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First Trimester Bleeding and Abortion

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 Erika E. Levi, MD Family Planning Program, Dept Ob/Gyn, UNC-Chapel Hill.

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First Trimester Bleeding and Abortion

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  1. 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 Erika E. Levi, MD Family Planning Program, Dept Ob/Gyn, UNC-Chapel Hill Updated August 17, 2011

  2. 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

  3. Most Common Differential Diagnosis of 1st Trimester Bleeding • Ectopic pregnancy • Normal intrauterine pregnancy • Threatened abortion • Abnormal intrauterine pregnancy

  4. 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

  5. Diagnostic tools for early pregnancy Transvaginal ultrasound Estimated βhCG values and associated findings on transvaginal ultrasound in early pregnancy

  6. Diagnosis of Spontaneous Abortion (SAB)or Early Pregnancy Failure (EPF) • 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

  7. Diagnosis of threatened abortion • 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

  8. Spontaneous Abortion (SAB) Early Pregnancy Failure (EPF) • 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

  9. Types of SAB/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

  10. SAB/EPF Epidemiology and etiology • 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

  11. SAB/EPF: Chromosomal Etiologies • 50% due to chromosomal abnormalities • 50% trisomies • 50% triploidy, tetraploidy, X0

  12. 50% Non-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

  13. 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

  14. Outcomes and management of threatened abortion • 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

  15. Management of spontaneous abortion • Uterine evacuation by suction • Manual • Electric • Uterine evacuation by medication

  16. 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 Surgical management SAB/EPF Manual vacuum aspiration MVA Label. Ipas. 2007.

  17. Surgical management SAB/EPF Electric Vacuum Aspirator • Electric vacuum aspirator • Uses an electric pump or suction machine connected via flexible tubing Creinin MD, et al. ObstetGynecolSurv. 2001.; Goldberg AB, et al. ObstetGynecol. 2004.; Hemlin J, et al. ActaObstetGynecol Scand. 2001.

  18. Pain Management • Aspiration/vacuum • Preparation • Music • Support during procedure • Conscious sedation • Paracervical block • Medication abortion • NSAIDS • Oral narcotics and antiemetics if necessary

  19. 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

  20. Comparison of surgical management Dean G, et al. Contraception. 2003.

  21. EVA and MVA risks and preventing the risks

  22. Medication management of SAB/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

  23. 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 Regimen Zhang J, et al. N Engl J Med. 2005. Creinin MD, et al. ObstetGynecol. 2006.

  24. Efficacy: Medication vs. Expectant Management Bagratee JS, et al. Hum Reprod. 2004.

  25. 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 Induced Abortion/Pregnancy Termination • 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

  26. Induced Abortion History • 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

  27. 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)

  28. Induced Abortion Epidemiology • 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

  29. Putting Induced Abortion into Perspective… Gold RB, Richards C. Issues SciTechnol.1990.; Hatcher RA. ContraceptTechnol Update.1998.; Mokdad AH, et al. MMWR Recomm Rep.2003.

  30. 1 4 Weeks Gestation 6 ≤8 Gestational Age 10 9 to 10 11 to 12 Strongest risk factor for abortion-related mortality 61% ≤8 weeks 13 to 15 16 to 20 18 ≥21 Earlier Procedures are Safer Abortions at < 8 weeks = lowest risk of death Bartlet L, et al. ObstetGynecol. 2004.

  31. Induced Abortion Methods • 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

  32. 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 abortion methods

  33. Medical abortion protocols • Mifepristone 200-600 mg orally, administered in clinic • Misoprostol 400-800 mcg orally or buccally 24-48h later • 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 ObstetGynecol. 1997.

  34. 2nd Trimester Induced Abortion Epidemiology • Epidemiology • 14 weeks gestation and above • 96% done by Dilation and Evacuation (D&E) • 4% done by labor induction

  35. 2nd Trimester Induced Abortion Etiology • 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

  36. 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

  37. 2nd trimester induced abortion Management

  38. D&E risks and prevention

  39. Requirements for a safe D&E Program • 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

  40. 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 1 cervical Preparation

  41. 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

  42. Labor Induction Abortion • One office visit – then hospital admission • Hypertonic saline amnioinfusion, intracardiacKCl, 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

  43. Labor Induction Abortion • Patient is awake • Can obtain analgesia for pain • Fetus delivered intact • Often only option for obese women

  44. 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

  45. Case No. 1 • 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?

  46. Case No. 1 Continued • 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?

  47. Case No. 2 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?

  48. Case No. 2 Continued 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?

  49. Case No. 3 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?

  50. Case No. 3 Continued 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?

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