Early pregnancy loss needn’t require a trip to the hospital

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Applied Evidence

Early pregnancy loss needn’t require a trip to the hospital

J Fam Pract. 2009 November;58(11):585-590

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References

1. Wilcox AJ, Weinberg CR, O’Connor JF, et al. Incidence of early loss of pregnancy. N Engl J Med. 1988;319:189-194.

2. Tang OS, Ho PC. The use of misoprostol for early pregnancy failure. Curr Opin Obstet Gynecol. 2006;18:581-586.

3. Jurkovic D. Modern management of miscarriage: is there a place for non-surgical treatment? Ultrasound Obstet Gynecol. 1998;11:161-163.

4. Dalton VK, Harris L, Weisman CS, et al. Patient p, satisfaction, and resource use in office evacuation of early pregnancy failure. Obstet Gynecol. 2006;108:103-110.

5. Royal College of Obstetricians and Gynaecologists. The Management of Early Pregnancy Loss. London: Royal College of Obstetricians and Gynaecologists; 2006. Guideline No. 25.

6. Deutchman M. Advanced Life Support in Obstetrics Syllabus Update: First Trimester Pregnancy Complications. Leawood, Kan: American Academy of Family Physicians; 2007:1-2.

7. Wieringa-de Waard M, Bindels PJ, Vos J, et al. Patient p for expectant management vs. surgical evacuation in first-trimester uncomplicated miscarriage. J Clin Epidemiol. 2004;57:167-173.

8. Edwards S, Tureck R, Fredrick M, et al. Patient acceptability of manual versus electric vacuum aspiration for early pregnancy loss. J Womens Health (Larchmt). 2007;16:1429-1436.

9. Smith LF, Frost J, Levitas R, Bradley H, et al. Women’s experiences of three early miscarriage management options: a qualitative study. Br J Gen Pract. 2006;56:198-205.

10. Nikcevic AV, Kuczmierczyk AR, Nicolaides KH. The influence of medical and psychological interventions on women’s distress after miscarriage. J Psychosom Res. 2007;63:283-290.

11. Sotiriadis A, Makrydimas G, Papatheodorou S, et al. Expectant, medical, or surgical management of first-trimester miscarriage: a meta-analysis. Obstet Gynecol. 2005;105(5 Pt 1):1104-1113.

12. Bagratee JS, Khullar V, Regan L, et al. A randomized controlled trial comparing medical and expectant management of first trimester miscarriage. Hum Reprod. 2004;19:266-271.

13. Blohm F, Friden B, Platz-Christensen JJ, et al. Expectant management of first-trimester miscarriage in clinical practice. Acta Obstet Gynecol Scand. 2003;82:654-658.

14. Gronlund L, Gronlund AL, Clevin L, et al. Spontaneous abortion: expectant management, medical treatment or surgical evacuation. Acta Obstet Gynecol Scand. 2002;81:781-782.

15. Graziosi GC, Mol BW, Ankum WM, et al. Management of early pregnancy loss. Int J Gynaecol Obstet. 2004;86:337-346.

16. Wood SL, Brain PH. Medical management of missed abortion: a randomized clinical trial. Obstet Gynecol. 2002;99:563-566.

17. Luise C, Jermy K, May C, et al. Outcome of expectant management of spontaneous first trimester miscarriage: observational study [see comment]. BMJ. 2002;324:873-875.

18. Wieringa-de Waard M, Ankum WM, Bonsel GJ, et al. The natural course of spontaneous miscarriage: analysis of signs and symptoms in 188 expectantly managed women. Br J Gen Pract. 2003;53:704-708.

19. Nanda K, Peloggia A, Grimes D, et al. Expectant care versus surgical treatment for miscarriage. Cochrane Database Syst Rev. 2006(2):CD003518.-

20. Neilson JP, Hickey M, Vazquez J. Medical treatment for early fetal death (less than 24 weeks). Cochrane Database Syst Rev. 2006;(3):CD002253.-

21. Weeks A, Faundes A. Misoprostol in obstetrics and gynecology. Int J Gynaecol Obstet. 2007;99(suppl 2):S156-S159.

22. World Health Organization. Medical Methods for Termination of Pregnancy. Geneva: WHO; 1997.

23. Tang OS, Gemzell-Danielsson K, Ho PC. Misoprostol: pharmacokinetic profiles, effects on the uterus and side-effects. Int J Gynaecol Obstet. 2007;99(suppl 2):S160-S167.

24. Gemzell-Danielsson K, Ho PC, Gomez Ponce de Leon R, et al. Misoprostol to treat missed abortion in the first trimester. Int J Gynaecol Obstet. 2007;99(suppl 2):S182-S185.

25. Blum J, Winikoff B, Gemzell-Danielsson K, et al. Treatment of incomplete abortion and miscarriage with misoprostol. Int J Gynaecol Obstet. 2007;99(suppl 2):S186-S189.

26. Moodliar S, Bagratee JS, Moodley J. Medical vs. surgical evacuation of first-trimester spontaneous abortion. Int J Gynaecol Obstet. 2005;91:21-26.

27. Graziosi GC, Bruinse HW, Reuwer PJ, et al. Women’s p for misoprostol in case of early pregnancy failure. Eur J Obstet Gynecol Reprod Biol. 2006;124:184-186.

28. Weeks A, Alia G, Blum J, et al. A randomized trial of misoprostol compared with manual vacuum aspiration for incomplete abortion. Obstet Gynecol. 2005;106:540-547.

29. Demetroulis C, Saridogan E, Kunde D, et al. A prospective randomized control trial comparing medical and surgical treatment for early pregnancy failure. Hum Reprod. 2001;16:365-369.

30. Zhang J, Gilles JM, Barnhart K, et al. A comparison of medical management with misoprostol and surgical management for early pregnancy failure [see comment]. N Engl J Med. 2005;353:761-769.

31. Trinder J, Brocklehurst P, Porter R, et al. Management of miscarriage: expectant, medical, or surgical? Results of randomized controlled trial (miscarriage treatment (MIST) trial) [see comment]. BMJ. 2006;332:1235-1240.

32. Fjerstad M, Trussell J, Sivin I, et al. Rates of serious infection after changes in regimens for medical abortion. N Engl J Med. 2009;61:145-151.

33. Creinin MD. Change in serum beta-human chorionic gonadotropin after abortion with methotrexate and misoprostol. Am J Ob Gyn. 1996;174:776-778.

34. Graziosi GC, Bruinse HW, Reuwer PJ, et al. Misoprostol versus curettage in women with early pregnancy failure: impact on women’s health-related quality of life. A randomized controlled trial. Hum Reprod. 2005;20:2340-2347.

35. Forna F, Gulmezoglu AM. Surgical procedures to evacuate incomplete miscarriage. Cochrane Database Syst Rev. 2001;(1):CD001993.-

36. Castleman L, Mann C. Manual Vacuum Aspiration (MVA) for Uterine Evacuation: Pain Management. Chapel Hill, NC: Ipas; 2002.

37. Baird T, Flinn SK. Manual Vacuum Aspiration: Expanding Women’s Access to Safe Abortion Services. Chapel Hill, NC: Ipas; 2001.

38. Goldberg AB, Dean G, Kang MS, et al. Manual versus electric vacuum aspiration for early first-trimester abortion: a controlled study of complication rates. Obstet Gynecol. 2004;103:101-107.

39. Paul ME, Mitchell CM, Rogers AJ, et al. Early surgical abortion: efficacy and safety. Am J Obstet Gynecol. 2002;187:407-411.

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41. Blumenthal PD, Remsburg RE. A time and cost analysis of the management of incomplete abortion with manual vacuum aspiration. Int J Gynaecol Obstet. 1994;45:261-267.

42. Maltzer DS, Maltzer MC, Wiebe ER, et al. Pain management. In: Paul M, Lichtenberg ES, Borgatta L, Grimes DA, Stubblefield PG, eds. A Clinician’s Guide to Medical and Surgical Abortion. Philadelphia: Churchill Livingstone; 1999.

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Follow-up. After misoprostol administration, follow-up includes confirmation of passage of the embryo or gestational sac by a combination of history, clinical examination, and serial hCG measurement or ultrasound. A completed abortion can be demonstrated by quantitative serum hCG showing a 50% drop between first and repeat test 48 to 72 hours after the passage of tissue.³³ Follow-up 1 to 2 weeks after treatment is common practice, but can be scheduled sooner if the patient has not had bleeding and cramping. In that situation, you can give her the option of proceeding to uterine aspiration or trying a second dose of misoprostol (see doses given earlier), as long as she remains hemodynamically stable.²⁴

Women who experience successful treatment with misoprostol like the method. In a multicenter, randomized clinical trial, 154 women with EPL confirmed by ultrasonography who had not passed the pregnancy after a week were randomly assigned to treatment with misoprostol (n=79) or curettage (n=75). In cases where misoprostol had caused complete evacuation, 76% of the women would opt for the same treatment, whereas only 38% of women who needed vacuum aspiration after unsuccessful misoprostol would do so (P<.01).³⁴

A sample protocol for medical management of EPL is provided in the box.

Management of early pregnancy loss with misoprostol: A protocol^24,25

Candidates

Women with ultrasound diagnosis of a nonviable pregnancy up to 10 weeks’ gestation. Nonviable pregnancy is diagnosed by ultrasound and subnormal, rising quantitative human chorionic gonadotropin (hCG) levels. Misoprostol treatment is not suitable in ectopic pregnancy, which must be excluded before treatment is begun.

Laboratory workup

Rh screen, hemoglobin, and quantitative serum hCG.

Procedure

Insert 800 mcg misoprostol in the vagina. (This can also be done by the patient at home.) If passage of tissue does not occur, the physician can give the patient a second dose of 800 mcg misoprostol. Anembryonic pregnancy or fetal demise can also be treated with 600 mcg given sublingually. Incomplete abortion is treated with a single dose of 600 mcg orally or 400 mcg sublingually.

Pain management

Provide a prescription for ibuprofen 800 mg and Tylenol #3 to the patient. Instruct her to take a tablet of ibuprofen at the time of misoprostol insertion and then every 6 hours as needed for pain. If pain is severe, she may take 1 to 2 tablets of Tylenol #3 every 3 to 4 hours as needed.

Instructions to patient

Tell the patient to call the office for “heavy bleeding,” defined as soaking 2 pads an hour for more than 2 hours. Tell the patient that there is no need to bring the expelled material for your inspection. Make sure she has your phone and pager numbers. If she needs to go to an emergency department or a hospital, tell her to request that you be called.

Follow-up

Schedule a follow-up visit 1 to 2 weeks after misoprostol insertion. A completed abortion can be demonstrated by quantitative serum hCG showing a 50% drop between first and repeat test 48 to 72 hours after the passage of tissue. Alternatively, a transvaginal ultrasound should show absence of a sac.

Of note: If one of these criteria is met, no further follow-up of serum hCG is warranted. Patients may elect manual vacuum aspiration at any time if the gestational sac and/or embryo have not passed.

Manual vacuum aspiration means less blood loss

A Cochrane review that compared vacuum aspiration with surgical D&C found that vacuum aspiration was associated with significantly less blood loss, pain, and time needed for the procedure.³⁵ Traditionally, vacuum aspiration for EPL has occurred in the OR, using electrical suction and general anesthesia. Recently, a manual vacuum aspirator that allows women to have the procedure done in the outpatient setting has become available. It is used with analgesia given PO and a paracervical block.^4,36

FAST TRACK

The manual vacuum aspirator is safe and provides the same degree of suction as an electric pump.

The manual vacuum aspirator (MVA) is a handheld syringe that works well in the ambulatory setting because it is small, quiet, portable, and inexpensive. The MVA is safe, provides the same degree of suction as an electric pump, and is as effective as electrical vacuum aspiration for the management of both spontaneous and induced abortion.³⁷

As safe, as effective. A study by Goldberg and colleagues compared complication rates with MVA and electric suction in EPL of up to 10 weeks’ gestation.³⁸ The researchers found no significant difference in perforation or need for re-aspiration. A comparison of the 2 methods in gestations of less than 6 weeks found a similar, small risk of failed abortion (<3%).³⁹ A study of 1677 women treated with MVA as outpatients in a primary care practice had a complication rate of only 1.25%.⁴⁰