Patients case:

CC: “ Abdominal pain and vaginal bleed x 4 days”

HPI

21 y/o G2P1001, LMP reported last weeks of 10/2019 (exact date unknown), presents to the ED with c/o lower abdominal pain and vaginal bleed x 4 days. Pt states this is her third visit to the ED, since 11/13/2019. Her first visit was here at QHC ED (11/13/2019) during which she was evaluated for the same complaint. Her BHCG on 11/13/2019 was 4,228 and ultrasound showed Intrauterine gestational sac without yolk sac and fetal pole. Her second visit was to NYHQ ED where she was once again evaluated for similar complaint. At the time she was discharged with a diagnosis of a threatened abortion. Today she c/o worsening pain and increase in bleeding (uses about 7 pads today). She states she passed large clots of blood from her vagina earlier today but did not witness passing of any tissue like substance. Denies any trauma, fever, chills, urinary symptoms, CP, SOB, dizziness, palpitations, headaches, visual disturbances.

PE:

Pelvic Exam: – cervix multiparous, 1cm cervix dilated, moderate blood in vaginal vault; uterus 10 weeks in size- anteverted- non-tender, adnexa non-tender with no masses, no cervical motion tenderness.

Labs show decreased BHCG @ 1406

Bedside US:

Assessment:  Incomplete abortion

I found this article which explains the options available for his patient and the effectiveness, safety, risk and S/E of each option. This article helps explain the importance of counseling a patient so they can be better informed to make the best decision for themselves.

Medical treatments for incomplete miscarriage (Review)

Kim, C., Barnard, S., Neilson, J. P., Hickey, M., Vazquez, J. C., & Dou, L. (2017). Medical treatments for incomplete miscarriage. Cochrane Database of Systematic Reviews. doi:10.1002/14651858.cd007223.pub4

This is a Cochrane Review conducted to assess the effectiveness, safety, and acceptability of any medical treatment for incomplete miscarriage (before 24 weeks).

Background Information

Miscarriage:

• Is loss of a baby before the baby before 24 weeks’ gestation at which point the baby would not be able to survive outside the womb.
• Occurs in about 10% to 15% of pregnancies
• MC signs are bleeding, usually with some abdominal pain and cramping.
• The traditional management of miscarriage was surgery

Cause of miscarriage:

• Often unknown
• May be due to chromosomal abnormalities

Miscarriage may cause :

• Women to feel distressed or have feelings of emptiness, guilt, and failure.
• Emotional distress to fathers
• Traditionally, surgery (curettage or vacuum aspiration) has been the treatment used to remove any retained tissue and it is quick to perform.
• It has now been suggested that medical treatments (usually misoprostol) may be as effective and may carry less risk of infection.

Methods:

• Search for evidence in Cochrane Pregnancy and Childbirth’s Trials Register (13 May 2016) and reference lists of retrieved papers.
• Identified 24 studies involving 5577 women
• All these studies were of women at less than 13 weeks’ gestation.
• They included randomized controlled trials comparing medical treatment with expectant care or surgery, or alternative methods of medical treatment.
• Excluded quasi-randomized trials.

Summary of main results:

Misoprostol compared with expectant care (Comparison 1):

• They did not identify any differences between misoprostol and expectant care
• It should be understood that the review was underpowered to assess this comparison with only three studies involving 335 women.
• Vaginal misoprostol was the only route of administration used in these comparisons and further studies would be needed to be sure of the findings.

Misoprostol compared with surgery (Comparison 2)

• Misoprostol appeared slightly less effective than surgery, but the difference was probably not clinically relevant, with the success rate for both treatments being high.
• There was a large reduction in surgery required when misoprostol was used.
• There was more blood loss with misoprostol,
• With Misoprostol cervical damage seemed less also consider possible risk of bias in losses to follow-up.
• There was more nausea and vomiting with misoprostol (particularly oral misoprostol)
• No difference in women’s satisfaction.

Vaginal misoprostol compared with expectant care (Comparison

• They did not identify any differences between vaginal misoprostol compared with expectant care in terms of women achieving a complete miscarriage.
• There was no information about women’s views of these two forms of care.

Vaginal misoprostol compared with surgery (Comparison 4):

• There was a small reduction in women achieving a complete miscarriage with vaginal misoprostol compared with surgery.
• Vaginal misoprostol showed a success rate of between 80% to 91%.
• There was a large reduction in the use of surgery and no difference in death or serious complications.
• The mean number of days of bleeding was higher with misoprostol and there was more need for pain relief.
• There was no difference in the other outcomes assessed (blood transfusion, anemia, pelvic infection, nausea, vomiting, diarrhea).

Oral misoprostol compared with surgery (Comparison 5):

• They did not identify a difference between oral misoprostol compared with surgery in terms of women achieving a complete miscarriage.
• There was a large reduction in the use of surgery, and deaths or serious complications were not reported.
• There was less pain relief needed with oral misoprostol, but increased nausea and vomiting. There was no difference in other outcomes assessed (pelvic infection, cervical damage, diarrhea).

Vaginal plus oral misoprostol compared with surgery (Comparison 6)

• Based on one study of 80 women, we did not identify any differences for complete miscarriage (success rates from 95% to 100%), days of bleeding and pelvic infection.
• There was a reduction in the use of surgery with medical management.

Sublingual misoprostol compared with surgery (Comparison 7):

• They did not identify a difference between sublingual misoprostol compared with surgery in terms of women achieving a complete miscarriage.
• There was a reduction in the use of surgery with medical management.
• There was increased nausea and vomiting with sublingual misoprostol.

Vaginal misoprostol compared with oral misoprostol (Comparison 8):

• They did not identify a difference between vaginal misoprostol compared with oral misoprostol in terms of women achieving a complete miscarriage or in the need for additional surgical intervention.
• The incidence of diarrhea was less with vaginal misoprostol compared with the oral route, but there was no difference in other outcomes assessed (pain relief, nausea, vomiting).

Dose comparison: 600 ug oral misoprostol compared with 1200 ug oral misoprostol (Comparison 9):

• More women experienced diarrhea with the higher dose.
• Sublingual misoprostol compared with oral misoprostol (Comparison 12)
• No difference identified between the two groups.

In conclusion:

• There is no real difference in the success between misoprostol and waiting for spontaneous miscarriage (expectant care), nor between misoprostol and surgery.
• The overall success rate of treatment (misoprostol and surgery) was over 80% and sometimes as high as 99%, and one study identified no difference in subsequent fertility between methods of medication, surgery or expectant management.
• Vaginal misoprostol was compared with oral misoprostol in one study which found no difference in success, but there was an increase in the incidence of diarrhea with oral misoprostol.
• Women on the whole seemed happy with their care, whichever treatment they were given.
• The review suggests that misoprostol or waiting for spontaneous expulsion of fragments are important alternatives to surgery, but all women should be offered an informed choice.
• Further studies are clearly needed to confirm these findings and should include long term follow-up.
• There is an urgent need for studies on women who miscarry at more than 13 weeks’ gestation.