1. 1 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

2. 2 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

3. 3 Focused History Last Menstrual Period Previous LMP LMP intervals Sexual history Contraception Sexually transmitted infection history Gynecological surgical history Other surgical history Obstetrics history

4. 4 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

5. 5 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

6. 6 Most common differential diagnosis of first trimester bleeding: Ectopic pregnancy Normal intrauterine pregnancy Abnormal intrauterine pregnancy

7. 7 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

8. 8 Diagnosis of Pregnancy by Transvaginal Ultrasound EGAβhCG (IU/L) Visualization 5 wks>1500Gestational sac 6 wks>5,200Fetal pole 7 wks>17,500Cardiac motion

9. 9 Signs of early pregnancy failure If ultrasound measurements are: ▪ 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 ▪ <15% rise in bhcg over 48 hours ▪ Gestational sac growth <2mm over 5 days ▪ Gestational sac growth <3mm over 7 days

10. 10 Spontaneous Abortion (SAB)/Early Pregnancy Failure (EPF) Language is important ▪ Abortion: termination or expulsion of a pregnancy, whether spontaneous or induced, prior to viability.

11. 11 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.

12. 12 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.

13. 13 Spontaneous Abortion Missed: embryo never formed or demised, but uterus hasn’t expelled the sac Blighted ovum/anembryonic pregnancy: empty gestational sac, embryo never formed Septic: missed/incomplete abortion becomes infected

14. 14 Threatened Abortion Definition ▪ Vaginal bleeding before the 20 th 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

15. 15 SAB/EPF Epidemiology Etiology Management

16. 16 SAB/EPF Epidemiology 80% in first 12 weeks

17. 17 SAB/EPF Epidemiology 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

18. 18 SAB/EPF Epidemiology 80% occur in the first 12 weeks

19. 19 SAB/EPF Chromosomal Etiologies 50% due to chromosomal abnormalities ▫50% trisomies ▫50% triploidy, tetraploidy, X0

20. 20 50% non-Chromosomal Etiologies ▪ Maternal systemic disease ▪ Infectious factors: ▫Mycoplasma, ▫Listeria ▫Toxoplasmosis ▪ Endocrine factors: ▫ DM, hypothyroidism, “luteal phase defect” from progesterone deficiency

21. 21 50% non-Chromosomal ▪ Abnormal placentation ▪ Anatomic considerations (fibroids, septum, bicornuate, incompetent cervix) ▪ Environmental factors ▫Smoking >20 cigarettes per day (increased 4X) ▫Alcohol >7 drinks/week (increased 4X) ▫Increasing age

22. 22 Management options 1.Uterine evacuation by suction ▫Manual ▫Electric 2.Uterine evacuation by medication

23. 23 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.

24. 24 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

25. 25 Pain management Aspiration/vacuum ▪ Preparation ▪ Music ▪ Support during procedure ▪ Conscious sedation ▪ Paracervical block Medication abortion ▪ NSAIDS ▪ Oral narcotics and antiemetics if necessary

26. 26 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

27. 27 Comparison of EVA to MVA Dean G, et al. Contraception. 2003. EVAMVA VacuumElectric pumpManual aspirator NoiseVariableQuiet PortableNot easilyYes AnesthesiaConscious sedation and paracervical block Capacity350–1,200 cc60 cc AssistantNot necessaryHelpful

28. 28 MVA and EVA Risks and preventing the risks Complication Rate/1000 procedures Prevention Uterine perforation1 Cervical preparation Intra-Op Ultrasound Hemorrhage<12 wks – 0 Efficient completion of procedure Retained products3 Ultrasound Gritty texture Examine POC Infection2.5 Prophylactic antibiotics PO doxy or IV cephalosporin Post-abortal hematometra 1.8 N/a – unpredictable Immediate re-aspiration required

29. 29 Medication management of early pregnancy failure 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

30. 30 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.

31. 31 Efficacy: Medication vs. Expectant Management Misoprostol 600 μg vaginally Expectant management (placebo) Success by day 273.1%13.5% Success by day 788.5%44.2% Evacuation needed 11.5%55.8% Bagratee JS, et al. Hum Reprod. 2004.

32. 32 Induced Abortion/ Pregnancy Termination 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 recommendation PPROM, hemorrrhage, SLE, pulm HTN, etc Anomalous fetus Intrauterine infection or Septic abortion Methods Dependent upon gestational age and provider abilities

33. Induced Abortion History 1821 – first abortion law enacted in Connecticut Following that “therapeutic abortion” allowable, definitions vague 33

34. Induced Abortion History 1973 – Roe v. Wade ▪ Woman’s constitutional right of privacy ▪ The government cannot prohibit or interfere with abortion without a “compelling” reason; 34

35. Induced Abortion History 1976 – Hyde Amendment ▪ 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

36. 36 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 ▪ mortality: 1/100,000 ▪ Complications are 3-4x higher for second-trimester than first trimester

37. 37 Induced abortion 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

38. 38 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 weeks1 in 500,000 Terminating pregnancy > 20 weeks1 in 8,000 Giving birth1 in 7,600 Driving an automobile1 in 5,900 Using a tampon1 in 350,000

39. 39 Earlier Procedures Are Safer Abortions 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 weeks 18 10 6 1 4 ≤8 9 to 10 11 to 12 13 to 15 16 to 20 ≥21 Weeks Gestation

40. 40 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

41. 41 First Trimester Medication Induced Abortion Gestational age (days) Complete abortion rate (%) Time to expulsion (after misoprostol) < 4991–97 49%–61% within 4 hours < 5683–95 87%–88% within 24 hours < 6388 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. 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.

42. 42 Second Trimester Induced Abortion Epidemiology Etiology Management

43. 43 Epidemiology 14 weeks and above 96% - dilation and evacuation

44. 44 Etiology Social indications ▪ Delay in diagnosis ▪ Delay in finding a provider ▪ Delay in obtaining funding ▪ Teenagers most likely to delay Fetal anomalies

45. Management Counseling Method options ▪ Dilation and evacuation (D&E) ▪ Labor Induction Abortion 45

46. 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 –Mifepristone 46

47. 47 2 nd 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

48. 48 Second trimester D & E risks and preventing the risks Complication Rate/1000 procedures Prevention Uterine perforation1 Cervical preparation Intra-Op Ultrasound Hemorrhage 13-15 wks: 12 17-25 wks: 21 Adequate anesthesia Paracervical block which includes vasopressin 4 units. Efficient completion of procedure Retained products5-20 Ultrasound, Gritty texture Examine POC Infection2.5 Prophylactic antibiotics PO doxy or IV cephalosporin Post-abortal hematometra 1.8 n/a – unpredictable Immediate re-aspiration required

49. Requirements for a safe D&E Program 49 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

50. 50 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

51. 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

52. 52 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

53. 53 Labor Induction Abortion Patient is awake Can obtain analgesia for pain Fetus delivered intact Often only option for obese women.

54. 54 References – Text books Management of Unintended and Abnormal Pregnancy. Paul M. et al. First Edition. Wiley Blackwell, 2009 Williams Obstetrics. Cunningham, FG et al. 22 nd Edition. McGraw Hill; 2005