View source for First trimester abortion

''See [[Vaginal bleeding in pregnancy (less than 20wks)]] for diagnostic approach to early vaginal bleeding in pregnancy.''
==Background==
*Estimates are up to 15% of pregnancies end in a 1st trimester abortion, usually due to fetal chromosomal abnormalities
*Primary risk factors include history of prior miscarriage and advanced maternal age<ref>Maconochie N, Doyle P, Prior S, Simmons R. Risk factors for first trimester miscarriage--results from a UK-population-based case-control study. BJOG. 2007;114(2):170–186. doi:10.1111/j.1471-0528.2006.01193.x</ref>
**Other risk factors include heavy alcohol use, uterine structure abnormalities, and systemic maternal disease
{{Abortion types}}

==Clinical Features==
*Visualize any clots or bleeding from external os
*Assess '''internal os''' as open or closed based on ability to pass finger through os
*Pregnancy ≤ 13 weeks

==Differential Diagnosis==
{{VB DDX less than 20}}

==Evaluation==
*See [[Vaginal Bleed Pregnant (less than 20wks)]]
*Type and Screen/ABO
*Hemoglobin
*[[pelvic ultrasound (transvaginal)|Transvaginal]] or [[pelvic ultrasound (transabdominal)|transabdominal ultrasound]][[ultrasound]] finding:
**+IUP = [[threatened abortion]]
***[[Ectopic]] ruled-out unless on fertility drugs
**Empty uterus + free fluid/adnexal mass = [[Ectopic]]
**'''Empty uterus + no free fluid / no mass'''
***[[Beta-HCG Levels|Beta-HCG]]:
****>1,500 = Presumed [[ectopic]]
****<1,500 = Indeterminate: follow serial [[B-HCG]] levels in 48hrs (if no peritonitis)
*****Increased >66% = normal IUP 
*****Increased <66% = [[Ectopic]]

==Management==
*[[Rho(D) Immune Globulin (RhoGAM)|RhoGam]] can be considered if Rh Negative
** Recent 2024 ACOG practice guideline update recommends forgoing routine Rh testing and RhoGam for patients less than 12 weeks <ref>[https://pubmed.ncbi.nlm.nih.gov/39255498/| ACOG Clinical Practice Update: Rh D Immune Globulin Administration After Abortion or Pregnancy Loss at Less Than 12 Weeks of Gestation]</ref>
*[[IVF]] and/or [[PRBCs]] if severe bleeding
*[[Misoprostol]] only for < 12 weeks gestation: give 800mcg vaginally, dose can be repeated once within 7 days if no response <ref>ACOG Practice Bulletin Update. Early Pregnancy Loss. November 2018. https://www.acog.org/-/media/Practice-Bulletins/Committee-on-Practice-Bulletins----Gynecology/Public/pb200.pdf?dmc=1&ts=20181207T1637252429</ref>
**If available, mifepristone 200mg PO should be given 24 hours prior to first dose of misoprostol (NNT = 6)
**Supportive care with anti-emetic and NSAIDs for misoprostol side effects
*D&C and OB/gyn consult may be necessary if medical management fails or continuous products/vaginal bleeding > 7-14 days


==Medication Dosing==
{{MedicationDose
| drug = Misoprostol
| dose = 800mcg vaginally, repeat once in 7 days if no response
| route = Vaginal
| context = Medical management of early pregnancy loss (<12 weeks)
| indication = First trimester abortion
| population = Adult
| notes = If available, give mifepristone 200mg PO 24hr prior (NNT 6)
}}

==Disposition==
*Discharge Criteria
**After brief period of observation and if hemodynamically stable
**Discharge w/ pain medications and close OB follow-up for repeat ultrasound 
**Give strict return precautions (heavy vaginal bleeding, worsening pain, or fever)
*Admission Criteria
**If hemodynamically unstable, septic, or suspect gestational trophoblastic disease/ectopic pregnancy
**Urgent OBGYN consult if active hemorrhage and need for Dilation and Curettage

==See Also==
*[[Vaginal Bleeding (Main)]]
*[[Vaginal bleeding in pregnancy (less than 20wks)]]

==External Links==
*[https://www.merckmanuals.com/professional/gynecology-and-obstetrics/abnormalities-of-pregnancy/spontaneous-abortion?query=spontaneous%20abortion| Merk Manual: Spontaneous Abortion (Miscarriage)]
*[http://www.emdocs.net/obcast-bleeding-in-early-pregnancy-and-threatened-miscarriage/| emDocs: Bleeding in Early Pregnancy and Threatened Miscarriage]
==References==
<references/>

[[Category:OBGYN]]