office management of early pregnancy loss. objectives discuss the differential and the work-up...
TRANSCRIPT
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Office Management of Early Pregnancy Loss
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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
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Epidemiology of Early Pregnancy Loss
• One in four women will experience EP• Up to 15- 20% of diagnosed pregnancies
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What are the clinical presentations of first trimester
losses?
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Causes of EPL
• Chromosomal abnormalities > 50%
• Infection
• Reproductive tract abnormalities
• Exposure to toxins
• Uncontrolled endocrine or autoimmune disease
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Jennifer
•22 years old •LMP was 7 weeks ago •Positive urine pregnancy•She is having some vaginal bleeding
Additional history? And on physical?
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Algorithm with Physical Exam
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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.
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Anembryonic Pregnancy
Mean sac diameter 18-25 mm with no yolk sac or fetal pole, or no growth 7-14 days
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Embryonic Demise when no FH
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Back to Jennifer…
What does she need to know?
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Risk Factors
• Age
• Prior miscarriages
• Smoking
• Cocaine use
• Fever/Infection
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Miscarriage Myths
• Air travel
• Blunt abdominal trauma
• Contraceptive use
• Exercise
• HPV vaccine
• Previous abortions
• Sexual activity
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Three Options:
1. Expectant Management
2. Medication Management
3. Aspiration Procedure
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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
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What are the potential benefits of expectant management?
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What would be the contraindications to expectant
management?
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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.
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What anticipatory guidance and help do we provide for expectant
management?
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Medical management of miscarriage: Misoprostol for early
pregnancy loss
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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.
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Side Effects of Misoprostol
• Bleeding
• Cramping
• Fevers and/or chills
• Nausea and vomiting
• Diarrhea
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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)
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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
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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
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What is done about the failure to pass tissue?
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How is completion of the miscarriage diagnosed?
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What do you need to start using misoprostol in your practice?
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“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
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Uterine Aspiration
Electric Vacuum Aspirator
Manual Vacuum Aspirator
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MVA Instruments and Supplies
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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.
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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
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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
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Cases for Review: Sonia
• LMP 8 weeks ago
• Started spotting 3 days ago
• Now having heavier cramping with bleeding
• Appears comfortable, normal vital signs
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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?
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Sonia, Continued
How do you explain to her what is happening?
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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.
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Katie, Continued
Very small, irregular sac with sub-chorionic bleed visible
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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?
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Katie, Continued
She decides to opt for treatment with medication.
What regimen do you use and how do you advise her?
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How is completion of the miscarriage diagnosed?
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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)
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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.
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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.
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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