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First Trimester Bleeding and Abortion. UNC School of Medicine Obstetrics and Gynecology Clerkship Case Based Seminar Series Gretchen S. Stuart, MD, MPHTM Amy G. Bryant, MD Jennifer H. Tang, MD Family Planning Program, Dept Ob/Gyn, UNC-Chapel Hill. Objectives. - PowerPoint PPT Presentation
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First Trimester Bleeding and Abortion
UNC School of MedicineObstetrics and Gynecology Clerkship
Case Based Seminar Series
Gretchen S. Stuart, MD, MPHTMAmy G. Bryant, MD
Jennifer H. Tang, MDFamily Planning Program, Dept Ob/Gyn, UNC-Chapel Hill
Objectives Develop a differential for first trimester vaginal bleeding
Differentiate the types of spontaneous abortion (missed, complete, incomplete, threatened, septic)
Describe the causes of spontaneous abortion
List the complications of spontaneous abortion
Provide non-directive counseling to patients surrounding pregnancy options
Explain surgical and non-surgical methods of pregnancy termination
Identify potential complications of induced abortion
Understand the public health impact of the legal status of abortion
Ectopic pregnancy Normal intrauterine pregnancy Threatened abortion Abnormal intrauterine pregnancy Language is important Abortion: termination or expulsion of a pregnancy,
whether spontaneous or induced, prior to viability.
Most Common Differential Diagnosis of
1st Trimester Bleeding
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
Diagnosis tools for early pregnancyUPT and beta-hCG
EGA βhCG (IU/L) Visualization
5 wks >1500 Gestational sac
6 wks >5,200 Fetal pole
7 wks >17,500 Cardiac motion
Diagnosis tools for early pregnancy transvaginal ultrasound
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 day
Diagnosis of SAB/EPFusing ultrasound and beta-hCG
Diagnosis made by ultrasound and/or ß-hCG – normally growing early pregnancy but with vaginal bleeding
More formal definition: Vaginal bleeding before the 20th week Bleeding in early pregnancy with no pregnancy loss
Outcomes 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
Diagnosis of threatened abortion
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
Spontaneous Abortion (SAB) Early Pregnancy Failure (EPF)
Complete Incomplete : cervix open, some tissue has passed Inevitable: intrauterine pregnancy with cervical dilation & vaginal
bleeding. Chemical pregnancy: +hcg but no sac formed. Missed: embryo never formed or demised, but uterus hasn’t
expelled the sac Blighted ovum/anembryonic pregnancy: empty gestational sac,
embryo never formed Septic: missed/incomplete abortion becomes infected
Types of SAB/EPF
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 80% in the first 12 weeks
Etiologies Chromosomal Non-chromosomal
SAB/EPFEpidemiology and etiology
50% due to chromosomal abnormalities 50% trisomies 50% triploidy, tetraploidy, X0
SAB/EPF: Chromosomal Etiologies
Maternal systemic disease Infectious factors:
Mycoplasma Listeria Toxoplasmosis
Endocrine factors: DM, hypothyroidism, “luteal phase defect” from
progesterone deficiency
50% Non-Chromosomal Etiologies
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
50% Non-Chromosomal Etiologies
1. Uterine evacuation by suction Manual Electric
2. Uterine evacuation by medication
Surgical and non-surgical management of spontaneous abortion
Surgical management SAB/EPFManual vacuum aspiration
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.
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
Surgical management SAB/EPFElectric Vacuum Aspirator
Aspiration/vacuum Preparation Music Support during procedure Conscious sedation Paracervical block
Medication abortion NSAIDS Oral narcotics and antiemetics
if necessary
Pain Management
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
Floating Chorionic Villi
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
Comparison of surgical management
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
EVA and MVA risks and preventing the risks
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
Medication management of SAB/EPF
Misoprostol 800 μg vaginallyRepeat dose on day 2 or 3 if indicatedPelvic U/S to confirm empty uterusConsider vacuum aspiration if expulsion
incomplete
Zhang J, et al. N Engl J Med. 2005.Creinin MD, et al. Obstet Gynecol. 2006.
Regimen
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.
Efficacy: Medication vs. Expectant Management
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 indication
(hemorrhage, infection) Medical recommendation
(SLE, Pulmonary HTN, PPROM) Fetus diagnosed with
anomalies
Methods Dependent upon gestational
age and provider abilities
Induced Abortion/Pregnancy Termination
Any discussion of abortion needs to include some of the legal and political aspects.
Providers should be familiar with the abortion laws in their own states
Providers performing abortions must know the laws in their own state
1821 – first abortion law enacted in Connecticut Following that “therapeutic abortion” allowable, definitions vague
1973 – Roe v. Wade Woman’s constitutional right of privacy The government cannot prohibit or interfere with abortion without a
“compelling” reason; 1976 – Hyde Amendment
Forbids use of federal money to pay for almost any abortion under Medicaid Some states have reinstated state funding (NY, VT, CA among others)
Induced Abortion History
1821 – first abortion law enacted in Connecticut Following that “therapeutic abortion” allowable, definitions vague
1973 – Roe v. Wade Woman’s constitutional right of privacy The government cannot prohibit or interfere with abortion without a
“compelling” reason; 1976 – Hyde Amendment
Forbids use of federal money to pay for almost any abortion under Medicaid Some states have reinstated state funding (NY, VT, CA among others)
Induced Abortion History
1 in 3 women by the age of 44 yrs 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
Induced Abortionepidemiology
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
Putting Induced Abortioninto Perspective…
Earlier Procedures are SaferAbortions 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 weeks
18
10
6
1
4≤8
9 to 10
11 to 12
13 to 15
16 to 20
≥21
Weeks Gestation
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
Induced Abortionmethods
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
Medical abortionmethods
Gestational age (days)
Complete abortion rate (%)
Time to expulsion (after misoprostol)
< 49 91–97 49%–61% within 4 hours
< 56 83–95 87%–88% within 24 hours
< 63 88
1. Mifepristone 200-600 mg p.o. administered in clinic2. 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.
Medical abortion protocols
Epidemiology @ 34% of all induced abortions 14 weeks and above 96% - dilation and evacuation 4% labor induced abortion
2nd Trimester Induced Abortionepidemiology
Etiology Social indications
Delay in diagnosis Delay in finding a provider Delay in obtaining funding Teenagers most likely to delay
Fetal anomalies Genetic such as Trisomy 13, 18, 21 Anatomic such as cardiac defects Neural tube such as anencephaly
2nd Trimester Induced Abortionetiology
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
2nd Trimester Induced Abortioncounseling
Dilation and evacuation Labor induction abortionTwo visits in 1-2 days Requires inpatient hospital stay
usually lasting 1-3 days
Anesthesia/analgesia required Average time to delivery 13 hrs
Procedure room required Increased likelihood of retained placenta resulting in uterine evacuation compared to D&E
Skilled surgeon Medication used misoprostol and/or mifepristone
Laminaria placement required before procedure
2nd trimester induced abortionmanagement
Complication Rate/1000 procedures Prevention
Uterine perforation 1Cervical preparationIntra-Op Ultrasound
Hemorrhage 13-15 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
D&E risks and prevention
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
Requirements for a safe D&E Program
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 Step 1cervical Preparation
Adequate anesthesia Ultrasound guidance Uterine evacuation using suction and instruments Paracervical block with 20cc 0.5% lidocaine and 4u
vasopressin to decrease blood loss
D&E Procedure
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 20% may require vacuum aspiration for retained
placenta
Labor Induction Abortion
Patient is awake Can obtain analgesia for pain Fetus delivered intact Often only option for obese women.
Labor Induction Abortion
Bottom Line Concepts First trimester bleeding occurs in 25% of all pregnancies and 25-50%
will progress to a spontaneous abortion Etiologies of first trimester bleeding include normal pregnancy,
spontaneous abortion/early pregnancy failure, or ectopic pregnancy. Diagnosis of normal vs abnormal early pregnancy made using physical
exam and ultrasound and/or ßhCG 50% of spontaneous abortions are the result of genetic abnormalities Management of spontaneous abortion can be medical or surgical and
surgical options can be in the operating room or in the clinic 1/3 women will have an induced abortion Induced abortion before 8 weeks is safest Risks associated with induced abortion are less than childbirth or
driving a car Methods for induced abortion include medication or surgical
24yo woman presents to your office and reports spotting dark blood for 4 days.
What is her differential diagnosis? What steps will you take to make the final
diagnosis?
Case No. 1
On the ultrasound exam you note a CRL consistent with 8 weeks but no cardiac motion.– What is the definition of abortion?– What proportion of clinically recognized pregnancies will end in spontaneous
abortion? – What proportions of spontaneous abortions are due to chromosomal abnormalities? – What are some of the non-chromosomal etiologies of spontaneous abortion?– What are the advantages of manual vacuum aspiration (MVA) over electric vacuum
aspiration (EVA)?– What are the advantages of EVA over MVA?– What are the advantages of medication management over vacuum aspiration?
Case No. 1 continued
A 24 year-old woman comes into your office because she is one week late for her period, she did a home pregnancy test and it was positive. She wants an abortion. She has known she would have an abortion should she become pregnant when she didn’t want to since she first became sexually active.
1. Where would you refer her?2. What proportion of induced abortions occurs before 12 weeks? 3. What is the chance of death if terminating a pregnancy before 9 weeks? 4. What is the chance of death from giving birth?
Case No. 2
A 38 year-old woman well known to you comes in because you are her family physician. She is pregnant and was seeing her Ob/Gyn and they have now diagnosed her fetus with a genetic anomaly and she desires pregnancy termination.
1. Where would you refer her?2. What are her options?
Case No. 3
References and Resources
APGO Medical Student Educational Objectives, 9th edition, (2009), Educational Topic 16 (p34-35), 34 (72-73)
Beckman & Ling: Obstetrics and Gynecology, 6th edition, (2010), Charles RB Beckmann, Frank W Ling, Barabara M Barzansky, William NP Herbert, Douglas W Laube, Roger P Smith. Chapter 13 (p147-150).
Hacker & Moore: Hacker and Moore's Essentials of Obstetrics and Gynecology, 5th edition (2009), Neville F Hacker, Joseph C Gambone, Calvin J Hobel. Chapter 7 (p74-78).