Bleed

First Trimester Bleeding

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First Trimester Bleeding, Early Pregnancy Loss, Spontaneous Abortion, Miscarriage, Inevitable Abortion, Missed Abortion, Septic Abortion, Incomplete Abortion, Complete Abortion, Blighted Ovum, Embryonic Resorption, Subchorionic Hemorrhage, Threatened Abortion, Decidua, Decidual Cyst

  • 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
  • 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, Embryonic Demise)
    1. Embryo >5 mm without fetal heart activity
    2. Retained non-viable conception products up to 4 weeks
  4. Septic Abortion
    1. Incomplete Abortion with secondary ascending 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, Anembryonic Pregnancy)
    1. Gestational Sac (>18 mm) and placenta present
    2. Failure of Embryo to develop (no Yolk Sac or Embryo)
  8. Subchorionic Hemorrhage
    1. Blood collected between chorion and uterine wall
  9. Threatened Abortion
    1. Uterine bleeding before 20 weeks (often accompanied by abdominal cramping)
    2. Cervix closed
    3. Ultrasound with intrauterine pregnancy (typically, Embryo with fetal heart activity)
    4. 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
  • 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
  • Risk Factors
  • Associated with Spontaneous Abortion
  1. See Ectopic Pregnancy for associated risk factors
  2. Advanced maternal age
  3. 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
  4. Alcohol Abuse increases risk of euplodic abortion
    1. Abortion risk doubled for twice weekly Alcohol
    2. Abortion risk tripled for daily Alcohol use
  5. Illicit Drug Use
  6. Occupational chemical exposure
  7. 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):1839-45 [PubMed]
    5. Savitz (2008) Epidemiology 19(1):55-62 [PubMed]
  8. Uterine surgeries or anomalies
  9. Incompetent Cervix
  10. Diabetes Mellitus (Uncontrolled)
  11. Progesterone deficiency
  12. Thyroid disease
  13. Connective Tissue disorder
    1. Systemic Lupus Erythematosus
    2. Antiphospholipid Antibodies
      1. Lupus Anticoagulant
      2. Anticardiolipin Antibodies
  • Myths
  • Factors not associated with pregnancy loss
  1. Stress
  2. Sexual activity
  3. Air Travel
  4. Exercise
  5. Contrceptive use
  6. HPV Infection
  • History
  1. Quantity and rate of blood loss
  2. Pelvic Pain or cramping
  3. Symptoms of pregnancy
  4. Positive Pregnancy Test
  5. Fever
  • Physical Exam
  1. Vital Signs
    1. Temperature
      1. Fever suggests Septic Abortion
    2. Orthostatic Blood Pressure and Pulse
      1. Hypotension raises suspicion for hemoperitoneum
  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. Pelvic and vaginal exam
    1. Cervical motion tenderness
    2. Adnexal Mass or pelvic mass
    3. Non-uterine source of bleeding
      1. Cervical erosions
      2. Cervical polyps
    4. Cervix dilated
      1. Undilated Cervix will not pass ring forceps
      2. Dilated Cervix suggests Inevitable Abortion
    5. Material at cervical os
      1. Blood from os
      2. Tissue at cervical os (products of conception)
        1. Remove with ring forceps if accessible
        2. May confirm intrauterine pregnancy loss (Incomplete Abortion)
  • Differential Diagnosis
  1. Threatened or Incomplete Abortion
  2. Ectopic Pregnancy
  3. Twin loss
  4. Placenta consolidation
  5. Cervicitis (may cause Friable Cervix)
  6. Vaginitis
  7. Cervical or vaginal neoplasia
  8. Hydatiform mole (complete or partial Molar Pregnancy)
  9. Chorionic cyst
  10. Subchorionic Hemorrhage
  1. Quantitative bhCG
    1. Anticipate doubling every 48-72 hours, weeks 4-8
    2. Precaution: Inadequate HCG increase does not distinguish ectopic from failing pregnancy
    3. Only helpful if no intrauterine pregnancy seen on Ultrasound
  2. 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 with Miscarriage
      1. Chorionic villi (rinse and float with saline)
      2. Embryo
      3. Intact Gestational Sac
  3. Complete Blood Count of Hemoglobin Indications
    1. Hemodynamically unstable patient
    2. Hemoperitoneum
    3. Suspected Ectopic Pregnancy
    4. Heavy Vaginal Bleeding
  4. Blood Type and Antibody screen Indications
    1. Obtain if hemodynamically unstable (also obtain cross-match for units)
    2. Obtain if not already performed in pregnancy and bleeding more than spotting (warranting RhoGAM, see below)
  5. STD Screening Indications
    1. Obtain if high suspicion or not yet performed in current pregnancy
    2. Gonorrhea DNA probe
    3. Chlamydia DNA probe
    4. Saline preparation (wet prep)
  6. Urinalysis
    1. Indicated for Urinary Tract Infection symptoms
    2. Urinary Tract Infection is not associated with pregnancy
  • Labs
  • Deferred to Obstetrics Visit
  1. Pap Smear
  2. Serum Progesterone (typically for obstetrician use)
    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
  • Imaging
  1. FAST Exam
    1. Hemoperitoneum
  2. Transvaginal Ultrasound (start with transabdominal Ultrasound)
    1. Gestational Sac by bHCG 1800 mIU/ml on Transvaginal Ultrasound
    2. Gestational Sac by bHCG 3500 mIU/ml on transabdominal Ultrasound
    3. Fetal cardiac activity by bHCG 20,000 mIU/ml
    4. Emergency Bedside UltrasoundTest Specificity >98%
      1. ED providers may safely exclude Ectopic Pregnancy with Bedside Ultrasound and discharge home
      2. McRae (2009) CJEM 11(4): 355-64 +PMID:19594975 [PubMed]
  • Management
  • Overall
  1. Precautions
    1. Assume Ectopic Pregnancy if no prior Ultrasound confirmation of intrauterine pregnancy
  2. General
    1. Bedside Ultrasound is highly accurate (98% Test Specificity) at identifying intrauterine pregnancy at 5.5 weeks
      1. Additional testing (unless other indication) is not needed if IUP confirmed
      2. RhoGAM is not needed for spotting and Quantitative hCG is not needed if IUP is confirmed
      3. Patient may safely be discharged home (see reference above under Ultrasound)
    2. Give RhoGAM if mother is Rh negative
      1. Dose prior to 12 weeks gestation: 50 mcg dose
        1. Controversial, especially for Threatened Abortion (many providers do not give if <12 weeks gestation)
      2. Dose after 12 weeks gestation: 300 mcg dose
        1. In some regions, 300 mcg dose is given regardless of Gestational age
  3. 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
        1. Hematoma between chorion and uterine wall
        2. Miscarriage risk: 9% (with risk up to 30% for older maternal age)
      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 and mild bleeding
          1. Maternal age under 35 years: 2.1%
          2. Maternal age over 35 years: 16.1%
  4. 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
  • Management
  • Threatened Abortion
  1. Maximize Hydration
    1. Intravenous isotonic crystalloid
    2. Oral hydration if tolerated
  2. Give RhoGAM if mother is Rh negative (see above)
    1. Evidence is poor for giving RhoGAM before 12 weeks for Threatened Abortion (Rh Sensitization rare at this gestation)
    2. In threatened Ab, most providers do not give RhoGAM for spotting, only for significant bleeding (or ectopic, Miscarriage)
    3. Karanth (2013) Cochrane Database Syst Rev (3):CD009617 [PubMed]
  3. Disposition: Expectant management
    1. Oral hydration
    2. Pelvic rest (including abstaining from intercourse)
    3. Precautions for return
    4. Close interval follow-up with obstetrics provider
  • Management
  • Inevitable, incomplete or Complete Abortion
  1. Precautions
    1. Incomplete Abortion require prompt obstetric evaluation due to risk of Septic Abortion or Hemorrhage with delay
  2. General
    1. Consider intravenous hydration
    2. Consider complications (e.g. Septic Abortion)
    3. Give RhoGAM if mother is Rh negative (see above)
    4. Follow serial Quantitative hCGs until 0
  3. Observation Indications (effective in 85% of cases)
    1. Gestational age under 8 weeks
    2. Most first trimester losses may pass spontaneously
    3. Stable patient
  4. Misoprostel (Cytotec)
    1. Efficacy
      1. Highly effective in missed Spontaneous Abortion
        1. Wood (2002) Obstet Gynecol 99:563-6 [PubMed]
      2. No benefit in incomplete Spontaneous Abortion
        1. Nielsen (1999) Br J Obstet Gynaecol 106:804-7 [PubMed]
      3. Completes first trimester SAB within 2 weeks: 66%
        1. Blanchard (2004) Obstet Gynecol 103:860-5 [PubMed]
    2. Dosing in first trimester Miscarriage
      1. Vaginal: 800 mcg intravaginally for 1 dose (may be repeated after 3 days if not effective)
      2. Oral: 600 mcg orally for 1 dose (may be repeated after 3 days if not effective)
  5. Dilatation and Curettage (or Dilatation and Evacuation) 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)
  6. 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
  7. Manage intrauterine bleeding
    1. Typical bleeding
      1. Remove products at Cervix (helps to decrease bleeding by allowing cervical os to close)
      2. Intravenous Normal Saline with 30u Pitocin/Liter at 200 cc/hour
      3. Methergine 0.2 mg orally four times daily for 6 doses as needed for bleeding
    2. Hemorrhage
      1. Perform typical bleeding measures as above
      2. Emergency obstetrics Consultation
      3. ABC Evaluation
      4. Obtain 2 large bore IVs (14-16 gauge)
      5. Transfusion Packed Red Blood Cells (O negative)
      6. Emergent dilatation and curettage (D & C)
      7. Vaginal packing with moist sterile gauze may be attempted for vaginal packing
      8. Foley Catheter inflated within Uterus
      9. Consider Tranexamic Acid IV
      10. Consider vasopressin if suspected or known Von Willebrand Disease
    3. References
      1. Herbert and Cardy in Cardy (2017) EM:Rap 17(6):4
  • Management
  • Post-Pregnancy Loss Care
  • Complications
  1. Septic Abortion (septic Miscarriage)
  2. Hemorrhage
  3. Rh Sensitization
  • References