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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.

• What questions do you ask her?

• What parts of the exam would you focus on?

• What’s your differential diagnosis?

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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

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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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 (“embryonic demise”)▪ 10mm Mean Sac Diameter and no yolk sac▪ 20mm Mean Sac Diameter and no fetal pole

▫ Gestational sac without an embryo is AKA an “anembryonic pregnancy” or “blighted ovum”

• 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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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

▪ SAB:▫ Abortion in the absence of an intervention▫ Usually refers to first 20 weeks

▫ If fetus dies in uterus after 20wks GA, referred to as (intrauterine) fetal demise or stillbirth.

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Types of SAB/EPF

• Complete: all tissue has passed

• Incomplete: cervix open, some tissue has passed

• Inevitable: vaginal bleeding w/cervical dilation, but no tissue has passed.

• Chemical pregnancy: +hcg but no sac formed.

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Spontaneous Abortion

• Missed Abortion (Mab): non-viable intrauterine pregnancy diagnosed by ultrasound, but no symptoms of miscarriage present yet

• Septic Abortion: 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

• Epidemiology▪ 15-25% of all clinically recognized pregnancies▪ 80% occur in first 12 weeks

▪ 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 Etiologies

• 50% due to chromosomal abnormalities▫ ~50% Trisomies: Trisomy 16 most common▫ ~50% Aneuploidy: 20% of Sabs are Triploidy

▫ 45,X most common single genetic abnormality (14.6% of Sabs)

▫ Aneuploidy increases with maternal age▫ If recurrent Sabs, consider parental

chromosomal anomaly (balanced translocation)

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SAB/EPF Non-Chromosomal Etiologies

▪ Maternal systemic disease:▫ HTN, renal disease, SLE, antiphospholipid syndrome

▪ Infectious factors: ▫ Rubella, CMV, Mycoplasma, Listeria, Toxoplasmosis

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

progesterone deficiency

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SAB/EPF 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)▫ Cocaine

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Management options

1. Uterine evacuation by suction (D&C)▫ Manual▫ Electric

2. Uterine evacuation by medication

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Using MVA for treatment/completion of spontaneous/incomplete abortion

• Ensures POCs are fully evacuated• Dilate cervix with metal/plastic dilators• Minimal anesthesia needed• Low noise level• Portable for use in physician office• 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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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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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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Medication management of EPF

• 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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Medication Management 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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Pain management • Aspiration/vacuum

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

• Medical management▪ NSAIDS▪ Oral narcotics and

antiemetics if necessary

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Language: • Pregnancy Termination• Elective abortion (Eab)• Therapeutic abortion

(Tab)• Interruption of

pregnancy

• Methods:• Dependent upon

gestational age and provider abilities

Indications:• Personal choice• Medical recommendation

• PPROM, hemorrhage, SLE, pulm HTN, pre-eclampsia, Ehlers-Danlos, etc.

• Fetal anomalies• Intrauterine infection or

Septic abortion

Induced Abortion

Induced Abortion History in the U.S.

• 1821: Connecticut passes 1st abortion law barring abortions after “quickening”

• 1860: 20 states have abortion laws • 1967: Colorado is 1st state to liberalize

abortion laws • 1970: Alaska, Hawaii, New York, and

Washington liberalize abortion laws

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Induced Abortion History in the U.S.• 1973: Roe v. Wade

▪ Based on constitutional right of privacy▪ The government cannot prohibit or interfere with

abortion without a “compelling” reason

• 1992: PP of SE Pennsylvania v. Casey • Reaffirms that women have a right to abortion

before viability, but allows states to restrict abortion access so long as it does not impose an "undue burden" on women.

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Induced Abortion History in the U.S.• 2003: Partial-Birth Abortion Act passed by

Congress• Thought to refer to “Dilation and Extraction” (D&X)• 8th Circuit U.S. Appeals Court holds it unconstitutional

because no exception for “health of the mother”

• 2007: U.S. Supreme Court reverses Appeals Court decision

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Induced Abortion History in the U.S.

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

any abortion under Medicaid▫ Exceptions: rape, incest, life endangerment▫ 17 states & DC reinstated Medicaid funding:

▫ AK, AZ, CA, CT, HI, IL, MD, MA, MN, MT, NJ, NM, NY, OR, VT, WA, WV

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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▪ 3-4x higher for second-trimester than first trimester▪ Mortality: 1/100,000

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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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Gestational Age at Abortion

Bartlet L, et al. Obstet Gynecol. 2004.

61%≤8 weeks

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10

6

1

4

≤8

9 to 10

11 to 12

13 to 15

16 to 20

≥21

Weeks Gestation

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Induced abortion

• Methods:▪ Uterine evacuation (same as treatment of Sab)

▫ Manual vacuum aspiration▫ Electric vacuum aspiration

▪ Medication▫ Mifepristone and misoprostol (different than

Sab)

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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 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.

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Second Trimester Induced Abortion

• Epidemiology• Etiology• Management

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Epidemiology

• 14 weeks and above• 96%: Dilation and Evacuation (D&E)

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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– Pitocin

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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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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

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2nd trimester Abortion Counseling

• 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

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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Labor Induction Abortion

• One office visit – then hospital admission.• Hypertonic saline amnioinfusion, intracardiac KCl,

intra-amniotic digoxin to induce fetal death• Misoprostol or pitocin 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.