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.

Considering the loss of abortion protection for our sailors, marines, and their spouses

Background reading

Although the SECDEF has vowed to maintain access to reproductive rights, we have already entered a time of uncertainty. Although many states that rushed to overturn Roe v. Wade laws are not fleet concentrations, there are likely over 15,000 active duty Navy personnel in states whose trigger laws were enacted in July 2022.

Update 17-Aug-2022: DoD Q&A about post-Dobbs care

Number of active duty Navy and Marines in States that are moving to ban pregnancy termination:

  • Texas (6,164 active duty Navy personnel / 2,282 active duty Marines)
  • Mississippi (4,742 / 447)
  • Oklahoma (1,647 / 558)
  • Tennessee (1,634 / 150)
  • Missouri (233 / 1,440)
  • Louisiana (398 / 761)
  • Utah (50 / 92)
  • Kentucky (53 / 89)
  • Arkansas (10 / 109)
  • Idaho (33 / 41)
  • South Dakota (4 / 14)
  • North Dakota (2 / 14)
  • Wyoming (2 / 8)

How can Navy physicians help?

Talk to your sailors, marines, and their family about this issue! Young servicemembers may be wary of starting this discussion. So create a safe space in the exam room or clinic to discuss their concerns. Train corpsmen on women’s health. Educated HMs act as your agent, sharing insight with patients (in the clinic) and other junior servicemembers (in casual settings).

Consider how you will react to challenging logistic and potentially ethically tough situations. If you are operational, find out what kind of support the CO gives to requests for travel for abortion services so that you can better counsel your patients as to their options.

Navy Pregnancy Instructions

Know the governing instructions. Current instructions do not provide guidance on the nuances of the recent legal changes, but they are essential background. My Navy HR’s AD pregnancy page has links to the relevant documents:

Emergency Contraception Options

When possible, educate servicemembers and patients on their emergency contraceptive options BEFORE they need them!

  • Levongesterol, 1.5 mg (Plan B One Step) – Available over the counter at any military pharmacy in any state, 1 dose.  2.5% pregnancy rate if taken within 120 hours, about half that if taken within 72 hours.
  • Ulipristal, 30 mg (Ella) – Requires prescription, 1 dose.  1.3% pregnancy rate if taken within 120 hours.
  • Copper IUD – 0.1% pregnancy rate if placed within 120 hours.
  • Mirena IUD – One large NEJM study suggests similar effectiveness to copper IUD, insufficient data for CDC to recommend yet.

Connecting Patients to Resources

Several organizations can connect patients to information and funding.

Medical Termination of Pregnancy

To be clear, military physicians working in an MTF may only offer treatment to terminate a pregnancy in cases of a nonviable pregnancy, rape, or to save the mother’s life. But it is helpful to understand the most likely treatment options in early pregnancy that may be offered at outside facilities (or online).

Mifepristone and Misoprostol for Undesired Pregnancy of Unknown Location

Preventing Future Pregnancies

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 Procedures

Endometrial Biopsy

Consent Forms

Ensure Patient is Not Pregnant

Equipment List

  1. Sponge forceps (1)
  2. Nitrile exam gloves (2 pair each)
  3. Exam-room sheet (1 sheet)
  4. Chux pads (4)
  5. Speculum (3 total: 1 white, 1 green, 1 blue)
  6. Lubricant gel packet (5)
  7. Pipelle (1)
  8. Os finder (1)
  9. Formalin cup (1 cup)
  10. Foxtail swabs (at least 5 or more)
  11. Sanitary pad (1)
  12. Iodine swab sticks (3)

Procedure Note

ENDOMETRIAL BIOPSY

Procedure was discussed with the patient including indications, risks, benefits, and alternatives.  The patient opted to go forward with procedure.  Timeout completed and documented on paper chart.

After visualization of the cervix with a clean speculum the cervix was prepped with iodine swab sticks, a single tooth tenaculum was used to stabilize the cervix, then an endometrial biopsy pipelle was inserted through the cervical os.  Uterus measured _ cm on the pipelle markings.  Tenaculum removed.  Pipelle plunger was withdrawn completely and a spiral motion of the pipelle was performed to sample the endometrial lining.  A total of _ passes were performed until  adequate sampling obtained.  Pipelle removed.  Tenaculum site was hemostatic.  Minimal bleeding noted from cervical os.  Patient tolerated procedure well.  Return precautions given.

Followup per pathology results.
Posted in Procedures

IUD Removal

Consent Form

Equipment List

  1. Chux pads (3)
  2. Exam-room sheet (1 sheet)
  3. Sanitary pad (1)
  4. Speculum (1 each size)
  5. Speculum light (1)
  6. Sponge forceps (1)
  7. Cytobrush (1)
  8. Foxtail swabs (10)
  9. Surgical lubricant (2)

Procedure Note

IUD REMOVAL

Pre-procedure counseling and consent completed, all questions answered.  A timeout was performed and time  documented on paper consent form.

The speculum was inserted and the cervix was identified.  The IUD strings were identified and grasped with a sponge forceps and the IUD was removed without difficulty.  The patient tolerated the procedure well.  No complications.  IUD inspected by myself and patient, complete IUD and attached strings present.  IUD disposed of appropriately.  Standby present throughout exam: _.
Posted in Procedures

IUD Replacement

Consent Form:

Equipment List

  1. IUD device
  2. Sterile gloves (2 pair)
  3. Chux pads (3)
  4. Exam-room sheet (1 sheet)
  5. Sanitary pad (1)
  6. Pipelle (1)
  7. Os finder (1)
  8. Speculum (1 each size)
  9. Speculum light (1)
  10. Sponge forceps (1)
  11. Cytobrush (1)
  12. Curved scissors (1)
  13. Tenaculum (1)
  14. Iodine swabs (5)
  15. Foxtail swabs (10)
  16. Surgical lubricant (2)

Procedure Note

IUD REMOVAL AND INSERTION

Before the procedure began the risks and benefits were discussed, including the risk of bleeding, device failure or expulsion, device migration, uterine perforation or insertion in the uterine wall, and infection.  Patient voiced understanding and desire to proceed.  Timeout performed (time documented on paper timeout form).  

The speculum was inserted and the cervix was identified.  The IUD strings were visualized and grasped with sponge forceps.  The IUD was removed without difficulty.  

IUD inspected by myself and patient, complete IUD and attached strings present.  IUD disposed of appropriately.

Betadine was used to clean the cervix.  After cleansing, tenaculum was applied to anterior/superior cervix.  Os Finder was inserted to gently dilate the cervix, and pipelle was used to sound the depth of the uterus.  Depth measured at _ centimeters.  The intrauterine device was inserted and deployed per manufacturer instructions.  The string was cut to 3 centimeters length and a sample of the remaining string was given to the patient for later comparison.  The patient tolerated the procedure well, without significant signs or symptoms of vasovagal responses.  EBL less than _ ml.  Standby present throughout the procedure including any pre-procedure examinations: _.  

The patient was given the patient handout and card for the specific device and lot number of inserted device.  The patient agrees to return for fever, severe lower abdominal cramping, heavy bleeding, or purulent discharge.  The patient was counseled on how to check the strings herself to ensure the IUD has not been displaced, and instructed to return for a post-placement exam if desired.
Posted in Procedures

Nexplanon Replacement

Consent

Equipment List

  1. Nitrile exam gloves (1 pair)
  2. Sterile gloves (1 pair)
  3. Nexplanon
  4. 1% lidocaine with epinephrine (1 vial)
  5. Mosquito curved ridged hemostat (1)
  6. 11 Blade disposable scalpel (1)
  7. Chux pads (2)
  8. Alcohol swabs (6)
  9. 18 gauge 1.5 inch needle (1)
  10. 27 gauge 1.5 inch needle (1)
  11. 5 ml syringe (1)
  12. ChloraPrep 3mL stick (1)
  13. Steri strips (1)
  14. Sterile 2×2 gauze (6)
  15. Coban roll (1)

Procedure Note

NEXPLANON REPLACEMENT

The Nexplanon rod in place was palpated in the patient's _ arm in the appropriate position.  After informed consent was obtained, and time-out completed, the patient's left arm was prepped in a sterile fashion with a ChloraPrep swab.  Approximately 5 cc of 1% lidocaine with epinephrine was infused along the planned incision site, and below and along the palpated rod.  An incision was made, the device brought to the level of the incision. The rod was removed intact and verified by patient and physician.  Patient tolerated procedure well. Minimal bleeding throughout procedure.  Steri-Strips were placed over incision, and covered by sterile gauze and pressure dressing.  Minimal (<1 ml) blood loss during procedure.  Post procedure instructions & precautions were given, including: keep top compression dressing in place for 24 hours, then dressing can be removed but allow Steri-strips to remain in place for 3-5 days.  Keep the area clean and dry until fully healed.  Return or call the clinic if there is bleeding, pus, or increasing redness, or pain at insertion site, or fever or chills.  Patient informed that effective immediately she must use another form of birth control if pregnancy is not desired.  

The needle of the Nexplanon insertion device was inserted into the skin through the newly created incision site.  Upon insertion the needle was brought horizontal and using a tenting - advance motion the needle was advanced to its entire length.  The applicator button was depressed and Nexplanon rod remained in place after the device was removed.  The rod was palpated in place subdermally by both the physician and the patient.  Minimal bleeding.  The patient tolerated the procedure well.  A Steri-strip and gauze dressing was applied over the insertion site and a pressure dressing was applied over the area.  Post procedure instructions & precautions were given, including: keep compression dressing in place for 24 hours, then keep area clean and covered (with Band-Aid or gauze dressing) until healed, usually 3-5 days.  Return or call the clinic if there is bleeding, pus, or increasing redness, or pain at insertion site, or fever or chills, the implant comes out or you have concerns about its location, or you have a positive pregnancy test or suspect you might be pregnant.  Wallet card given.

Patient informed replacement date: _.
Posted in Procedures

Nexplanon Removal

Consent

Equipment List

  1. Nitrile exam gloves (1 pair)
  2. Sterile gloves (1 pair)
  3. 1% lidocaine with epinephrine (1 vial)
  4. Mosquito curved ridged hemostat (1)
  5. 11 Blade disposable scalpel (1)
  6. Chux Pads (2)
  7. Alcohol swabs (6)
  8. 18 gauge 1.5 inch needle (1)
  9. 27 gauge 1.5 inch needle (1)
  10. 5 ml syringe (1)
  11. ChloraPrep 3mL stick (1)
  12. Steri strips (1)
  13. Sterile 2×2 gauze (6)
  14. Coban roll (1)

Procedure Note

NEXPLANON REMOVAL

The Nexplanon rod in place was palpated in the patient's _ arm in the appropriate position.  After informed consent was obtained, and time-out completed, the patient's left arm was prepped in a sterile fashion with a ChloraPrep swab.  Approximately 3 cc of 1% lidocaine with epinephrine was infused along the planned incision site, and below the palpated rod.  An incision was made, the device brought to the level of the incision. The rod was removed intact and verified by patient and physician.  Patient tolerated procedure well. Minimal bleeding throughout procedure.  Steri-Strips were placed over incision, and covered by sterile gauze and pressure dressing.  Minimal (<1 ml) blood loss during procedure.  Post procedure instructions & precautions were given, including: keep top compression dressing in place for 24 hours, then dressing can be removed but allow Steri-strips to remain in place for 3-5 days.  Keep the area clean and dry until fully healed.  Return or call the clinic if there is bleeding, pus, or increasing redness, or pain at insertion site, or fever or chills.  Patient informed that effective immediately she must use another form of birth control if pregnancy is not desired.
Posted in Procedures

Nexplanon Insertion

Consent

Ensure Patient is Not Pregnant

Equipment List

  1. Nitrile exam gloves (1 pair)
  2. Nexplanon device (1 package)
  3. 1% Lidocaine with epinephrine (1 vial)
  4. Chux pads (2)
  5. Alcohol swabs (6)
  6. 18 Gauge 1.5 inch needle (1)
  7. 27 Gauge 1.5 inch needle (1)
  8. 5 ml Syringe (1)
  9. ChloraPrep 3 ml stick (1)
  10. Steri strips (1)
  11. Sterile 2×2 gauze (6)
  12. Coban roll (1)

Procedure Note

NEXPLANON INSERTION

After informed consent was obtained and pregnancy reasonably excluded, a time-out was completed.  The patient's _ arm was then prepped in a sterile fashion with a ChloraPrep swab.  A subdermal wheal was created at the entry point, then approximately 5 cc of 1% lidocaine with epinephrine was infused along the planned insertion path.  The needle of the Nexplanon insertion device was inserted into the skin.  Upon insertion the needle was brought horizontal and using a tenting - advance motion the needle was advanced to its entire length.  The applicator button was depressed and Nexplanon rod remained in place after the device was removed.  The rod was palpated in place subdermally by both the physician and the patient.  Minimal bleeding.  The patient tolerated the procedure well.  A Steri-strip and gauze dressing was applied over the insertion site and a pressure dressing was applied over the area.  Post procedure instructions & precautions were given, including: keep compression dressing in place for 24 hours, then keep area clean and covered (with Band-Aid or gauze dressing) until healed, usually 3-5 days.  Return or call the clinic if there is bleeding, pus, or increasing redness, or pain at insertion site, or fever or chills, the implant comes out or you have concerns about its location, or you have a positive pregnancy test or suspect you might be pregnant.  Patient instructed to use a back-up form of birth control for 7 days past insertion date.  Wallet card given.

Patient informed replacement date is three years from today.
Posted in Procedures

IUD Insertion

Consent Form:

Patient Handouts

Ensure Patient is Not Pregnant

Equipment List

  1. IUD device
  2. Sterile gloves (2 pair)
  3. Chux Pads (3)
  4. Exam-room sheet (1 sheet)
  5. Sanitary Pad (1)
  6. Pipelle (1)
  7. Os Finder (1)
  8. Speculum (1 each size)
  9. Speculum Light (1)
  10. Sponge Forceps (1)
  11. Curved Scissors (1)
  12. Tenaculum (1)
  13. Iodine swabs (5)
  14. Foxtail Swabs (10)
  15. Surgical Lubricant (2)

Procedure Note

IUD INSERTION

Before the procedure the risks and benefits were discussed, including the risk of bleeding, expulsion or migration of IUD, uterine perforation or embedding in the uterine wall, and infection.  Patient voiced understanding and desire to proceed.  Timeout performed (time documented on paper timeout form).  

The speculum was inserted and the cervix was identified.  Betadine was applied to the cervix and cervical os.  Tenaculum was applied to anterior/superior cervix.  Os Finder was inserted to gently dilate the cervix, and pipelle was used to sound the depth of the uterus.  Depth measured at _ centimeters.  The intrauterine device was inserted and deployed per manufacturer instructions.  The string was cut to 3 centimeters length and a sample of the remaining string was given to the patient for later comparison.  The patient tolerated the procedure well, without significant signs or symptoms of vasovagal responses.  EBL less than _ ml.  Standby present throughout the procedure including any pre-procedure examinations: _.  

The patient was given the patient handout and card for the specific device and lot number of inserted device.  The patient agrees to return for fever, severe lower abdominal cramping, heavy bleeding, or purulent discharge.  The patient was counseled on how to check the strings herself to ensure the IUD has not been displaced, ind instructed to return for a post-placement exam if desired.