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 May 2012 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 Most Common Differential Diagnosis of 1st Trimester Bleeding Ectopic pregnancy Normal intrauterine pregnancy Threatened abortion Abnormal intrauterine pregnancy 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 every 48-72 hours Important for pregnancy diagnosis prior to ultrasound diagnosis Diagnostic tools for early pregnancy Transvaginal ultrasound Estimated βhCG values and associated findings on transvaginal ultrasound in early pregnancy EGA βhCG (IU/L) Visualization 5 wks >1500 Gestational sac 6 wks >5,200 Fetal pole 7 wks >17,500 Cardiac motion 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 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 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 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 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 SAB/EPF: Chromosomal Etiologies 50% due to chromosomal abnormalities 50% trisomies 50% triploidy, tetraploidy, X0 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 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 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 Management of spontaneous abortion 1. Uterine evacuation by suction Manual Electric 2. Uterine evacuation by medication Surgical management SAB/EPF Manual 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. 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. Obstet Gynecol Surv. 2001.; Goldberg AB, et al. Obstet Gynecol. 2004.; Hemlin J, et al. Acta Obstet Gynecol Scand. 2001. Pain Management Aspiration/vacuum Preparation Music Support during procedure Conscious sedation Paracervical block Medication abortion NSAIDS Oral narcotics and antiemetics if necessary 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 Comparison of surgical management 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. EVA and MVA risks and preventing the risks Complication Uterine perforation Hemorrhage Retained products Infection Post-abortal hematometra Rate/1000 procedures 1 <12 wks – 0 3 Prevention Cervical preparation Intra-Op Ultrasound 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 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 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. 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. Induced Abortion/Pregnancy Termination Language: Indications Personal choice Medical indication (hemorrhage, infection) Medical recommendation (SLE, Pulmonary HTN, PPROM) Fetus diagnosed with anomalies 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 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 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 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 Putting Induced Abortion into Perspective… Incident Terminating pregnancy < 9 weeks Chance of death 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. Earlier Procedures are Safer Abortions at < 8 weeks = lowest risk of death 1 Gestational Age Strongest risk factor for abortion-related mortality Weeks Gestation 4 ≤8 6 9 to 10 10 61% 18 11 to 12 ≤8 weeks 13 to 15 16 to 20 ≥21 Bartlet L, et al. Obstet Gynecol. 2004. 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 Medical abortion methods 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 protocols 1. Mifepristone 200-600 mg orally, administered in clinic 2. Misoprostol 400-800 mcg orally or buccally 24-48h later 3. Evaluate with ultrasound 13-16 days later to confirm completion Complete abortion rate (%) Time to expulsion (after misoprostol) 91–97 49%–61% within 4 hours < 56 83–95 87%–88% within 24 hours < 63 88 Gestational age (days) < 49 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. 2nd Trimester Induced Abortion Epidemiology Epidemiology 14 weeks gestation and above 96% done by Dilation and Evacuation (D&E) 4% done by labor induction 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 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 2nd trimester induced abortion Management Dilation and evacuation Labor induction abortion Two 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 D&E risks and prevention Complication Uterine perforation Hemorrhage Retained products Infection Post-abortal hematometra Rate/1000 procedures 1 13-15 wks: 12 17-25 wks: 21 Prevention Cervical preparation Intra-Op Ultrasound Adequate anesthesia Paracervical block which includes vasopressin 4 units. Efficient completion of procedure 5-20 Ultrasound, Gritty texture Examine POC 2.5 Prophylactic antibiotics PO doxy or IV cephalosporin 1.8 n/a – unpredictable Immediate re-aspiration required 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 D&E Step 1 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 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 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 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 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? 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? 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? 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? 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? 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? Case No. 4 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? 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).