EPL OPTIONS COUNSELING

Options counseling for EPL can begin by reviewing all management options, including advantages, disadvantages, and outcomes, as discussed in the Comparison Table above. Consider a shared decision making approach to counseling – after providing the relevant medical information, elicit the patient’s priorities for treatment through discussion, or use of the checklist below. Then together you can agree on a management decision that honors the patient’s preferences and values for care.

Once the patient has chosen a management method, formulate a treatment and follow-up plan. For expectant or medication management, providers can follow a protocol such as outlined in the Step-by-Step Approach below, and for aspiration management, please see Chapter 6: What to Expect after an Abortion or Miscarriage for additional guidance.

STEP BY STEP APPROACH TO EXPECTANT MANAGEMENT OR MANAGEMENT WITH MISOPROSTOL
First Visit
1. Rule out contraindications

  • Suspected ectopic pregnancy
  • Hemodynamic instability, pelvic infection
  • Caution: anemia, bleeding disorder or taking anticoagulants
  • If medication management:
  • Allergy to medications used
  • An IUD in place (remove)
2. Ultrasound if indications:

  • No definitive intrauterine EPL confirmed by previous US
  • Bleeding since last US
  • See Chapter 3 for US findings suspicious vs. diagnostic of EPL
3. Other diagnostic testing

  • Pregnancy test /serum hCG if needed (See algorithm)
  • Rh
  • Hgb / Hct (if home mgmt, heavy/ persistent bleeding or if anemia suspected)
  • STD risk assessment / testing per CDC Guidelines
4. Counseling and informed consent

  • Consider patient access to emergency services & follow-up
  • Evaluate patient’s treatment priorities and discuss the risks, benefits, and alternatives
  • Discuss expected symptoms and reasons to call for expectant and misoprostol management
  • Assess the patient’s social support, coping strategies, and emotional state, and offer support as appropriate

If >9 week embryo, discuss possible recognizable fetal tissue

5. Management / Medications

  • Offer NSAID and a mild opioid
  • Administer Rh IG if Rh negative (50mcg for EPL <13 weeks)

If patient elects medication mgmt:

  • Misoprostol (see Table above )
  • Incomplete AB 600 mcg PO
  • or 400 mcg SL
  • Other types of EPL
  • 8000 mcg PV
  • Dispense 1-2 doses with instructions to take 2nd dose if no bleeding by follow up.

If patient elects aspiration:

  • See Chapter 5 for additional guidance & follow-up.
6. Establish follow-up and instructions

  • Answer all questions, and provide 24-hour contact information for patient
  • Review plans for the follow-up visit at 7-14 days
  • Make a contraceptive plan if appropriate
Follow up visit(s) as needed
Assess for completion of miscarriage Findings consistent with completed miscarriage
  • History +/- physical
  • Serial HCG levels (in all patients without a prior confirmed IUP)
  • Serial hCG or US (in cases where Hx and physical are not consistent with a completed EPL)
History
Cramping, bleeding with or without clots or tissue (POC) with:

  • Diminishing bleeding
  • No ongoing pregnancy symptoms

Physical exam if diagnosis remains unclear

  • Uterus firm and smaller size consistent with aborted pregnancy
  • VS +/- orthostatics as clinically appropriate
Serial hCG
Decline >50% in 2 days suggests completed EPL
Ultrasound

  • Absence of previously identified gestational sac
  • Note: A thickened endometrial stripe and heterogeneous intrauterine material are typical after successful management, does not indicate failure, and without ongoing bleeding should not indicate the need for aspiration
If miscarriage not completed If miscarriage is completed
  • Clinically stable patients may continue expectant management, consider 2nd dose of misoprostol and a 2nd follow-up, or opt for aspiration. Many providers dispense a 2nd misoprostol dose, to be taken after phone follow-up if no bleeding has occurred
  • Uterine aspiration is recommended if there are signs of clinical instability or infection
  • Confirm contraceptive plans and offer emergency contraception if pregnancy is not desired
  • Patient can try to get pregnant when emotionally ready. Discuss future fertility plans and address concerns, as appropriate
  • Offer support and referral for additional counseling if needed