hi friends dr marta perez here welcome to my channel where you can learn everything about pregnancy and birth and pregnancy complications every friday today's episode is going to be on miscarriage management this can be a really tough topic for some people so please protect your mental health if this will be a difficult topic for you to view right now maybe come back to this video later don't forget to hit subscribe i have tons of information about pregnancy and birth in my videos and let's get started on today's episode [Music] so i really wanted to cover different options for miscarriage management often miscarriage feels like a really lonely experience because many times people haven't told anyone that they're pregnant or they may not want to share that they're having a miscarriage at all and so i hope this video can give you a lot of information that helps you feel empowered to talk with your doctor or midwife or ob gyn care provider about what's happening here's a summary of what we're going to go over in today's video the first thing i'm going to go over is what is a miscarriage and different terminologies around miscarriage because it can get confusing the main thing i'm going to cover is all of the different types of management of miscarriage so after you have a miscarriage diagnosed how is it managed because there's three main ways and then finally i'm going to go over a few precautions and a few things that i think everyone having a miscarriage should know and should talk to their physician about okay so the term miscarriage is actually a colloquial term another medical term that we use is sometimes called early pregnancy loss so early pregnancy loss is defined as any non-viable intrauterine pregnancy with either an empty gestational sac meaning no fetus is growing within the gestational sac in the uterus or a gestational sac containing an embryo or a fetus without fetal heart activity in the first 12 weeks and six days of pregnancy sometimes the word spontaneous abortion is also used abortion is any term that means a pregnancy is ending whether that is intentional because the person is seeking out seeking to end the pregnancy or spontaneous the person is not seeking it out and the pregnancy ends so abortion is a blanket term spontaneous abortion means that the pregnancy ended on its own and that can be used to describe pregnancies both in the first trimester but also in the second i'm gonna limit this whole discussion to pregnancy loss in the first trimester so anything 12 weeks and below so i mentioned the term spontaneous abortion that means any pregnancy loss that happened on its own we also in the medical field use the term missed abortion sometimes a missed abortion is where a person doesn't have any of the signs or symptoms of a miscarriage meaning bleeding or cramping but when they go in for a routine ultrasound they notice that the fetus or embryo or previously viable pregnancy is no longer growing or thriving and because they didn't have any symptoms it's called mist i like to use the term early pregnancy loss and miscarriage when i'm talking to my patients because i think it's easier for them to understand although i definitely am a fan of destigmatizing the term abortion because unfortunately that term carries a lot of stigma but it's just a medical term so early pregnancy loss is actually very common the rate is most closely linked to the age of the pregnant person so pregnancy law statistics for people in their 20s ranges from about 7 to 17 of all pregnancies end in early pregnancy loss in one's 30s the rate goes up to about 20 in there and by the time one is 40 the rate of spontaneous pregnancy loss is 40 and that's because the most common cause of pregnancy loss has to do with genetics and maternal age i like to describe it as the fetus or developing embryo just doesn't have all of the tools it needs to actually become a fetus and human there are of course other causes for pregnancy loss but that's going to be the most common one and of all pregnancy loss 80 of them happen in the first trimester so the rates of pregnancy loss go down dramatically throughout the first trimester meaning the further in the first trimester you are the lower your rate of then having a miscarriage and they also dramatically decrease once the first trimester is over the next thing i want to talk about is how we diagnose an early pregnancy loss and so i'm going to try to summarize this as best i can in an easy to understand way but basically an early pregnancy loss is diagnosed in a few different ways there are some people who when they're having an early pregnancy loss or miscarriage they start having vaginal bleeding and heavy cramping but vaginal bleeding and cramping are also completely normal in the first trimester if you want to watch my video about subchorionic hematomas i'm going to link it above and that's about bleeding in the first trimester that doesn't end up being a miscarriage so it's really hard because sometimes crampy and bleeding although it can be a sign of a miscarriage it also can be present in normal and healthy and well-developing pregnancies as well so sometimes when people have bleeding and cramping they may go to the doctor and see that a miscarriage is progressing sometimes we don't know which i'll talk about in a second the other way to diagnose a miscarriage is via ultrasound so there are a bunch of specific criteria that we use based on transvaginal ultrasonography to diagnose whether a pregnancy is progressing normally or progressing towards an early pregnancy loss and sometimes there may be clear evidence for example if you had fetal cardiac activity on one ultrasound and then the next ultrasound a week two weeks later there is no fetal cardiac activity and the fetus hasn't grown in size appropriately then that's an easy diagnosis of an early pregnancy loss however a lot of diagnoses of early pregnancy loss are not made at one particular point in time a lot of times the diagnosis is a little bit unclear because it's so early in the pregnancy that we're not sure which way it's going to go so often times you see someone at one point in time you are worried they might be having an early pregnancy loss but we can't be sure and so the recommendation might be to follow the person and get repeat either lab values from the blood of the pregnancy hormone and or with follow-up ultrasounds which might be done in a few days or usually a week in between to see if the pregnancy is progressing and in those times where we're not sure if it's early pregnancy loss or not the things we're thinking about is is this an early pregnancy loss or miscarriage is this a normal healthy pregnancy it's just early and we need to follow what happens but we're also seeing if it's some kind of abnormal pregnancy could it be an ectopic pregnancy that might be in the fallopian tube or an abnormal location could it be a molar or partial molar pregnancy which is a genetically abnormal pregnancy that is incompatible with a healthy fetus so i know that that can be really difficult especially mentally on patients when we see someone in time we say look this could be a miscarriage but we don't know yet we're just gonna have to follow you once a miscarriage is diagnosed there are three options you can choose with your provider one of the three options and discuss what's best for you but i'm going to tell you about all three the first thing to note though is for anyone who's having very heavy bleeding already has significant anemia or has any signs or symptoms of an infection in the uterus then expectant management and medical management is usually not recommended unless it's directly under a physician's care the first option is expectant management expectant management means waiting on the body to recognize that a miscarriage is going on and handle it itself given enough time most people's bodies will recognize that the pregnancy isn't progressing and cause the bleeding and cramping for a miscarriage and what do i mean by an adequate amount of time well by about eight weeks eighty percent of people will have passed the pregnancy that's a long time and that can be a long time for someone to wait if they don't want to with both medical management and expectant management it's really important to know from your doctor what to expect as the pregnancy passes so a few things i want to go over one is bleeding the bleeding can be pretty significant when passing a pregnancy at home it's normal for bleeding to be very heavy for about a few hours and then it should lighten up i tell patients and get big maxi pads if you're completely filling up two maxi pads an hour or more for two or more hours that's a reason to call your ob gyn a lot of people will be right at that limit they'll fall out two per hour for two hours and then it lightens up and that's okay if you have any other symptoms of anemia feeling faint feeling dizzy those are other reasons to call the other precaution is about pain the variety of different pain people experience with miscarriage depends on your individual body but it definitely can be very uncomfortable i give my patients warnings about the pain and when to call i also probably give them a prescription strength pain medication to take alongside tylenol and ibuprofen if they need it some people just need tylenol and ibuprofen i would say most people but it is nice if i see someone who's expecting to miscarry at home to give them some additional pain medicine medicine should they need it the next thing to note about expectant management is it does require follow-up so if you have heavy bleeding and cramping and think you've passed the pregnancy at home it is important to follow up with your doctor just to make sure that pregnancy has completely resolved the second option is medical management medical management relies on using medications to help the body recognize the miscarriage and pass the pregnancy the medical management strategies are nice because they allow the patient to not wait many weeks for the pregnancy to pass and take more definitive action but also schedule it on their own time for example when they've set up child care over a weekend and have control of that in their own home and so that's why a lot of patients choose medical management medical management traditionally is done with a medication called misoprostol it can be done via one dose so within one dose of placing misoprostol vaginally 71 of individuals will completely pass the pregnancy you can also do a follow-up dose 24 hours later the addition of the follow-up dose if there isn't heavy bleeding and cramping from the first dose results in an 80 resolution of the pregnancy in another 24 hours so you get a pretty high success rate with that two dose regimen which is pretty good for patients but really exciting is that back in 2018 a nice big study came out showing that there's higher levels of effective passing of the pregnancy lower levels of needing surgery when you add mifapristone to mesopostal that regimen you take methopreston orally and then 24 hours later you take the mesoprostol mifipristone is an anti-progesterone if your body hasn't gotten the message of the pregnancy is over it stops it from growing additionally and then the mesopostal helps with the bleeding and cramping so that has a higher efficacy and a lower need for any follow-up treatments or surgery and the same side effect profile as mesoprostol alone so i really like this regimen and i think it's the one that people should use unfortunately mythopristone's first use where it first came out and was used for was an induced abortion or a termination of pregnancy on purpose it is a really safe and effective medicine because it was used for that reason people have put up barriers to doctors being able to access it and pharmacies being able to dispense it that is solely just based on not good medical care but on stigma so unfortunately some doctors and some pharmacies don't have access to prescribing methopreston even though it's a better and safer method than mesoprostol alone that's really unfortunate we need to change that acog has been lobbying to change it and in fact some fda rules on it did loosen during the pandemic like the ability to prescribe it via telehealth and after this study came out more and more ob gyns are motivated to be able to get their patients mifapristone for miscarriage management because it's a safe and effective medicine just like i described with expectant management i gave give my patients the same bleeding pain warnings and when to call 9-1-1 if you skip that part go back and watch it and i also after medical management you do need follow-up to make sure your body has completely passed the pregnancy just like with expectant management as well all right the final management is surgical or procedural management and that is with a dnc or dilation in curettage that is a very short medical procedure done with a small suction device that removes the pregnancy tissue the advantages of this method are one it is one and done there's no waiting and there's no experiencing something at home often this procedure can be done with a variety of anesthetic options that the patient can choose between it can either be done with local blocks right in an office or ambulatory care setting i've done this before with numbing the uterus and feeling pretty moderate cramping in the office but it's for less than 10 minutes or it can be done under sedated anesthesia either in an operating room or procedure room there's a range of comfort and options about anesthesia which is nice the patient can also schedule this and know that it's going to work it is 99 effective about completely removing the pregnancy with no residual so it's really the most definitive treatment that someone can choose without any waiting or experiencing something at home and without the room for failure that the other ones have of about 20 percent it also is the option that one goes to if they fail either expectant management medical management or both like i said this is a very common procedure it's usually done with a suction device it takes less than 10 minutes and it's pretty much definitive with any procedure there's risk of infection and bleeding however these risks are pretty low and the complication rate is extremely low okay last part of the videos things i want everyone to know about miscarriage and discuss with their doctor the first thing is that even though i described three different options i do have patients who choose kind of in between options and i think that's fine for example i've had patients who i diagnose a miscarriage and they say well i'd like to see over the next two weeks if my body handles it on its own so they say expect it management for two weeks but they don't want to wait the full eight or forever to say if after two weeks my body hasn't handled it i'd like to go to a dnc so those are some of the different ways you can choose it doesn't have to be strictly one or the other once you choose one path especially expectant management if you're tired of waiting you can change course to the other path as well i also want all my patients to know what to expect with bleeding and cramping again the bleeding and cramping can be quite heavy and difficult at home and usually the worst of that time is limited to about two hours or a few hours of that and then it improves i also want them to know when to go to the er it's really important because although having a miscarriage at home has a low risk of needing medical care that risk is there and the bleeding can be quite heavy and still be safe but it can also be quite heavy and if it doesn't stop you need medical attention you need to move on to a dnc you need to maybe get a blood transfusion or be monitored for anemia so again what's normal is completely filling up two pads per hour for two hours in a row anything in excess of that like filling four pads per hour or still filling more than two pads per hour after the third hour is abnormal and that i would want to hear about that from my patients the other thing is that you should know your blood type if you have a negative blood type an rh negative blood type then depending on how early your pregnancy loss is it may be recommended that you receive a shot of rogan within 72 hours of the pregnancy loss and that is to protect against the health of future pregnancies to make sure your body doesn't become sensitized to a possible rh positive blood type in a fetus the final thing to note is that many individuals either want to access contraception at the time of their miscarriage which is a really good time to access it and to start it right away after a miscarriage or they want to know about repeat pregnancy fortunately i have a whole video on getting pregnant again after miscarriage it's linked right above watch that next if you have that question yourself i hope this was really helpful please send to friends please keep this video in your back pocket pregnancy loss is really common and it's really scary and lonely and hard to undergo so my belief is that knowledge is power and hopefully this video helps you or a loved one navigate pregnancy loss leave me a comment if there's other aspects of pregnancy loss that you want me to cover because this is a topic i really like covering because it feels so lonely and hard don't forget to subscribe so you don't miss any of my videos any friday and i will see you next week you