1. 1 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

2. 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. 3 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 Focused History for Case No. 1

4. 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. 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 6

7. 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. 8 Diagnosis of Pregnancy by Transvaginal Ultrasound EGAβhCG (IU/L) Visualization 5 wks>1500Gestational sac 6 wks>5,200Fetal pole 7 wks>17,500Cardiac motion

9. 9 Signs of early pregnancy failure If ultrasound measurements are: ▪ 5mm CRL and no FHR (“embryonic demise”) ▪ 10mm Mean Sac Diameter and no 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. 10 Early Pregnancy Failure (EPF) Language is important ▪ Abortion: termination or expulsion of a pregnancy, whether spontaneous or induced, prior to viability.

11. 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. 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. 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. 14 Threatened Abortion Definition ▪ Vaginal bleeding before the 20 th 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. 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. 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. 17 SAB/EPF Non-Chromosomal Etiologies ▪ Maternal systemic disease: ▫HTN, renal disease, SLE, antiphospholipid syndrome ▪ Infectious factors: ▫Rubella, CMV, Mycoplasma, Listeria, Toxoplasmosis ▪ Endocrine factors: ▫DM, hypothyroidism, “luteal phase defect” from progesterone deficiency

18. 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. 19 Management options 1.Uterine evacuation by suction (D&C) ▫Manual ▫Electric 2.Uterine evacuation by medication

20. 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. 21 Electric Vacuum Aspirator Creinin MD, et al. Obstet Gynecol Surv. 2001.; Goldberg AB, et al. Obstet Gynecol. 2004.; Hemlin J, et al. Acta Obstet Gynecol Scand. 2001. Electric vacuum aspirator Uses an electric pump or suction machine connected via flexible tubing

22. 22 Comparison of EVA to MVA Dean G, et al. Contraception. 2003. EVAMVA VacuumElectric pumpManual aspirator NoiseVariableQuiet PortableNot easilyYes AnesthesiaConscious sedation and paracervical block Capacity350–1,200 cc60 cc AssistantNot necessaryHelpful

23. 23 MVA and EVA Risks and preventing the risks Complication Rate/1000 procedures Prevention Uterine perforation1 Cervical preparation Intra-Op Ultrasound Hemorrhage<12 wks – 0 Efficient completion of procedure Retained products3 Ultrasound Gritty texture Examine POC Infection2.5 Prophylactic antibiotics PO doxy or IV cephalosporin Post-abortal hematometra 1.8 N/a – unpredictable Immediate re-aspiration required

24. 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. 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. 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. 27 Efficacy: Medication vs. Expectant Management Misoprostol 600 μg vaginally Expectant management (placebo) Success by day 273.1%13.5% Success by day 788.5%44.2% Evacuation needed 11.5%55.8% Bagratee JS, et al. Hum Reprod. 2004.

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

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

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

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. 31

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 32

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 33

34. 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. 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. Incident Chance of death Terminating pregnancy < 9 weeks1 in 500,000 Terminating pregnancy > 20 weeks1 in 8,000 Giving birth1 in 7,600 Driving an automobile1 in 5,900 Using a tampon1 in 350,000

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

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

38. 38 Medication Abortion 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

39. 39 First Trimester Medication Induced Abortion Gestational age (days) Complete abortion rate (%) Time to expulsion (after misoprostol) < 4991–97 49%–61% within 4 hours < 5683–95 87%–88% within 24 hours < 6388 1.Mifepristone 200-600 mg p.o. administered in clinic 2.Misoprostol 400-800 mcg orally or buccally 24-48h later. 3.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. 40 Second Trimester Induced Abortion Epidemiology Etiology Management

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

42. 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 43

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

45. 45 D&E 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

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 46

47. 47 Second trimester D&E risks and preventing the risks Complication Rate/1000 procedures Prevention Uterine perforation1 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 products5-20 Ultrasound, Gritty texture Examine POC Infection2.5 Prophylactic antibiotics PO doxy or IV cephalosporin Post-abortal hematometra 1.8 n/a – unpredictable Immediate re-aspiration required

48. 48 2 nd trimester 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

49. Requirements for a Safe D&E Program 49 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. 50 Labor Induction Abortion One office visit – then hospital admission. Hypertonic saline amnioinfusion, intracardiac KCl, intra-amniotic digoxin to induce fetal death Misoprostol or pitocin to cause contractions and uterine evacuation May require vacuum aspiration for retained placenta

51. 51 Labor Induction Abortion Patient is awake Can obtain analgesia for pain Fetus delivered intact Often only option for obese women.

52. 52 References – Text books Management of Unintended and Abnormal Pregnancy. Paul M. et al. First Edition. Wiley Blackwell, 2009. Williams Obstetrics. Cunningham, FG et al. 22 nd Edition. McGraw Hill; 2005.