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HWN Suggests

We Can Do Better: The Mishandling of Miscarriage in Emergency Medicine

First trimester miscarriage care falls squarely within the domain of the practicing emergency physician (after that of the gynecologist). As emergency medicine providers, early pregnancy loss is our jam, so to speak. Or at least I argue that it should be considered so. These patients come to us, and we should own their care. We should understand and be comfortable explaining miscarriage and counseling these patients on the different treatments they may ultimately be offered by our OBGYN consultants, in addition to setting up appropriate follow up. But with respect to providing optimal care for these patients, do you think we’re doing a good job? More importantly, do our patients?

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Featured

  Misoprostol for Early Pregnancy Loss Management

The recommended dose of misoprostol is 800 mcgs (4 200-mcg tablets) inserted vaginally.1 Study results have demonstrated that vaginal administration is more effective than oral use of misoprostol. One dose is about 70% effective, and 2 is about 84% effective

 Misoprostol for medical treatment of missed abortion: a systematic review and network meta-analysis

Sublingual misoprostol of 600 ug or vaginal misoprostol of 800 ug may be a good choice for the first dose. The ideal dose and medication interval of misoprostol however needs to be further researched.

 POTD: OB/Miscarriage

If complete (everything came out), just follow for recurrent bleed/signs of infxn. If incomplete, inevitable, or miss, ob may do D&C or administer prostaglandins (misoprostol). If threatened, pelvic rest w/ nothing per vagina. At increased risk for preterm labor and PPROM. Should receive RhoGAM if Rh negative.

 Recent Elective Abortion

Immediate (<24 hours) complications of induced abortion include hemorrhage and pain, commonly caused by cervical laceration and uterine perforation. Delayed (24 hours – 4 weeks) complications include retained products of conception and infection.

 Rhogam Redux

As Emergency Physician’s we are classically taught that we can help to prevent HDFN by recognizing sensitizing events in Rh-negative women and subsequently providing RhoGAM. But which patients really need RhoGAM? The evidence seems to be lacking and recommendations are often inconsistent.

Previously Featured

Bleeding in Early Pregnancy and Threatened Miscarriage

Threatened Miscarriage: Definition = PV bleeding + viable IUP. Easily and rapidly diagnosed by PoCUS. Subsequent miscarriage rate 10-25%.

Clinical Concept: Managing first trimester vaginal bleeding in the ED

The majority of patients who present to the ED will be diagnosed with “threatened abortion,” which includes bleeding or cramping, a viable pregnancy, and a closed cervix. Approximately 50% of these patients will proceed to have a miscarriage.

Spontaneous Abortion

Spontaneous abortion most commonly presents with vaginal bleeding and cramping, ranging from mild to severe. However, most women with first-trimester bleeding will not undergo spontaneous abortion. Bleeding associated with spontaneous abortion often involves passage of clots or fetal tissue, and the cramping can be constant or intermittent, often worse with passage of tissue.