Learning Objectives and CME/Disclosure Information
This activity is intended for healthcare providers delivering care to women and their families.
After completing this activity, the participant should be better able to:
1. Define early pregnancy loss 2. State the three options for managing early pregnancy loss
Estimated time to complete activity: 0.25 hours
Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project
Disclosure of Conflicts of Interest
Postgraduate Institute for Medicine (PIM) requires faculty, planners, and others in control of educational content to disclose all their financial relationships with ineligible companies. All identified conflicts of interest (COI) are thoroughly vetted and mitigated according to PIM policy. PIM is committed to providing its learners with high quality accredited continuing education activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of an ineligible company.
The PIM planners and others have nothing to disclose. The OBG Project planners and others have nothing to disclose.
Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.
Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.
Method of Participation and Request for Credit
Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from August 7 2018 through Jan 25 2023, participants must read the learning objectives and faculty disclosures and study the educational activity.
If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.
For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.
Joint Accreditation Statement
In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
Physician Continuing Medical Education
Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Continuing Nursing Education
The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.
Designated for 0.1 contact hours of pharmacotherapy credit for Advance Practice Registered Nurses.
Early Pregnancy Loss (EPL) describes a nonviable intrauterine pregnancy identified prior to 13 weeks gestation, often a consequence of significant fetal chromosome abnormalities incompatible with life. Frequency of EPL increases with maternal age.
Limit expectant management to the first trimester
Spontaneous complete expulsion will occur in 80% of women with EPL ≤8 weeks gestation
Educate patient on moderate-to-heavy bleeding and cramping
Provide support and pain medications as needed
Ultrasound expulsion criteria
Absence of gestational sac and endometrial thickness <30 mm (common criteria)
No evidence of increased morbidity with thicker endometrium
Prior to medical management, ensure patient does not have
Misoprostol 800 micrograms vaginally
Repeat once, as needed, no earlier than 3 hours and within 7 days if no response
Consider mifepristone (if available) 200 mg orally 24 hours before misoprostol (see ‘Note’ and ‘Related ObG Topics’ below)
Mifepristone is limited by FDA restrictions
ACOG supports “improving access to mifepristone for reproductive health indications”
Counsel patient about bleeding and cramping
If soaking >2 maxipads/hour for > 2 hours, surgical intervention may be indicated
Use ultrasound to document expulsion or serial quantitative HCGs if ultrasound is unavailable
In case of failure, patient can still consider expectant management (see above) or surgical intervention
Note: Research (RCT) demonstrates the administration of 200 mg mifepristone followed by 800 micrograms misoprostol improves outcomes
83.8% of women in the mifepristone-pretreatment group vs 67.1% in the misoprostol-alone group experienced complete expulsion (see summary in ‘Related ObG Topics’, below)
Suction curettage in office or ambulatory surgery setting with local anesthesia/sedation
May be preferred treatment by women who want a faster and more controlled treatment path
ACOG recommends a single preoperative dose of doxycycline to prevent infection following surgical management
200-mg dose of doxycycline 1 hour prior to surgery (consensus and expert opinion)
Surgical intervention is management of choice in the following scenarios
Expectant, medical or surgical management to treat miscarriage are considered equivalent. Unless there is a change in clinical status (e.g. hemorrhage or infection), patient preference can guide decision making.
Risk of serious complications after treatment of EPL are rare, and comparable for all three treatment types
Medical management compared to expectant management
Increases time to complete expulsion
Does not increase need for surgical intervention
Medical management with misoprostol appears to be the most cost-effective treatment of EPL
Women should avoid intercourse for 1-2 weeks after passage of pregnancy tissue is complete
Risk and dosage for women undergoing EPL
Risk is low
‘Consider’ for women undergoing EPL, especially later in first trimester
If given, administer ‘at least’ 50 micrograms Rh(D)-immune globulin within 72 hours
Note: In the case of medical management, the ACOG Guideline states that “Women who are Rh(D) negative and unsensitized should receive Rh(D)-immune globulin within 72 hours of the first misoprostol administration”
Higher risk of alloimmunization
Patients ‘should receive’ at least 50 micrograms Rh(D)-immune globulin
OBG Project CME requires a modern web browser (Internet Explorer 10+, Mozilla Firefox, Apple Safari, Google Chrome, Microsoft Edge). Certain educational activities may require additional software to view multimedia, presentation, or printable versions of their content. These activities will be marked as such and will provide links to the required software. That software may be: Adobe Flash, Apple QuickTime, Adobe Acrobat, Microsoft PowerPoint, Windows Media Player, or Real Networks Real One Player.
Disclosure of Unlabeled Use
This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.
The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.
Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.
Jointly provided by
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