• Whatdoesthebleedingmean?– Upto20%chanceofectopicpregnancy– 50%ongoingpregnancyratewithclosedcervicalos– 85%ongoingpregnancyratewithviableIUPonsono– 30%ofnormalpregnancieshavevaginalbleeding
Evaluation
• History– Riskfactorsforectopicpregnancy
• Physicalexam– Vitalsigns– Abdominalandpelvicexam
• Ultrasound– Transvaginal oftennecessary
• Lab– Rhfactor– HemoglobinorHematocrit– β‐hCG whenindicated
Isthepregnancydesired?
Ectopic Pregnancy
• 1‐2%ofallpregnancies• Upto20%ofsymptomaticpregnancies• ½ofectopicpatientshavenoriskfactors• Mortalityhasdramaticallydeclined:0.5/100,000
– 6%ofpregnancy‐relateddeaths– 21deathsperyearinUS
• Earlydiagnosisimportant• Concernaboutmanagementerrors
Early Pregnancy Loss (EPL)
• 15‐20%ofclinicallyrecognizedpregnancies
• 1in4womenwillexperienceEPLintheirlifetime
• Includesallnon‐viablepregnanciesinfirsttrimester=Miscarriage
Positive pregnancy test, vaginal bleeding and/or abdominal pain
61% Ongoing IUP28% Spontaneous Abortion 9% Ectopic Pregnancy
Dx upon presentation (80%)
77% Ongoing IUP16% Spontaneous Abortion6% Ectopic Pregnancy
49% of all women with Ectopic Dxat presentation
Dx with additional testing (20%)
11% Ongoing IUP77% Spontaneous Abortion17% Ectopic Pregnancy
51% of all women with Ectopic Dxafter outpatient follow-up
Ectopic PregnancyGOAL: Early Diagnosis
• Decreasedchanceofrupture(rupturecanoccuratanylevelofbetaHCGandwhetherrising,fallingorplateauing)
• Ruptureassociatedwithdecreasedfertility,increasedmorbidityandmortality
• Moretreatmentoptions(eg methotrexate,conservativesurgicaltreatment) ifdiagnosedearlier
• Methotrexatemoreeffectiveifdiagnosedearlier
Ectopic Diagnosis: Simplified
1. Whereisthepregnancy? U/S(sameday)2. Isthepregnancyundesired? uterineaspiration3. Ifdesiredandwecan’ttellwhereitis:Isitnormalor
abnormal? serialquantitativeBeta‐HCG– IfBhcg abovethresholdandnoIUP=Abnormal– IfBhcg drops>50%in48hours=Abnormal– IfBhcg rises>50%in48hours=Mostlikelynormal(canbeEP)– Ifbetween=Mostlikelyabnormal(stillcanbenormal)
4. Oncepregnancydeterminedtobeabnormalorifundesired uterineaspirationtodetermineifIUP,Ectopictreatmentifnot.
(Goal:Diagnoseasquicklyaspossible)
IUP=Intrauterine pregnancy
β‐hCG Utility in Symptomatic Early Pregnancy Diagnosis
• β‐hCG medianserumconcentration:– 4weeks:100mIU/ml(5‐450)– 10weeks:60,000(5,000– 150,000)
DiscriminatoryLevel• Serumβ‐hCG atwhichanormalintrauterinepregnancyshouldbevisualizedonultrasound– If>2000nl IUPunlikelybutpossible newvalues
• Oncebeyonddiscriminatorylevel,limitedrolefor“followingbetas”
Discriminatory & Threshold level
• 366♀withVB/pain nl IUP
• Highestseenwithnosac:2,300Oldvalues:1500=80%&2000=91%prob.
ofseeingGSinviableIUP
99%PredictedProbabilityofDetectionDiscriminatory Threshold
GestationalsacYolk sacFetalpole
351017,71647,685
39010941394
Connolly2013Obstet GynecolConnolly,Obstet Gynecol,2013.
• HCG2000‐ 3000– Non‐viablepregnancymostlikely,2Xectopic– Ectopicis19xmorelikelythanviablepregnancy– Foreachviablepregnancy:
• 19ectopicpregnancies• 38nonviablepregnancies
– 2%chanceofviablepregnancy
• HCG>3000– Ectopic70xandnonviableIUP140xmorelikelythanviablepregnancy
– 0.5%chanceofviableIUP
Inwomenwithdesiredpregnancyconsiderbetahcg cut‐offof>=3000.
Society of Radiologists in Ultrasound: No Gestational Sac
Balance of Diagnostic Tests
• MaximizesensitivityatthecostofdiagnosingsomeIUPsasEctopicPregnancies– Error– interruptingdesiredIUP
• MaximizespecificityatthecostofdiagnosingsomeEPsasIUPs– Error– delaydiagnosisresultinginrupture
• Engagethepatientindecision‐making• Cut‐offof3,000v.repeatbetahcg +/‐ u/s
Role of Ultrasound in Ectopic Diagnosis
• Only2%ofu/sarediagnosticforEP– “Diagnostic”=GestationalSacwithyolksacorfetalpolevisualizedoutsideuterus
• Normaladnexalexamdoesnotexcludeectopic• Suggestiveofectopic
• Emptyuterus+hCG abovediscriminatoryzone• Complexmass+fluidincul‐de‐sac(94%areEP)• Shouldstillfollowthemifdesiredpregnancy
MainroleofU/SistoruleinIUP
β HCG trends in normal IUP
Barnhart2004ObstetGynecol
99%ofnl IUPs1dayrise≥24%2dayrise≥53%
Medianrise:1day=50%2day=124%
Slowestexpected48‐hourincreasefornormalpregnancy=53%(20%ofectopics increase)
Ectopic Diagnosis: Other Key Points
• Twohcg valuesmaynotbeenough• Ifclosetothethresholds– checkanother• Presumedectopicpregnancy– uterineaspirationbeforeMTX– HighHCGnothingintheuterus(50%SAB)– VerylowHCG withabnl riseordefinitefall(25%SAB)
Barnhart, Ob Gyn, 2002
Ultrasound Findings to R/o EP
• RememberthatanEPhasnotbeenruledoutuntilthereisanintrauterinepregnancy– Gestationalsacwithayolksacand/orembryo
Ectopic Diagnosis: Simplified
1. Whereisthepregnancy? U/S(sameday)2. Isthepregnancyundesired? uterineaspiration3. Ifdesiredandwecan’ttellwhereitis:Isitnormalor
abnormal? serialquantitativeBeta‐HCG– IfBhcg abovethresholdandnoIUP=Abnormal– IfBhcg drops>50%in48hours=Abnormal– IfBhcg rises>50%in48hours=Mostlikelynormal(canbeEP)– Ifbetween=Mostlikelyabnormal(stillcanbenormal)
4. Oncepregnancydeterminedtobeabnormalorifundesired uterineaspirationtodetermineifIUP,Ectopictreatmentifnot.
(Goal:Diagnoseasquicklyaspossible)
IUP=Intrauterine pregnancy
Incomplete abortion, treat as indicated
Peritoneal signs or hemodynamic instability
Non‐obstetric cause of bleeding identified
EDDiagnose and treat
as indicated
Threatened abortion; repeat TVUS if further
bleeding
Transvaginal ultrasound (TVUS) and β‐hCG level
Products of conception(POC’s) visible on exam
Presume ectopic;refer for high‐level TVUS
and/or treatment
Viable intrauterine pregnancy (IUP)
Ectopic or signs suggestive of ectopic pregnancy
Nonviable IUP
Embryonic demise, anembryonic gestation, or retained POC’s;
discuss treatment options
Repeat TVUS in one week and/or follow serial β‐
hCG’s
Physicalexam
Bleeding in desired pregnancy, < 12 weeks gestation
SeeFigure2
Figure 1. Evaluation of first‐trimester bleeding
Patient stable, no POC’s or other cause of bleeding
No IUP, no ectopic seen
IUP, viability uncertain
IUP seen on prior TVUS?
Yes
No
Completed abortion; expectant
management
Reproductive Health Access Project/October 2013 www.reproductiveaccess.org
First‐trimester Bleeding Algorithm
Repeat β‐hCG fell< 50% or rose < 53%***
Suggests completed
abortion; ectopic precautions, follow β‐hCG weekly to
zero**
β‐hCG < 1500 – 2000*
Ectopic precautions, Repeat β‐hCG in 48 hours
Suggests viable pregnancy but does not
exclude ectopic; follow β‐hCG until > 1500 – 2000*,
then TVUS for definitive diagnosis
Repeat β‐hCG> 1500 – 2000*
Suggests early pregnancy failure or ectopic;
serial β‐hCG’s +/‐ high‐level TVUS until definitive
diagnosis or β‐hCG zero**
Repeat β‐hCGrose > 53%***
Ectopic precautions, repeat β‐hCG in 48 hrs
Repeat β‐hCG fell > 50%
β‐hCG > 1500 – 2000*
Repeat β‐hCG< 1500 – 2000*
Repeat β‐hCGfell
> 50%
Repeat β‐hCG fell <50%or rose
Single β‐hCG > 1500 – 2000*and bleeding history consistent
with having passed POC’s
Obtain high‐level TVUS & serial bhCGs to differentiate between ectopic, early IUP, and retained
POCs’ treat as indicated
Single β‐hCG > 1500 – 2000*and bleeding history not consistentwith having passed POC’s
Serial β‐hCG’s rising and
> 1500 – 2000*
NO IUP or EP seen on TVUS
IUP seen on prior TVUS?Yes
No
Completed abortion; expectant management
Figure 2. Evaluation of first‐trimester bleeding with no intrauterine pregnancy on ultrasound
ContinuedfromFigure1
* The β‐hCG level at which an intrauterine pregnancy should be seen on transvaginal ultrasound is referred to as the discriminatory zone and varies between 1500 – 2000 mIU depending on the machine and the sonographer. ** β‐hCG needs to be followed to zero only if ectopic pregnancy has not been reliably excluded. If a definitive diagnosis of completed miscarriage has been made there is no need to follow further β‐hCG levels. *** In a viable intrauterine pregnancy there is a 99% chance that the β‐hCG will rise by at least 53% in 48 hours. In ectopic pregnancy, there is a 21% chance that the β‐hCG will rise by 53% in 48 hours.
RepeatTVUS;SeeTVUSinFigure1
Modified from Reproductive Health Access Project/October 2013 www.reproductiveaccess.org
First‐trimester Bleeding Algorithm
If patient stable repeat bHCG and once higher than 3000 and no IUP – uterine aspiration to rule
out EPL and treat for EP if no IUP
EPL Diagnosis, Counseling, and Management
EPL – Making the diagnosis
Spontaneous abortionVaginal bleeding + IUP, <20 wks
threatened, inevitable,incomplete, complete
Embryonic demiseEmbryo with no cardiac activity
Anembryonic gestationGestational sac without
embryonic pole
Clinicaldiagnosis: Ultrasounddiagnosis:
Ultrasound Diagnosis of EPL:Anembryonic Gestation
Meansacdiameter>=21mm(20mm=0.5%falsepositive)ANDnofetalpole
Abdallah etal2011(Aug)UltrasoundObstet Gynecol
Ultrasound Diagnosis of EPL:Anembryonic gestation
Abdallah etal2011(AugandOct)UltrasoundObstet Gynecol
MSD(mm) Specificity False + Growthperday(wk) Specificity False+
8mm 64% 36% 0.2mm(1.4mm) 99% 1%
16mm 95.6% 4.4% 0.6mm(4.2mm) 90% 10%
20mm 99.5% 0.5% 1.0mm (7mm) 45% 55%
21mm 100% 0 1.2mm (8.4mm) 24% 76%
MSD,noYS,noembryo
MSD(mm) Specificity False + Growthperday(wk) Specificity False+
8mm 35.7% 64.3% 0.2mm 98.6 1.4
16mm 97.4% 2.6% 0.6mm 87.3 12.7
20mm 99.6% 0.4% 1.0mm 43.7 56.3
21mm 100% 0 1.2mm 25.2 74.8
MSD,+YS,noembryoGROWTH:
0mm/d=0False+
Ultrasound Diagnosis of EPL:Embryonic Demise
Fetalpole>=5.3ANDnocardiacactivity
Abdallah etal2011(Aug)UltrasoundObstet Gynecol
Ultrasound Diagnosis of EPL:Embryonic Demise
Abdallah etal2011(Aug&Oct)UltrasoundObstet Gynecol
CRL(mm) Specificity False + Growthperday(wk) Specificity False+
3mm 75% 25% 0.2mm(1.4mm) 100% 0%
4mm 91.7% 8.3% 0.6mm(4.2mm) 56.3% 63.7%
5mm 91.7% 8.3% 1.0mm (7mm) 0*
5.3mm 100% 0 1.2mm (8.4mm) 0% 0%
*16FP,0TN.37TP,1TN
Fetalpole– 7mm
MSD– 25mm
Radiologists in Ultrasound: Account for Margin of Error
Ultrasound MilestonesNormalIUPfindings
Whenshouldyouseeit?
Abnormalityiflandmarkisabsent
GestationalSac DiscriminatoryLevelβ =3,000?
CompletedEPLMultiplegestationEctopicpregnancy
Yolksac MSD>13‐16mm SuspiciousforEPL
Fetalpole MSD≥21mm(newrec25duetovariability)
Anembryonic gestation
Cardiacactivity CRL≥5.3mm(newrec7mm)
Embryonicdemise
Intervalgrowth(MSDorCRL)
1mm/day(over3‐7days)
ConfirmedEPL
EPL Management
• Fouroptionsfortheclinicallystablepatient1. Aspirationw/general/deepsedation(operatingroom)2. Aspirationw/local/moderatesedation(office‐based)3. Medication(misoprostol+/‐ mifepristone)4. Expectantcare
• Allmethodsareeffective,withequivalentsafetyandpatientacceptability= clinicalequipoise
NSFG2004;Chen2007;Wieringa‐deWaard,2002;Zhang2005;Trinder 2006
EPL Management: A Preference‐Sensitive Decision
• Bestchoiceformanagementreflectsthewoman’svaluesandpreferences
• Patientshavestrong andwidelydivergentpreferences– ChallengesinrecruitmentforRCTs– Reporthighersatisfactionwhentreatedaccordingtopatient’spreference
Wieringa‐deWaard 2002;Dalton2006;Smith2006
Expectant Medication Office-based aspiration
Operating room
aspiration
EPL Management:Patient Preferences
No ‘one best way’ to treat miscarriage that suits all individuals.
Expectant management is preferred over aspiration by 40-70% of women
When aspiration is indicated or preferred, the majority of women will choose an office-based procedure over one in the OR
Smith2006;Wieringa‐deWaard 2002;Dalton2006
Research on EPL Counseling
• Womenwantunbiasedandcomprehensivecounselingaboutoptionsforthispreference‐sensitivedecision.
• WomenperceivecommunicationduringEPLdiagnosisasacriticaltimetoinitiatediscussionsofmanagement.
• Womenareoftenweighingpersonalpriorities tomakedecisionsaboutEPLmanagement.
• Useofadecisionaidmayofferasystematiccounselingapproachforapatient‐centereddecision‐makingprocess.
Early Pregnancy Failure: Counseling
• Womenblamethemselves(“wasitthestress?”)
• Wonderifwillhappenagain
Patientcounselingshouldinclude:• Howcommonitis(encouragetotalktofriends)
• Reassurancethatitisbeyondhercontrolandunlikelytorecur(“Nothingcouldhavebeendonetopreventit.”)
• Acknowledge/validategrieving
• Noneedtowaittoattemptanotherpregnancy‐ oktotryafterresumptionofmenses(whenemotionallyready)
Importance of Options
“I think sometimes doctors have you do things or they prescribe things to you that are unnecessary.…I like the way it was presented to me…as options, and they were optional, they weren't necessary or required.”
“They never said the word ‘miscarriage,’ I did.…I felt like I had to drag it out of them.…I said, ‘Okay, once we realize that I’m not mistaken with my dates and that this pregnancy should be 12 weeks and it is what you said it looks like, 5 weeks, so then what does that mean? What are the next steps?’”
Frustration with Ambiguous or Delayed News Delivery
Patient Priorities
Pain Time Complications
Safety Bleeding Privacy
Anesthesia Past experience Finality
Provider Practice
Training Safety Data
EfficacyData
SystemResources
Staff Buy-in Assumptions
EPL Management Practices in the U.S.
0
5
10
15
20
25
30
35
40
45
50
Expectant Misoprostol Officeaspiration
OR
PercentofEPLproviders
Ob/Gyn CNM FP
AdaptedfromDalton2010
Patient Case: Counseling
• Mayawasdiagnosedwithanembryonicdemise.• Howdowecounselheraboutmanagementoptions?
Shared Decision‐Making
1. Providerpresentsallrelevantmedicalinformation.
2. Patientprovidesinformationaboutpersonalcircumstances,values,andpriorities.
3. Provideralsodiscussespreferenceswhileacknowledgingpersonalvaluesandbiases.
4. Decisionisreached.
InformationExchange
Deliberation
Negotiation & Agreement
EPL Management
Early Pregnancy Loss (EPL) Management
• Fouroptionsfortheclinicallystablepatient1. Aspirationw/general/deepsedation(operatingroom)2. Aspirationw/local/moderatesedation(office‐based)3. Medication(misoprostol+/‐ mifepristone)4. Expectant
• Allmethodsareeffective,withequivalentsafetyandpatientacceptability= clinicalequipoise
NSFG2004;Chen2007;Wieringa‐deWaard,2002;Zhang2005;Trinder 2006
Reference: Helping your patient to choose treatment for EPF
Misoprostol(800PV):Success:80%at1wk.Advantages:Privacy,availability,mostcanavoidsurgicaltx,?decreasedinfection,similarsatisfactionassurgicalDisadvantages:multiplevisits,30%require2nd dose,morepain,N/V&bleedingthansurgical
UterineAspiration:Success:~100%Advantages:2‐4hrs,highsuccessrate,lessblding &painDisadvantages:lessavailable,raresurgicalcomplications,?increasedinfection
Expectant:Success:60%at2wks.Advantages:Privacy,somecanavoidsurgicaltreatment,?decreasedinfectionDisadvantages:upto6wks tocomplete,morebleeding&morevisits,lesspatientsatisfaction
EPL Management: A preference‐sensitive decision
• Bestchoiceformanagementreflectsthewoman’svaluesandpreferences
• Comprehensivemanagementoptionscanbeofferedinatypicalprimarycareoroutpatientsetting
Wieringa‐deWaard 2002;Dalton2006;Smith2006
Expectant Medication Office-based aspiration
Operating room
aspiration
Expectant Management
• “Watchfulwaiting”• Provensafetyupto8weeks• TypeofEPLaffectsexpectedefficacy• Highlyacceptabletopatientswithrealisticexpectationsabout:
Duration, Discomfort, and potential D&C
Expectant Management
Advantages• Non‐invasive• Bodynaturallyexpelsnon‐viablepregnancy
• Avoidsanesthesiaandsurgeryrisks
• Allowsforpatientprivacyandcontinuityofcare
Disadvantages• Unpredictableoutcomeandtimescale
• Processcanlastdaystoweeks
• Canhaveprolongedbleedingandcramping
• Despitewaiting,maystillneeduterineaspiration
Expectant Management
Contraindications• Uncertaindiagnosis• Suspectedgestationaltrophoblasticdisease
• Indicatedkaryotyping• Severehemorrhageorpain• Infection• IUDinplace
Same contraindications for medication management
Medication Management
• UseofmedicationsforactivemanagementofEPL• Misoprostol
– Stimulatesuterinecontractions&softenscervix– Inexpensive,easystorage
• Mifepristone– Anti‐progestinusedforpregnancytermination– Currentresearchdoesnotsupportroutineuseinnon‐viablepregnancies
Medication Management
Advantages• Highlycost‐effective• Non‐invasive• Safe• Canbehighlyeffective• Avoidsanesthesiaandsurgeryrisks
• Allowsforpatientprivacyandcontinuityofcare
Disadvantages• Increasedneedforanalgesicsandpaincontrol
• Maycauseheavierorlongerbleeding
• Maycauseshort‐termgastrointestinalandothersideeffects
• Maystillneeduterineaspiration
Practice Integration for Medication Management
• Evaluation– Exam,lab,orsono?
• Medications– DispensedinclinicorRx?
• 24hourcallservice• Back‐upplanforaspiration
– Emergentvs.non‐urgent
• Follow‐upplan
Misoprostol for EPL
Recommended inACOGPracticeBulletin
800mcgvaginally(PV) withoptionalrepeatdose>3hourslaterifnoinitialresponse
Medications for Symptoms and Side Effects
Cramping Ibuprofen600mgQ6hrs or800mgQ8hrs (orotherNSAID)
Severecrampingpainnotrelievedbyibuprofen
Hydrocodone/APAP5/500or5/325Q4‐6hrs prn
Nausea/vomiting Promethazine25mgQ4‐6hrsprn or otheranti‐emetic
Typical Follow‐Up
Phonecontact Callpatient1‐2daysafterfirstmisoprostoldosetoassessneedforseconddose.
In‐personvisit 1‐2weeksafterchoosingexpectantormedicationmanagementtoassess:1. Ifmiscarriageisnotcomplete– Is patient
interestedinalternatetreatments?2. Confirmcompletion (seebelow)
Confirmingcompletion
1. Clinicalhistoryconsistentwithcompletemiscarriageplusβ‐hCG declineof>50%ornegativeurinepregnancytest
2. Clinicalhistoryplusdisappearanceofintrauterinepregnancyontransvaginalultrasound
Aspiration for EPL
• Historicallydoneinoperatingroomundergeneralanesthesia
• Terminology:– Surgical“D&C”– SuctioncurettagewithMUAorEVA
Operating Room Aspiration
Advantages• Predictable• Offersfastestresolutionofmiscarriage
• Reduceddurationofbleeding
• Lowrisk(<5%)ofneedingfurthertreatment
• Canbeasleep
Disadvantages• Rarerisksassociatedwithinvasiveprocedureandgeneralanesthesia
• Morecostthanoffice‐basedprocedures
• Moretimeandphysicalexamsthanoffice‐basedprocedures
• Maybemorebleedingcomplicationsundergeneralanesthesiathaninoffice‐basedprocedures
Office‐based Aspiration
Advantages• Predictable• Offersfastestresolutionof
miscarriage• Reduceddurationofbleeding• Lowrisk(<5%)ofneeding
furthertreatment• Paincontrolwithlocalplusoral
orIVmeds
Disadvantages• Rarerisksofinvasiveprocedure• Lesspaincontroloptionsinsome
settings
Compared to OR management:• May allow improved patient access
and continuity of care • Improved privacy • Less patient and staff time• Resource and cost savings
EPL Management Principles
• Clinicalchecklistforcareoptions:– Cleardiagnosis– Patientisstable– Accesstophone&emergencycare– Paincontroloptionsavailable– Anticipatoryguidanceforbleeding,S/Sx infection– Rhstatus– Reliablefollow‐up
Patient Case: Management
• HowdowemanageMaya?• Chanceofsuccessforembryonicdemise:
– Expectant 1week(30%)2weeks(60%)6weeks(75%)
– Medical 1week(80%)– Aspiration InofficeorOR (97‐100%)
EPL: Patient‐Centered Care
1. Keepherinformedthroughoutthediagnosticwork‐up.2. Useclearandcompassionatelanguageindelivering
newsaboutmiscarriage.3. Bepreparedtodiscussmanagementoptionsat
diagnosis.4. Presentadvantagesanddisadvantagesofeach.5. Facilitaterecognitionofpatient’sprioritiesfor
managementdecision.6. Ensureappropriatefollow‐upandallowopportunityto
changemanagementdecision.
Patient Case: Management
• Mayachosetousemisoprostolathome.• Sheplacedthepillsvaginallyandbeganhavingcrampingandbleeding2hourslater.
• Herheavybleedinglasted4hours,andshenoticedoneparticularlylargeclot,thatmayhavehadtissueinit.
• Shestillhassomelightbleedingatherfollow‐upappointment,7dayslater.
Howdoweconfirmsuccessoftreatment?
EPL Management: Follow‐up
• Usebothhistoryandexamtoconfirmcompletion.– β‐HCGdrop>50%in48hoursornegativeUPT2weekslater
– Vaginalultrasound
• Treatthepatient,nottheultrasound.• Addressfertility.
– Contraceptionvsprenatalvitamins
• Offergriefcounselingfollow‐uporreferrals.
Vaginal Ultrasound
*ThicknessofendometriumNOTassociatedwithneedforfutureintervention
ACOG Practice Bulletin Early Pregnancy Loss (May 2015)
LevelA• 800mcgmisoprostolformedicalmanagement• Useofanticoagulantsdoesn’treduceriskLevelB• USpreferredmodalitytoverifyviableIUP• D&Cnotrequiredforthickstripeaftertreatmentifasymptomatic
• Rh‐ patientsshouldreceiveRhogamLevelC• Cansafelyaccommodatepreferences• Doxycyclinebeforesurgicalmanagement
Exploretheresourcepageandlinktothelearningmodule:
www.earlypregnancylossresources.org
Ectopic Pregnancy Management
• Methotrexateisnotforeveryone
• NodifferenceinfutureIUPorectopicrates
• Single‐doselesseffectivethansalpingostomy (OR=0.38)
• 5%haverupturedespiteMTX
• Requiressignificantfollow‐up
Ectopic Treatment: MTX vs Surgery
Medical Treatment of EP
Methotrexate• AntimetabolitethatinterruptsDNAsynthesisinactivelydividingtissues
• Successfulin80‐95%• BetaHCGlevels>5000higherfailureratewithsingle‐dosetx (14%v.4%iflessthan5000)
• Single‐,two‐,multi‐doseregimens• Startwithsingle‐doseifb‐hcg <5000• Multi‐doseforcervicalorinterstitialectopics
Also:Inabilitytofollow‐up
ACOGPracticeBulletin#94
Medical Treatment of EP
ACOGPracticeBulletin#94
Treatment of EPSurgery• Ifhemodynamically unstable,patientdesiressurgery,contraindicationstoorfailedMTXtreatment
• Laparotomyorlaparoscopy• Salpingectomyorsalpingostomy
– Salpingectomyiftubecompromised– Similaroutcomesifnotcompromisedandothertubehealthy– Ifothertubeabsentorunhealthy– salpingostomy preferred
• 10%failurerateifsalpingostomy,requireb‐hcg followup
Expectantmanagement• IfbetaHCG<20088%resolvespontaneously• DecliningbetaHCG‐ thirdvaluelessthanfirst• Asymptomatic,informedconsent• Careful!
Conclusion
Conclusions
• Bleedinginearlypregnancyiscommon.• Takepossibilityofectopicpregnancyseriously!• Pregnancyofunknownlocationtakespatiencetosortout.
• PatientpreferenceiscriticalinmanagementofEPL.