1. Office Management of Miscarriage in the First Trimester Sarah Miller MD, Alyssa Luddy MD, Linda Prine MD Department of Family Medicine, Beth Israel Medical Center and The Institute for Family Health, New York, NY
Beth Israel Residency in Urban Family Practice
Background: Early pregnancy loss is very common; an estimated 15-20% of diagnosed pregnancies miscarry in the first trimester. One in four women has a miscarriage during her lifetime. Miscarriage can be managed safely in the primary care setting. Three treatment options exist, which vary in efficacy depending on type of miscarriage. Primary care office management is preferable to operating room procedures because it decreases cost and allows patients to be treated within their medical home, especially important for effective counseling and long term follow up.
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Pic 1: empty sac, anembryonic gestation (mean sac diameter > 18mm with no yolk sac and no fetal pole = non-viable pregnancy)
Pic 2: missed abortion, fetal demise (crown-rump length > 6mm without visible fetal heart rate = non-viable pregnancy)
Pic 3: incomplete abortion (no intrauterine pregnancy, some remaining tissue and blood passing into cervix)
Need to add description of success rate of expectant management for each dx
Need to add description of success rate of medication management for each dx
Need to add regimen for medication management
Sotiriadis A, Makrydimas G, Papatheodorou S, Ioannidis JP. Expectant, medical, or surgical management of first-trimester miscarriage: a meta-analysis. Obstet Gynecol, 2005;105:
Anembryonic gestation: ultrasound shows a gestational sac >18mm without a yolk sac or fetal pole. Also referred to as “blighted ovum”
Missed Abortion: Embryo with crown-rump length ≥5mm without visible cardiac activity. Cervix closed on exam. Nonviable embryo not yet passed.
Incomplete Abortion: Ultrasound shows some gestational tissue retained. History of bleeding with open os on exam.
Comparative Risks: Infection, excessive bleeding, and the need for emergent aspiration are rare complications (<1%) and exist for all management strategies, with no overall difference in complication rates between the three methods.
“Watchful waiting” as the miscarriage proceeds spontaneously.
Pros: Perceived as less invasive, more natural, more private. Avoids surgical and anesthetic risk. Decreased cost.
Cons: Unpredictable timing, longer average time to completion, lower rate of successfully completed miscarriage.
Contraindications: ectopic pregnancy, excessive bleeding or hemodynamic instability, uterine infection, lack of access to emergent uterine aspiration.
How to: Anticipatory guidance and regular follow up until completion. Counseling should address concerns about future fertility and reassurance that the miscarriage was not the woman’s fault. Regardless of management strategy, determine Rh status and treat Rh negative women with Rhogam.
Misoprostol, a prostaglandin E1 analogue, is used to stimulate uterine contractions and promote uterine evacuation.
Pros: more predictable timeframe, shorter interval to miscarriage resolution, lack of instrumentation and less cost than MVA. Success rates higher than with expectant care, especially for missed abortions and anembryonic gestations
Contraindications: same as expectant management, plus allergy to prostaglandins.
How to: No one codified protocol regarding oral, buccal, sublingual, or vaginal use. 800mcg vaginally, with a repeat dose if needed, is common and has been shown to be safe, effective, and acceptable. Follow up needed.
“Surgical” management uses manual suction to evacuate the uterus, and is associated with less pain, shorter procedure time, and less blood loss than sharp curettage, often done under general anesthesia, as was traditional.
Pros: immediate and effective, success rates > 98%, cost substantially less than dilatation and curettage in the operating room.
Contraindications: Fetal demise beyond 12 weeks is a relative contraindication to primary care outpatient office management.
Category of Pregnancy Loss
Completion rate with Expectant Management by Day 7
Completion rate with Expectant Management by Day 14
Completion rate with Expectant Management by Day 46
Success Rate* with Misoprostol by day 8
Anembryonic
25%
52%
66%
81%
Missed Abortion
30%
59%
76%
88%
Incomplete
53%
84%
91%
93%
TOTAL
40%
70%
References:
Sotiriadis A, Makrydimas G, Papatheodorou S, Ioannidis JP. Expectant, medical, or surgical management of first-trimester miscarriage: a meta-analysis. Obstet Gynecol, 2005;105:
Wilcox AJ, Weinberg CR, O'Connor JF, Baird DD, Schlatterer JP, Canfield RE, et al. Incidence of early loss of pregnancy. N Engl J Med, 1988;319:
Prine L, MacNaughton H. Office Management of Miscarriage in, Fife R and Schrager S.  ACP Office Handbook of Women's Health, ACP Press, Philadelphia, PA, In press.
Trinder J, Brocklehurst P, Porter R, Read M, Vyas S and Smith L, Management of Miscarriage; expectant, medical, or surgical. (miscarriage treatment (MIST) trial). BMJ 2006;332;
Chen BA, Creinin MD. Contemporary management of early pregnancy failure. Clinical Obstetrics and Gynecology, 2007;50(1):67-88
* Success rate is defined as completed abortion without the need for surgical intervention. Success rates increase over time and vary significantly depending on the type of spontaneous abortion.