Transcript Document

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 Complete Success
Day 7
Day 14
Day 49
Incomplete
Missed
Anembryonic
221
117 (53%)
185 (84%)
201 (91%)
138
41 (30%)
81 (59%)
105 (76%)
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 hours
Zhang 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
Manual Vacuum Aspirator
Electric
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, 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?
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-dee1-4f94b13fca26a177216a%40sessionmgr15&hid=24&bdata=JnNpdGU9ZHluYW1lZC1MSVZFJn
Njb3BlPXNpdGU%3d#db=dme&AN=113658