FIRST TRIMESTER BLEEDING

I. Abortion--diff types:

  1. Threatened Ab = Bloody d/c from uterus w/o dil. of Cx; may subside & pregnancy may continue to term
  2. Inevitable Ab = Profuse or prolonged uterine bleeding with effaced or dilated Ca; Ab generally proceeds
  3. Missed Ab = Uterine Retention of fetus dead for >8wks; cervix usually closed
  4. Incomplete Ab = Uterus not entirely emptied of contents
  5. Septic Ab = Incomplete Ab + infection.; can lead to sepsis
  6. Induced Ab = just that; don't forget to think of back-alley
  7. Blighted ovum = Identifiable sac + placental tissue but no embryo; doesn't differentiate IUP vs. ectopic

II. 1st trimester spontaneous abortion/threatened abortion--50% of cases of 1st-TM bleeding

  1. First-trimester bleeding a.k.a. "Threatened abortion"
    1. Occurs in 15-25% of pregnancies
  2. 2/3 of first-trimester spontaneous abortions have chromosomal abnormality
  3. Risk factors:
    1. Coffee intake
      1. > 6 cups/day (NEJM 341:1639, 1999--JW)
      2. > 24 oz/day coffee ass'd with OR about 1.4 c/w < 5oz after adjusting for other risk factors in a case-control study of 562 women with miscarriage at 6-12wks and 953 controls (NEJM 343:1839, 2000--FP News; JW)
    2. Infection
    3. Poor nutrition
    4. EtOH
    5. Smoking
    6. Severe trauma
  4. "Habitual" miscarriage
    1. Traditional definition is 3 or more pregnancy losses prior to 20 weeks' gestation
    2. Occurs in about 1% of women but about 75% will have a subsequent successful pregnancy
    3. Specific etiology identifiabel only in about 40% of women
    4. Risk factors
      1. Anatomic uterine abnormalities, e.g. bicornuate or septate uterus or "cervical insufficiency" (aka "cervical incompetence");  The former two can be diagnosed via hysterosalpingogram or hysteroscopy.  A 2003 Cochrane review found evidence that cervical cerclage improved outcomes in women with habitual miscarriage who present with preterm cervical change.
      2. Luteal phase defect
      3. Autoimmune disorders
      4. Hypercoagulable states particularly Antiphospholipid Ab syndrome (click link for details)
      5. Polycystic ovary syndrome (presumably due to elevated androgen levels and/or elevated leutenizing hormone levels; metformin may reduce risk)
      6. Uncontrolled diabetes mellitus
      7. Parental chomosomal abnormalities
  5. Management of threatened and/or other forms of spontaneous abortion
    1. Follow serial hCG's to determine fetal viability (should double Q2-3d in wks 4-8)
    2. Consider checking progesterone--Single level in early pregnancy: < 5ng/mL predicts poor outcome; > 25ng/mL ass'd with viable IUP
    3. Surgical treatment vs. expectant management
      1. 35 women w/SpAb at < 13wks randomized to suction curettage vs. expectant management w/oral analgesics; no sig. diffs in days of bleeding, days of pain requiring meds, days in which activities were disrupted, time until return of menses, or satisfaction w/tx (Br. J. Obs. Gyn 104:840, 1997-JWWH)
      2. In a study in 1,200 women with fetal demise or incomplete Ab at < 13wks, randomized to expectant, surgical, or medical management, incidence of gynecologic infection over 14d was not sig. diff in any of the groups, though the curettage group had sig. lower incidence of hosp. admission and of unplanned surgical curettage (BMJ 332:1235, 2006--JW)
    4. Surgical treatment vs. medical treatment
      1. In study of 604 women presenting with spontaneous abortion and with retained products seen on transvaginal u/s randomized to D & E vs. misoprostol (400mg PO Q4h up to max of 3 doses). Repeat transvaginal u/s at 24h showed retained products in about 50% of misoprostol group, "complications" occurred more often in surgical group (Fertil. Steril. 71:1054, 1999--AFP)
      2. In a trial of 50 women 18-50yo with spontaneous Ab < 12wks gestation randomized to misoprostol 800ug intravaginally (re-administered at 24-48h is products of conception still visible on u/s; D & C done if tissue persisted 72h after initial tx) vs. D & C, 40% of the medical arm eventually had a D & C (Am. J. Obs. Gyn. 187:321, 2002--JW)
      3. In a trial of 169 women with incomplete abortion in 1st trimester randomized to misoprostol 600ug PO x 1 or x 2 doses, there was no diff. in the eventual need for surgical intervention (Obs. Gyn. 103:860, 2004--AFP)
      4. In a study in 652 women with incomplete spontaneous abortion randomized to misoprostol 800 micrograms intravaginally (on day 1 and again on day 3 if expulsion incomplete) vs. vacuum aspiration, 16% in the intravaginal group needed eventual surgical treatment (3% in the surgical group needed repeat aspiration within 30d) (NEJM 353:761, 2005--JW)
    5. Treatment of missed abortion
      1. Expectant management
      2. Curettage
      3. Intravaginal misoprostol
        1. In a study in 652 women with first-trimester incomplete or inevitabl Ab but no heavy bleeding randomized to vacuum aspiration vs. misoprostol (800ug vaginally with a 2nd dose on day 3 if vaginal ultrasound showed persistent products of conception and vacuum aspiration on day 8 if expulsion still incomplete), 71% of misoprostol recipients had complete expulsion of products of conception after 1 dose and 84% after 2 doses; vacuum-aspiration success rate was 90% (NEJM 353:761, 2005--JW)

II. Ectopic pregnancy--#1 cause for hypovolemic shock in 1st trimester without evidence of trauma/bleeding

III. Molar pregnancy--20% risk of recurrence

IV. Local lesion (vulva, vagina, Cx, urethra); including trauma and infection

 

APPROACH TO A PATIENT WITH FIRST TRIMESTER BLEEDING

I. Check vitals (with orthostatics & for signs of shock)

II. If pt. in shock (BP < 90/60, P > 110)

  1. Start IVF
  2. Send blood for type & cross-match 2U, CBC w/plats, PT/PTT, fibrinogen, quant. hCG
  3. Do U/S: if IUP and + FHR then < 1% chance of miscarriage
  4. Do culdocentesis--if blood, prob. ruptured ectopic!
  1. Take immediately to O.R. for laparotomy
  2. Transfuse with RBCs as rapidly as possible

III. If not in shock,

  1. On Px:
  1. CMT suggests various dx's (see "Acute pelvic pain and salpingitis" below)
  2. May see local source for bleeding
  3. Uterine/adnexal tenderness suggests infection
  4. Disruption of rectovag. septum suggests dissecting pelvic abcess
  1. Do vaginal u/s; look for gest. sac (visible in IUP @6wks), fetal heart (after 6wks), adnexal masses, fluid in cul-de-sac
  2. Laparoscopy sometimes indicated
IV. If stable and IUP, see above re: management of spontaneous abortion/threatened abortion

(Sources include Core Content Review of Family Medicine, 2012)