Reproductive Health

NPWH 2018 Conference Podium Presentation Abstracts

   This issue of Women’s Healthcare: A Clinical Journal for NPs features the podium presentation abstracts that were introduced at the 21st annual NPWH conference in San Antonio in October 2018. Abstracts of the first- and second-place poster award winners and the first- and second-place student poster award winners appeared in the September 2019 issue of the journal.

My heartiest congratulations to all! Each year the NPWH conference is enriched by these podium presentations. Please take time to review the abstracts that provide state-of-the-science information about women’s health, and please consider submitting your work for 2020.

–Lorraine Byrnes, PhD, FNP-BC, PMHNP-BC, CNM (ret.), FAANP
2018 NPWH Research Committee Chair

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New evidence-based guideline for accurate HPV testing in head and neck cancers

The College of American Pathologists has released its newest evidence-based practice guideline, “Human Papillomavirus Testing in Head and Neck Carcinomas,” now available in Archives of Pathology and Laboratory Medicine. The guideline recommends accurate assessments of a patient’s high-risk HPV status, directly or by surrogate markers. Read more.

PrEP for prevention: Practice update

According to the Centers for Disease Control and Prevention (CDC), about 1.2 million persons are living with HIV in the United States, and about 20% of them are unaware of it.1 Lack of awareness of HIV status contributes to viral transmission. Healthcare providers (HCPs) play a vital role in the screening, diagnosis, and treatment of HIV infection, but they can also play an important role in HIV prevention. This article focuses on pre-exposure prophylaxis (PrEP), a safe and effective intervention that is rapidly becoming a major tool in HIV transmission prevention. The article also provides an overview of the assessment and management of patients prior to and during the use of PrEP.

The CDC estimates that 50,000 persons in the United States are newly infected with HIV every year.1 Most of the new cases involve men who have sex with men (MSM) (n = 30,689), but African-American women represent a disproportionate number of new infections (n = 5,300) when compared with white non-Hispanic women (n = 1,300) and Hispanic/Latina women (1,200).2

The birth rate among HIV-infected women has increased from 6,000-7,000 live births in 2000 to 8,700 live births in 2006, the last year reported.3 This increase in births may be related to the increased availability and use of antiretroviral medications, which significantly decrease mother-to-child transmission risk. Other factors are also in play. Study data suggest that women who are HIV positive and desire children, including those who disclose their seropositive status to their partners, may not be using condoms consistently.4,5 Little is known about birth rates in women who are HIV negative, desire children, and are in a relationship with an HIV-positive partner.

Pre exposure prophylaxis is the most recent intervention in the effort to fight the HIV epidemic. PrEP is a combination of two antiretrovirals, tenofovir disoproxil fumarate (TDF) 300 mg and emtricitabine (FTC) 200 mg, taken once daily. This treatment has been shown to reduce transmission risk by upwards of 92%.6 PrEP is available to adult men and women who are HIV negative but have an increased risk of exposure to HIV through sexual and/or injection drug use. PrEP is not approved for use in children or adolescents. Guidelines for PrEP were released in 2014 by the U.S. Public Health Service.<sup.6

Assessment

Health history
To identify and reduce their patients’ risk for contracting HIV infection, HCPs need to take a sexual history as part of primary care and specialty care services. Studies have shown that many HCPs do not ask about risky sexual behaviors and many patients do not disclose them.4,5,7 Assessment of patients’ sexual behaviors and their potential contribution to HIV risk should be part of every healthcare encounter. The 5 P’s of sexual health—partners, practices, protection from sexually transmitted infections (STIs), past history of STIs, and prevention of pregnancy—provide a framework to assess each patient.8

Many patients are not comfortable talking about their sexual practices, partners, and history. HCPs can facilitate this discussion by informing patients that they routinely take a sexual history so that they can provide appropriate sexual health care, and that all information provided is confidential. HCPs can begin by asking these questions, as recommended in the 2014 PrEP guidelines.6 In the past 6 months:

  • Have you had sex with men, women, or both?
  • How many men/women have you had sex with?
  • How many times did you have vaginal or anal sex when neither you nor your partner wore a condom?
  • How many of your sex partners were HIV-positive?
  • If you did have sex with HIV-positive partners, how many times did you have vaginal or anal sex without a condom?
  • Do you have sex with partners who do not know their HIV status?

Next, HCPs need to inquire about any past history of STIs, treatment, past or current symptoms, their partner(s)’ history of STIs, and whether they would like to be tested for HIV during this healthcare encounter. In addition, HCPs can ask patients if they have ever injected drugs not prescribed by their HCP. If the answer is yes, patients are asked whether they have shared injection or drug preparation equipment or been in a drug treatment program in the past 6 months.

If this assessment suggests that a given patient is at high risk for HIV infection, the HCP initiates a discussion about PrEP. Adult MSM who do not have acute or established HIV infection and are not in a monogamous relationship with a recently tested HIV-negative man are potential candidates if they have had anal sex with a male (receptive or insertive) without a condom and/or have had an STI diagnosed in the past 6 months. Adult men and women who are heterosexually or bisexually active who do not have acute or established HIV infection and are not in a monogamous relationship with a recently tested HIV-negative partner are potential candidates if they infrequently use condoms during sex with partner(s) of unknown HIV status who are at substantial risk for HIV infection. Any individual who is HIV negative and in an ongoing sexual relationship with an HIV-positive partner is a potential candidate. In addition, individuals who have used illicit injection drugs in the past 6 months that included sharing injection and drug preparation equipment or who have been in a drug treatment program in the past 6 months are potential candidates. If a patient found to be a potential candidate is interested in PrEP, then further evaluation is needed to determine whether this intervention is appropriate for him or her.

Physical examination and lab screening/testing
No specific physical examination is required prior to initiation of PrEP. However, HCPs should recognize and further investigate fever, rash, and cervical adenopathy as potential clinical signs of acute HIV infection. These findings are especially relevant if a patient reports having experienced viral infection symptoms such as fatigue, myalgia, headache, night sweats, and diarrhea in the prior 4 weeks.

Laboratory tests for prospective PrEP recipients include HIV testing, hepatitis B virus (HBV) screening, and renal function tests. HIV testing is done within 1 week of initiating PrEP. If the test result is positive, PrEP is not initiated because it does not provide adequate therapy for HIV; in addition, there is some concern about the development of drug resistance. If the test result is indeterminate, PrEP initiation is postponed until further testing determines HIV status.

Both TDF and FTC suppress replication of HBV as well as HIV, so the PrEP intervention may offer an additional benefit if a patient has active HBV infection. Reactivation of HBV infection may occur if PrEP is discontinued or taken inconsistently. If screening indicates that a patient is not infected by HBV or immune to it, HBV vaccination is recommended. Patients who have significantly reduced renal function should not take PrEP.

Pregnancy testing is done if indicated. Although data regarding the use of TDF/FTC in terms of fetal health and growth are limited, the FDA has approved PrEP use during pregnancy. No evidence exists of harm to fetuses exposed to TDF or FTC when used for treatment of HIV during pregnancy.6

Management

PrEP must be taken on a consistent basis for maximum prevention benefit. PrEP is safe and effective but may cause a loss of appetite, mild gastric upset, or mild headaches initially. HCPs need to counsel patients about these side effects and inform them about over-the-counter drugs that may lessen these effects. Patients are asked to contact their HCP if the side effects do not subside. PrEP reaches maximum intracellular concentrations in about 20 days; therefore, patients should be advised that effectiveness is not immediate.

All other medications that patients are taking should be reviewed. Drug interaction data are available for TDF, but not for FTC. TDF has no significant effect on oral contraceptive hormone levels. Serum concentrations of some drugs (e.g., acyclovir, valacyclovir, aminoglycosides) or of TDF may be increased when these agents are combined.6

Regardless of whether or not a patient decides to take PrEP, HCPs and patients need to discuss other ways to reduce HIV infection risk (e.g., limiting the number of sexual partners, always using a condom). For some individuals, multi-session behavioral counseling may be required. Women who have the potential to become pregnant should receive counseling and provision of contraception if they do not want to become pregnant, and pre-conception counseling if they are considering a pregnancy. Patients who report substance abuse should receive referrals for appropriate treatment.

Patients should receive information on the signs and symptoms of acute HIV infection and should be advised to contact their HCP if these occur. In addition, those patients who are taking PrEP need to know that they should not discontinue the regimen without first discussing it with their HCP.

Patients taking PrEP are seen for follow-up at least every 3 months. At these visits, HCPs need to assess them for side effects, medication adherence, and HIV risk behaviors, as well as for signs and symptoms of acute HIV infection. HIV testing is repeated at each follow-up visit. A pregnancy test is performed for women who could become pregnant, and STI tests are done as indicated. Renal function tests are conducted every 6 months.

These follow-up visits provide an important opportunity to reinforce the need for consistent medication use and to support HIV risk-reduction behaviors. Discussion about continuing PrEP should take into account personal preference, change in risk profile, and ability to adhere to the daily dosing regimen. PrEP must be discontinued if a patient’s HIV test result is positive or if renal function is significantly impaired.

Conclusion

PrEP is a safe and effective pharmacologic intervention for women and men at high risk for HIV infection. HCPs have the opportunity to improve the lives of their patients and provide preventive care in the fight against HIV.

Lorraine Byrnes is Associate Professor at Hunter Bellevue School of Nursing, Hunter College, City University of New York, in New York City. The author states that she does not have a financial interest in or other relationship with any commercial product named in this article.

Resources

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References
1. Centers for Disease Control and Prevention. CDC Vital Signs: New Hope for Stopping HIV. 2011. cdc.gov/vitalsigns/HIVtesting/index.html

2. Centers for Disease Control and Prevention. Fact Sheets: HIV/AIDS. 2013. cdc.gov/hiv/library/factsheets/index.html

3. Centers for Disease Control and Prevention. HIV among Pregnant Women, Infants, and Children. 2015. cdc.gov/hiv/
group/gender/pregnantwomen/index.html

4. Sanders LB. Sexual behaviors and practices of women living with HIV in relation to pregnancy. J Assoc Nurses AIDS Care. 2009;20(1):62-68.

5. Sullivan K, Voss J, Li D. Female disclosure of HIV-positive serostatus to sex partners: a two-city study. Womens Health. 2010;50(6):506-526.

6. Centers for Disease Control and Prevention. Pre-Exposure Prophylaxis (PrEP). 2015. cdc.gov/hiv/prevention/
research/prep

7. Bernstein KT, Liu KL, Begier EM, et al. Same sex attraction disclosure to health care providers among New York City men who have sex with men: implications for HIV testing approaches. Arch Intern Med. 2008;168(13):1458-1464.

8. Centers for Disease Control and Prevention. A Guide to Taking a Sexual History. cdc.gov/STD/treatment/
SexualHistory.pdf

Strategies for effective group prenatal care with pregnant adolescents

Managing the prenatal care of adolescents is both challenging and rewarding. Given adolescents’ developmental needs, group prenatal care (GPC) such as that modeled after Centering- Pregnancy is particularly well suited to members of this age group. The authors share their strategies for providing developmentally appropriate GPC for adolescents.

Most females receive prenatal care via a traditional model focused on screening for health-related complications. A healthcare provider (HCP) offers this care on an individual and regular basis throughout the pregnancy. At minimum, each visit involves assessment of maternal weight and blood pressure (BP), fundal height, and fetal heart rate. The initial visit is more comprehensive than subsequent visits, and includes taking a personal and family history, conducting a complete physical examination, and ordering laboratory tests. Education is provided about prenatal care and avoidance of risky behaviors. Subsequent visits include screening for problems and provision of information about nutrition, pregnancy complications, childbirth, and infant care. When indicated, special fetal assessment tests may be recommended and the need for genetic counseling discussed.1

In 1993, CenteringPregnancy (CP) was introduced as an alternative model for delivering prenatal care.2,3 The CP model provides comprehensive prenatal care to small groups of women at similar points in their pregnancies. For participants in this group prenatal care (GPC) program, learning and support are enhanced by group dynamics and by the HCP’s leadership.Compared with traditional care, CP has been associated with improved patient satisfaction, knowledge, and attendance; similar or superior maternal/newborn health outcomes; and greater affordability.4-10

The advent of the Affordable Care Act of 2010, with its provision of access to healthcare for additional millions of Americans, has created a distinct need for innovative, cost-effective, high-quality prenatal care models. GPC can be both safe and affordable, provided at convenient times for better access, and directed at meeting a group’s special needs. GPC is ideal for pregnant adolescents: Management of adolescent pregnancy in group settings has been shown to foster optimal maternal and neonatal outcomes.4-7,11,12 The authors, with many years’ experience in delivering prenatal care to adolescents using the group model, discuss their own program.

Background information on CenteringPregnancy

The authors’ adolescent GPC approach was based on principles of CP. According to Rising,developer of CP, attending prenatal sessions can result in better pregnancy outcomes, with less maternal stress, lower rates of substance abuse, improved labor progress, higher infant birth weights, and higher 5- minute Apgar scores. The CP model, which includes essential components of traditional prenatal care within a group framework, integrates three major components of prenatal care: health assessment, interactive learning, and community building.13 CP groups comprise 8-12 females at similar points in their pregnancies. After a one-onone prenatal visit with an HCP, participants attend regular group sessionslasting 1.5-2 hours, usually held in the late afternoon or early evening, for the remainder of their care. The sessions, typically led by an HCP and a nurse, meet every 4 weeks until the 28th week and then every 2 weeks until delivery.

At the start of every group session, each participant has a quick private visit with a nurse and an HCP for checks of weight, BP, fundal height, and fetal heart tones and for an opportunity to ask personal questions. During this time, the other participants chat or watch an educational video. Once individual checks are done, the group session begins. Topics discussed include nutrition, exercise and relaxation, discomforts of pregnancy, childbirth preparation, infant care and feeding, postpartum concerns, contraception, communication/self-esteem, and parenting skills. Participants are encouraged to ask questions, which can help others with similar concerns,12 and they are invited to bring a partner or a family member. Additional prenatal visits are necessary only if problems with the pregnancy arise or if a participant requires a confidential private exam.

The CP structure comprises 13 essential elements,14 which are also used in the authors’ prenatal program: (1) Health assessment occurs within the group space; (2) Women are involved in self-care activities; (3) A facilitative leadership style is used; (4) Each session has an overall plan; (5) Attention is given to the core content, but emphasis may vary; (6) There is stability of group leadership; (7) Group conduct honors the contribution of each member; (8) The group is conducted in a circle; (9) Group composition is stable but not rigid; (10) Group size is optimal to promote the process; (11) Involvement of family support is optional; (12) Opportunity for socializing within the group is provided; and (13) There is ongoing evaluation of outcomes. Primary differences between CP and traditional prenatal care are the time spent in care and the opportunity for group interaction. Traditional visits usually last 5-10 minutes, whereas CP visits are about 90 minutes long. This amount of time allows participants to grow comfortable with their HCPs and each other, which enhances discussions and learning. In addition, belonging to a group can help participants feel valued and important, and provide support during the pregnancy.12

Adolescents and group prenatal care: Literature review

Adolescence is a challenging stage of life, but when pregnancy complicates the picture, additional physical, social, and emotional stresses must be managed. Because pregnant adolescents are more likely than their non-pregnant counterparts to be in a lower socioeconomic bracket, they are less likely to receive adequate prenatal care unless it is accessible and affordable. GPC may be optimal for these individuals; not only can it be offered at convenient times and be covered by Medicaid, but it is also geared toward adolescents’ developmental level and learning needs.15,16 To ascertain  what the literature shows in terms of the usefulness of GPC for young females, especially adolescents, the authors searched the CINAHL and Medline databases for studies and systematic reviews reported from 2010 through 20115. Table 1. Selected studies on group prenatal care can be accessed here. 4 5,7,11,12,17-21

Authors’ experiences and strategies

The authors’ outpatient prenatal program was affiliated with a large urban medical center and enrolled adolescents aged 12-19 who were African American (65%), Caucasian (20%), Latino (10%), or Southeast Asian (5%). Most participants came from low-income families receiving public assistance. Initial training for the program’s staff was provided by two CP consultants during a 2-day workshop on content and process. Funding for the training came from the program’s budget; ongoing training for new staff was derived from continuing education funds and a community agency grant.

A nurse practitioner (NP), midwife, or nurse who saw prospective program participants at their intake and first obstetric visit invited  them to join the GPC program. The authors expected that all recruited adolescents would participate in the program, but they made exceptions when a patient needed individual care because of privacy concerns or a conflict with another participant. Each group was managed by an HCP (either an NP or a midwife) and a nurse. A social worker performed psychosocial evaluations and was available to address psychosocial concerns, and a nutrition specialist performed one-on-one  assessments early in the pregnancy and participated in a group discussion of prenatal nutrition and meal planning. The group meeting room accommodated 15 people and was set up to be comfortable and welcoming— similar to a setting for a baby shower. The CP model recommends that participants sit in a large circle with no table, but the authors used the existing large oval table in their space, which did not seem to affect group interactions. Educational aids available in the room included models of a bony pelvis, fetus, uterus, and dilating cervixes; posters; and a TV with a DVD player and videos to reinforce topics such as maternal nutrition, vaginal and cesarean delivery, and newborn and self-care.

The first GPC session took place when participants were at 12-16 weeks’ gestation. For scheduling purposes, the groups were referred to by their due dates (e.g., the September/October group). As with the CP program, at the start of each session, a nurse weighed each participant and checked her BP. Next, the participant lay on a small firm couch and an HCP assessed fundal height and fetal heart tones and obtained other relevant information. A curtain divider between the couch area and the group meeting area ensured privacy. During the initial group meeting, the HCP and the adolescents reviewed “Teen Rules for Group Prenatal Care” as follows:

• Be sensitive to others’ confidential information: “What is said in group stays in group.”

• Discuss who should be allowed to come to group (usually one guest who was a partner, friend, or mother figure, but no children).

• Behave politely and respectfully toward other group members (e.g., when one person is talking, others should listen).

• Do not use hand-held electronic devices during the sessions.

• Encourage everyone to be involved in discussions, and reinforce that no one should dominate or be excluded.

• Describe how group works: weight, urine sample, and fundal height measurement, followed by the education component, with the option of being seen individually after group as needed.

• Know the danger signs of pregnancy.

• Know how to contact the practice and use the after-hours oncall service for labor and emergencies.

In the authors’ program, 3-4 groups attended GPC sessions once weekly in the afternoon. Participants received phone reminders the day before the sessions; any transportation problems were resolved at this time. Although 8-10 participants were assigned to each group, only 5-6 attended regularly. Postpartum group reunions—including the infants— were scheduled to occur 4- 6 weeks after the last girl in each group had delivered. However, because of low participation, these sessions were discontinued.

At first, GPC participants kept copies of their health records. When the authors’ practice converted to an electronic health record (EHR) system, this information was stored on a laptop. Patient encounter forms were printed prior to group meetings for easy completion with billing codes and designations of return visits. GPC visits were reimbursed the same way as an individual visit. Some insurance was fee-forservice, but most patients were covered by Medicaid managed care programs that reimbursed globally. The prenatal portion was then applied to the adolescent   program budget and the delivery portion to the midwifery budget. Table 2 lists websites specific curriculum content for adolescent GPC and general information on teen pregnancy. Topics of greatest interest to participants in the authors’ program included preparation for labor and birth, pain management, bringing baby home, bottle feeding versus breastfeeding parenthood, relationships with their boyfriend, and contraception.

Table 3 lists GPC activities that the authors found particularly useful. GPC worked best when HCPs were facilitators of group activities rather than lecturers of content. The adolescents appreciate knowing what they could expect from their HCP as well as what was expected of them. HCPs reinforced the confidentiality of patient information and demonstrated respect to gain the trust and confidence that promote regular group attendance and participation. In the authors’ experience, HCPs who were seasoned clinicians, had senses of humor, were approachable, and had knowledge of community resources were best suited as GPC providers.  Group attendees completed a satisfaction survey at the last session. Over the years, the surveys demonstrated high satisfaction with the program, especially with regard to its structure, the knowledge it imparted, the relationships it fostered, and the preparation it provided for labor, delivery, and newborn care.

Discussion

Initiating a GPC model requires considerable planning and commitment. The authors learned the importance of gaining commitment to the program from everyone involved, from the clerical staff to the HCPs themselves, because they all needed to adapt to a new way of providing care. Periodic retreats were held to address the challenges that arose as the program was implemented.

The GPC program needed to be budget neutral; ensuring that reimbursement covered costs meant having at least 6-8 patients per session. Given the substantial no show rate among adolescents, the groups were intentionally overbooked. Obtaining funding for training and costs for snacks was an ongoing challenge. The program received contributions from various community organizations, and small grants were sought.

Regular planning time was essential for the administrative support staff to schedule groups, assign HCPs, write grants, and perform program evaluation. Nursing staff members took responsibility for setting up the room, providing handouts and snacks, and following up on no-shows. HCPs were busy managing traditional patients before and after groups, so a pre-group huddle was used to prepare co-leaders for the session.

The conversion to EHRs was an added challenge, particularly because laboratory test and ultrasound order entries and follow-ups became an HCP task rather than a nursing one. A laptop and Wi-Fi access were required to manage the EHR during the group sessions. The commitment of all staff to GPC and allocation of extra time were essential to successful transitioning to this system.

This GPC model encourages mutually beneficial relationships between pregnant adolescents and obstetric HCPs and provides opportunities for interdisciplinary collaboration.22,23  The authors’ program included a strong collaboration with the pediatric resident clinic, wherein GPC participants transitioned into well-child care groups that encouraged follow-up visits and immunizations. In addition, the authors had collaborative arrangements with the pediatric dental clinic and hospital social work department.

Conclusion

Given the developmental needs of adolescents, GPC provides a satisfying experience for both those who are pregnant and their HCPs.24   The authors modeled their program after CP principles for evidence-based care. 4-6,8,11 They created a supportive environment for prenatal care and helped adolescents learn the essentials about pregnancy, labor delivery, and postpartum and newborn care, with the goal of optimizing outcomes for both mother and child.

Joanne B. Stevens is Associate Professor at the University of Tampa, Department of Nursing, in Tampa, Florida. Elizabeth Cooper is Professor Emeritus in Obstetrics and Gynecology at the University of Rochester in Rochester, New York. Stasha Roberts is an alumna of the University of Tampa and an advanced registered nurse practitioner. The authors state that they do not have a financial interest in or other relationship with any commercial product named in this article.

References

1. American Academy of Pediatrics and American College of Obstetricians and Gynecologists. Guidelines for Perinatal Care. 7th ed. Elk Grove, IL: American Academy of Pediatrics; 2012.

2. Thielen K. Exploring the group prenatal care model: a critical review of the literature. J Perinat Educ. 2012; 21(4):209-218.

3. Rising SS. Centering pregnancy. An interdisciplinary model of empowerment. J Nurse Midwifery. 1998; 43(1):46-54.

4. Tanner-Smith EE, Steinka-Fry KT, Gesell SB. Comparative effective of group and individual prenatal care on gestational weight gain. Matern Child Health J. 2014; 18(7):1711-1720.

5. Picklesimer AH, Billings D, Hale N, et al. The effect of CenteringPregnancy group prenatal care on preterm birth in a low-income population. Am J Obset Gynecol.  2012;206(5):415.e1-7.

6. Kennedy HP, Farrell T, Paden R, et al. A randomized clinical trial o group prenatal care in two military settings. Mil Med. 2011;176(10):1169-1177.

7. Barr WB, Aslam S, Levin M. Evaluation of a group prenatal care-based curriculum in a family medicine residency. Fam Med. 2011;27(2):138-145.

8. Teate A, Leap N, Rising SS, Homer CS. Women’s experience of group antenatal care in Australia—the CenteringPregnancy Pilot Study. Midwifery. 2011;27(2):138-145.

9. Novick G, Sadler LS, Knafl KA, et al. The intersection of everyday life and group prenatal care for women in two urban clinics. J Health Care Poor Underserved. 2012;23(2):589-603

10. Gaudion A, Menka Y. ‘No decision about me without me’: centering pregnancy. Pract Midwife. 2010; 13(10):15-18.

11. Tandon SD, Colon L, Vega P, et al. Birth outcomes associated with receipt of group prenatal among low-income Hispanic Women. J Midwifery Womens Health. 2012;57(5):476-481.

12. Ickovics JR, Reed E, Magriples U, et al. Effects of group prenatal care on psychosocial risk in pregnancy: results from a randomised controlled study. Psychol Health.2011;26(2):235-250.

13. Rising SS. Group prenatal care. UpToDate. Last updated April 29, 2015.

14.  Rising SS. Kennedy HpP, Klima CS. Redesigning prenatal care through CenteringPregnancy. J Midwifery Womens Health. 2004;49(5):398-404.

15. Grady MA, Bloom, KC. Pregnancy  outcomes of adolescents enrolled in a CenteringPregnancy program. J Midwifery Womens Health. 2004;49(5):412-420.

16. Feldman JB. Best practice for adolescent prenatal care: application of an attachment theory perspective to enhance prenatal care and diminish birth risks. Child Adolesc Soc Work J. 2012;29(2):151-166.

17. Cypher RL. Collaborative approaches to prenatal care: strategies of successful adolescent programs. J Perinat Neonatal Nurse. 2013;27(2): 134-144.

18. Hale N, Picklesimer AH, Billings DL, Covington-Kolb S. The impact of Centering Pregnancy Prenatal Care on postpartum family planning. Am J Obstet Gynecol. 2014;210(1):50.e1-7.

19. Homer CS, Ryan C, Leap N, et al. Group versus conventional antenatal care for women. Cochrane Database Syst Rev. 2012;14(11): CD007622.

20. Novick G, Reid AE, Lewis J, et al. Group prenatal care: model fidelity and outcomes. Am J Obstet Gynecol. 2013;209(2):112.e1-6.

21. Tanner-Smith EE, Steinka-Fry KT, Lipsey MW. Effects of CenteringPregnancy group prenatal care on breastfeeding outcomes. J Midwifery Womens Health. 2013;58(4):389-395.

22. Picklesimer A, Heberlein E, Covington-Kolb S. Group prenatal care: has its time come? Clin Obstet Gynceol. 2015;58 (2): 380-391.

23. Stevens J, Iida, H. Implementing an oral health program in a group prenatal practice. J Obstet Gynceol Neonat Nurs. 2007;26(6):244-249.

24. Ellison T. Group prenatal care: a pilot study evaluating patient satisfaction. Unpublished Honor’s Senior Thesis. Department of Nursing, The State University of NY at Brockport; 2010.

Web resource

A. npwomenshealthcare.com/?p=4641

Early pregnancy loss management for nurse practitioners and midwives

Early pregnancy loss (EPL), or miscarriage, is a common phenomenon in pregnancy; up to 30% of pregnancies result in miscarriage in women who have identified themselves as being pregnant.Various treatment modalities can be used to assist women who have experienced EPL, including expectant management, pharmacologic treatment, and vacuum aspiration. Patients should be assessed for their preferences for management of EPL based on their priorities for care. The role of the nurse practitioner or midwife in counseling women who have experienced EPL is to help them manage symptoms, resolve the passage of tissue, and cope with the emotional experience of losing a pregnancy.

Early pregnancy loss (EPL), or miscarriage—the spontaneous loss of a pregnancy before 13 weeks’ gestation1—is a devastating problem for women who lose a highly desired pregnancy. In addition to the emotional turmoil caused by the interruption of a wanted pregnancy, these women are faced with managing the physical reality of resolving a nonviable gestation. Nurse practitioners (NPs) and midwives are frequently the first providers to encounter women who have bleeding early in an already-diagnosed pregnancy. In addition to providing much needed emotional support and compassion, providers can help women and their families move through the steps of completing the process of EPL.

Most bleeding in pregnancy is the result of a disruption in the complex processes associated with implantation, including the formation of the decidua and the actual burrowing of the blastocyst into the uterine lining.2 Bleeding in the first trimester occurs in up to 40% of pregnancies; more than half of these pregnancies progress normally, with preterm delivery and low birth weight as possible outcomes.Although cervical polyps or friability, vaginal laceration, irritation, or neoplasm may also lead to bleeding in early pregnancy, the possibility of pregnancy loss or ectopic pregnancy must always be considered.3

Causes of early pregnancy loss

The three main causes of problematic bleeding leading to EPL are spontaneous abortion, ectopic pregnancy, and gestational trophoblastic disease (GTD).Ultrasound guidance and serum hCG assessment can assist in the diagnosis of ectopic pregnancy and GTD and in the assessment of pregnancy viability.3 Once ectopic pregnancy and GTD have been ruled out, the problematic bleeding can be classified as a threatened abortion, an incomplete abortion, or a complete abortion. A threatened abortion occurs when vaginal bleeding occurs in the absence of cervical dilatation; 30%-50% of women with these symptoms go on to have a complete abortion.3 An incomplete abortion is diagnosed when some fetal or embryonic tissue remains in the uterus. A complete abortion reflects the passage of all pregnancy tissue.

Management of early pregnancy loss

The focus of EPL management is on meeting the needs of each individual woman. After establishing that the patient is clinically stable, the provider should offer appropriate emotional support; regardless of whether or not the pregnancy was planned, the woman is experiencing the loss of the pregnancy and maybe a change in her sense of self. The provider should establish the meaning of the pregnancy for the woman, and recognize that her management options for resolving the EPL should be guided by her medical needs and by her self-identified needs and preferences.

One way to assess the needs and preferences of a woman experiencing an EPL is to ask her these questions: What are your priorities related to the timing and cost of the process? What is your previous experience with miscarriage and/or abortion? How do you feel about taking medications or undergoing a procedure, either in the office or the hospital? How do you assess your own ability to manage the pain and bleeding that you will experience?4 Her responses to these questions can guide the provider in helping her choose how to resolve the EPL.

Early pregnancy loss can be resolved in one of three ways: expectant management (watchful waiting); medication management to complete the process of uterine evacuation; or an aspiration procedure to empty the uterus, either in an inpatient or outpatient setting.Each approach has benefits and minimal risks. These approaches vary slightly in terms of efficacy, depending on how much tissue remains inside the uterus. All of these approaches are considered acceptable and should be offered to women experiencing EPL. However, if a woman presents with heavy bleeding or is medically unstable, the situation requires immediate resolution; her preference for expectant management or medication management cannot be honored because neither is a safe option.

Expectant management

In 85% of cases, EPL resolves with expectant management within 2 weeks of the first signs and symptoms (S/S) of miscarriage. Within an additional 2 weeks, 10% of the remaining cases resolve. Aspiration intervention is recommended for the resolution of pregnancies that continue after 4 weeks of bleeding.A woman who chooses expectant management must be counseled about the possibility of a prolonged period of waiting for resolution, as well as what to expect when she finally passes the pregnancy tissue. She may experience a short period of intense cramping and bleeding, followed by mild bleeding and/or spotting for up to 2 weeks. During this period of time, she needs to monitor her temperature and report any S/S that would indicate infection, such as a malodorous discharge or flu-like S/S. The provider should ascertain the woman’s ease of access to emergency resources if needed and encourage follow-up within 2 weeks of the passage of tissue to ensure that the pregnancy has been completely resolved.

Many women choose expectant management because it does not require any intervention, and can generally be experienced privately and without any increased cost or provider visits. However, they need to understand that they may see the pregnancy tissue and they may have considerable pain and bleeding with this option. In addition, they must have ready access to care if bleeding becomes excessive.

Medication management

Use of medications can enhance the speed with which the pregnancy tissue is passed. The most widely used medication for this purpose is misoprostol, a prostaglandin antagonist that has a variety of off-label obstetric and gynecologic uses in addition to its FDA-approved indication for the prevention of gastric ulcers and as part of the medication abortion regimen.Misoprostol causes cervical softening and uterine contractions that accelerate passage of the pregnancy tissue, producing the same symptoms as expectant management but within 24-48 hours of administration of the medication. Use of misoprostol to accelerate resolution of EPL is successful in about 90% of cases after two doses.7 Women should be counseled to expect the same S/S as with expectant management, but within a shorter time period. If no tissue passes, and increased bleeding does not occur, women should return for an assessment of retained products of conception. Misoprostol users should also have access to analgesics, and they should be aware of potential side effects: fever, nausea, diarrhea, and/or shaking. Over-the-counter medications can be used to treat fever and gastrointestinal side effects, and application of warm blankets can reduce shaking.

Aspiration management

An aspiration procedure may be the choice of women who prefer an expedient and closely managed process for resolution of the EPL. If ultrasound dating  shows a gestational age of less than 12 weeks 6 days, uterine evacuation can be performed in an outpatient clinic or ambulatory surgical center. In some places, aspiration procedures can be performed only in a hospital, but this approach consumes more resources and has not been shown to improve outcomes.In these circumstances, providers should counsel women about other settings in the community that offer outpatient management services and facilitate their obtaining care if they choose an outpatient procedure.

Aspiration management provides clear advantages for a woman who prefers to have a procedure that can be scheduled, has a limited impact on the amount of time before normal activities can be resumed, and during which she can receive additional pain management. Uterine evacuation with either a manual or electric vacuum procedure is highly successful but does carry minimal risks of infection, uterine perforation, cervical trauma, or damage to the endometrium.9

Resources

Various resources are available to NPs and midwives to help counsel women facing a decision about how to manage an EPL. TEAMM (Training, Education & Advocacy in Miscarriage Management), a project of the Department of Obstetrics and Gynecology at the University of Washington, provides educational materials and training for practitioners and educational materials for women about outpatient manual vacuum aspiration.10 The University of California San Francisco’s website, Innovating Education in Reproductive Health, has information about managing EPL, including a video and patient education materials for decision making following EPL.11

Conclusion

Early pregnancy loss can be a devastating experience for a woman, but the compassion and understanding of her provider can assist her in identifying the safest and most satisfying way for her to resolve her physical S/S while she is processing her emotional experience. Whether a woman chooses an inpatient or outpatient procedure, takes medication, or elects to wait for the natural course of miscarriage to occur, reviewing all the possibilities for resolution is an important part of the NP’s or midwife’s responsibility in caring for women who are undergoing an EPL.

Amy J. Levi is the Leah L. Albers Professor of Midwifery at the University of New Mexico in Albuquerque. Tara Cardinal is a Consultant at Training, Education and Advocacy in Miscarriage Management in Seattle, Washington. The authors state that they do not have a financial interest in or other relationship with any commercial product named in this article.

References

1. Wang X, Chen C, Wang L, et al. Conception, early pregnancy loss, and time to clinical pregnancy: a populationbased prospective study. Fertil Steril. 2003;79(3):577-584.

2. Lykke JA, Dideriksen KL, Lidegaard O, Langhoff-Roos J. First-trimester vaginal bleeding and complications later in pregnancy. Obstet Gynecol. 2010;115(5):935-944.

3. Isoardi K. Review article: the use of pelvic examination with the emergency department in the assessment of early pregnancy bleeding. Emerg Med Australas. 2009;21(6):440-448.

4. Wallace RR, Goodman S, Freedman LR, et al. Counseling women with early pregnancy failure: utilizing evidence, preserving preference. Patient Educ Couns. 2010;81(3):454-461.

5. Nanda K, Lopez LM, Grimes DA, et al. Expectant care versus surgical treatment for miscarriage. Cochrane Database Syst Rev. 2012;3:CD003518.

6. Webber K, Grivell RM. Cervical ripening before first trimester surgical evacuation for non-viable pregnancy. Cochrane Database Syst Rev. 2015;11:CD009954.

7. Hasan R, Bhal K, Joseph B. The need for repeat evacuation of retained products of conception: how common is it? Obstet Gynaecol. 2013;33(1):75-76.

8. Dalton VK, Harris L, Weisman C, et al. Patient preferences, satisfaction, and resource use in office evacuation of early pregnancy failure. Obstet Gynecol. 2006;108(1):103-109.

9. Jurkovic D, Overton C, Bender-Atik R. Diagnosis and management of first trimester miscarriage. BMJ. 2013;346:f3696.

10. TEAMM Training, Education & Advocacy in Miscarriage Management. 2016.

11. Innovating Education in Reproductive Health. Early Pregnancy Loss.