Posted in Clinician Information

Misoprostol Only Protocol for Management of Early Pregnancy Loss

This protocol was useful when stationed in Sasebo, Japan, for managing missed abortions. The Japanese clinics did not have access to these medications and could only offer mechanical evacuation. Our clinic only had access to misoprostol (not mifepristone). Before you start this, it’s critical to know your backup plan in case of serious bleeding.

Credit

Adapted verbatim January 2019 from www.reproductiveaccess.org

Eligibility

Patients with a nonviable pregnancy up to 12 weeks gestational age are eligible for medical management.

Non-viable pregnancy is diagnosed by ultrasound and/or falling quantitative hCG levels. Gestational age is based on ultrasound findings rather than last menstrual period (LMP). Ectopic pregnancy must be excluded, as medical treatment for ectopic pregnancy differs from that of nonviable intrauterine pregnancy.

Exclusionary criteria include severe anemia, allergy to mifepristone or misoprostol, bleeding disorders, and liver disease.

Procedure

1. Labs:Necessary labs include Rh screen, hematocrit, and quantitative serum hCG level. If prior knowledge of Rh status is available, Rh typing need not be repeated. Serum hCG level may be deferred in patients who can follow-up with ultrasound, if the initial diagnosis was made by ultrasound. Consider gonorrhea and chlamydia screening for those at risk.

2. Counseling:Clinically stable patients should be counseled on all options for managing early pregnancy loss including expectant, medical management, and uterine aspiration. Patients who choose medical management with misoprostol alone should understand that mifepristone/misoprostol is more effective for treatment of nonviable intrauterine pregnancy.

3. Misoprostol:Prescribe or dispense four tablets of 200 mcg misoprostol (800 mcg total) for the patient to use vaginally. The patient places 800 mcg of misoprostol in the vagina at home at a convenient time. The patient should be given a second dose of 800 mcg of misoprostol in case passage of tissue does not occur with the first dose.

4. Pain medications:A prescription for ibuprofen 600 mg should be offered to the patient. Instruct the patient to take ibuprofen prior to misoprostol insertion, and then every 6 hours as needed for pain. A small supply of low-dose narcotic may also be prescribed for severe breakthrough pain.

5. Patient Instructions(see RHAP take home instructions to give to patient):

The patient should be given contact information for how to reach their provider and be provided with guidelines regarding when to call. Patients should be instructed to call for:

  • Heavy bleeding, defined as soaking through two thick maxi pads per hour for 2 hours in a row;
  • Fever or purulent vaginal discharge; or
  • Uncontrolled pelvic cramps or pain not improved with medication.
  • The patient does not need to bring products of conception back to the provider and should not be instructed to do so.

6. Follow up:Patients 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. Note: if one of these criteria has been met, no further follow-up of serum hCGs is warranted.

If no passage of tissue occurs (the patient has not bled as much as a period) within 12-24 hours of taking the misoprostol, the patient may use a second vaginal dose of 800 mcg misoprostol. If no passage of tissue occurs by 48 hours, the patient may resume expectant management or be referred for uterine aspiration.

7. Documentation:A chart note must be completed, to document the above and ensure a follow-up plan.

References

Chung TKH et al. Spontaneous abortion: a randomized, controlled trial comparing surgical evacuation with conservative management using misoprostol. Fertility and Sterility, 1999, 71(6)1054-1059. Prine LW, MacNaughton H. Office Management of Early Pregnancy Loss. American Family Physician. 2011 July 1; 84(1):75-82.

Wood SL, Brain PH. Medical management of missed abortion: A randomized clinical trial. Obstetrics and Gynecology, 2002, 99(4)563-566.

Posted in Clinician Information

Clomiphene (Clomid) to Induce Ovulation

Adapted (partially verbatim) from LexiComp.

How to take it:

50 mg once daily for 5 days. Begin on or about the fifth day of cycle if progestin-induced bleeding is scheduled or spontaneous uterine bleeding occurs prior to therapy. Therapy may be initiated at anytime in patients with no recent uterine bleeding.

Contraindications

Hypersensitivity to clomiphene citrate or any of its components; liver disease or history of liver disease; abnormal uterine bleeding; enlargement or development of ovarian cyst (not due to polycystic ovarian syndrome); uncontrolled thyroid or adrenal dysfunction; presence of an organic intracranial lesion such as pituitary tumor; pregnancy

Canadian labeling: Additional contraindications (not in the US labeling): Hormone-dependent tumors, thrombophlebitis, uterine fibroids, mental depression.

Warnings/Precautions

Concerns related to adverse effects:

  • Ovarian enlargement: May be accompanied by abdominal distention or abdominal pain and generally regresses without treatment within a few days or weeks after therapy discontinuation. If ovaries are abnormally enlarged, withhold therapy until ovaries return to pretreatment size; reduce clomiphene dose and duration of future cycles.
  • Ovarian hyperstimulation syndrome (OHSS): OHSS is a rare exaggerated response to ovulation induction therapy (Corbett 2014; Fiedler 2012). This syndrome may begin within 24 hours of treatment but may become most severe 7 to 10 days after therapy (Corbett 2014). Symptoms of mild/moderate OHSS may include abdominal distention/discomfort, diarrhea, nausea, and/or vomiting. Severe OHSS symptoms may include severe abdominal pain, anuria/oliguria, ascites, severe dyspnea, hypotension, or nausea/vomiting (intractable). Decreased creatinine clearance, hemoconcentration, hypoproteinemia, elevated liver enzymes, elevated WBC, and electrolyte imbalances may also be present (ASRM 2016; Corbett 2014; Fiedler 2012). Treatment is primarily symptomatic and includes fluid and electrolyte management, analgesics, and prevention of thromboembolic complications (ASRM 2016; SOGC-CFAS 2011).
  • Visual disturbances: Blurring or other visual symptoms can occur; symptoms may increase with higher doses or duration of therapy and in some cases may be irreversible. Patients with visual disturbances should discontinue therapy and receive prompt ophthalmic evaluation.

Disease-related concerns:

  • Ovarian cancer: Prolonged use may increase the risk of borderline or invasive ovarian cancer.
  • Polycystic ovarian syndrome (PCOS): Use with caution in patients unusually sensitive to pituitary gonadotropins (eg, PCOS); a lower dose may be necessary.
  • Uterine fibroids: Use caution in patients with uterine fibroids, may cause further enlargement.

Other warnings/precautions:

  • Appropriate use: To minimize risks, use only at the lowest effective dose for the shortest duration of therapy (especially for the first course of therapy). Women with PCOS, amenorrhea-galactorrhea syndrome, psychogenic amenorrhea, post oral contraceptive amenorrhea, and some cases of secondary amenorrhea of undetermined cause may most likely benefit from clomiphene therapy.
  • Experienced physician: Use should be supervised by physicians who are thoroughly familiar with infertility problems and their management.
  • Multiple births: May result from the use of this medication; advise patient of the potential risk of multiple births before starting the treatment.
Posted in Clinician Information

Tuberculosis Screening and Latent TB Treatment for Primary Care

Screening Recommendations for Tuberculosis in Healthcare Workers

In the May 17, 2019 MMWR, the CDC changed their recommendation on how to screen healthcare workers for TB. Here’s the short version of their recommendations:

  1. TB screening with an individual risk assessment and symptom evaluation at baseline (preplacement);
  2. TB testing with an interferon-gamma release assay (IGRA) or a tuberculin skin test (TST) for persons without documented prior TB disease or latent TB infection (LTBI);
  3. No routine serial TB testing at any interval after baseline in the absence of a known exposure or ongoing transmission;
  4. Encouragement of treatment for all health care personnel with untreated LTBI, unless treatment is contraindicated;
  5. Annual symptom screening for health care personnel with untreated LTBI;
  6. Annual TB education of all health care personnel.

Diagnosing Latent TB

If a person has a positive IGRA or TST, but has no symptoms of disease they meet criteria for Latent TB.

Treatment of Latent TB

Want to keep it simple? Treat latent tuberculosis with 4 months (120 doses) of once daily Rifampin. Dose is weight based. Adults are 10 mg/kg. Children must be age 2 years or older, their dose is 15-20 mg/kg. Rifampin (rifampicin; RIF) is formulated as 150 mg and 300 mg capsules. Max dose is 600 mg.

You can use these logs from the CDC to help the patient track their medications. CDC says that patients should be seen monthly to check for treatment-associated adverse events (systemic drug reactions, loss of appetite, vomiting, yellow eyes, tenderness of the liver, easy bruising, rash). Sounds like a good idea at least to have a telephone call with the patient each month. Don’t panic if the patient reports urine or saliva turning a reddish-orange color – it is not uncommon (although you should make sure that’s the only symptom they are experiencing).

There are great handouts and more information on the CDC website for Latent TB.

Reference:

  1. Health System Costs of Treating Latent Tuberculosis Infection With Four Months of Rifampin Versus Nine Months of Isoniazid in Different Settings, Annals of Internal Medicine