First Trimester Bleeding and Abortion
MS-3 Case Based Series
Gretchen S. Stuart, MD, MPHTM
Amy G. Bryant, MD
Jennifer H. Tang, MD
Family Planning Program, Department of Obstetrics and Gynecology
UNC-Chapel Hill
Updated November 1, 2010
1
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
2
Focused History
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Last Menstrual Period
Previous LMP
LMP intervals
Sexual history
Contraception
Sexually transmitted infection history
Gynecological surgical history
Other surgical history
Obstetrics history
3
Focused History for Case no. 1
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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
4
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
5
Most common differential diagnosis of
first trimester bleeding:
• Ectopic pregnancy
• Normal intrauterine pregnancy
• Abnormal intrauterine pregnancy
6
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
7
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
8
Signs of early pregnancy failure
• If ultrasound measurements are:
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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
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<15% rise in bhcg over 48 hours
Gestational sac growth <2mm over 5 days
Gestational sac growth <3mm over 7 days
9
Spontaneous Abortion (SAB)/Early Pregnancy
Failure (EPF)
• Language is important
▪
Abortion: termination or expulsion of a
pregnancy, whether spontaneous or
induced, prior to viability.
10
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.
11
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.
12
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
13
Threatened Abortion
• Definition
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▪
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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
14
SAB/EPF
• Epidemiology
• Etiology
• Management
15
SAB/EPF Epidemiology
• 80% in first 12 weeks
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SAB/EPF Epidemiology
• Epidemiology
▪
15-25% of all clinically recognized pregnancies
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Offer reassurance: probability of 2 consecutive
miscarriages is 2.25%
▫ 85% of women will conceive and have normal
third pregnancy if with same partner
17
SAB/EPF Epidemiology
• 80% occur in the first 12 weeks
18
SAB/EPF Chromosomal Etiologies
• 50% due to chromosomal abnormalities
▫ 50% trisomies
▫ 50% triploidy, tetraploidy, X0
19
50% non-Chromosomal Etiologies
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Maternal systemic disease
Infectious factors:
▫ Mycoplasma,
▫ Listeria
▫ Toxoplasmosis
Endocrine factors:
▫ DM, hypothyroidism, “luteal phase defect” from
progesterone deficiency
20
50% non-Chromosomal
▪
Abnormal placentation
▪
Anatomic considerations (fibroids, septum, bicornuate,
incompetent cervix)
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Environmental factors
▫ Smoking >20 cigarettes per day (increased 4X)
▫ Alcohol >7 drinks/week (increased 4X)
▫ Increasing age
21
Management options
1. Uterine evacuation by suction
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▫
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.
23
Electric Vacuum Aspirator
Electric vacuum aspirator
• Uses an electric pump or
suction machine connected
via flexible tubing
Creinin MD, et al. Obstet Gynecol Surv. 2001.; Goldberg AB, et al. Obstet
Gynecol. 2004.; Hemlin J, et al. Acta Obstet Gynecol Scand. 2001.
24
Pain management
• Aspiration/vacuum
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Preparation
Music
Support during procedure
Conscious sedation
Paracervical block
• Medication abortion
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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
26
Comparison of EVA to MVA
EVA
MVA
Vacuum
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
Dean G, et al. Contraception. 2003.
27
MVA and EVA
Risks and preventing the risks
Complication
Uterine perforation
Hemorrhage
Retained products
Rate/1000
procedures
1
<12 wks – 0
3
Infection
2.5
Post-abortal
hematometra
1.8
Prevention
Cervical preparation
Intra-Op Ultrasound
Efficient completion of procedure
Ultrasound
Gritty texture
Examine POC
Prophylactic antibiotics
PO doxy or IV cephalosporin
N/a – unpredictable
Immediate re-aspiration required
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Medication management of early
pregnancy failure
• Misoprostol
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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.
30
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%
Evacuation
needed
11.5%
55.8%
Bagratee JS, et al. Hum Reprod. 2004.
31
Induced Abortion/ Pregnancy Termination
Language:
Indications
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• Personal choice
• Medical recommendation
• PPROM, hemorrrhage,
SLE, pulm HTN, etc
• Anomalous fetus
• Intrauterine infection or Septic
abortion
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
Methods
•
Dependent upon gestational
age and provider abilities
32
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
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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
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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
35
Induced abortion
• 1/3 occur in women older than 24
• Gestational age:
• 90% within first 12 weeks
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50% within first 8 weeks
• Complications
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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
36
Induced abortion
• Methods:
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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…
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
Gold RB, Richards C. Issues Sci Technol. 1990.; Hatcher RA. Contracept Technol
Update. 1998.; Mokdad AH, et al. MMWR Recomm Rep. 2003.
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Earlier Procedures Are Safer
Abortions at <8 weeks = lowest risk of death
1
Gestational Age
Weeks Gestation
4
≤8
6
9 to 10
10
Strongest risk factor
for abortion-related
mortality
61%
18
11 to 12
≤8 weeks
13 to 15
16 to 20
≥21
Bartlet L, et al. Obstet Gynecol. 2004.
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Medication Abortion
• Mifepristone
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▪
▪
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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
40
First Trimester Medication Induced Abortion
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.
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
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
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Delay in diagnosis
Delay in finding a provider
Delay in obtaining funding
Teenagers most likely to delay
• Fetal anomalies
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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
Labor induction abortion
• Requires hospital stay
• Medication administration
to initiate contractions
– Misoprostol
– Mifepristone
– Often 1 to 2 days prior
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2nd trimester induced 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
47
Second trimester D & E
risks and preventing the risks
Complication
Uterine perforation
Hemorrhage
Retained products
Infection
Post-abortal
hematometra
Rate/1000
procedures
1
13-15 wks: 12
17-25 wks: 21
5-20
Prevention
Cervical preparation
Intra-Op Ultrasound
Adequate anesthesia
Paracervical block which includes vasopressin 4
units.
Efficient completion of procedure
Ultrasound, Gritty texture
Examine POC
2.5
Prophylactic antibiotics
PO doxy or IV cephalosporin
1.8
n/a – unpredictable
Immediate re-aspiration required
48
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 hospitalbased care
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D&E cervical preparation
• Laminaria
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▪
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Osmotic dilators
Dried compressed seaweed sticks, 510mm 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
50
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
51
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
52
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
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