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

 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 in 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  Medication abortion

 Preparation  NSAIDS
 Music  Oral narcotics and antiemetics
 Support during procedure if necessary
 Conscious sedation
 Paracervical block
 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 Rate/1000 Prevention

procedures
Cervical preparation
Uterine perforation 1 Intra-Op Ultrasound

Hemorrhage <12 wks – 0 Efficient completion of procedure

Ultrasound
Retained products 3 Gritty texture
Examine POC
Prophylactic antibiotics
Infection 2.5 PO doxy or IV cephalosporin

Post-abortal N/a – unpredictable

hematometra 1.8 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 Expectant
600 μg management
vaginally (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:
 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 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 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.
 Earlier Procedures are Safer
Abortions at < 8 weeks = lowest risk of death

1 Weeks Gestation

Gestational Age 6
4
≤8

10 9 to 10

Strongest risk factor 61% 11 to 12

for abortion-related 18
≤8 weeks
13 to 15

mortality 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  Misoprostol
 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
 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

Gestational age Complete abortion rate Time to expulsion

(days) (%) (after misoprostol)
49%–61%
< 49 91–97
within 4 hours
87%–88%
< 56 83–95
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.
 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 Rate/1000 Prevention

procedures
Cervical preparation
Uterine perforation 1 Intra-Op Ultrasound

Adequate anesthesia
13-15 wks: 12 Paracervical block which includes vasopressin 4 units.
Hemorrhage
17-25 wks: 21 Efficient completion of procedure

Ultrasound, Gritty texture

Retained products 5-20 Examine POC

Prophylactic antibiotics
Infection 2.5 PO doxy or IV cephalosporin

n/a – unpredictable
Post-abortal 1.8
hematometra 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).