Surgical Management of First Trimester Miscarriage (894)

Surgical evacuation of uterus can be offered to women with a non continuing pregnancy at ≤13 weeks gestation. 

Where clinically appropriate, offer women a choice of manual vacuum aspiration under local anaesthetic (see MVA guideline), or surgical management in an operating theatre under general anaesthetic ².

Surgical management of miscarriage (SMM) should be the first line-treatment for ²:

• persistent excessive bleeding
• haemodynamic instability
• evidence of infected retained tissue
• suspected gestational trophoblastic disease

Provide oral and written information to all women about the treatment options available and what to expect during and after the procedure ³.

The intended benefits and risks of the procedure and any extra procedures that may become necessary should be discussed. 

Written consent should be taken by a health professional familiar with the procedure.

Women who are obese, who have significant pre-existing medical conditions or who have had previous surgery must be made aware that the quoted risks for serious or frequent complications may be increased ².

If the woman wishes to avoid a pregnancy after the procedure, sensitively counsel the woman regarding contraceptive options. SMM can be an opportunity for the insertion of intrauterine contraception. If the woman wishes this, additional consent should be obtained ².

• Discuss and +/- obtain consent for Pathology ¹ and sensitive disposal of fetal remains ⁴. Ensure completion of the appropriate paperwork.
• Offer Chlamydia screening to all women. If screening is accepted, women should be instructed on how to obtain a low vaginal swab.

Anaesthetic pre-assessment should be performed to determine the patient’s suitability for a surgical procedure, and to identify risk factors. Where any increased risk factors or contraindications are identified, discussion with, or review by, the clinician / anaesthetist should be arranged as appropriate. 

Obtain baseline full blood count (FBC) and group and save (G&S). In addition, perform any other relevant investigation as indicated by patient clinical history.

Women with a BMI ≥ 30, a history of peptic ulceration or indigestion should receive prophylactic oral Omeprazole 20mg at 22.00hrs on the evening prior to surgery and repeated at 07.00hrs on the morning of surgery ^{5, 6} or as indicated by local Patient Group Directive.

• Determine change in clinical condition since pre-assessment. If, in the interim, there has been significant PV loss, consider rescan to confirm that surgical evacuation is still the most appropriate management option.
• Complete admission portion of Assessment Booklet as locally indicated.
• Administer Misoprostol 400 micrograms vaginally 3 hours prior to surgery OR sublingually 2–3 hours prior to surgery. (Refer to Appendix ‘Cervical Priming Guidance’ for caution / exclusion criteria).

Antibiotic prophylaxis should be offered using the following regimen⁷:   

• All women should be offered Metronidazole 800mg administered orally 2 hours pre-operatively.

IF

• Chlamydia NEGATIVE - no further antibiotics required.
• Chlamydia POSITIVE - Doxycycline 100mg orally 12 hourly for 7 days post-op is the first line treatment.
• Offer Azithromycin 1g orally as a single dose followed by 500mg daily for 2 days where chlamydia screening is declined, or in individuals who are allergic to or intolerant of tetracyclines ⁸.

Bleeding at the time of the procedure or shortly after can be caused by uterine atony, coagulopathy or abnormal placentation, OR by complications such as uterine perforation, cervical laceration and retained pregnancy tissue². 

If there is unexpected heavy bleeding at the time of surgery it should alert the surgeon to the possibility of gestational trophoblastic disease and in a woman with a history of caesarean section, a previously undiagnosed caesarean scar pregnancy².

Management of uterine perforation will depend on the instruments used²: 

• If a perforation occurs when using a dilator or curette then conservative management with antibiotics, observation and explanation to the patient may be appropriate.
• If larger diameter instruments or a suction curette is used, or if there is significant revealed bleeding, then laparoscopy should be performed.

• Observation of blood pressure and pulse should be monitored as per Early Warning Chart or as clinically indicated.
• Assessment of pain levels and vaginal blood loss at least 1hourly or as clinically indicated.
• Discharge may be 2 hrs post-operatively or when local Day Surgery discharge criteria are fulfilled⁹.
• Non-sensitised rhesus (Rh) negative women should receive anti-D immunoglobulin where the uterus has been surgically evacuated¹.
• Ensure patient receives appropriate discharge information. Where possible, this information should be given in written form.
• Ensure women and their families have an awareness of, and access to, appropriate support and counselling services.
• Arrange appropriate follow up based on individual needs.
• Inform all relevant primary care professionals of pregnancy outcome and management.

Introduction

Cervical priming with misoprostol (an E1 prostaglandin analogue) prior to surgical management of miscarriage (SMM) aims to reduce the possibility of injury to the uterus and cervix, and to improve the surgical ease of the procedure².

It should be noted that although cervical priming has been shown to reduce both the need for mechanical dilation and the operating time, there have been no studies confirming a reduction in cervical or uterine injury². 

Criteria

Cervical priming should be administered to all patients with a non-continuing pregnancy ≤12+0 gestation (CRL 65 mms or less), who wish surgical uterine evacuation and who have no contraindication to misoprostol administration.  

Patients with an incomplete miscarriage do not require any cervical preparation as the cervix is already dilated to a degree. 

Exclusion criteria

Severe asthma not controlled by therapy¹⁰. 

Known hypersensitivity to misoprostol or any component of the product¹¹

Caution 

• If aged >35yrs and a smoker.¹²
• In patients with a history of cerebrovascular or cardiovascular disease.¹³
• In patients with haemorrhagic conditions or on anticoagulation therapy.¹¹
• In patients with conditions that predispose them to diarrhoea, such as inflammatory bowel disease¹⁴.

Management. 

Misoprostol 400micrograms administered ^{15, 16, 17}

• vaginally 3 hours prior to surgery OR
• sublingually 2–3 hours prior to surgery

Practitioners may consider oral or vaginal cervical preparation based on individual patient circumstance. 

Women may self-administer the vaginal tablets if preferred, without compromising efficacy¹⁵.

Misoprostol administered via the sublingual route is superior to vaginal administration but is associated with more gastrointestinal adverse effects¹⁵.  

Vaginal administration: Misoprostol 400 micrograms (2 x 200 micrograms tablets) in a single dose should be placed in the posterior fornix of the cervix and allowed to dissolve. Patient should therefore be advised to lie in semi recumbent position for 30 minutes post administration. 

Sublingual administration: Misoprostol 400 micrograms (2 x 200 micrograms tablets) in a single dose should be placed in the buccal pouch and allowed to dissolve over a 15 minute period. If not dissolved within this timeframe it may be swallowed with small sip of water.

Possible short term side effects ^{14, 18} usually in the several hours following administration:  

• Abdominal cramp
• PV bleeding
• Nausea and/or vomiting (may affect the efficacy of the drug if it occurs within two hours of administration).
• Diarrhoea or constipation
• Headache
• Rash
• Malaise
• Transient chills, shivering and fever
• Dizziness

Post administration

Patient observation and assessment to ensure early identification of adverse reaction.  

Guidelines will be updated periodically to incorporate results of local audit and published literature.