First trimester abortion: Difference between revisions

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''See [[Vaginal bleeding in pregnancy (less than 20wks)]] for diagnostic approach to early vaginal bleeding in pregnancy.''
==Background==
==Background==
*Estimates are up to 15% of pregnancies end in a 1st trimester abortion usually due to fetal chromosomal abnormalities
*Estimates are up to 15% of pregnancies end in a 1st trimester abortion, usually due to fetal chromosomal abnormalities


===Types===
{{Abortion types}}
====Complete Abortion====
*<12 weeks + no IUP
*Distinguish from ectopic based on decreasing hCG, decreased bleeding
*Only need to send hCG if unable to examine POC
====Threatened Abortion====
*Closed os + IUP + bloody vaginal dischrage or frank bleeding
*If <11wk >90% go to term
*If between 11 and 20wk 50% go to term
====Inevitable Abortion====
*Open os + contractions/cramps
====Incomplete Abortion====
*>12 wks + passage of only portion of POC
====Missed Abortion====
*Fetal death at <20wk w/o passage of any fetal tissue for 4wk after fetal death
====Septic abortion====
*Evidence of infection during any stage of abortion
*Most commonly caused by retained products of conception


==Clinical Features==
==Clinical Features==
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{{VB DDX less than 20}}
{{VB DDX less than 20}}


==Workup==
==Evaluation==
*See [[Vaginal Bleed Pregnant (less than 20wks)]]
*See [[Vaginal Bleed Pregnant (less than 20wks)]]
**Pelvic or Transabdominal ultasound to assess fetal dating and heartrate
*Type and Screen/ABO
**Type and Screen
*Hemoglobin
**Hemaglobin
*[[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==
==Management==
*[[Rho(D) Immune Globulin (RhoGAM)|RhoGam]] if Rh Negative
*[[Rho(D) Immune Globulin (RhoGAM)|RhoGam]] if Rh Negative
*[[IVF]] and/or [[PRBCs]] if severe bleeding
*[[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


==Disposition==
==Disposition==
*Discharge with close OB followup for repeat ultrasound  
*Discharge with close OB follow-up for repeat ultrasound  
*Urgent OBGYN consult if active hemorrhage and need for Dilation and Curretage
*Urgent OBGYN consult if active hemorrhage and need for Dilation and Curretage


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


==Sources==
==References==
*Hasan R, Baird DD, Herring AH, Olshan AF, Jonsson Funk ML, Hartmann KE. Association between first-trimester vaginal bleeding and miscarriage. Obstet Gynecol. Oct 2009;114(4):860-7
<references/>
<references/>


[[Category:OB/GYN]]
[[Category:OBGYN]]

Revision as of 19:26, 3 October 2019

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

Abortion Types

Classification Characteristics OS Fetal Tissue Passage Misc
Threatened Abdominal pain or bleeding; < 20 weeks gestation Closed No If < 11 weeks (with fetal cardiac activity) 90% progress to term. If between 11 and 20 weeks 50% progress to term
Inevitable Abdominal pain or bleeding; < 20 weeks gestation Open No
Incomplete Abdominal pain or bleeding; < 20 weeks gestation Open Yes, some
Complete Abdominal pain or bleeding; < 20 weeks gestation Closed Yes, complete expulsion of products Distinguish from ectopic based on decreasing hCG and/or decreased bleeding
Missed Fetal death at <20 weeks without passage of any fetal tissue for 4 weeks after fetal death Closed No
Septic Infection of the uterus during a miscarriage. Most commonly caused by retained products of conception Open No, or may be incomplete Uterine tenderness and purulent discharge from the OS may be present

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

Vaginal Bleeding in Pregnancy (<20wks)

Evaluation

Management

  • RhoGam if Rh Negative
  • 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 [1]
    • 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

Disposition

  • Discharge with close OB follow-up for repeat ultrasound
  • Urgent OBGYN consult if active hemorrhage and need for Dilation and Curretage

See Also

References