1. First Trimester Bleeding and Abortion

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 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

3. What are your initial history questions?
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?

4. Most Common Differential Diagnosis of 1st Trimester Bleeding
Ectopic pregnancy
Normal intrauterine pregnancy
Threatened abortion
Abnormal intrauterine pregnancy

5. Diagnosis tools for early pregnancy
Urine pregnancy test (UPT)
Accurate on first day of expected menses
β-hCG
6-8 days after ovulation – present
Date of expected menses days after ovulation) – βhCG is 100 IU/L
Within first 30 days – β-hCG doubles in hours
Important for pregnancy diagnosis prior to ultrasound diagnosis
Based on ultrasound sizes
5mm CRL and no FHR
10mm Mean Sac Diameter and no yolk sac
20mm Mean Sac Diameter and no fetal pole
Based on change in size of bHcg
<15% rise in bhcg over 48 hours
Gestational sac growth <2mm over 5 days
Gestational sac growth <3mm over 7 days

6. 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

7. Threatened abortion Signs/ Symptoms Work Up Management Closed cervix
Viable fetus
Uterine size = GA
Minimal bleeding
Minimal/no pain
Ultrasound for viability
T&S
No specific treatment
No evidence bed rest works for management of inevitable abortion

8. 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
No evidence bed rest works for management of inevitable abortion

9. 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 proportion 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?

10. Diagnosis of Spontaneous Abortion (SAB) or Early Pregnancy Failure (EPF)
SAB/EPF if
Ultrasound measurements are:
> 7mm CRL and no fetal heart rate
> 25mm Mean Sac Diameter and no embryo
Absence of embryo with heartbeat
> 2 weeks after scan showing gestational sac w/o yolk sac
> 11 days after scan showing gestational sac w/ yolk sac
Gestational sac growth
<2mm over 5 days
<3mm over 7 days
Change in β-hCG is
<35% (vs 15%) rise in β-hCG over 48 hours*
Based on ultrasound sizes
5mm CRL and no FHR
10mm Mean Sac Diameter and no yolk sac
20mm Mean Sac Diameter and no fetal pole
Based on change in size of bHcg
<15% rise in bhcg over 48 hours
Gestational sac growth <2mm over 5 days
Gestational sac growth <3mm over 7 days
Doubilet, NEJM 2013
Morse, Fert Ster 2012

11. Abortion definitions Definition Types of abortion
Any pregnancy loss before 28 weeks or a fetus < 500 g
Types of abortion
Miscarriage – Also called spontaneous abortion (SAB) or early pregnancy failure (EPF)
Induced
Consider in any woman of reproductive age with:
Amenorrhea
Bleeding, abdominal pain
Partial expulsion of products of conception, dilated cervix
Uterus smaller than expected

12. Types of spontaneous abortion
Inevitable: intrauterine pregnancy with cervical dilation & vaginal bleeding
Incomplete: cervix open, some tissue has passed
Complete: pregnancy has been expelled completely
Missed: embryo never formed or demised, but uterus has not expelled the sac
Septic: missed/incomplete abortion becomes infected
Chemical pregnancy: (+)β-hcg but no sac formed
Blighted ovum/anembryonic pregnancy: empty gestational sac, embryo never formed

13. Spontaneous abortion: Epidemiology and etiology
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 – 50%
Non-chromosomal – 50%

14. SAB/EPF: Chromosomal Etiologies
50% trisomies
50% triploidy, tetraploidy, X0

15. SAB/EPF: Non-Chromosomal Etiologies
Maternal systemic disease
Antiphospholipid antibody syndrome, lupus, coagulation disorders
Infectious factors
Brucella, chlamydia, mycoplasma, listeria, toxoplasma, malaria, tuberculosis
Endocrine factors
Diabetes, hypothyroidism, “luteal phase defect” from progesterone deficiency

16. SAB/EPF: 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

17. Inevitable Abortion Signs/Symptoms Work Up Management Open cervix
Bleeding, but no passage of POCs
Abdominal pain
Uterine size = GA
T&S
CBC prn
Crossmatch prn
Vitals – if concern for infection, treat as with septic abortion
Three options:
Expectant
2) Medical
3) Surgical
Bereavement counseling
Contraception prn

18. Incomplete Abortion Signs/Symptoms Investigations Management
Open cervix
POCs partially expelled
Bleeding/pain
Uterine size < GA
Abdominal pain
T&S
CBC
Crossmatch prn
Same as with inevitable abortion
If in shock:
- IVF and/or blood
- Surgical
management

19. Complete Abortion Signs/Symptoms Work Up Management Closed cervix
POCs completely expelled
Small uterus
Minimal pain/bleeding
T&S
CBC prn
Ultrasound to confirm empty uterus
Bereavement counseling
Fe supplement prn
Contraception prn: start immediately if passage of POCs within past 2 weeks

20. Missed Abortion Signs/Symptoms Investigations Management Closed cervix
No bleeding/pain
Loss of pregnancy symptoms
T&S
CBC prn
Ultrasound to confirm non-viability
1) Expectant – okay for longer than inevitable abortion
2) Medical
3) Surgical

21. Management of spontaneous abortion
Expectant management
Uterine evacuation by medication
3. Uterine evacuation by suction
Manual
Electric

22. Medication vs. Expectant Management
Options for Early Pregnancy Loss: MVA and Medication Management
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%
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Original content for this slide submitted by the ARHP Clinical Advisory Committee for the Manual Vacuum Aspiration Education Partnership Project in December Original funding received from Ipas and the John Merck Fund through an unrestricted educational grant. Last reviewed/updated by the ARHP Clinical Advisory Committee for the Manual Vacuum Aspiration Education Partnership Project in October This slide is available at
Bagratee JS, et al. Hum Reprod
Slide 22

23. Medication management
Options for Therapeutic Abortion: Aspiration Versus Medication
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
Original content for this slide submitted by the ARHP Clinical Advisory Committee for the Manual Vacuum Aspiration Education Partnership Project in December Original funding received from Ipas and the John Merck Fund through an unrestricted educational grant. Last reviewed/updated by the ARHP Clinical Advisory Committee for the Manual Vacuum Aspiration Education Partnership Project in October This slide is available at
Slide 23

24. Surgical management SAB/EPF
Options for Early Pregnancy Loss: MVA and Medication Management
Surgical management SAB/EPF
Manual Vacuum Aspiration
Ensures products of conception (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
Do not need electricity
Dilators if os is closed
Women very satisfied with method
Treatment for spontaneous abortion
Ensures POC are fully evacuated
Comfortable for women because of the low noise level
Portable for use in physician office, a setting that is familiar to the woman
Women are very satisfied with the method
Original content for this slide submitted by the ARHP Clinical Advisory Committee for the Manual Vacuum Aspiration Education Partnership Project in December Original funding received from Ipas and the John Merck Fund through an unrestricted educational grant. Last reviewed/updated by the ARHP Clinical Advisory Committee for the Manual Vacuum Aspiration Education Partnership Project in October This slide is available at
MVA Label. Ipas
Slide 24

25. Surgical management SAB/EPF
Options for Therapeutic Abortion: Aspiration Versus Medication
Surgical management SAB/EPF
Electric Vacuum Aspirator
Electric vacuum aspirator
Uses an electric pump or suction machine connected via flexible tubing
Talking Points
To perform an electric vacuum aspiration (EVA) procedure, a cannula of appropriate size (depending on uterine size) is inserted into the uterus and then attached to the tubing and connected to the electric aspirator. The contents of the uterus are evacuated through the tubing into a container.
Because the initial cost of an EVA machine is relatively high, EVA is typically used in centralized settings that have high caseloads.
References
Creinin MD, Schwartz JL, Guido RS, Pymar HC. Early pregnancy failure—current management concepts. Obstet Gynecol Surv. 2001;56(2):105–13.
Goldberg AB, Dean G, Kang MS, Youssof S, Darney P. Manual versus electric vacuum aspiration for early first-trimester abortion: a controlled study of complication rates. Obstet Gynecol. 2004;103:101–7.
Hemlin J, Moller B. Manual vacuum aspiration, a safe and effective alternative in early pregnancy termination. Acta Obstet Gynecol Scand. 2001;80:563–7.
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Original content for this slide submitted by the ARHP Clinical Advisory Committee for the Manual Vacuum Aspiration Education Partnership Project in December Original funding received from Ipas and the John Merck Fund through an unrestricted educational grant. Last reviewed/updated by the ARHP Clinical Advisory Committee for the Manual Vacuum Aspiration Education Partnership Project in October This slide is available at
Creinin MD, Obstet Gynecol Surv. 2001
Goldberg AB, Obstet Gynecol. 2004
Hemlin J, Acta Obstet Gynecol Scand. 2001
Slide 25

26. Floating Chorionic Villi
Options for Therapeutic Abortion: Aspiration Versus Medication
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
Original content for this slide submitted by the ARHP Clinical Advisory Committee for the Manual Vacuum Aspiration Education Partnership Project in December Original funding received from Ipas and the John Merck Fund through an unrestricted educational grant. Last reviewed/updated by the ARHP Clinical Advisory Committee for the Manual Vacuum Aspiration Education Partnership Project in October This slide is available at
Source: A Clinicians Guide to Medical and Surgical Abortion; Paul M, Grimes D, National Abortion Federation, available online Hyman AG, Castleman L. Ipas. 2005
Slide 26

27. Comparison of surgical management
Options for Therapeutic Abortion: Aspiration Versus Medication
Comparison of surgical management
EVA
MVA
Vacuum
Electric pump
Manual aspirator
Noise
Variable
Quiet
Portable
Not easily
Yes
Anesthesia
IV or oral sedation and/or paracervical block
Capacity
350–1,200 cc
60 cc
Assistant
Not necessary
Helpful
A study done at the University of California, San Francisco investigated the acceptability of MVA vs. EVA and tried to quantify the impact of noise on women undergoing vacuum aspiration (Dean 2003). The study included 84 women undergoing abortion at less than 10 weeks of gestation. There was no significant difference in patient satisfaction, although significantly more women in the EVA group were bothered by noise (19% vs. 2%; P = 0.03). There were significantly more times in the EVA group that physicians would have preferred manual aspiration (43% vs. 17%; P = 0.02); this usually applied to early pregnancies.
Reference
Dean G, Cardenas L, Darney P, Goldberg A. Acceptability of manual versus electric aspiration for first trimester abortion: a randomized trial. Contraception. 2003;67 201–6.
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Original content for this slide submitted by the ARHP Clinical Advisory Committee for the Manual Vacuum Aspiration Education Partnership Project in December Original funding received from Ipas and the John Merck Fund through an unrestricted educational grant. Last reviewed/updated by the ARHP Clinical Advisory Committee for the Manual Vacuum Aspiration Education Partnership Project in October This slide is available at
Dean G, et al. Contraception
Slide 27

28. EVA and MVA risks and prevention Complication Rate/1000 procedures
Uterine perforation 1
Cervical preparation
Intra-Op Ultrasound
Hemorrhage
<12 wks – 0
Efficient completion of procedure
Retained products 3
Ultrasound
Gritty texture
Examine POC
Infection
2.5
Prophylactic antibiotics
PO doxy or IV cephalosporin
Post-abortal hematometra
1.8
N/a – unpredictable
Immediate re-aspiration required

29. Pain Management Aspiration/vacuum Medication abortion Preparation
Music
Support during procedure
PO or IV sedation
Paracervical block
Medication abortion
NSAIDS
Oral narcotics and antiemetics if necessary

30. Case No. 2
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?

31. Case No. 2 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?

32. Septic Abortion Signs/Symptoms Investigations Management
Any of above types of abortion with any of the following:
- T ≥ 38◦C
- Tachycardia
- Purulent discharge
- Pelvic pain
- Possible pregnancy
interference
CBC with diff
T&S
T&C prn
IVF and/or blood
Monitor VS and UOP
IV antibiotics
D&C
At risk for coagulopathy

33. Case No. 3 What’s in your differential diagnosis?
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?

34. Diagnostic tools for early pregnancy Transvaginal ultrasound
Estimated β-hCG values and associated findings on transvaginal ultrasound in early pregnancy
EGA
β-hCG (IU/L)
Visualization
5 wks
>1500*
Gestational sac
6 wks
>5,200
Fetal pole
7 wks
>17,500
Cardiac motion
*Discriminatory zone depends on resolution of ultrasound used.

35. Case No. 3 Continued What is her likely diagnosis?
Her β-HCG 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?

36. Case No. 4
A 38 year-old G1P0 had an ultrasound that showed fetal anencephaly at 20 weeks. 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?

37. 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

38. 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

39. 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
1/3 in women under 20 yrs 1/
1/3 older than 24

40. Putting Induced Abortion
Options for Therapeutic Abortion: Aspiration Versus Medication
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
Talking Points
The risk of dying from an abortion is low compared with many other risks to which women are regularly exposed.
References
Gold RB, Richards C. RU 486: medical breakthrough held hostage. Issues Sci Technol. 1990;6(4):74–8.
Hatcher RA. 10 common questions on emergency contraception. Contracept Technol Update. 1998;19(1):6,11–12.
Mokdad AH, Stroup DF, Giles WH. Public Health Surveillance for Behavioral Risk Factors in a Changing Environment: Recommendations from the Behavioral Risk Factor Surveillance Team. MMWR Recomm Rep. 2003;52(RR-09):1–12
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Original content for this slide submitted by the ARHP Clinical Advisory Committee for the Manual Vacuum Aspiration Education Partnership Project in December Original funding received from Ipas and the John Merck Fund through an unrestricted educational grant. Last reviewed/updated by the ARHP Clinical Advisory Committee for the Manual Vacuum Aspiration Education Partnership Project in October This slide is available at
Gold RB, Richards C. Issues Sci Technol ; Hatcher RA. Contracept Technol Update ; Mokdad AH, et al. MMWR Recomm Rep
Slide 40

41. Earlier Procedures are Safer
Options for Therapeutic Abortion: Aspiration Versus Medication
Earlier Procedures are Safer
Abortions at < 8 weeks = lowest risk of death
61%
≤8 weeks 18 10 6 1 4 ≤8
9 to 10
11 to 12
13 to 15
16 to 20
≥21
Weeks Gestation
Gestational Age
Strongest risk factor for abortion-related mortality
Talking Points
The lowest rates of abortion-related mortality are among women who have their abortions in the first trimester of pregnancy, particularly within the first 8 weeks of pregnancy:
Gestational Age Mortality Rate Relative Risk
(deaths/100K procedures)
< 8 wks Referent
9–10 wks (0.5, 4.2)
11–12 wks (1.2, 9.7)
Up to 87% of deaths in women undergoing aspiration abortions after 8 weeks could have been avoided if the abortion had been performed before 8 weeks.
Reference
Bartlett L, Berg CJ, Shulman HB, et al. Risk factors for legal induced abortion-related mortality in the United States. Obstet Gynecol. 2004;103(4):729–37.
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Original content for this slide submitted by the ARHP Clinical Advisory Committee for the Manual Vacuum Aspiration Education Partnership Project in December Original funding received from Ipas and the John Merck Fund through an unrestricted educational grant. Last reviewed/updated by the ARHP Clinical Advisory Committee for the Manual Vacuum Aspiration Education Partnership Project in October This slide is available at
Bartlet L, et al. Obstet Gynecol
Slide 41

42. 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

43. Medical abortion methods Mifepristone Misoprostol
Options for Therapeutic Abortion: Aspiration Versus Medication
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 hours for this to occur*
Misoprostol
Synthetic prostaglandin E1 analog
Inexpensive
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
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Original content for this slide submitted by the ARHP Clinical Advisory Committee for the Manual Vacuum Aspiration Education Partnership Project in December Original funding received from Ipas and the John Merck Fund through an unrestricted educational grant. Last reviewed/updated by the ARHP Clinical Advisory Committee for the Manual Vacuum Aspiration Education Partnership Project in October This slide is available at
Slide 43

44. Contraindications to Medical Abortion
Suspected or confirmed ectopic pregnancy
Anemia (Hb < 9.5 g/dL)
IUCD
Coagulopathy or use of anti-coagulants
Chronic adrenal failure
Intolerance or allergy to medications
Inability to follow instructions

45. Gestational age (days) Complete abortion rate (%)
Options for Therapeutic Abortion: Aspiration Versus Medication
Medical abortion protocols
Mifepristone 200 mg orally
Misoprostol 800 mcg
Vaginally 6 hours later or
Buccal or sublingual hours later
Follow up 1-2 weeks later with history and pelvic exam or ultrasound
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Original content for this slide submitted by the ARHP Clinical Advisory Committee for the Manual Vacuum Aspiration Education Partnership Project in December Original funding received from Ipas and the John Merck Fund through an unrestricted educational grant. Last reviewed/updated by the ARHP Clinical Advisory Committee for the Manual Vacuum Aspiration Education Partnership Project in October This slide is available at
Gestational age (days)
Complete abortion rate (%)
< 63
95-99%
64-70
93%
SFP Guidelines, Contraception 2014.
Slide 45

46. 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 days after a second trimester abortion; risk of pregnancy is great and must be addressed
Lactation can occur between days 3-7 post-abortion
Procedure
Follow-up
Nyoboe 1990

47. 2nd trimester induced abortion
Labor induction
Dilation & evacuation (D&E)

48. 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
Cervical preparation required before procedure

49. Labor Induction Abortion
Patient is awake
Fetus delivered intact

50. Labor Induction Abortion
Hospital admission
Misoprostol or misoprostol and mifepristone to cause contractions and uterine evacuation
20% may require vacuum aspiration for retained placenta

51. 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

52. D&E Step 1 Laminaria cervical Preparation Osmotic dilators
Dried compressed seaweed sticks, mm 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

53. 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

54. D&E risks and prevention
Complication
Rate/1000 procedures
Prevention
Uterine perforation 1
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 products
5-20
Ultrasound, Gritty texture
Examine POC
Infection
2.5
Prophylactic antibiotics
PO doxy or IV cephalosporin
Post-abortal hematometra
1.8
n/a – unpredictable
Immediate re-aspiration required

55. 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 ß-hCG
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

56. References and Resources
Additional references not included in slides:
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 (p ).
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).
These slides were modified from the original slides created by Jennifer Tang, MD and Erika Levi, MD.