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First Trimester Bleeding and Abortion

MS-3 Case Based Series

Gretchen S. Stuart, MD, MPHTMAmy G. Bryant, MD

Jennifer H. Tang, MDFamily Planning Program, Department of Obstetrics and Gynecology

UNC-Chapel Hill

Updated November 1, 2010

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Case No. 1

• 24yo woman presents to your office with complaints of spotting dark blood for 4 days.

• First trimester bleeding:▪ Any bleeding in the first 14 weeks of pregnancy▪ Occurs in up to 25% of pregnancies▪ Multiple etiologies▪ Does not always mean pregnancy loss

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Focused History

• Last Menstrual Period

• Previous LMP

• LMP intervals

• Sexual history

• Contraception

• Sexually transmitted infection history

• Gynecological surgical history

• Other surgical history

• Obstetrics history

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• LMP – 8 wks ago• Previous LMP – 4 wks before that• LMP interval – every 4 weeks• Sexual history – one sexual partner for 2 years• Contraception – none• Sexually transmitted infection history - none• Gyn surgical history - none• Other surgical history - none• Obstetrics history – never been pregnant before

Focused History for Case no. 1

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Physical Findings for Case No. 1

• Vital Signs▪ 120/70, P80, T36.8, RR12

• General: Healthy, NAD• Abdomen: soft, nontender• Pelvic:

▪ V/V – small amount of dark blood in vaginal▪ CVX: closed▪ Uterus: 8 weeks size, non-tender▪ Adnexa: No masses, non-tender

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Most common differential diagnosis of first trimester bleeding:

• Ectopic pregnancy• Normal intrauterine pregnancy• Abnormal intrauterine pregnancy

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Diagnosis tools for early pregnancy

• Urine pregnancy test (UPT)▪ Accurate on first day of expected menses

• βhCG▪ 6-8 days after ovulation – present▪ Date of expected menses (@14 days after ovulation) –

βhCG is100 IU/L▪ Within first 30 days – βhCG doubles in 48-72 hours

▫ Important for pregnancy diagnosis prior to ultrasound diagnosis

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Diagnosis of Pregnancy by Transvaginal Ultrasound

EGA βhCG (IU/L) Visualization

5 wks >1500 Gestational sac

6 wks >5,200 Fetal pole

7 wks >17,500 Cardiac motion

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Signs of early pregnancy failure

• If ultrasound measurements are:▪ 5mm CRL and no FHR▪ 10mm Mean Sac Diameter and no yolk sac▪ 20mm Mean Sac Diameter and no fetal pole

• If change in beta=hCG is▪ <15% rise in bhcg over 48 hours▪ Gestational sac growth <2mm over 5 days▪ Gestational sac growth <3mm over 7 days

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Spontaneous Abortion (SAB)/Early Pregnancy Failure (EPF)• Language is important

▪ Abortion: termination or expulsion of a pregnancy, whether spontaneous or induced, prior to viability.

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Spontaneous Abortion (early pregnancy failure)

▪ SAB (spontaneous abortion): ▫ Usually refers to first 20 weeks▫ Abortion in the absence of an intervention▫ If fetus dies in uterus after 20wks GA

▫ (fetal demise) or stillbirth.

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Types of SAB/EPF

• Complete • Incomplete – cervix open, some tissue has passed• Inevitable: intrauterine pregnancy with cervical

dilation & vaginal bleeding. • Chemical pregnancy: +hcg but no sac formed.

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Spontaneous Abortion

• Missed: embryo never formed or demised, but uterus hasn’t expelled the sacBlighted ovum/anembryonic pregnancy: empty gestational sac, embryo never formed

• Septic: missed/incomplete abortion becomes infected

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Threatened Abortion• Definition

▪ Vaginal bleeding before the 20th week▪ Bleeding in early pregnancy with no pregnancy loss▪ 30-40% of all pregnant women▪ 25-50% will progress to spontaneous abortion▪ However – if the pregnancy is far enough along that an ultrasound

can confirm a live pregnancy then 94% will go on to deliver a live baby

• Management▪ Reassurance

▫ Pelvic rest has not been shown to improve outcome

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SAB/EPF

• Epidemiology• Etiology• Management

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SAB/EPF Epidemiology

• 80% in first 12 weeks

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SAB/EPF Epidemiology

• Epidemiology▪ 15-25% of all clinically recognized pregnancies

▪ Offer reassurance: probability of 2 consecutive miscarriages is 2.25% ▫ 85% of women will conceive and have normal

third pregnancy if with same partner

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SAB/EPF Epidemiology

• 80% occur in the first 12 weeks

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SAB/EPF Chromosomal Etiologies

• 50% due to chromosomal abnormalities▫ 50% trisomies▫ 50% triploidy, tetraploidy, X0

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50% non-Chromosomal Etiologies

▪ Maternal systemic disease▪ Infectious factors:

▫ Mycoplasma, ▫ Listeria▫ Toxoplasmosis

▪ Endocrine factors:▫ DM, hypothyroidism, “luteal phase defect” from

progesterone deficiency

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50% non-Chromosomal

▪ Abnormal placentation

▪ Anatomic considerations (fibroids, septum, bicornuate, incompetent cervix)

▪ Environmental factors▫ Smoking >20 cigarettes per day (increased 4X)▫ Alcohol >7 drinks/week (increased 4X)▫ Increasing age

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Management options

1. Uterine evacuation by suction▫ Manual▫ Electric

2. Uterine evacuation by medication

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Using MVA for treatment/completion of spontaneous abortion

• Ensures POCs are fully evacuated.• Minimal anesthesia needed.• Comfortable for women due to low noise

level.• Portable for use in physician office familiar to

the woman.• Women very satisfied with method.

MVA Label. Ipas. 2007.

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Electric Vacuum Aspirator

Creinin MD, et al. Obstet Gynecol Surv. 2001.; Goldberg AB, et al. Obstet Gynecol. 2004.; Hemlin J, et al. Acta Obstet Gynecol Scand. 2001.

Electric vacuum aspirator• Uses an electric pump or

suction machine connected via flexible tubing

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Pain management • Aspiration/vacuum

▪ Preparation▪ Music▪ Support during procedure▪ Conscious sedation▪ Paracervical block

• Medication abortion▪ NSAIDS▪ Oral narcotics and

antiemetics if necessary

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Floating chorionic villi

Tissue examination• Basin for POC• Fine-mesh kitchen strainer• Glass pyrex pie dish• Back light or enhanced light• Tools to grasp tissue and POC• Specimen containers

Source: A Clinicians Guide to Medical and Surgical Abortion; Paul M, Grimes D,

National Abortion Federation, available online Hyman AG, Castleman L. Ipas. 2005

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Comparison of EVA to MVA

Dean G, et al. Contraception. 2003.

EVA MVAVacuum Electric pump Manual aspirator

Noise Variable Quiet

Portable Not easily Yes

Anesthesia Conscious sedation and paracervical block

Capacity 350–1,200 cc 60 cc

Assistant Not necessary Helpful

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MVA and EVA Risks and preventing the risks

Complication Rate/1000 procedures Prevention

Uterine perforation 1Cervical preparationIntra-Op Ultrasound

Hemorrhage <12 wks – 0 Efficient completion of procedure

Retained products 3UltrasoundGritty textureExamine POC

Infection 2.5Prophylactic antibioticsPO doxy or IV cephalosporin

Post-abortal hematometra 1.8

N/a – unpredictableImmediate re-aspiration required

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Medication management of early pregnancy failure

• Misoprostol▪ Synthetic prostaglandin E1 analog

▪ Inexpensive

▪ Orally active

▪ Multiple effective routes of administration

▪ Can be stored safely at room temperature

▪ Effective at initiating uterine contractions

▪ Effective at inducing cervical ripening

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Regimen

• Misoprostol 800 μg vaginally• Repeat dose on day 2 or 3 if indicated• Pelvic U/S to confirm empty uterus• Consider vacuum aspiration if expulsion

incomplete

Zhang J, et al. N Engl J Med. 2005.Creinin MD, et al. Obstet Gynecol. 2006.

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Efficacy: Medication vs. Expectant Management

Misoprostol 600 μg

vaginally

Expectant management

(placebo)

Success by day 2 73.1% 13.5%

Success by day 7 88.5% 44.2%

Evacuationneeded

11.5% 55.8%

Bagratee JS, et al. Hum Reprod. 2004.

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Induced Abortion/ Pregnancy Termination

Language: • Termination• Abortion• Elective abortion• Therapeutic abortion• Interruption of

pregnancy • Definition: The removal

of a fetus or embryo from the uterus before the stage of viability

Indications• Personal choice• Medical recommendation

• PPROM, hemorrrhage, SLE, pulm HTN, etc

• Anomalous fetus• Intrauterine infection or Septic

abortion

Methods• Dependent upon gestational

age and provider abilities

Induced Abortion History

• 1821 – first abortion law enacted in Connecticut

• Following that “therapeutic abortion” allowable, definitions vague

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Induced Abortion History

• 1973 – Roe v. Wade▪ Woman’s constitutional right of privacy▪ The government cannot prohibit or interfere with

abortion without a “compelling” reason;

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Induced Abortion History

• 1976 – Hyde Amendment▪ Forbids use of federal money to pay for almost

any abortion under Medicaid

▫ 13 states reinstated Medicaid funding for abortion:

▫ Vermont, West Virginia, Hawaii, Maryland, New York and Washington

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Induced abortion

• 1/3 occur in women older than 24

• Gestational age:• 90% within first 12 weeks

▪ 50% within first 8 weeks

• Complications▪ Dependent upon gestational age▪ 7-10 weeks have lowest complication rates▪ mortality: 1/100,000▪ Complications are 3-4x higher for second-trimester than first trimester

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Induced abortion

• Methods:▪ Uterine evacuation (basically the same as

treatment of abortion however the cervix is closed)▫ Manual vacuum aspiration▫ Electric vacuum aspiration

▪ Medication▫ Mifepristone and misoprostol

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Putting Induced Abortion into Perspective…

Gold RB, Richards C. Issues Sci Technol. 1990.; Hatcher RA. Contracept Technol Update. 1998.; Mokdad AH, et al. MMWR Recomm Rep. 2003.

Incident Chance of death

Terminating pregnancy < 9 weeks 1 in 500,000

Terminating pregnancy > 20 weeks 1 in 8,000

Giving birth 1 in 7,600

Driving an automobile 1 in 5,900

Using a tampon 1 in 350,000

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Earlier Procedures Are Safer Abortions at <8 weeks = lowest risk of death

Bartlet L, et al. Obstet Gynecol. 2004.

Gestational Age

Strongest risk factor for abortion-related

mortality

61%

≤8 weeks18

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6

1

4≤8

9 to 10

11 to 12

13 to 15

16 to 20

≥21

Weeks Gestation

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Medication Abortion• Mifepristone

▪ 19-norsteroid that specifically blocks the receptors for progesterone and glucocorticosteroids

▪ Antagonizing effect blocks the relaxation effects of progesterone

▫ Results in uterine contractions

▫ Pregnancy disruption

▫ Dilation and softening of the cervix

▪ Increases the sensitivity of the uterus to prostaglandin analogs by an approximate factor of five

▪ Takes 24-48 hours for this to occur

• Misoprostol▪ Synthetic prostaglandin E1 analog▪ Inexpensive▪ Orally active▪ Multiple effective routes of

administration▪ Can be stored safely at room

temperature▪ Effective at initiating uterine

contractions▪ Effective at inducing cervical

ripening▪ Used in decreasing doses as

pregnancy advances

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First Trimester Medication Induced Abortion

Gestational age (days)

Complete abortion rate (%)

Time to expulsion (after misoprostol)

< 49 91–9749%–61%

within 4 hours

< 56 83–9587%–88%

within 24 hours

< 63 88

1. Mifepristone 200-600 mg p.o. administered in clinic

2. Misoprostol 400-800 mcg orally or buccally 24-48h later.

3. Evaluate with U/S 13-16d later to confirm completion.

WHO Task Force. BJOG. 2000.; Peyron R, et al. N Engl J Med. 1993. Spitz IM, et al. N Engl J Med. 1998; Winikoff B, et al. Am J Obstet Gynecol. 1997.

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Second Trimester Induced Abortion

• Epidemiology• Etiology• Management

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Epidemiology

• 14 weeks and above• 96% - dilation and evacuation

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Etiology

• Social indications▪ Delay in diagnosis▪ Delay in finding a provider▪ Delay in obtaining funding▪ Teenagers most likely to delay

• Fetal anomalies

Management

•Counseling•Method options

▪ Dilation and evacuation (D&E)▪ Labor Induction Abortion

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Methods

Dilation and evacuation• Anesthesia• Procedure room• Laminaria placement

required before procedure– Often 1 to 2 days prior

Labor induction abortion• Requires hospital stay• Medication administration

to initiate contractions– Misoprostol– Mifepristone

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2nd trimester induced abortioncounseling

• Discuss pain management• Informed Consent• Discuss contraception – even those with abnormal or

wanted pregnancy may not want to follow immediately with another pregnancy

• Ovulation can occur 14-21 days after a second trimester abortion; risk of pregnancy is great and must be addressed

• Lactation can occur between days 3-7 postabortion• Procedure• Follow up

Nyoboe et al 1990

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Second trimester D & E risks and preventing the risks

Complication Rate/1000 procedures Prevention

Uterine perforation 1Cervical preparationIntra-Op Ultrasound

Hemorrhage13-15 wks: 1217-25 wks: 21

Adequate anesthesiaParacervical block which includes vasopressin 4 units.Efficient completion of procedure

Retained products 5-20Ultrasound, Gritty textureExamine POC

Infection 2.5Prophylactic antibioticsPO doxy or IV cephalosporin

Post-abortal hematometra 1.8

n/a – unpredictableImmediate re-aspiration required

Requirements for a safe D&E Program

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• Surgeons skilled and experienced in D&E provision• Adequate pain control options with appropriate monitoring• Requisite instruments available• Staff skilled in patient education, counseling, care and

recovery• Established procedures at free standing facilities for

transferring patients who require emergency hospital-based care

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D&E cervical preparation

• Laminaria▪ Osmotic dilators▪ Dried compressed seaweed sticks, 5-

10mm diameter in size▪ 4-19 dilators can be placed▪ Slow swelling to exert slow

circumferential pressure and dilation ▪ 1-2 days prior to procedure▪ Paracervical block with 20cc 0.25%

bupivicaine

D&E Procedure

• Adequate anesthesia• Ultrasound guidance• Uterine evacuation using suction and

instruments• Paracervical block with 20cc 0.5% lidocaine

and 4u vasopressin to decrease blood loss

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Labor Induction Abortion

• One office visit – then hospital admission.

• Hypertonic saline amnioinfusion, intracardiac KCl, intra-amniotic digoxin to induce fetal death

• Misoprostol or misoprostol and mifepristone to cause contractions and uterine evacuation

• May require vacuum aspiration for retained placenta

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Labor Induction Abortion

• Patient is awake

• Can obtain analgesia for pain

• Fetus delivered intact

• Often only option for obese women.

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References – Text books

• Management of Unintended and Abnormal Pregnancy. Paul M. et al. First Edition. Wiley Blackwell, 2009

• Williams Obstetrics. Cunningham, FG et al. 22nd Edition. McGraw Hill; 2005