Obstetrics Book

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First Trimester BleedingAka: Spontaneous Abortion, Incomplete Abortion, Complete Abortion, Blighted Ovum, Embryonic Resorption, Subchorionic Hemorrhage, Threatened Abortion, Decidua, Decidual Cyst, Miscarriage, Inevitable Abortion, Missed Abortion, Septic Abortion

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  1. See Also
    1. Uterine Bleeding in Pregnancy
    2. Late Pregnancy Bleeding
  2. Epidemiology
    1. Incidence of first trimester bleeding: 25-30%
      1. Miscarriage occurs in 50% of bleeding cases
      2. Even if viable, higher complication risk post-bleed
    2. Half of conceptions miscarry in first 12 weeks
  3. Definitions
    1. Spontaneous Abortion (miscarriage)
      1. Gestational age <20 weeks
      2. Considered early spontaneous abortion if <12 weeks
      3. Weight <500 grams
    2. Inevitable Abortion
      1. Bleeding and rupture of Gestational Sac <20 weeks
      2. Cervix dilated
      3. Menstrual-type cramping
      4. No products of conception expelled yet
    3. Missed Abortion (fetal demise)
      1. Retained non-viable conception products up to 4 weeks
    4. Septic abortion
      1. Incomplete abortion with secondary infection
      2. Results in Endometritis, parametritis or peritonitis
    5. Incomplete Abortion
      1. Incomplete evacuation of products of conception
    6. Complete Abortion
      1. Complete evacuation of products of conception
      2. Difficult to differentiate from Incomplete Abortion
        1. May require dilatation and curettage for diagnosis
    7. Blighted Ovum (Embryonic Resorption)
      1. Gestational Sac and placenta present
      2. Failure of Embryo to develop
    8. Subchorionic Hemorrhage
      1. Blood collected between chorion and uterine wall
    9. Threatened Abortion
      1. Uterine bleeding
      2. Cervix closed
      3. Risk of Complete Abortion: 50%
    10. Decidua
      1. Pregnancy endometrium passed with miscarriage
      2. Consider Ectopic Pregnancy if passed intact
        1. Known as decidual cyst
    11. Induced Abortion
      1. Elective Abortion or
      2. Therapeutic Abortion
  4. Causes
    1. Autosomal Trisomy (most common miscarriage etiology)
    2. Chromosomal Triploidy or Monosomy
    3. Uterine anomaly (e.g. Leiomyoma, DES Exposure)
    4. Incompetent cervix
    5. Progesterone deficiency (late Luteal Phase defect)
    6. Environmental factors
      1. See risk factors below
  5. Risk Factors: Associated with Spontaneous Abortion
    1. Advanced maternal age
    2. Cigarette smoking increases risk of euploidic abortion
      1. Over 14 Cigarettes/day doubles risk over non-smokers
      2. Relative Risk increases 1.2x for each 10 cigs/day
    3. Alcohol Abuse increases risk of euplodic abortion
      1. Abortion risk doubled for twice weekly Alcohol
      2. Abortion risk tripled for daily Alcohol use
    4. Illicit Drug Use
    5. Occupational chemical exposure
    6. Caffeine may be associated with miscarriage (variable evidence)
      1. Small amounts of caffeine are safe in pregnancy
      2. Limit caffeine intake to 200 mg/day (e.g. 12 ounces coffee)
      3. Be aware of all potential caffeine sources
      4. Cnattingius (2000) N Engl J Med 343(25):1839
      5. Savitz (2008) Epidemiology 19(1):55
    7. Uterine surgeries or anomalies
    8. Incompetent cervix
    9. Diabetes Mellitus (Uncontrolled)
    10. Connective Tissue disorder
      1. Systemic Lupus Erythematosus
      2. Antiphospholipid Antibodies
        1. Lupus Anticoagulant
        2. Anticardiolipin Antibodies
    11. Factors not associated with pregnancy loss
      1. Stress
      2. Sexual activity
  6. History
    1. Quantity and rate of blood loss
    2. Pelvic Pain or cramping
    3. Symptoms of pregnancy
    4. Positive Pregnancy Test
    5. Fever
  7. Physical Exam
    1. Vital Signs
      1. Temperature
      2. Orthostatic Blood Pressure and Pulse
    2. Assess pregnancy and dating
      1. Fetal Heart Tones (if >10-11 weeks gestation)
      2. Determine Uterine Size by bimanual exam
        1. Smaller than expected size in miscarriage
      3. Chadwick's Sign (cervix cyanotic)
      4. Hegar's Sign (soft isthmus)
    3. Abdominal exam (always consider Ectopic Pregnancy)
      1. Peritoneal signs (e.g. rebound tenderness)
      2. Abdominal distention
    4. Vaginal exam
      1. Cervical motion tenderness
      2. Non-uterine source of bleeding
        1. Cervical Erosions
        2. Cervical polyps
      3. Cervix dilated
        1. Undilated cervix will not pass ring forceps
        2. Dilated cervix suggests inevitable abortion
      4. Material at cervical os
        1. Blood from os
        2. Tissue at cervical os
          1. Remove with ring forceps if accessible
  8. Differential Diagnosis
    1. Threatened or incomplete Abortion
    2. Ectopic Pregnancy
    3. Twin loss
    4. Placenta consolidation
    5. Cervicitis or Vaginitis
    6. Cervical or vaginal neoplasia
    7. Hydatiform mole
    8. Chorionic cyst or subchorionic hemorrhage
  9. Diagnostics: Initial
    1. Quantitative bhCG
      1. Anticipate doubling every 48-72 hours, weeks 4-8
    2. Transvaginal Ultrasound
      1. Gestational Sac by bHCG 1800 mIU/ml on transvaginal
      2. Gestational Sac by bHCG 3500 mIU/ml on transabdominal
      3. Fetal cardiac activity by bHCG 20,000 mIU/ml
    3. Serum Progesterone
      1. Predicts pregnancy outcome <10 weeks
      2. Serum Progesterone >25 ng/ml suggests live IUP
      3. Serum Progesterone <5 ng/ml suggests poor outcome
        1. Ectopic Pregnancy
        2. Spontaneous abortion
    4. Examine passed products of conception
      1. Examining physician should evaluate any tissue
      2. Also send to pathology for complete exam
      3. Findings that confirm intrauterine pregnancy
        1. Chorionic villi (rinse and float with saline)
        2. Embryo
        3. Intact Gestational Sac
  10. Diagnostics: Other
    1. Complete Blood Count
    2. Blood Type and Antibody screen
    3. Gonorrhea Culture
    4. Chlamydia screen
    5. Pap Smear
    6. Urinalysis
    7. Saline preparation (wet prep)
    8. Consider Coagulation Studies if indicated
      1. ProTime (PT)
      2. Partial Thromboplastin Time (aPTT)
      3. Fibrin split products (Fibrin Degradation Products)
      4. Fibrinogen
  11. Management: Overall
    1. General
      1. Manage Friable Cervix if present
      2. Give RhoGAM 50 mcg if mother Rh negative
    2. Quantitative bhCG >1800 to 2000
      1. Transvaginal Ultrasound shows no Gestational Sac
        1. Evaluate for Ectopic Pregnancy
        2. Bright endometrial stripe suggests complete SAB
      2. Transvaginal Ultrasound shows Gestational Sac
        1. Follow for threatened abortion
        2. Subchorionic hemorrhage (30% risk of miscarriage)
          1. Hematoma between chorion and uterine wall
        3. Gestational Sac >2 cm should contain an Embryo
        4. Embryo >5 mm in crown-rump should have heart beat
          1. Risk of miscarriage if heartbeat present
            1. Maternal age under 35 years: 2.1%
            2. Maternal age over 35 years:16.1%
    3. Quantitative bhCG <1800 to 2000
      1. Patient unstable
        1. Presumed to be Ectopic Pregnancy
        2. Immediate consult obstetrics for possible surgery
      2. Patient stable
        1. Follow serial Quantitative bhCG every 48 hours
        2. Confirm Quantitative bhCG doubles in 48 hours
        3. Confirm intrauterine pregnancy when bHCG >1800-2000
  12. Management: Threatened Abortion
    1. Maximize Hydration
      1. Intravenous isotonic crystalloid
      2. Oral hydration if tolerated
    2. Give RhoGAM if mother is Rh negative
      1. Previously gave 50 mcg dose
      2. Now full dose typically given
    3. Bedrest
    4. Pelvic rest (including abstaining from intercourse)
  13. Management: Inevitable, incomplete or complete abortion
    1. General
      1. Consider intravenous hydration
      2. Consider complications (e.g. septic abortion)
      3. Give RhoGAM if mother is Rh negative
      4. Follow serial Quantitative hCGs until 0
    2. Observation Indications
      1. Gestational age under 8 weeks
      2. Most first trimester losses may pass spontaneously
      3. Stable patient
    3. Misoprostel (Cytotec) Indications (see below)
      1. Highly effective in missed spontaneous abortion
        1. Wood (2002) Obstet Gynecol 99:563
      2. No benefit in incomplete spontaneous abortion
        1. Nielsen (1999) Br J Obstet Gynaecol 106:804
    4. Dilatation and Curettage Indications
      1. Gestational age 8 to 14 weeks
      2. Excessive intrauterine bleeding (>1 pad/hour) or pain
      3. Prolonged symptoms or delayed passage of tissue
      4. Confirm intrauterine pregnancy (chorionic villi)
    5. Delivery options for 14-20 weeks gestation
      1. Pitocin
        1. Prepare 40 units/Liter in D5LR
        2. Start at 1 mu and double rate every 20-30 minutes
        3. Endpoint
          1. Contractions adequate
          2. Hyperstimulation
      2. Prostaglandin (PG) Cervical Ripening
        1. PGE2 intravaginal suppository
          1. Dose: 20 mg suppository intravaginally
          2. Insert q3 hours until contractions adequate
        2. PG F2 alpha intraamniotic preparation
          1. Test-Dose: 6 mg (6 mg/ml)
          2. Actual Dose: 40 mg vial slowly
      3. Misoprostol orally or vaginally
        1. First trimester miscarriage : 600 mcg PO x1 dose
        2. Completes first trimester SAB within 2 weeks: 66%
        3. Blanchard (2004) Obstet Gynecol 103:860
    6. Dilatation and Evacuation
    7. Manage intrauterine bleeding
      1. Remove products at cervix
      2. Intravenous NS with 30u Pitocin/Liter at 200 cc/hour
      3. Methergine 0.2 mg PO qid for 6 doses prn bleeding
  14. Post-Pregnancy Loss Care
    1. See Grief in Pregnancy Loss
  15. References
    1. Simpson in Gabbe (2002) Obstetrics, p. 729-44
    2. Stenchever (2001) Gynecology p. 156-7
    3. Nadukhovskaya (2001) Am J Emerg Med 19(6):495
    4. Paspulati (2004) Radiol Clin North Am 42(2):297

Spontaneous abortion (C0000786)

Definition (MSH)Expulsion of the product of FERTILIZATION before completing the term of GESTATION and without deliberate interference.
Definition (CSP)the natural premature expulsion from the uterus of the products of conception, the embryo, or non-viable fetus.
Definition (NCI)Loss of the products of conception from the uterus before the fetus is viable; spontaneous abortion.
Definition (NCI)Expulsion of the products of conception before the completion of gestation without deliberate interference.
ConceptsDisease or Syndrome (T047)
ICD9634, 761.8
MSHD000022
DanishAbort spontan
DutchSpontane abortus
Englishabortion, Abortion - spontaneous, Abortion spontaneous, Abortions.spontaneous, Miscarriage, Miscarriages, Spontaneous Abortion, Spontaneous abortion unspecified, Spontaneous Abortions, Vaginal expulsion of fetus, Vaginal expulsion of product of conception
FinnishKESKENMENO
FrenchAvortement spontane
GermanSpontanabort
Hebrewhapala spontanit
Hungarianspontan abortus
ItalianAborto spontaneo
NorwegianABORT SPONTAN/INA
PortugueseAborto espontaneo
Spanishaborto espontaneo, expulsion vaginal del feto, expulsion vaginal del producto de la concepcion
SwedishSPONTAN ABORT
Parent Conceptsintrauterine disorder (C0598364), Abortion-related disorders (C0810328), Pregnancy loss (C0687675), OTHER PREGNANCY WITH ABORTIVE OUTCOME (C0178294), PREGNANCY, CHILDBEARING, FAMILY PLANNING (C0497427), Diagnosis/Diseases Component (C0497531), Pregnancy Complications (C0032962), Unspecified Abortion (C0156543), Spontaneous abortion (C0000786), Duplicate concept (C1274013)
SourcesAOD, CCS, COSTAR, CSP, CST, DXP, ICD9CM, ICPC, ICPCBAQ, ICPCDAN, ICPCDUT, ICPCFIN, ICPCFRE, ICPCGER, ICPCHEB, ICPCHUN, ICPCITA, ICPCNOR, ICPCPOR, ICPCSPA, ICPCSWE, LNC, MEDLINEPLUS, MSH, MTH, MTHICD9, NCI, NDFRT, SCTSPA, SNOMEDCT
Derived from the NIH UMLS (Unified Medical Language System)


Decidua (C0011106)

Definition (MSH)The hormone-responsive glandular layer of ENDOMETRIUM that sloughs off at each menstrual flow (decidua menstrualis) or at the termination of pregnancy. During pregnancy, the thickest part of the decidua forms the maternal portion of the PLACENTA, thus named decidua placentalis. The thin portion of the decidua covering the rest of the embryo is the decidua capsularis.
Definition (CSP)endometrium of the pregnant uterus; shed at parturition, except for the deepest layer.
Definition (NCI)The epithelial tissue of the endometrium.
ConceptsBody Part, Organ, or Organ Component (T023)
MSHD003656
EnglishDecidua, Decidua Graviditas, Decidua structure, Decidual, Deciduas, Deciduum, Endometrial decidua, Menstrual decidua
Spanishestructura de la membrana caduca, membrana caduca, membrana decidua endometrial
Parent ConceptsUterus (C0042149), Endometrium (C0014180), Placenta (C0032043), Female Reproductive System Part (C1517153), Gravid uterus structure (C0227812), Structure of product of conception (C0230953), Uterus part (C1268132)
SourcesCSP, LCH, MSH, MTH, NCI, SCTSPA, SNOMEDCT
Derived from the NIH UMLS (Unified Medical Language System)



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