Literature:
ACOG 2018: Com Opinion Early Pregnancy Loss
Society of Family Planning Guide on Rhogam
ALSO Chapter: First Trimester Complications
Progesterone Use for Patients Experiencing Recurrent Miscarriages
The data is mixed although does suggest some benefit, particularly in patients with higher numbers of prior SABs. Per discussion with OB colleagues, the recommended treatment is Prometrium 400mg BID vaginally for patients with 2 or more miscarriages (chemical pregnancies could also be included). Recommendation to patients: start treatment 3 days after positive ovulation predictor kit, take a home pregnancy test 2 weeks later (stop progesterone if test is negative).
https://pubmed.ncbi.nlm.nih.gov/35514538/
Other useful links:
Reproductive Health Access Project: Abortion
Reproductive Hub on U-Connect (must log in with UW log in)
UConnect link for managing early pregnancy loss
Management of pt seeking care before and after abortion - Dalby 2023
RHEDI Curriculum site (including options counseling)
Family Planning/Abortion Nursing Coordination in UW Health
• Family Planning/Abortion Nursing Coordination is now available through the Early Pregnancy Assessment Clinic (EPAC).
• Providers can refer patients desiring abortion care, in need of medically indicated abortion or pregnancy options counseling.
• EPAC team facilitates access to care within UW Health and assists in referrals outside UW Health. • Pregnant patients can get guidance and comprehensive support and can self refer.
• Check the Reproductive Hub on U-Connect (must log in with UW log in) for this information Contact information: Providers only: 608-282-8275 (not for patients) General public: 608-287-2830; UWHealth.org
Management of EPL includes 3 possible options:
Expectant Management
(Patient Handout English, Patient Handout Spanish)
Medication Management
Misoprostol alone
Mifepristone + Misoprostol (see below)
(Patient Handout English, Patient Handout Spanish)
Surgical Management
Manual Vaccuum Aspiration (MVA)
D&C
**UW Health OB/GYN has an Early Pregnancy Assessment Clinic on Wednesdays, staffed by Drs. Eliza Bennett, Abigail Cutler, and Laura Jacques. This clinic also houses the Early Pregnancy Loss Tissue Disposition Program, PP included for more information.
Important info to review:
**RHAP Early Pregnancy Loss Office Management Powerpoint** Review prior to initiating use of Mifepristone in clinic
Link for RHAP information: https://www.reproductiveaccess.org/resource/medication-abortion-protocol/
Mifepristone Prescriber agreement forms:
Quick start in Epic: Use SmartSet "Medical Managment of Early Pregnancy Loss"
Use the links as pictured below with the clinic dispensed mifepristone order
(misoprostol, anti-emetics, and additional labs are within the order set)
Summary of Steps:
Labs - ensure HCG, H/H, ABO/Rh have all been obtained
Counseling - review with the patient the process of M+M meds using the above patient handouts and the consent forms
Consent - sign the UW consent form (English Consent, Spanish Consent) AND the distributor specific, GenBioPro or Danco, consent form (both attached)
Mifepristone - one tablet of mifepristone 200 mg should be dispensed to the patient while in the office. This is held in our locked medication box in the med room.
Misoprostol - prescribe four tablets of 200 mcg misoprostol (800 mcg total) for the patient to use vaginally or buccally 24 hours following mifepristone. *Use the "Medical Management of Early Pregnancy Loss" SmartSet in Epic *
Supportive meds - prescribe NSAIDS and anti-emetics to the patient *Use the "Medical Management of Early Pregnancy Loss" SmartSet in Epic *
Patient instructions - give patient the corresponding handout (accessible through above links or in the Epic SmartSet)
Documentation - Jess Dalby has the following note template that can be used to appropriately document the visit. Use: ".MISCARRIAGEMIFE" [1014872]. Ensure the NDC and lot number from each package of Mifeprex are recorded in the patient’s record.
Follow up - patient should schedule follow-up to ensure a complete passage of tissue in one of two ways: 1) repeat quantitative serum HCG level following passage of tissue (a drop of 80% by 7 days) or 2) a transvaginal ultrasound with absence of sac.
Bleeding concerns - https://www.reproductiveaccess.org/wp-content/uploads/2016/07/phone-triage-for-miscarriage-management-2016-06-20.pdf
Legal Notes:
Per the UW Health Pharmacy Manager, Mifepristone is a part of the FDA risk evaluation and mitigation strategy (REMS) program. Dr. Jessica Dalby holds the Provider Certification for dispensing mifepristone across all UW family medicine residency clinics. Therefore, she is listed as the supervising physician for all mifepristone dispenses; however, it does not mean she needs to be present for dispensing the medication at our clinic. We can dispense mifepristone when all of the above steps have been completed.