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First Trimester
Bleeding and Abortion
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
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?
Most Common Differential Diagnosis of
1st Trimester Bleeding




Ectopic pregnancy
Normal intrauterine pregnancy
Threatened abortion
Abnormal intrauterine pregnancy
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 (@14 days after ovulation)
– βhCG is 100 IU/L
 Within first 30 days – β-hCG doubles in 48-72 hours
 Important for pregnancy diagnosis prior to
ultrasound diagnosis
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
Threatened abortion
Signs/
Symptoms
•
•
•
•
•
Closed cervix
Viable fetus
Uterine size = GA
Minimal bleeding
Minimal/no pain
Work Up
• Ultrasound for
viability
• T&S
Management
• No specific
treatment
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
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?
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*
Doubilet, NEJM 2013
Morse, Fert Ster 2012
Abortion definitions
 Definition
 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
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
Spontaneous abortion:
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 – 50%
 Non-chromosomal – 50%
SAB/EPF: Chromosomal Etiologies
 50% trisomies
 50% triploidy, tetraploidy, X0
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
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
Inevitable Abortion
Signs/Symptoms
• Open cervix
• Bleeding, but no
passage of POCs
• Abdominal pain
• Uterine size = GA
Work Up
•
•
•
•
T&S
CBC prn
Crossmatch prn
Vitals – if concern
for infection, treat
as with septic
abortion
Management
Three options:
1) Expectant
2) Medical
3) Surgical
• Bereavement counseling
• Contraception prn
Incomplete Abortion
Signs/Symptoms
Investigations
• Open cervix
• POCs partially
expelled
• Bleeding/pain
• Uterine size < GA
• Abdominal pain
• T&S
• CBC
• Crossmatch prn
Management
• Same as with
inevitable abortion
• If in shock:
- IVF and/or blood
- Surgical
management
Complete Abortion
Signs/Symptoms
• Closed cervix
• POCs completely
expelled
• Small uterus
• Minimal
pain/bleeding
Work Up
• T&S
• CBC prn
• Ultrasound to
confirm empty
uterus
Management
• Bereavement
counseling
• Fe supplement prn
• Contraception prn:
start immediately if
passage of POCs
within past 2 weeks
Missed Abortion
Signs/Symptoms
• Closed cervix
• No bleeding/pain
• Loss of pregnancy
symptoms
Investigations
• T&S
• CBC prn
• Ultrasound to
confirm nonviability
Management
1) Expectant – okay for longer
than inevitable abortion
2) Medical
3) Surgical
Management of spontaneous abortion
1. Expectant management
2. Uterine evacuation by medication
3. Uterine evacuation by suction


Manual
Electric
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%
Bagratee JS, et al. Hum Reprod. 2004.
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
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
MVA Label. Ipas. 2007.
Surgical management SAB/EPF
Electric Vacuum Aspirator
Electric vacuum aspirator
 Uses an electric pump or suction
machine connected via flexible
tubing
Creinin MD, Obstet Gynecol Surv. 2001
Goldberg AB, Obstet Gynecol. 2004
Hemlin J, Acta Obstet Gynecol Scand. 2001
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
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
Dean G, et al. Contraception. 2003.
EVA and MVA risks
and prevention
Complication
Uterine
perforation
Hemorrhage
Rate/1000
procedures
Prevention
Cervical preparation
1
Intra-Op Ultrasound
<12 wks – 0 Efficient completion of procedure
Retained
products
3
Infection
2.5
Post-abortal
hematometra
1.8
Ultrasound
Gritty texture
Examine POC
Prophylactic antibiotics
PO doxy or IV cephalosporin
N/a – unpredictable
Immediate re-aspiration required
Pain Management
 Aspiration/vacuum





 Medication abortion
Preparation
Music
Support during procedure
PO or IV sedation
Paracervical block
 NSAIDS
 Oral narcotics and
antiemetics if necessary
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?
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?
Septic Abortion
Signs/Symptoms
Investigations
• Any of above types • CBC with diff
of abortion with
• T&S
any of the
• T&C prn
following:
- T ≥ 38◦C
- Tachycardia
- Purulent discharge
- Pelvic pain
- Possible pregnancy
interference
Management
•
•
•
•
•
IVF and/or blood
Monitor VS and UOP
IV antibiotics
D&C
At risk for coagulopathy
Case No. 3
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?
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.
Case No. 3 Continued
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?
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?
Induced Abortion/Pregnancy Termination
Language:
Indications





 Personal choice
 Medical indication
(hemorrhage, infection)
 Medical recommendation
(SLE, Pulmonary HTN, PPROM)
 Fetus diagnosed with
anomalies
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
Methods
 Dependent upon gestational
age and provider abilities
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
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
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
Gold RB, Richards C. Issues Sci Technol. 1990.; Hatcher RA. Contracept Technol Update.
1998.; Mokdad AH, et al. MMWR Recomm Rep. 2003.
Earlier Procedures are Safer
Abortions at < 8 weeks = lowest risk of death
1
Gestational Age
Strongest risk factor
for abortion-related
mortality
Weeks Gestation
4
≤8
6
9 to 10
10
61%
18
11 to 12
≤8 weeks
13 to 15
16 to 20
≥21
Bartlet L, et al. Obstet Gynecol. 2004.
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
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 24-48 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
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
Medical abortion protocols
1. Mifepristone 200 mg orally
2. Misoprostol 800 mcg
- Vaginally 6 hours later or
- Buccal or sublingual 24-48 hours later
3. Follow up 1-2 weeks later with history and pelvic exam or
ultrasound
Gestational age (days)
Complete abortion rate (%)
< 63
95-99%
64-70
93%
SFP Guidelines, Contraception 2014.
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 post-abortion
 Procedure
 Follow-up
Nyoboe 1990
2nd trimester induced abortion
• Labor induction
• Dilation & evacuation (D&E)
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
Labor Induction Abortion
 Patient is awake
 Fetus delivered intact
Labor Induction Abortion
 Hospital admission
 Misoprostol or misoprostol and mifepristone to cause
contractions and uterine evacuation
 20% may require vacuum aspiration for retained
placenta
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 hospitalbased care
D&E Step 1
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
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
D&E risks and prevention
Complication
Uterine
perforation
Hemorrhage
Retained
products
Infection
Post-abortal
hematometra
Rate/1000
procedures
Prevention
Cervical preparation
1
Intra-Op Ultrasound
Adequate anesthesia
13-15 wks: 12 Paracervical block which includes
17-25 wks: 21 vasopressin 4 units.
Efficient completion of procedure
Ultrasound, Gritty texture
5-20
Examine POC
Prophylactic antibiotics
2.5
PO doxy or IV cephalosporin
n/a – unpredictable
1.8
Immediate re-aspiration required
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
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 (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).
These slides were modified from the original slides created by Jennifer
Tang, MD and Erika Levi, MD.