Management of Early Pregnancy Loss

Judith Bliss, MDApril 2009

Goals for Today

Discuss Practical Management of Abnormal First Trimester Pregnancy

Discuss four management options for spontaneous abortion (miscarriage)

1. Expectant Management2. Medication Management (Misoprostol)3. Manual Vacuum Aspiration in the clinic4. 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 pseudosacNo 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

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

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.

Ultrasound post Medical Abortion

Incomplete Abortion

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)

1. Brentwood: Tomasulo, Sara Levin2. Antioch: Nancy Palmer3. Pittsburg: Feierabend4. Concord: Tomasulo, Bliss5. 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.

MVA Instruments and Supplies

Inexpensive Small Portable Quiet Specimen likely

to be intact May require repeated reloading of

suction

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