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First Trimester Bleeding and Abortion MS-3 Case Based Series

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 . Case No. 1.

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First Trimester Bleeding and Abortion MS-3 Case Based Series

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  1. First Trimester Bleeding and AbortionMS-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. Case No. 1 • 24yo woman presents to your office with complaints of spotting dark blood for 4 days. • What questions do you ask her? • What parts of the exam would you focus on? • What’s your differential diagnosis?

  3. Focused History for Case No. 1 • 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. 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

  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. Diagnosis of Pregnancy by Transvaginal Ultrasound

  9. Signs of early pregnancy failure • If ultrasound measurements are: • 5mm CRL and no FHR (“embryonic demise”) • 10mm Mean Sac Diameter andno yolk sac • 20mm Mean Sac Diameter and no fetal pole • Gestational sac without an embryo is AKA an “anembryonic pregnancy” or “blighted ovum” • 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. Early Pregnancy Failure (EPF) • Language is important • Abortion: termination or expulsion of a pregnancy, whether spontaneous or induced, prior to viability.

  11. Spontaneous Abortion • SAB: • Abortion in the absence of an intervention • Usually refers to first 20 weeks • If fetus dies in uterus after 20wks GA, referred to as (intrauterine) fetal demise or stillbirth.

  12. Types of SAB/EPF • Complete: all tissue has passed • Incomplete: cervix open, some tissue has passed • Inevitable: vaginal bleeding w/cervical dilation, but no tissue has passed. • Chemical pregnancy: +hcg but no sac formed.

  13. Spontaneous Abortion • Missed Abortion (Mab): non-viable intrauterine pregnancy diagnosed by ultrasound, but no symptoms of miscarriage present yet • Septic Abortion: missed/incomplete abortion becomes infected

  14. Threatened Abortion • Definition • 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

  15. SAB/EPF Epidemiology • Epidemiology • 15-25% of all clinically recognized pregnancies • 80% occur in first 12 weeks • Offer reassurance: probability of 2 consecutive miscarriages is 2.25% • 85% of women will conceive and have normal third pregnancy if with same partner

  16. SAB/EPF Etiologies • 50% due to chromosomal abnormalities • ~50%Trisomies: Trisomy 16 most common • ~50%Aneuploidy: 20% of Sabs are Triploidy • 45,X most common single genetic abnormality (14.6% of Sabs) • Aneuploidy increases with maternal age • If recurrent Sabs, consider parental chromosomal anomaly (balanced translocation)

  17. SAB/EPF Non-Chromosomal Etiologies • Maternal systemic disease: • HTN, renal disease, SLE, antiphospholipidsyndrome • Infectious factors: • Rubella, CMV, Mycoplasma, Listeria, Toxoplasmosis • Endocrine factors: • DM, hypothyroidism, “luteal phase defect” from progesterone deficiency

  18. SAB/EPF Non-Chromosomal Etiologies • Abnormal placentation • Anatomic considerations • Fibroids, septum, bicornuate, incompetent cervix • Environmental factors • Smoking >20 cigarettes per day (increased 4X) • Alcohol >7 drinks/week (increased 4X) • Cocaine

  19. Management options • Uterine evacuation by suction (D&C) • Manual • Electric • Uterine evacuation by medication

  20. Using MVA for treatment/completion of spontaneous/incomplete abortion Ensures POCs are fully evacuated Dilate cervix with metal/plastic dilators Minimal anesthesia needed Low noise level Portable for use in physician office Women very satisfied with method MVA Label. Ipas. 2007.

  21. 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.

  22. Comparison of EVA to MVA Dean G, et al. Contraception. 2003.

  23. MVA and EVA Risks and preventing the risks

  24. 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

  25. Medication management of 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

  26. Medication Management 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.

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

  28. Pain management • Aspiration/vacuum • Preparation • Music • Support during procedure • Conscious sedation • Paracervical block • Medical management • NSAIDS • Oral narcotics and antiemetics if necessary

  29. Language: Pregnancy Termination Elective abortion (Eab) Therapeutic abortion (Tab) Interruption of pregnancy Methods: Dependent upon gestational age and provider abilities Induced Abortion • Indications: • Personal choice • Medical recommendation • PPROM, hemorrhage, SLE, pulm HTN, pre-eclampsia, Ehlers-Danlos, etc. • Fetal anomalies • Intrauterine infection or Septic abortion

  30. Induced Abortion History in the U.S. • 1821: Connecticut passes 1st abortion law barring abortions after “quickening” • 1860: 20 states have abortion laws  • 1967: Colorado is 1st state to liberalize abortion laws • 1970: Alaska, Hawaii, New York, and Washington liberalize abortion laws

  31. Induced Abortion History in the U.S. • 1973: Roe v. Wade • Based on constitutional right of privacy • The government cannot prohibit or interfere with abortion without a “compelling” reason • 1992: PP of SE Pennsylvania v. Casey • Reaffirms that women have a right to abortion before viability, but allows states to restrict abortion access so long as it does not impose an "undue burden" on women.

  32. Induced Abortion History in the U.S. • 2003: Partial-Birth Abortion Act passed by Congress • Thought to refer to “Dilation and Extraction” (D&X) • 8th Circuit U.S. Appeals Court holds it unconstitutional because no exception for “health of the mother” • 2007: U.S. Supreme Court reverses Appeals Court decision

  33. Induced Abortion History in the U.S. • 1976: Hyde Amendment • Forbids use of federal money to pay for almost any abortion under Medicaid • Exceptions: rape, incest, life endangerment • 17 states & DC reinstated Medicaid funding: • AK, AZ, CA, CT, HI, IL, MD, MA, MN, MT, NJ, NM, NY, OR, VT, WA, WV

  34. 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 • 3-4x higher for second-trimester than first trimester • Mortality: 1/100,000

  35. 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.

  36. 1 4 Weeks Gestation 6 ≤8 10 9 to 10 11 to 12 61% ≤8 weeks 13 to 15 16 to 20 18 ≥21 Gestational Age at Abortion Bartlet L, et al. Obstet Gynecol. 2004.

  37. Induced abortion • Methods: • Uterine evacuation (same as treatment ofSab) • Manual vacuum aspiration • Electric vacuum aspiration • Medication • Mifepristone and misoprostol (different than Sab)

  38. 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 Medication Abortion

  39. First Trimester Medication Induced Abortion • Mifepristone 200-600 mg p.o. administered in clinic • Misoprostol 400-800 mcg orally or buccally 24-48h later. • 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.

  40. Second Trimester Induced Abortion • Epidemiology • Etiology • Management

  41. Epidemiology • 14 weeks and above • 96%: Dilation andEvacuation (D&E)

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

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

  44. Methods Dilation and evacuation Labor induction abortion Requires hospital stay Medication administration to initiate contractions Misoprostol Pitocin • Anesthesia • Procedure room • Laminaria placement required before procedure • Often 1 to 2 days prior

  45. 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 cervical preparation

  46. 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

  47. Second trimester D&E risks and preventing the risks

  48. 2nd trimesterAbortion 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

  49. 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

  50. Labor Induction Abortion • One office visit – then hospital admission. • Hypertonic saline amnioinfusion, intracardiacKCl, intra-amniotic digoxin to induce fetal death • Misoprostol orpitocin to cause contractions and uterine evacuation • May require vacuum aspiration for retained placenta

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