1. Do Nothing, Do Something, Do Surgery: an Overview of Miscarriage Management Sarah Prager, MD Department of Obstetrics and Gynecology University of Washington

2. Disclosure Management of Early Pregnancy Loss I train providers in Nexplanon insertion and removal I train providers in Nexplanon insertion and removal I do not receive any honoraria for this I do not receive any honoraria for this

3. Management of Early Pregnancy Loss Objectives Review etiologies of EPL Review etiologies of EPL Review the three methods of EPL management: — Expectant — Medical — Surgical Review the three methods of EPL management: — Expectant — Medical — Surgical Discuss benefits of outpatient EPL management Discuss benefits of outpatient EPL management

4. Nomenclature Management of Early Pregnancy Loss Early Pregnancy Loss (EPL) Spontaneous Abortion (SAb) Miscarriage These all mean exactly the same thing!

5. Background Management of Early Pregnancy Loss Spontaneous Abortion (SAb) most common complication of early pregnancy — 8–20% clinically recognized pregnancies — 13–26% all pregnancies Spontaneous Abortion (SAb) most common complication of early pregnancy — 8–20% clinically recognized pregnancies — 13–26% all pregnancies — ~ 800,000 SABs each year in the US 80% of SAbs occur in 1st trimester 80% of SAbs occur in 1st trimester

6. Samantha 26 yo G2P1 presents to your office for a new ob visit. An ultrasound shows a CRL of 7mm but no cardiac activity. 26 yo G2P1 presents to your office for a new ob visit. An ultrasound shows a CRL of 7mm but no cardiac activity. She wants to know why this happened. She wants to know why this happened.

7. Risk Factors Management of Early Pregnancy Loss Age Prior SAb SmokingAlcohol Caffeine (controversial) Maternal BMI 25 Celiac disease (untreated) CocaineNSAIDs High gravidity Fever Low folate levels

8. Etiology Management of Early Pregnancy Loss 33% anembryonic 33% anembryonic 50% due to chromosomal abnormalities — Autosomal trisomies 52% — Monosomy X 19% — Polyploidies 22% — Other 7% 50% due to chromosomal abnormalities — Autosomal trisomies 52% — Monosomy X 19% — Polyploidies 22% — Other 7% Host factors — Structural abnormalities — Maternal infection/endocrinopathy/coagulopathy Host factors — Structural abnormalities — Maternal infection/endocrinopathy/coagulopathy Unexplained Unexplained

9. Normal Implantation & Development Management of Early Pregnancy Loss Implantation: — 5-7 days after fertilization — Takes ~72 hours — Invasion of trophoblast into decidua Implantation: — 5-7 days after fertilization — Takes ~72 hours — Invasion of trophoblast into decidua Embryonic disc: — 1 wk post-implantation — If no embryonic disc, trophoblast still grows, but no embryo (anembryonic pregnancy) Embryonic disc: — 1 wk post-implantation — If no embryonic disc, trophoblast still grows, but no embryo (anembryonic pregnancy) Embryonic disc embryonic/fetal pole Embryonic disc embryonic/fetal pole

10. U/S Dating in Normal Pregnancy Management of Early Pregnancy Loss Gestational Age (days) Mean Sac Diameter (mm) + 30 OR Crown-Rump Length (mm) + 42 =

11. Clinical Presentation of EPL Management of Early Pregnancy Loss Bleeding Bleeding Pain/cramping Pain/cramping Falling or abnormally rising ßhCG Falling or abnormally rising ßhCG Decreased symptoms of pregnancy Decreased symptoms of pregnancy No symptoms at all! No symptoms at all!

12. Ultrasound Findings of EPL Management of Early Pregnancy Loss Anembryonic Pregnancy — No fetal pole with mean sac diam >25 mm (transabdominal) OR >18 mm (transvaginal) — 10 mm) Anembryonic Pregnancy — No fetal pole with mean sac diam >25 mm (transabdominal) OR >18 mm (transvaginal) — 10 mm) Embryonic Demise — No cardiac activity with CRL ≥5 mm Embryonic Demise — No cardiac activity with CRL ≥5 mm Mishell DR, Comprehensive Gynecology 2007

13. Samantha Samantha and her partner request information on all the treatment options. You confirm the rest of her history. PMH: wisdom teeth removed Ob Hx: term SVD without complication All: NKDA

14. Management Options Early Pregnancy Loss Do Nothing: Expectant management Do Something: Medical management Do Surgery: Surgical management Sotiriadis A, Obstet Gynecol 2005 Nanda K, Cochrane Database Syst Rev 2006

15. Do Nothing Expectant Management Requirements for therapy: — <13 weeks gestation — Stable vital signs — No evidence infection Requirements for therapy: — <13 weeks gestation — Stable vital signs — No evidence infection What to expect: — Most expel within 1st 2 wks after diagnosis — Prolonged follow-up may be needed — Acceptable and safe to wait up to 4 wks post-diagnosis What to expect: — Most expel within 1st 2 wks after diagnosis — Prolonged follow-up may be needed — Acceptable and safe to wait up to 4 wks post-diagnosis

16. Outcomes Do Nothing: Expectant Management Overall success rate81% Overall success rate81% Success rates vary by type of miscarriage (helpful to tailor counseling) — Incomplete/inevitable abortion91% — Embryonic demise76% — Anembryonic pregnancies66% Success rates vary by type of miscarriage (helpful to tailor counseling) — Incomplete/inevitable abortion91% — Embryonic demise76% — Anembryonic pregnancies66% Luise C, Ultrasound Obstet Gynecol 2002

17. What is Success? Definitions Used in Studies ≤15 mm endometrial thickness (ET) 3 days to 6 weeks after diagnosis ≤15 mm endometrial thickness (ET) 3 days to 6 weeks after diagnosis No vaginal bleeding No vaginal bleeding Negative urine hCG Negative urine hCG

18. Problems with ET Cut-off No clear rationale for this cut-off No clear rationale for this cut-off Study of 80 women with successful medical abortion — Mean ET at 24 hours 17.5 mm (7.6–29 mm) — At one week 15% with ET >16 mm Study of 80 women with successful medical abortion — Mean ET at 24 hours 17.5 mm (7.6–29 mm) — At one week 15% with ET >16 mm Study of medical management after miscarriage — 86% success rate if use absence of gestational sac — 51% success rate if use ET ≤15 mm Study of medical management after miscarriage — 86% success rate if use absence of gestational sac — 51% success rate if use ET ≤15 mm Harwood B, Contraception 2001 Reynolds A, Eur. J Obstet Gynecol Reproduct. Biol 2005

19. When to intervene for Expectant Management? Continued gestational sac Continued gestational sac Clinical symptoms Clinical symptoms Patient preference Patient preference Time (?) Time (?) Vaginal bleeding and positive UPT are possible for 2–4 weeks — Poor measures of success Vaginal bleeding and positive UPT are possible for 2–4 weeks — Poor measures of success

20. Samantha Samantha appears anxious about waiting and shares with you that she really needs to do something. Samantha appears anxious about waiting and shares with you that she really needs to do something.

21. Do Something Medical Management Misoprostol Misoprostol Misoprostol + Mifepristone Misoprostol + Mifepristone Misoprostol + Methotrexate Misoprostol + Methotrexate No medical regimen for management of EPL is FDA approved

22. Medical Management Requirement for Therapy <13 weeks gestation <13 weeks gestation Stable vital signs Stable vital signs No evidence of infection No evidence of infection No allergies to medications used No allergies to medications used Adequate counseling and patient acceptance of side effects Adequate counseling and patient acceptance of side effects

23. Misoprostol Prostoglandin E1 analogue Prostoglandin E1 analogue FDA approved for prevention of gastric ulcers FDA approved for prevention of gastric ulcers Used off-label for many Ob/Gyn indications: — Labor induction — Cervical ripening — Medical abortion (with mifepristone) — Prevention/treatment of postpartum hemorrhage Used off-label for many Ob/Gyn indications: — Labor induction — Cervical ripening — Medical abortion (with mifepristone) — Prevention/treatment of postpartum hemorrhage Can be administered by oral, buccal, sublingual, vaginal and rectal routes Can be administered by oral, buccal, sublingual, vaginal and rectal routes Chen B, Clin Obstet Gynecol 2007

24. Why Misoprostol? Do something while still avoiding surgery Do something while still avoiding surgery Cost effective Cost effective Stable at room temperature Stable at room temperature Readily available Readily available

25. Misoprostol Dosing Regimens Embryonic Demise & Anembryonic Pregnancy StudyDoseEfficacy Creinin400 mcg po vs 800 pv 25% vs. 88% Ngoc800 mcg po vs 800 pv 89% vs. 93% (NS) Tang600 mcg SL vs 600 pv 87.5% q 3 hrs x 3 doses (SL had more side effects— diarrhea, 70% vs 27.5%) Phupong600 mcg po x 1 vs. 82% vs 92% (NS) q 4 hrs x 2 doses (Repeat dosing increased diarrhea, 40% vs 18%) Gilles800 mcg pv saline- 83% vs 87% (NS) moistened vs. dry Creinin MD, Obstet Gynecol 1997; Ngoc NTN, Int.J Gynaecol Obstet 2004; Tang OS, Hum Reproduct 2003; Phupong V, Contraception 2005; Gilles JM, Am J Obstet Gynecol 2004

26. Misoprostol Dosing Incomplete Abortion Study NDosevs. Results Weeks et al, ‘05 317600 oral d1,2MVA96.3% in 1–2 wks Moodliar et al, ‘05 94600 vag D&C 91.5% in 1 wk Zhang et al, ‘05*652800 vag d1,3 D&C 84% in 8 days Coughlin et al, ‘04131400 oral x 278% 1 dose/ 92.4% ultimately Ngai et al, ‘0130400 vag d1,3,5 observe83% by day 15 Pang et al, ‘01103800 oral 65% in 24 hrs 95800 vaginal61% in 24 hrs Demetroulis, ‘01*40800 vaginal D&C 93% in 8-10 hrs Chung et al, ‘99321400 oral q4h D&C 50% Chung et al, ‘97225400 oral tid D&C 50% Chung et al, ‘95141400 oral q4h50% *also included missed abortions

27. Pooled Outcomes Medical Management Success Rates Success Rates Placebo16–60% Single dose misoprostol 25–88% 400–800 mcg Repeat dose x 1 if incomplete 80–88% at 24 hours Wood SL, Obstet Gynecol 2002; Bagratee JS, Hum Reproduct 2004; Blohm F, BJOG: Int J Obstet Gynecol 2005 Success rate depends on type of miscarriage — 100% with incomplete abortion — 87% for all others Success rate depends on type of miscarriage — 100% with incomplete abortion — 87% for all others

28. Serum Level Comparison Misoprostol by Route of Administration

29. Uterine Tone Over 5 Hours Misoprostol by Route of Administration Rectal p =.006 Meckstroth, not yet published

30. Uterine Activity Over 5 Hours Misoprostol by Route of Administration Meckstroth, not yet published

31. Side Effects and Complications Misoprostol vs. Placebo N/V, Diarrhea:No difference Pain:More pain and analgesics in one study Hemoglobin Conc:No difference Infection:0% for placebo vs..2–4.7% for misoprostol No benefit with repeat dosing within 3–4 hours No benefit with repeat dosing within 3–4 hours Improved outcome with 1 repeat dose at 12-24 hours, if incomplete Improved outcome with 1 repeat dose at 12-24 hours, if incomplete 90% found medical management acceptable and would elect same treatment again 90% found medical management acceptable and would elect same treatment again Wood SL, Obstet Gynecol 2002; Bagratee JS, Hum Reproduct 2004; Blohm F, BJOG: Int J Obstet Gynecol 2005

32. Misoprostol Bottom Line Medical Management 800 mcg pv (or buccal) 800 mcg pv (or buccal) Repeat x 1 at 12–24 hours, if incomplete — Occasionally repeat more than once Repeat x 1 at 12–24 hours, if incomplete — Occasionally repeat more than once Measure success as with expectant management Measure success as with expectant management Intervene with surgical management if — Continued gestational sac — Clinical symptoms — Patient preference — Time (?) Intervene with surgical management if — Continued gestational sac — Clinical symptoms — Patient preference — Time (?)

33. Mifepristone and Misoprostol Medical Management Mifepristone: Progestin antagonist that binds to progestin receptor — Used with elective medical abortion to “destabilize” implantation site — Current evidence-based regimen: 200 mg mifepristone + 800 mcg misoprostol Mifepristone: Progestin antagonist that binds to progestin receptor — Used with elective medical abortion to “destabilize” implantation site — Current evidence-based regimen: 200 mg mifepristone + 800 mcg misoprostol Success rates for mifepristone & misoprostol in EPL: — 52–84% (observational trials, non-standard dose) — 90–93% (standard dose) Success rates for mifepristone & misoprostol in EPL: — 52–84% (observational trials, non-standard dose) — 90–93% (standard dose) No direct comparison between misoprostol alone and mifepristone/misoprostol with standard dosing No direct comparison between misoprostol alone and mifepristone/misoprostol with standard dosing Mifepristone may help (data still pending) Mifepristone may help (data still pending) Gronlund A, Acta Obstet Gynaecol 1998; Nielsen S, Br J Obstet Gynaecol 1997; Niinimaki M, Fertility Sterility 2006; Schreiber CA, Contraception 2006

34. Methotrexate and Misoprostol Medical Management Methotrexate: — Folic acid antagonist — Cytotoxic to trophoblast Methotrexate: — Folic acid antagonist — Cytotoxic to trophoblast Used in medical management for ectopic pregnancy Used in medical management for ectopic pregnancy Introduced in 1993 in combination with misoprostol to treat elective abortion medically — Success rates up to 98% (misoprostol administered 7 days after methotrexate) Introduced in 1993 in combination with misoprostol to treat elective abortion medically — Success rates up to 98% (misoprostol administered 7 days after methotrexate) No data for use in early pregnancy loss No data for use in early pregnancy loss Creinin MD, Contraception 1993

35. Samantha Samantha opts to try misoprostol and returns to the office 7 days later for follow up. How do you assess whether or not her treatment is complete? Samantha opts to try misoprostol and returns to the office 7 days later for follow up. How do you assess whether or not her treatment is complete?

36. Samantha At her follow-up appointment, Samantha says that she had a period of heavy bleeding and is now spotting. Her cramping has resolved. She has noted a marked decrease in breast tenderness and nausea. Her ultrasound shows a uniform endometrial stripe measuring 30mm in its greatest width. Is she complete?

37. Samantha

38. Rebecca 32 yo G3P2 at 8 weeks by LMP was diagnosed with a fetal demise on her ultrasound and presents to your office after 2 weeks of expectant management stating that she “wants to be done”. She declines medical management and requests a D&C. 32 yo G3P2 at 8 weeks by LMP was diagnosed with a fetal demise on her ultrasound and presents to your office after 2 weeks of expectant management stating that she “wants to be done”. She declines medical management and requests a D&C.

39. Rebecca What questions would you ask to see if she was a good candidate? What questions would you ask to see if she was a good candidate?

40. Surgical Management Early Pregnancy Loss Suction dilation and curettage (D&C) Suction dilation and curettage (D&C) Who should have surgical management? — Unstable — Significant medical morbidity — Infected — Very heavy bleeding — Anyone who WANTS immediate therapy Who should have surgical management? — Unstable — Significant medical morbidity — Infected — Very heavy bleeding — Anyone who WANTS immediate therapy

41. Surgical Management Early Pregnancy Loss Convenient timing Observed therapy High success rates (almost 100%) Infection (1/200) Perforation (1/2000) Cervical trauma Uterine synechiae (very rare) BENEFITSRISKS

42. Infection Prophylaxis Surgical Management Periabortal antibiotics  infection risk 42% Periabortal antibiotics  infection risk 42% No strong evidence on what to use No strong evidence on what to use Doxycycline (2–14 doses) Doxycycline (2–14 doses) Metronidazole:— Bacterial vaginosis — Trichomoniasis — Suspicious discharge Metronidazole:— Bacterial vaginosis — Trichomoniasis — Suspicious discharge Sawaya GF, Obstet Gynecol 1996; Prieto JA, Obstet Gynecol 1995

43. Comparison of Outcome by Method Management of Early Pregnancy Loss FactorComparison of Methods Success rateSurgical > Medical Medical ≥ Expectant Resolution Surgical > Medical > Expectant within 48 hrs Infection riskExpectant = Medical = Surgical.2–3% Nanda K, Cochrane Database Syst Rev 2006; Nielsen S, Br J Obstet Gynaecol 1999; Shelly JM, Aust. NZ J Obstet Gynaecol 2005; Sotiriadis A, Obstet Gynecol 2005; Tinder J, (MIST) BMJ, 2006 Number differed by highly variable success rates reported for expectant management

44. Patient Satisfaction Management of Early Pregnancy Loss Meta-analysis shows studies report high satisfaction with medical management Meta-analysis shows studies report high satisfaction with medical management Caution: Few studies looked at satisfaction Caution: Few studies looked at satisfaction Satisfaction depended on choice: — If women randomized 55-74% satisfied — If women chose 84-88% satisfied — Both were independent of method Satisfaction depended on choice: — If women randomized 55-74% satisfied — If women chose 84-88% satisfied — Both were independent of method Unsuccessful expectant resulting in surgical showed most profound anxiety and depression Unsuccessful expectant resulting in surgical showed most profound anxiety and depression Sotiriadis 2005

45. Zhang, NEJM 2005

46. Cost Analysis Management of Early Pregnancy Loss Medical management most cost effective — 2 studies — Misoprostol vs. expectant vs. surgical: $1000 vs. $1172 vs. $2007 Medical management most cost effective — 2 studies — Misoprostol vs. expectant vs. surgical: $1000 vs. $1172 vs. $2007 Expectant management most cost effective — MIST trial — Expectant vs. medical vs. surgical: £1086 vs. £1410 vs. £1585 Expectant management most cost effective — MIST trial — Expectant vs. medical vs. surgical: £1086 vs. £1410 vs. £1585 Doyle NM, Obstet. Gynecol 2004; You JH, Hum Reprod 2005; Petrou S, BJOG 2006

47. Rebecca Refer to OR? Manage with MVA? The clinic schedule is packed…does this have to be done today?

48. Where to perform? Surgical Management Women with SAb in Canada: — 92.5% presenting to hospital have D&C — 51% presenting to family physician have D&C Women with SAb in Canada: — 92.5% presenting to hospital have D&C — 51% presenting to family physician have D&C Manual vacuum aspiration (MVA) in outpatient setting can  hospital costs by 41% Manual vacuum aspiration (MVA) in outpatient setting can  hospital costs by 41% Weibe E, Fam Med 1998; Finer LB, Perspect Sexu Reproduct Health 2003; Blumenthal PD, Int J Gynaecol Obstet 1994

49. Advantages Moving Rx from OR to Outpatient Setting Avoid repeated exams that often occur in hospital Avoid repeated exams that often occur in hospital Simplify scheduling and reduce wait time — Average OR waiting time in UK-based study: 14 hours, with 42% of women not satisfied Simplify scheduling and reduce wait time — Average OR waiting time in UK-based study: 14 hours, with 42% of women not satisfied Save resources Save resources Avoid cumbersome OR protocols — Prolonged NPO requirements and discharge criteria Avoid cumbersome OR protocols — Prolonged NPO requirements and discharge criteria Demetroulis 2001; Lee and Slade 1996

50. Advantages Moving Rx from OR to Outpatient Setting Office affords more treatment options — Vacuum aspiration or misoprostol — Pain management choices Office affords more treatment options — Vacuum aspiration or misoprostol — Pain management choices Improved patient autonomy and privacy Improved patient autonomy and privacy Convenience Convenience Personalized care Personalized care Lee and Slade 1996

51. Moving Incomplete Abortion to Outpatient Setting Johns Hopkins Study Methods N = 35, incomplete 1st-trimester abortion N = 35, incomplete 1st-trimester abortion Treatment comparison: Treatment comparison: Blumenthal and Remsburg 1994 ManualConventional vacuumcare aspiration (suction (MVA) curretage) L&DOR Procedure:Setting: vs.

52. Moving Incomplete Abortion to Outpatient Setting Johns Hopkins Study Results  Anesthesia requirements  Overall hospital stay, from 19 6 hours  Patient waiting time by 52%  Procedure time, from 33 19 minutes  Costs per case: $1,404 in OR $827 in L&D $200 or less in ER Blumenthal 1994

53. Use Outpatient Management Cautiously in Women with… Uterine anomalies Uterine anomalies Coagulation problems Coagulation problems Active pelvic infection Active pelvic infection Extreme anxiety Extreme anxiety Any condition causing patient to be medically unstable Any condition causing patient to be medically unstable

54. What Is a Manual Vacuum Aspirator? Creinin MD, et al. Obstet Gynecol Surv. 2001.; Goldberg AB, et al. Obstet Gynecol. 2004. Hemlin J, et al. Acta Obstet Gynecol Scand. 2001. Locking valve Portable and reusable Equivalent to electric pump Efficacy same as electric vacuum (98%–99%) Semi-flexible plastic cannula

55. Comparison EVA to MVA Dean G, et al. Contraception. 2003. EVAMVA Vacuum Electric pump Manual aspirator NoiseVariableQuiet Portable Not easily Yes Cannula 4–16 mm 4–12 mm Capacity 350–1,200 cc 60 cc SuctionConstant Decreases to 80% (50 mL) as aspirator fills

56. Clinical Indications for MVA Uterine evacuation in the first trimester: Induced abortion Spontaneous abortion Incomplete medication abortion Uterine sampling Post-abortal hematometra Hemorrhage Creinin MD, et al. Obstet Gynecol Surv. 2001.; Edwards J, Creinin MD. Curr Probl Obstet Gynecol Fertil.1997.; Castleman LD et al. Contraception. 2006; MVA Label. Ipas. 2007.

57. MVA Instruments

58. Steps for Performing MVA A step-by-step poster is available from the manufacturer to guide clinicians through the procedure is in your packet - “Performing Manual Vacuum Aspiration (MVA)...”

59. Very rare Very rare Same as EVA Same as EVA May include: — Incomplete evacuation — Uterine or cervical injury — Infection — Hemorrhage — Vagal reaction May include: — Incomplete evacuation — Uterine or cervical injury — Infection — Hemorrhage — Vagal reaction Complications with MVA MVA Label. Ipas. 2004.

60. MVA vs. EVA Complication Rates Methods Vacuum aspiration for abortion up to 10 wks LMP Retrospective cohort analysis Choice of method (MVA vs. EVA) up to physician n = 1,002 for MVA; n = 724 for EVA Charts reviewed for complications Goldberg AB, et al. Obstet Gynecol. 2004. more…

61. MVA vs. EVA Complication Rates (continued) Goldberg AB, et al. Obstet Gynecol. 2004. Complications 2.5% for MVA 2.1% for EVA (p = 0.56) No significant difference more… *Elective not spontaneous studies

62. MVA vs. EVA Complication Rates (continued) Goldberg AB, et al. Obstet Gynecol. 2004. Choice of MVA vs EVA in procedures Attendings: 52% MVA Gyn residents: 59% MVA Other residents: 76% MVA (p<0.001)

63. MVA and POC: Study In group overall In group overall n = 1,726, up to 10 weeks LMP Complication rates between MVA and EVA Complication rates between MVA and EVA 37 patients at < 6 weeks’ gestation In 35 of 37, provider chose MVA No re-aspirations needed in patients < 6 weeks Goldberg AB, et al. Obstet Gynecol. 2004. more…

64. MVA and POC: Study (continued) “…Significantly more re-aspirations for inability to accurately identify the pregnancy occurred in electric group.” Goldberg AB et al. Obstet Gynecol, 2004 Goldberg AB, et al. Obstet Gynecol. 2004.

65. Early Abortion with MVA: Study Methods Methods 2,399 MVA procedures, < 6 weeks LMP Meticulous inspection of POC immediately after MVA Results Results 99.2% effective in terminating pregnancy 6 repeat aspirations (0.25%) 14 ectopic pregnancies (0.6%) diagnosed and treated Edwards J, Creinin MD. Curr Probl OIbstet Gynecol Fertil. 1997.

66. Products of Conception (POC) Edwards J, et al. Am J Obstet Gynecol. 1997. MacIsaac L, et al. Am J Obstet Gynecol. 2000. Procedure is complete when POC are identified Electric Suction Machine MVA Aspirator

67. Patient Satisfaction Both EVA and MVA groups were highly satisfied Both EVA and MVA groups were highly satisfied No differences in: No differences in:PainAnxietyBleedingAcceptabilitySatisfaction More EVA patients were bothered by noise More EVA patients were bothered by noise Bird ST, et al. Contraception. 2003.; Dean G, et al. Contraception. 2003.; Edelman A, et al. Am J Obstet Gynecol. 2001.

68. MVA Safety and Efficacy: Summary MVA is simple MVA is simple Easily incorporated into office setting Training/Practice Issues Training/Practice Issues Expanding pain management options Ultrasound as needed No sharp curettage Patient-provider interaction Instrument processing for multiple use (new guidelines)

69. Rebecca Rebecca is wanting to have an office procedure, but she is concerned about the pain. Rebecca is wanting to have an office procedure, but she is concerned about the pain. What can you tell her about pain management in the office? What can you tell her about pain management in the office?

70. MVA and Pain Pain is made worse by: FearfulnessAnxietyDepression Belanger E, et al. Pain. 1989.; Smith GM, et al. Am J Obstet Gynecol. 1979. Hansen GR, Streltzer J. Emerg Med Clin N Am. 2005.

71. Effective Pain Management Respectful, informed, and supportive staff Warm, friendly environment Gentle operative technique Women’s involvement Effective pain medications

72. Pain Management Techniques Lichtengerg ES, et al. Contraception. 2001. Good M, et al. Pain Manag Nurs. 2002. Local General or nitrous Local + IV 10% 32% 58% With addition of: Focused breathing: 76% Visualization: 31% Localized massage: 14%

73. Efficacy of Ancillary Anesthesia Importance of psychological preparation and support Importance of psychological preparation and support Music as analgesia for abortion patients receiving paracervical block Music as analgesia for abortion patients receiving paracervical block 85% who wore headphones rated pain as “0,” compared with 52% of controls Verbicaine (“Vocal Local”)/Distraction Therapy Verbicaine (“Vocal Local”)/Distraction Therapy Shapiro AG, Cohen H. Contraception. 1975. Stubblefield PG.Suppl Int J Gynecol Obstet. 1989.

74. Paracervical Block Regular Injection Deep Injection Castleman L, Mann C. 2002. Maltzer DS, et al. 1999.

75. Sharp Curettage and Pain Often requires increased dilatation Often painful More difficult to reduce anesthesia Generally not indicated Not routinely recommended after MVA Forna F, Gulmezoglu AM. Cochrane Library. 2002. WHO. 2003

76. Ultrasound and MVA Not required for MVA Used by some providers routinely Use contingent on provider preference and experience Word Health Organization. 2003.

77. Counseling for MVA Effective counseling occurs before, during, and after the procedure Prepare women for procedure-related effects Prepare women for procedure-related effects Address women’s concerns about future desired pregnancies Address women’s concerns about future desired pregnancies more… Breitbart V, Repass DC. J Am Med Womens Assoc. 2000.; Hogue CJ, et al. Epidemiol Rev. 1982; Steward FH, et al. 2004. Hyman AG, Castleman L. 2005

78. Rebecca Rebecca is scheduled for a uterine aspiration with MVA procedure during the next procedure clinic. Rebecca is scheduled for a uterine aspiration with MVA procedure during the next procedure clinic. The procedure is uncomplicated and her questions include: The procedure is uncomplicated and her questions include: Can I get pregnant right away? Am I at risk for another miscarriage?

79. Future Miscarriage Risk 20% 28% 43%

80. Counseling for MVA (continued) Picker Institute. 1999. Quality of counseling Patient satisfaction with care

81. Postmiscarriage Care Management of Early Pregnancy Loss Rhogam at time of diagnosis or surgery Rhogam at time of diagnosis or surgery Pelvic rest for 2 weeks Pelvic rest for 2 weeks No evidence for delaying conception No evidence for delaying conception Initiate contraception upon completion of procedure (even IUDs!) Initiate contraception upon completion of procedure (even IUDs!) Expect light-moderate bleeding for 2 weeks Expect light-moderate bleeding for 2 weeks Menses return after 6 weeks Menses return after 6 weeks Negative ßhCG values after 2–4 weeks Negative ßhCG values after 2–4 weeks Appropriate grief counseling Appropriate grief counseling Goldstein R, Am J Obstet. Gynecol 2002; Wyss P, J Perinat Med 1994; Grimes D, Cochrane Database Syst Rev 2000

82. When Women Should Contact Clinician Heavy bleeding with dizziness, lightheadedness Worsening pain not relieved with medication Flu-like symptoms lasting >24 hours Fever or chills Syncope Any questions

83. For more information on EPL Association of Reproductive Health Professionals (ARHP) archived webinar: Options for Early Pregnancy Loss: MVA and Medication Management Association of Reproductive Health Professionals (ARHP) archived webinar: Options for Early Pregnancy Loss: MVA and Medication Management www.arhp.org/healthcareproviders/cme/webc me/index.cfm www.arhp.org/healthcareproviders/cme/webc me/index.cfm Ipas WomanCare Kit for Miscarriage Management Ipas WomanCare Kit for Miscarriage Managementwww.ipaswomancare.com

84. ? Questions pragers@u.washington.edu deborahv@nwlink.com T hanks !