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, MDErika E. Levi, MD

Family Planning Program, Dept Ob/Gyn, UNC-Chapel Hill

Updated August 17, 2011

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 management options for spontaneous abortion

Describe reasons for induced abortion

List methods of induced abortion

Understand the public health impact of the legal status of abortion

Ectopic pregnancy Normal intrauterine pregnancy Threatened abortion Abnormal intrauterine pregnancy

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 pregnancy

EGA βhCG (IU/L) Visualization

5 wks >1500 Gestational sac

6 wks >5,200 Fetal pole

7 wks >17,500 Cardiac motion

Diagnostic tools for early pregnancy Transvaginal ultrasound

Estimated βhCG values and associated findings on transvaginal ultrasound in early pregnancy

SAB/EPF if Ultrasound measurements are:

5mm CRL and no fetal heart rate 10mm Mean Sac Diameter and no yolk sac 20mm Mean Sac Diameter and no fetal pole

Change in βhCG is <15% rise in βhCG over 48 hours Gestational sac growth <2mm over 5 days Gestational sac growth <3mm over 7 days

Diagnosis of Spontaneous Abortion (SAB)

or Early Pregnancy Failure (EPF)

Diagnosis made by ultrasound and/or ßhCG – 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

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

Called a 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: +βhcg but no sac formed Blighted ovum/anembryonic pregnancy: empty gestational sac,

embryo never formed Missed: embryo never formed or demised, but uterus hasn’t

expelled the sac 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 Antiphospholipid antibody syndrome, lupus, coagulation

disorders

Infectious factors Brucella, chlamydia, mycoplasma, listeria, toxoplasma,

malaria, tuberculosis

Endocrine factors DM, hypothyroidism, “luteal phase defect” from

progesterone deficiency

50% Non-Chromosomal Etiologies

Abnormal placentation

Anatomic considerations (fibroids, polyps, septum, bicornuate uterus, incompetent cervix, Asherman’s)

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

50% Non-Chromosomal Etiologies

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

Outcomes and management of threatened abortion

1. Uterine evacuation by suction Manual Electric

2. Uterine evacuation by medication

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 3

UltrasoundGritty 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

Induced Abortion History

1821 – First abortion law enacted in Connecticut Bars abortion after “quickening”, but 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 years

1/3 occur in women older than 24 years

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 weeks18

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 orally, administered in clinic2. Misoprostol 400-800 mcg orally or buccally 24-48h later3. Evaluate with ultrasound 13-16 days 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 14 weeks gestation and above 96% done by Dilation and Evacuation (D&E) 4% done by labor induction

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

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

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 G1P0 presents to your office and reports spotting dark blood for 4 days.

What are your initial history questions? 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 kind of abortion does she have?– 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 her options for management?– What are the advantages of each option?

Case No. 1 Continued

32yo G2P1 presents with lower abdominal pain, vaginal spotting, and an LMP 6 weeks ago.

What’s in your differential diagnosis?What pertinent things about her history

would you like to know?What would you look for on physical

exam?What labs/imaging studies would you

order?

Case No. 2

Her BHCG returns as 3200 and a pelvic ultrasound does not demonstrate an intrauterine pregnancy

What is her likely diagnosis? What are some risk factors for this

diagnosis? What are her treatment options? What would you tell her about future

pregnancies?

Case No. 2 Continued

27yo G5P4 with LMP 8 wks ago presents with fever to 101.4, abdominal pain, and vaginal bleeding

What is in your differential diagnosis? What are your initial history questions? What pertinent findings might you look for

on physical exam?

Case No. 3

The patient states that she “took a pill to make her period come down” a couple weeks ago and has had spotting ever since. The fever started last night, and the bleeding has now gotten heavier. On exam, her os is open and she has purulent discharge. She also has fundal tenderness.

What kind of abortion does she have? What risk factors does she have for this diagnosis? What are her options for management?

Case No. 3 Continued

A 38 year-old G1P0 with an IVF pregnancy at 16wks presents to discuss the results of her recent fetal survey, which shows fetal anencephaly. You know that most anencephalic fetuses do not survive birth. How do you counsel this patient? What are her options for management? What questions do you ask her to help her make a

decision for management? How would you counsel the patient if the ultrasound

showed features consistent with Trisomy 21 instead of anencephaly?

Case No. 4

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).