1. Abortion

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

3. 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 days after ovulation) – βhCG is100 IU/L
Within first 30 days – βhCG doubles every 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

4. 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

5. 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
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. 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

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

9. Epidemiology and etiology
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

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

11. 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

12. 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

13. Outcomes and management of threatened abortion
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

14. Management of spontaneous abortion
Uterine evacuation by suction
Manual
Electric
Uterine evacuation by medication

15. Surgical management SAB/EPF
Options for Early Pregnancy Loss: MVA and Medication Management
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
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
Reference
MVA Label, United States, English. Ipas
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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
MVA Label. Ipas
Slide 15

16. 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, et al. Obstet Gynecol Surv ; Goldberg AB, et al. Obstet Gynecol ; Hemlin J, et al. Acta Obstet Gynecol Scand
Slide 16

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

18. 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
Talking Points
To perform the tissue examination part of the MVA procedure, the following equipment is needed:
Basin for POC
Fine-mesh kitchen strainer
Back light or enhanced light
Tools to grasp tissue and POC
Specimen containers
Reference
Hyman AG, Castleman L. Woman-Centered Abortion Care: Reference Manual. Chapel Hill, NC: Ipas
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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
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 18

19. 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
Conscious sedation and paracervical block
Capacity
350–1,200 cc
60 cc
Assistant
Not necessary
Helpful
Talking Points
Implications of being quiet:
Perceived as a benefit by some patients (see Dean study summarized below).
Improves patient-provider rapport.
Improves provider’s ability to “hear” the procedure (the grittiness sometimes has a sound).
Reduces patient noise-imprinting.
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 19

20. and preventing the risks
EVA and MVA risks
and preventing the risks
Complication
Rate/1000 procedures
Prevention
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

21. 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
Talking Points
Module 3: Medication Abortion includes:
Regimens for Early Medication Abortion
Early Medication Abortion Safety and Efficacy
Pain Management
- - -
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 21

22. Misoprostol 800 μg vaginally Repeat dose on day 2 or 3 if indicated
Options for Early Pregnancy Loss: MVA and 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
Talking Points
One regimen for medical treatment of early pregnancy loss is 800 μg misoprostol vaginally, with a repeat dose on day 3 if expulsion is not complete.
Lack of expulsion of the products of conception has been defined as the presence of a visible gestational sac or an endometrial lining greater than 30 mm on transvaginal ultrasound.
At this point, clinicians can offer expectant management if the woman is clinically stable, or if expulsion is incomplete, MVA or EVA can be used.
References
Zhang J, Gilles JM, Barnhart K, Creinin MD, Westhoff C, Frederick MM. A comparison of medical management with misoprostol and surgical management for early pregnancy failure. N Engl J Med. 2005;353:761–9.
Creinin MD, Huang X, Westhoff C, Barnhart K, Gilles JM, Zhang J. Factors related to successful misoprostol treatment for early pregnancy failure. Obstet Gynecol. 2006;107:901–7.
- - -
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
Zhang J, et al. N Engl J Med
Creinin MD, et al. Obstet Gynecol
Slide 22

23. Efficacy: 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%
Talking Points
Efficacy from a study by Bagratee et al. (2004), with 104 women with first trimester miscarriage who were randomly assigned to either 600 μg misoprostol vaginally or placebo.
All differences shown are statistically significant.
Reference
Bagratee JS, Khullar V, Regan L, Moodley J, Kagoro H. A randomized controlled trial comparing medical and expectant management of first trimester miscarriage. Hum Reprod. 2004;19:266–71.
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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 23

24. 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

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

26. 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)

27. Induced Abortion Epidemiology Gestational age: Complications
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
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. 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

29. 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
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
Talking Points
Module 3: Medication Abortion includes:
Regimens for Early Medication Abortion
Early Medication Abortion Safety and Efficacy
Pain Management
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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 29

30. 2nd Trimester Induced Abortion
Epidemiology
Epidemiology
14 weeks gestation and above
96% done by Dilation and Evacuation (D&E)
4% done by labor induction
1/3 in women under 20 yrs 1/
1/3 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

31. 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
1/3 in women under 20 yrs 1/
1/3 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

32. 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 postabortion
Procedure
Follow-up
Nyoboe et al 1990

33. 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

34. 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

35. 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

36. D&E Step 1 Laminaria cervical Preparation Osmotic dilators
Dried compressed seaweed sticks, mm diameter in size
Slow swelling to exert slow circumferential pressure and dilation
1-2 days prior to procedure

37. 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

38. 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

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

40. 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

41. Septic abortion CVS Broad spectrum AB. Emergency uterine evacuation.
Abdominal and chest x- ray.
culture of Uterocervical discharge.
Tetanus prophylaxis.