SAN DIEGO – "It’s not your fault."
Family physicians should relay those words of assurance to patients who present to them with early pregnancy loss, according to Dr. Linda Prine.
"In busy emergency rooms, that’s rarely the kind of thing an ER doc is going to have time to sit down and discuss with the patient," said Dr. Prine, women’s health director of the Institute for Family Health in New York. "They’re trying to make a diagnosis and move the patient on. Here you often have a woman who’s already thinking about what color she’s going to paint the bedroom, or buying a baby crib, or a stroller. This feels like a tragic loss to her. It needs to be explained gently as a natural process and some time taken for understanding. Her partner also needs to hear that it wasn’t her fault or his fault. It wasn’t the sex they had, the snow she shoveled – all of the things that start to go through a woman’s mind to blame herself."
Dr. Linda Prine
Risk factors for miscarriage include advanced age or very young age, having prior miscarriages, smoking, cocaine use, and fever or infection. Contrary to myth, air travel does not cause miscarriage, she continued, and blunt abdominal trauma, contraceptive use, exercise, the human papillomavirus vaccine, previous abortions, and sexual activity are also not to blame.
Options for miscarriage include expectant management, medication management, and an aspiration procedure. "The patient should be involved in the decision making here," Dr. Prine said at the annual meeting of the American Academy of Family Physicians. "When the women are involved, their mental health outcomes are better. Family physicians are best suited to work through these events with our patients."
The potential risks of expectant management are rare but include infection, the need for emergent uterine aspiration, and bleeding or the need for blood transfusion. The benefits of expectant management include "avoiding the risks, though rare, that can happen with instrumentation such as perforation, introducing infection, or bleeding from a procedure that’s done too vigorously," she noted.
Fever with a tender uterus is a contraindication for expectant management. Incomplete abortions are more likely to have successful expectant management than are fetal demises or anembryonic pregnancies (at day 49, a success rate of 91% vs. 76% and 66%, respectively). "There’s no outside limit for how long you can wait for expectant management," Dr. Prine said. "Usually the woman is not going to want to wait for weeks and weeks, and that becomes the patient-centered limiting factor. How heavy can the bleeding get before she should start to worry about it? If she’s bleeding through two pads an hour for 2 hours back to back, she should call us, though this is rare."
For medical management of an early pregnancy loss, a common protocol involves 800 mcg misoprostol administered vaginally or buccally and repeated in 24 hours if the abortion is incomplete, with vacuum aspiration on day 8 if still incomplete. "Alternative oral regimens cause more GI side effects," Dr. Prine said. Side effects of misoprostol are bleeding, cramping, fever and/or chills, nausea and vomiting, and diarrhea. Misoprostol treatment is safest when used 10 weeks or less after an ultrasound exam confirming the pregnancy loss. "Rule out ectopic pregnancy because the medical treatment for ectopic pregnancy differs from miscarriage treatment," she said. Testing may include an ultrasound, an rh factor screen, hematocrit assessment, and measurement of the serum human chorionic gonadotropin level.
If medical management is not working, "we can repeat the misoprostol again, or she can come into the office for an aspiration procedure," Dr. Prine said.
Sample clinical protocols, patient education sheets, and other resources for providing miscarriage care can be found here.
Dr. Prine said she had no relevant financial conflicts to disclose.