First Trimester Bleeding and Abortion

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 Family Planning Program, Dept Ob/Gyn, UNC-Chapel Hill

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 complications of spontaneous abortion • Provide non-directive counseling to patients surrounding pregnancy options • Explain surgical and non-surgical methods of pregnancy termination • Identify potential complications 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 • Language is important • Abortion: termination or expulsion of a pregnancy, whether spontaneous or induced, prior to viability.

4. Diagnosis tools for early pregnancyUPT and beta-hCG • 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. Diagnosis tools for early pregnancy transvaginal ultrasound

6. Diagnosis of SAB/EPFusing ultrasound and beta-hCG • 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 day

7. Diagnosis of threatened abortion • Diagnosis made by ultrasound and/or ß-hCG – 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 • 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

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 • (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: +hcg but no sac formed. • 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

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 • Infectious factors: • Mycoplasma • Listeria • Toxoplasmosis • Endocrine factors: • DM, hypothyroidism, “luteal phase defect” from progesterone deficiency

13. 50% 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) • Increasing age

14. Surgical and non-surgical management of spontaneous abortion • Uterine evacuation by suction • Manual • Electric • Uterine evacuation by medication

15. 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.

16. 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.

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

18. 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

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

20. EVA and MVA risks and preventing the risks

21. 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

22. 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.

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

24. 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

25. 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 • 1821 – first abortion law enacted in Connecticut • Following that “therapeutic abortion” allowable, 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)

26. Induced Abortion History • 1821 – first abortion law enacted in Connecticut • Following that “therapeutic abortion” allowable, 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)

27. Induced Abortion epidemiology • 1 in 3 women by the age of 44 yrs • 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

28. 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.

29. 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.

30. 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

31. 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

32. Medical abortion protocols • 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 ObstetGynecol. 1997.

33. 2nd Trimester Induced Abortion epidemiology • Epidemiology • @ 34% of all induced abortions • 14 weeks and above • 96% - dilation and evacuation • 4% labor induced abortion

34. 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

35. 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

36. 2nd trimester induced abortion management

37. D&E risks and prevention

38. 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

39. 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

40. 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

41. 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

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

43. 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

44. Case No. 1 • 24yo woman presents to your office and reports spotting dark blood for 4 days. • What is her differential diagnosis? • What steps will you take to make the final diagnosis?

45. Case No. 1 continued • On the ultrasound exam you note a CRL consistent with 8 weeks but no cardiac motion. • What is the definition of abortion? • 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 the advantages of manual vacuum aspiration (MVA) over electric vacuum aspiration (EVA)? • What are the advantages of EVA over MVA? • What are the advantages of medication management over vacuum aspiration?

46. Case No. 2 A 24 year-old woman comes into your office because she is one week late for her period, she did a home pregnancy test and it was positive. She wants an abortion. She has known she would have an abortion should she become pregnant when she didn’t want to since she first became sexually active. • Where would you refer her? • What proportion of induced abortions occurs before 12 weeks? • What is the chance of death if terminating a pregnancy before 9 weeks? • What is the chance of death from giving birth?

47. Case No. 3 A 38 year-old woman well known to you comes in because you are her family physician. She is pregnant and was seeing her Ob/Gyn and they have now diagnosed her fetus with a genetic anomaly and she desires pregnancy termination. • Where would you refer her? • What are her options?

48. 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).