Management of spontaneous miscarriage

MANAGEMENT OF SPONTANEOUS MISCARRIAGE
Adapted for Pakistan from the Green top RCOG guideline No: 20a, 2006 By the Guideline Committee of SOGP through consensus & literature review 1. Purpose and Scope
Clinical guidelines have been developed to assist clinicians and patients in making decisions about appropriate management of miscarriages. Here we will mainly address the spontaneous miscarriage, which is defined‟ as pregnancy loss with in first 2. Background
Miscarriage is usually a distressing experience. Emotional support and care is essential throughout the course of assessment, decision-making and treatment .In Pakistan out of every 100 women 14 ends up in miscarriage 1, it has been estimated that about one million miscarriages occur per year.36.81% of miscarriage are conducted by unskilled traditional birth attendants (TBA).2 Complications of miscarriages account for 12.5 % of maternal deaths.5 Although surgical curettage has been the standard care for more than 50 years, there is now good evidence that expectant and/or medical management can be appropriate for some women. Care should include information and advice about options which are medically appropriate for each woman‟s particular situation and support in decision Page 1 of 11
3. Service provision
Dedicated out patient “Abortion care services” should be included in the existing frame of health care system with training of the same staff in the diagnosis and management 4. Definition of terms
4.1 Early pregnancy loss: gestation up to 13 weeks and 6 days.
4.2 RPOC: Retained products of conception.
4.3 Miscarriage: The recommended medical term for pregnancy loss less than 20
weeks is 'miscarriage' in both professional and direct care contexts. The term „abortion‟ should not be used. Types of miscarriages are outlined below. 5. Clinical presentation and diagnosis
Diagnosis of miscarriage is based on confirmed passage of RPOCs or ultrasound 5.1 Missed miscarriage: This includes „early fetal demise‟ and „blighted ovum‟.
Criteria for miscarriage diagnosis are: vaginal u//s showing no fetal heart activity with fetal pole >6mm or gestational sac >20mm without fetal pole or lack of sac/ fetal 5.2 Incomplete miscarriage: Some product of conception remained in the uterus.
There is a history of pregnancy symptoms followed by an episode of heavy bleeding with passage of clots. If RPOCs are passed vaginally, management may be based on 5.3 Complete miscarriage: clinical assessment and/or previous ultrasound
examination have confirmed intrauterine pregnancy and all the product of conception 5.4 Hydatidiform mole is usually diagnosed by ultrasound examination or histology.
Treatments include suction evacuation and then follow up with serial beta HCG. Page 2 of 11
5.5 Septic miscarriage: Any type of miscarriage accompanied by evidence of
intrauterine infection; urgent treatment is required 6. Investigations
 Blood group and Rh factor.  Complete blood count  Hepatitis B and C screening  Transvaginal ultrasound  High vaginal swab and blood cultures in septic miscarriage. 6.1 Role of ultra sound, serum beta HCG and progesterone levels
Ultrasound, serial beta HCG levels and serum progesterone are not considered to be essential pre requisites of abortion in all cases but services must have an access. 7. Management Modalities
 Surgery
 Medication
 Expectant
7.1 Selecting an appropriate management method.
a. Clinical symptoms/signs
 Active pain and/bleeding usually warrant surgery regardless of type of miscarriage.  Signs suggestive of intrauterine infection such as uterine tenderness or purulent discharge indicate prompt evacuation after broad spectrum antibiotic cover. b. Type of Miscarriages
 Missed miscarriage  Incomplete miscarriage.  Complete miscarriage.  Septic miscarriage. Page 3 of 11
8. Treatment options according to the size of sac
With increasing sac size there is a tendency to shift the recommendation from expectant to medication to surgical management. Sac or RPOCs <15mm
Expectant management
RPOCs>50mm, Usually surgical management Usually medical or sometimes surgical management Usually surgical management, sometimes repeat medication required 9. Expectant management:
9.1 Indications;
 Incomplete miscarriage with sac diameter on US <15mm  Incomplete miscarriage with RPOCs diameter, up to around 35mm (some  Missed miscarriage with sac size up to around 35mm (embryo size 9.2 Treatment schedule;
 Explain treatment to the woman (and partner)  Provide written information and counsel the couple  Provide contact numbers / appointments for support services  Contact the doctor if concerns regarding pain, signs of infection or bleeding. Page 4 of 11
9.3 Preconditions:
 No active bleeding or infection  Woman‟s preference  Counsel woman regarding pain and bleeding at home  She should have contact details/plan for emergency care  Well Compliant for follow up 9.4 Advantages:
 Spontaneous passage of products of conception  Avoids surgical and anesthetic risks.  Cost effective  No need of Hospitalization 9.5 Disadvantages:
 Unpredictable time frame (may take 2/52 for spontaneous resolution)  May have ongoing pain and bleeding  May require surgical treatment.  Risk of Sepsis 9.6 Anticipated outcome
 RCTs have quoted a success rate between 16-80% with expectant management for up to 6 weeks; selection criteria and management  Allow 2 weeks for resolution  Incomplete Miscarriage  RPOC are <50mm Page 5 of 11
9.7 Follow up and monitoring
 Consider rescanning in 1-2 weeks if required.  Surgical intervention is required if: Woman becomes symptomatic, woman changes her mind, and wants to have surgical management or tissue becomes infected. 9.8 Prevention of Infective Complication
Miscarriage care should encompass a strategy for minimizing the risk of post- abortion infective morbidity. As a minimum services should offer antibiotic The following regimens are suitable for peri-abortion prophylaxis  Tab Metronidazole 400mg three times daily plus  Doxycycline 100mg twice daily For 7 days commencing on the day of 10. Medication Management
 Misoprostol, a prostaglandin analogue, is used to induce/hasten the  RCTs have quoted a success rate between 50-95% with medication management for up to 2 weeks; selection criteria and management Resolution rates are higher than expectant management, lower than 10.1 Indications:
 Missed miscarriage  Incomplete miscarriage  No contraindications to prostaglandins such as allergy, severe uncontrolled Page 6 of 11
10.2 Advantages:
Allows women to avoid surgical and anesthetic risks 10.3 Disadvantages:
 Unpredictable time frame (allow up to 2-5 weeks for spontaneous  Concerns with on going pain and bleeding  Potential for requiring an emergency suction curettage (1%)  Potential side effects: Nausea, vomiting, diarrhea (up to 40%). 10.4 Preconditions:
 No active bleeding or infection  Woman‟s preference  Ensure woman aware of excessive pain and bleeding at home  Have contact details/plan for emergency care  Aware of uncertain time frame and possible need for later/urgent  Support at home  Access to phone and medical care  Well Compliant for follow up. 10.5 Treatment regimen:
 Misoprostol 800mcg PV followed by a repeat dose of 400mcg in 4 hours  Admit to ward for observation for a total of 6 hours  Allow to eat and drink  Prescribe analgesia and anti-emetics (paracetamol 4 hourly Diclofenac 50mg once only, narcotic and metoclopramide as needed).  400 micro grams misoprostol 4 hourly had 68 percent success rate in 10  200 micro grams sublingual misoprostol 4 hourly had no extra advantage to the same dosage of vaginal misoprostol rather nausea and abdominal cramps are increased by the former method.4  No statistical difference was noted in using vaginal versus combined Page 7 of 11
10.6 Follow up of medical management
 Ultrasound examination after passage of RPOCs.  Anti-D as indicated.  Exceptions to admission: if the woman has a strong preference to be at home, if she is well supported and clearly understands what is likely to  If RPOC not passed in ward, may offer surgical management or review 11. Surgical Management (suction/surgical curettage)
11.1 Advantages.
 Allows planned procedure.  Immediate relief from symptoms.  Less blood loss and shorter duration of bleeding than expectant/ medical 11.2 Disadvantages.
 Risks of surgery i.e. uterine perforation.  Risk of anaesthesia.  Infection. 11.3 When to do surgical curettage
 Active pain and/or bleeding and hemodynamically unstable women usually warrant surgery, regardless of type of miscarriage.  Signs suggestive of intrauterine infection.  Women‟s preference 11.4 Treatment schedule
 Contact Operation Theatre to book a time and date for surgery.  Explain treatment (including risks of surgery and anaesthetic) to the woman and partner, and provide written information. Page 8 of 11
 Explain contraceptive options including intrauterine contraceptive device (IUCD) and implanon which may be initiated with surgery.  Obtain written informed consent.  For missed miscarriages, consider oral or vaginal Misoprostol 200 micro gram 4 hours prior to surgical evacuation. The advantages of prostaglandins administration prior to surgical abortions are well established with significant reduction in dilation force, hemorrhage and cervical trauma especially if the patient is less than 18 years of age or 11.5 Surgical uterine evacuation for miscarriage should be performed using
suction curettage.
 Vacuum aspiration is considered as the method of choice for the  Reported complications includes perforation, cervical tears, intra- abdominal trauma, intrauterine adhesions and hemorrhage 12, 13 For women who are haemodynamically unstable:  Remove any RPOC from cervix.  Secure immediately I.V line and arrange blood.  Send blood for FBC and cross match 2 units.  Inform Theatre, Anesthetist, and On-call Gynaecology Consultant.  The urgency of the situation must be stressed to all concerned.  Surgery should be performed even before blood and fluid losses have NB: Tissue obtained at the time of evacuation should be sent to histology to
exclude gestational trophoblastic disease if suspicious. 11.6 On discharge after surgery
 Provide discharge card with operative findings.  Advise woman of the following:  To come back for follow-up in 2 weeks or earlier if significant bleeding /  She may take simple analgesia for pain. Page 9 of 11
12. Post abortion care
 Contraception/future pregnancy should be discussed with women before she is discharged. Intra uterine contraception device (IUCD) can be inserted immediately following a first or second trimester termination of pregnancy. Sterilization at the time of induced abortion is associated with high rates of failure and of regret on the part of women.  Non sensitized rhesus(Rh) negative women should receive anti-D immunoglobulin in the following situations; ectopic pregnancy, all miscarriages over 12 weeks of gestation ( including threatened) and all miscarriages where the uterus is evacuated( whether medically or  To avoid vaginal intercourse until bleeding stops  Provide contact numbers  Prescribe analgesia, such as paracetamol with codeine.  Advise woman to come for review at 4-6 weeks or sooner if she has any  Specialist follow up if indicated for recurrent (≥3) miscarriages or other Page 10 of 11
REFERENCES
1. National committee for maternal and neonatal health services (NMCH) MAY 2009 Khan F.M, Amina A, F-L Ahmed, NK Naeem. medical termination of first trimester 2. 2 Bdour NA Akasheh A, A Jayousi T. missed abortion; termination using single dose verses two doses of vaginal Misoprostol tablets. PJ MED SCI 23,(6 )920-923 3 AwanSA, Bakhtiar U,N Riffat, Akhter S .management of first trimester miscarriage with minimal surgical intervention. Pak armed forces med J 2008VOL 8. 4 FM Khan, Attiqua, FL Ahmed, NK Naeem. The medical management of first trimester .annals f king Edward medical 2007.13(2) 5 Najmi R. Complication attributed to illicit Abortion.J Pak assoc 1998 48(2) 42-5. 6 FawadA, NazH, KhanK, Nisa S.J Ayub med coll abbo.2008.2008.2 (4), 195-. 7 Farzana F, sheikh JanalN ,Malikn, Malik M, Javed L. Mid trimester termination of pregnancy comparison of sub lingual with vaginal misoprostol. Biomedic J2004,20(1) 8 Kamal R, Parveen F, Mazhar BS. Role of Misoprostol in vaginal verses double oro vaginal route for termination of pregnancy in mid trimester pregnancy. Ann Pak Sci 9 NadraS Naz S. Roleo. Misoprostol for therapeutic termination of pregnancy from 10-28 weeks of gestation. Jpak med assoc 2007, 57(3); 129-32. 10 Ashraf R, Gul A, Noor R, Nasim chohan.Septic induced abortion maternal mortality and morbidity.Ann king Edward med col 2004, 10 (4)346-7. 11 Ashraf M, Sheikh NH, A H Sheikh, Yusuf WA, maternal mortality; A 10 years study at lady Wallington hospital Lahore. Ann medical2001,7 (3);2087 12 J Bradly N Sikazwe J Healy. Improving abortion care in Zambia. 1991,22(6)391-4 13 LukmanHY, D Pogharian. Management of in complete abortion with manual vacuum aspiration in comparison to sharp curette in an Ethiopian setting. East Afr Med J. 1996, 14 K Rogo. Manual vacuum aspiration saves live. Plan parent 1993(1) 32-3. Page 11 of 11

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