1st+Trimester+Bleeding

[|Miscarriage Patient Handout]: Please print and give to patient.

Outpatient SAB Management Guidelines

Purpose: To facilitate management and outpatient follow-up for miscarriage (incomplete, missed, anembryonic or threatened) at less than 10 weeks size IUP.

Inclusion Criteria:

 * Confirmed failed intrauterine pregnancy (anembryonic gestation, no FHT, open os, irregular sac, B-HCG dropping


 * 10 weeks gestation or less by sonographic size, (not by LMP)

Exclusion Criteria:

 * Suspected ectopic pregnancy (rising or plateau of HCG w/o confirmed IUP), /hydatidiform mole


 * Desired pregnancy (for threatened abortion)(HCG levels can sometimes rise erratically w/ viable IUP)


 * Severe anemia (Hgb <9)


 * Unstable patient: febrile, hypotensive, tachycardic, heavy bleeding etc.

Treatment options:
**Expectant Management:** Pain control with motrin/vicodin and follow-up in clinic. If patient amenable, majority of women will spontaneously pass POC’s (hours to weeks).

**Medication Management:** Misoprostol best studied drug for miscarriage management. About 85% success w/o needing D&C. Recommend 800mcg (Four 200mcg tablets) placed buccally at once. Patient should keep medication in cheeks for 20 minutes and then swallow. Should expect most intense cramping and bleeding within 4-6 hours of taking. Include 1 refill on prescription. Consider givingMotrin/Vicodin/Phenergan for symptom control.

**Aspiration/D&C:** Clinic based manual vacuum aspiration can be offered up to 10 weeks gestational age (by size) on Monday and Wednesday mornings in Martinez. If greater than 10 weeks, D&C in the OR should be scheduled through the GYN attending-on-call. Patients who are greater than 10 weeks or who prefer general anesthesia may be scheduled into “TAB” slots on Tuesdays and Thursdays or any free OR time. Patients may be referred to laminaria clinic or GYN clinic for pre-op laminaria, if necessary.

The patient can be treated symptomatically and/or offered misoprostol prior to coming to clinic. An MVA(manual vacuum aspiration) in the Emergency room can be the most convenient solution for the patient and should be considered if adequate staff is available. An immediate MVA in the ER or D and C in the OR are should be strongly considered if bleeding or pain is significant, a molar pregnancy is suspected, or there is significant concern for ectopic, especially if there will be delay in obtaining an outpatient procedure.

Follow-up:

 * Identify appropriate patient for outpatient management of 1st trimester bleeding (consider discussing with GYN attending on call if unsure).


 * On discharge instructions, wait list patient to the Laminaria Clinic - MTZ, to be scheduled into a clinic appointment (may be a few days).


 * Leave message with Michele Tomasulo, FNP at x 5059 with patient name, MRN, and urgency of referral.


 * Prescribe appropriate medication for pain and if giving Misoprostol.


 * Ask clerk to place on Wait List to Laminaria – MART1 (Tomasulo) at next available clinic (Monday and Wednesday morning in Martinez).


 * Labs: Rh, possible repeat bHCG. Repeat HCG not needed if D&C planned.


 * Provide patient with [|Miscarriage Patient Info] and the phone number for the advice nurse.

This page has been edited {$pagerevisions} times. The last modification was made by user:{$revisioneditor} on {$revisiondate}