| Problematic bleeding and/or cramping |
- Prolonged cramping, pain and/or bleeding
- Retained gestational sac or tissue may be seen on US; inappropriate decline in hCG
|
- Expectant management
- Repeat misoprostol
- Uterine aspiration
|
2-9%
(varies by study & GA) |
| Continuing Pregnancy |
- May have scant bleeding after medications, persistent pregnancy symptoms
- Ongoing viable intrauterine pregnancy (growing gestational sac or cardiac activity on US; rapidly rising hCG)
|
- Uterine aspiration
- Repeat misoprostol (if embryonic pole seen, expulsion occurred in 36% with and 54% without gestational cardiac activity after one dose)1
- Consider repeating misoprostol dosing until pregnancy expelled
|
≤63 d: <3.1%2,3
64-70 d:
3.6% with 1 dose, 0.4% with 2 doses2,3
71-77 d: 8.7% with 1 dose, 1.6% with 2 doses3
|
| Endometritis |
- Typical endometritis: fever (>24 hours after misoprostol), pelvic/abdominal pain, vaginal discharge with odor, uterine/adnexal tenderness
- Atypical endometritis: included here for historical importance. Etiology: Clostridium sordelii or perfringens-mediated toxic shock syndrome; can be severe or fatal.
- Occurs 2-7 days after MAB
- Symptoms: nausea, abdominal bloating, diarrhea, pain, malaise
- Signs: usually afebrile, tachycardic, hypotensive, elevated WBC
|
- May follow CDC guidelines for antibiotic therapy for PID
- Outpatient regimen: Ceftriaxone 500mg IM x1 dose + doxycycline 100mg BID x14d + metronidazole 500mg BID x14d
- Uterine aspiration if retained tissue present
- Immediate hospitalization and aggressive treatment for atypical infection
|
0.01-0.5%2
< 10 case reports by CDC4 |
| Ectopic Pregnancy |
- May be asymptomatic or present with minimal bleeding or inappropriate decline in hCG after misoprostol, persistent positive UPT
- May present with pelvic/abdominal pain, history of bleeding or spotting during the pregnancy, shoulder pain, tachycardia/hypotension.
|
- Treat or refer as appropriate
- Low threshold to have patient evaluated in the ER if suspected ectopic pregnancy
- Asymptomatic meeting criteria may be treated with methotrexate (see Access Bridge treatment protocols and/or refer to GYN)
|
0.6%
(in study of GA < 6 weeks in the U.S.)2 |
| Excessive Bleeding |
- Heavy or prolonged vaginal bleeding with associated signs or symptoms (may include Hgb drop >2 points, orthostatic hypotension, tachycardia)
- True hemorrhage is rare, but is a life-threatening emergency
- May result from retained pregnancy tissue; may present 2-5 weeks after misoprostol
|
- Medical management (misoprostol, NSAIDs)
|
|
- Uterine aspiration
- Iron supplementation
|
<1%2 |
- Blood transfusion
- Iron supplementation
|
<0.02-0.6% 2 |