Outpatient Management of Early Pregnancy Loss Linda Prine, MD Associate Clinical Professor of Family Medicine Beth Israel & Harlem Family Medicine Residency Institute for Family Health Sarah Pickle, MD Clinical Instructor of Family Medicine Rutgers Robert Wood Johnson Medical School
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Outpatient Management of Early Pregnancy Loss
Linda Prine, MD Associate Clinical Professor of Family Medicine
Beth Israel & Harlem Family Medicine Residency Institute for Family Health
Sarah Pickle, MD
Clinical Instructor of Family Medicine Rutgers Robert Wood Johnson Medical School
Nothing to Disclose
Session Objectives
• Define contemporary terms used to describe EPL
• Describe 3 methods of outpatient management of EPL
• Discuss perceived benefits of outpatient management of EPL
• Explore best practice strategies for providing support to women experiencing EPL
• Identify key elements needed to apply patient-centered strategies for EPL management
Warburton, Am J Hum Genetics, 1964; Hemminki E, Obstet Gynecol, 1998; Ventura SJ, NCHS, 2012.
15- 30% of All Pregnancies
1 million annually in US
1 in 4 lifetime risk
Early Pregnancy Loss is Common
Gina, age 22 • LMP 8 weeks ago (definite, normal
menses, had an early sono that confirmed IUP)
• + Mild cramping and vaginal bleeding x 2 days
• Exam: Vital signs stable. Speculum: Blood, no tissue, os slightly open
• Ultrasound: Thickened, heterogenous endometrium; no gestational sac
Incomplete
Retained Products of Conception Davis P C et al. Radiographics 2002;22:803-816
What will you discuss with Jennifer in regards to her miscarriage? After hearing her options, she decides she does not want treated with instruments, wants it over at a predictable time – decides to take misoprostol.
Medication management of miscarriage
Misoprostol for early pregnancy loss
Misoprostol for Miscarriage
Common Protocol
• 800 mcg vaginally or buccally with repeat in 24 hours if incomplete
Alternative Protocols
• 600 mcg oral, 400 mcg sublingual
• Repeat doses q 24 hours vs. q 3 hours
Zhang et al. NEJM, 2005.
Guidelines for Misoprostol Use for EPL
• Clear diagnosis
• Rule out ectopic pregnancy because medical treatment for ectopic pregnancy differs from miscarriage treatment
• 10 weeks or under by ultrasound
• Testing: Ultrasound, Rh screen, hematocrit, quantitative serum hCG (not always needed if ultrasound diagnosis is definitive)
Expectant Management (%) Misoprostol (%)
By Day 7
By Day 14
By Day 49
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
Completion of Miscarriage: Expectant Management versus Misoprostol
Adapted from Prine, L. Am Fam Physician. 2011.
Side Effects of Misoprostol
• Bleeding
• Cramping
• Fevers and/or chills
• Nausea and vomiting
• Diarrhea
Patient Instructions: EPL with Misoprostol
Soak more than 2 pads in an hour for 2 hours in a row
Sustained temperature >100.4o F
(> 24 hours after misoprostol)
Severe pain that does not respond to analgesics
Lisa, age 34
• Definite LMP 9 weeks ago
• Has had intermittent spotting x 1 week
• No pregnancy symptoms
• Exam: Uterus consistent with 6 week exam, os closed
• Management of first trimester pregnancy complications can be done in an outpatient 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 delayed pregnancy loss (missed abortions/anembryonic pregnancies.)
References 1. Warburton D, Fraser FC. Spontaneous abortion risks in man: data from repro- ductive histories collected in a medical genetics unit. Am J Hum Genetics. 1964;16:1–25. (1 in 4 women) 2. Everett C (1997) Incidence and outcome of bleeding before the 20th week ofpregnancy: prospective study from general practice. Br Med J 315, 32–34. Hemminki E. Treatment of miscarriage: current practice and rationale. Obstet Gynecol. 1998;91:247–253. 3. Estimated Pregnancy Rates and Rates of Pregnancy Outcomes for the United States, 1990–2008 by Stephanie J. Ventura, M.A., Sally C. Curtin, M.A., Joyce C. Abma, Ph.D., Division of Vital Statistics; and Stanley K. Henshaw, Ph.D., The Guttmacher Institute. National Vital Statistics Reports. 2012; (60) 7. 4. Chen B, Creinin M. Contemporary management of early pregnancy failure. Clinical Obstetrics & Gynecology. 2007; (50) 1; 67–88. 5. Allison J, Sherwood R, Schust D. Management of First Trimester Pregnancy Loss Can Be Safely Moved Into the Office. Rev Obstet Gynecol. 2011; 4(1): 5-14. 6. Sotiriadis A, Makrydimas G, Paptheodorous S, Ioannidis JP. Expectant, medical, or surgical management of first-trimester miscarriage: a meta-analysis. Obstet Gynecol. 2005 May;105(5 Pt 1):1104-13. 7. Nanda K, Peloggia A, Grimes D, Lopez L, Nanda G. Expectant care versus surgical treatment for miscarriage. Cochrane Database Syst Rev. 2006 Apr 19;(2):CD003518. 8. Luise C, Jermy K, May C, Costello G, Collins WP, Bourne TH. Outcome of expectant management of spontaneous first trimester miscarriage: observational study. BMJ. 2002 Apr 13;324(7342):873-5. 9. Zhang J, Gilles JM, Barnhart K, Creinin MD, Westhoff C, Frederick MM; National Institute of Child Health Human Development (NICHD) Management of Early Pregnancy Failure Trial. A comparison of medical management with misoprostol and surgical management for early pregnancy failure. N Engl J Med. 2005 Aug 25;353(8):761-9. 10. Prine, L, MacNaughton, H. Office Management of Early Pregnancy Loss. Am Fam Physician. 2011 Jul 1;84(1):75-82 11. Forna F, Gulmezoglu AM. Surgical procedures to evacuate incomplete abortion. Cochrane Database Syst Rev. 2001(1):CD001993 12. Blumenthal PD, Remsburg RE. A time and cost analysis of the management of incomplete abortion with manual vacuum aspiration. Int J Gynecol Obstet 1994;45:261-267.