Bleeding Jen Phillips MD 452017 Thanks to Dr Nicole Yonke and baby Anya Objectives Understand how to address early pregnancy bleeding and pregnancy of unknown location Learn ID: 660640
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Management of 1st TrimesterBleedingJen Phillips, MD4/5/2017 Slide2Slide3
Thanks to Dr. Nicole Yonke and baby AnyaSlide4
ObjectivesUnderstand how to address early pregnancy bleeding and pregnancy of unknown location.Learn how to diagnose abnormal intrauterine pregnancy vs ectopic vs early normal pregnancy.Compare the risks and benefits of expectant management vs medical vs surgical intervention with miscarriage.Understand how to use misoprostol for medical management of miscarriage .Learn about the MVA.Slide5
pretestHow often does spontaneous abortion occur?What is a threatened vs incomplete vs inevitable vs missed abo?What are the options for management of missed abortion?How can we ‘rule out’ ectopic pregnancy?How can MVA (manual vacuum aspiration) help?Slide6
Epidemiology of early pregnancy lossOne in four women will have a miscarriage during her lifetime.May only form a gestational sac (blighted ovum or anembryonic pregnancy) or demise may occur after embryo forms. Usually under 10 weeks gestational age.Spontaneous abortion occurs 8-20% of pregnancies.Slide7
Clinical presentation of early pregnancy failureMissed abortionIncomplete abortionInevitable abortionComplete abortionSpontaneous abortionSlide8Slide9
21 yo G1 at 6w by LMPPresents with vaginal bleeding in OB triage x 1 dayWhat is the differential diagnosis? Viable IUP pregnancy MiscarriageEctopic pregnancy
Pregnancy of unknown location(PUL)
+
hCG
, but no IUP seen on USSlide10
What other history do you want?Is this a desired pregnancy?Has she had an US alreadyHistory Ectopic pregnancySABPID/STIsAMAKnown anatomic abnormalitiesDM/Thyroid diseaseSlide11
our patient continued…Ultrasound performed in triageSmall fluid collection in the uterus, no IUPSent to DI with same results on USβhCG is 2200No cramping or abdominal painNormal exam, scant brown blood in vaginal vaultHct 41, vital signs are normalRh positiveWhat category does she fall into? How would you describe this situation?Slide12
PUL: Pregnancy unknown location8-31% of women presenting with first trimester pain or vaginal bleeding will have a PUL7-20% of these women ultimately diagnosed with ectopic pregnancy40% of women with ectopic are not diagnosed at initial visitCrochet JAMA 2013; 309:1722-29Slide13
What should we do with her?Add her to the new MCH beta bookCall MCH fellow to discuss follow-up plan Place patient phone number, PUL, hCG value and follow-up plan in the comments sectionSlide14
What if pregnancy is undesired?Aspirate to rule out ectopicFollow BhCG to make sure they are falling (confirms IUP)Send POC to pathology to confirm IUPSlide15
She follows up for labs and ultrasoundDay 3 – BhCG 3520Day 5 – BhCG 5632Day 7 – repeat US gestational sac with yolk sac and embryo, no cardiac motionWhat is her diagnosis now?Has an IUP – unclear if it is viable Slide16
Previous criteria for diagnosing nonviable pregnancy were too “loose” Did not address 19% variability in ultrasonographer measurements of gestational sac and fetal pole sizeSmall study sizesErroneous treatments with methotrexate causing adverse fetal outcomes and rising lawsuitsRisk of harming a normal pregnancy with old criteriaDoubilet PM et al. N Engl J Med 2013;369:1443-1451
.Slide17
New Guidelines
for
TVUS
Dx
of
an IUP of
Uncertain
Viability
Doubilet PM et al. N Engl J Med 2013;369:1443-1451.Slide18
She returns for another US one week laterCRL 7.5 mm, no cardiac motionWhat is your diagnosis?Slide19
She asks, “How many women have a miscarriage?”One in four women will have a miscarriage during her lifetimePrine AFP 2011 Office Management of Early Pregnancy LossSlide20
She asks, “How many pregnancies end in SAB?”12-24% of women with a +PGU will have a pregnancy lossTrue rate likely higher ~30% because many losses occur pre-clinically before a missed LMPUsually under 10 weeks gestational ageJurkovic
BMJ 2013; 345Slide21
What is the most common cause of pregnancy loss?Chromosomal abnormalities are the most common cause Detected in 50-85% of pregnancy tissue specimens after a spontaneous abortionJurkovic BMJ 2013; 345Slide22
What are risk factors for early loss?Advanced Maternal AgeModerate alcohol useCaffeine useCigarette SmokingChronic disease Antiphospholipid Antibody Syndrome, PCOS, thyroid disease, DMObesityPrevious pregnancy lossReproductive tract abnormalitiesMaternal infections – Syphilis, CT, toxo, vaginal mycoplasma or ureaplasma
Prine
AFP 2011 Office Management of Early Pregnancy LossSlide23
Recurrent pregnancy lossReasonable to perform evaluation after two consecutive losses based on patient desire and age50-75% are unexplained after workup and 50% or more will still conceiveUterine anatomy, parental karyotype, antiphospholipid antibodies, TSH, r/o diabetes, prolactinConsider karyotype on POCs in this scenarioEvaluation and treatment of recurrent pregnancy loss: a committee opinion ;The Practice Committee of the American Society for Reproductive Medicine:
Fertility
and Sterility® Vol. 98, No. 5, November 2012Slide24
Treatment of Early Pregnancy LossExpectant Management (waiting)Misoprostol (can be done in clinic, triage, CRH)Aspiration procedure (D&C)Patient Hand outs from Reproductive Access Website discuss optionsCan give info in triage and then refer back to PCP or CRH if she is unsure on what she would like to do for managementSlide25
Study of family medicine physicians56% had seen women with EPL in last 6 months18% only referred patients59% only offered expectant management 24% offered aspiration 16% offered misoprostol medical management Adds to >100% due to multiple modalities. “Offered” means on their own not via referralWallace Fam
Med 2013;45(3):173-9.) Slide26
What number of women experience first trimester bleeding?Ranges from 15% to 25%.Half of women with bleeding will have pregnancy loss by 20w gestation.Risk of SAB may be related to amount of spottingConnolly , Obs&Gyn Jan 2013Prine AFP 2011 Office Management of Early Pregnancy LossSlide27
How should we evaluate first trimester bleeding?Physical ExamVital signs - is she stable?Large blood loss requiring transfusion possible with SAB and ectopic pregnanciesAbdominal Exam Peritoneal signs?Pelvic Exam How much blood do you see in the vaginal vault?Is there active bleeding from the cervix? How much?Is her cervix open?Is she tender on bimanual exam?Slide28
Laboratory TestsβhCGHematocrit ?Rh negative: give Rhogam to all Rh negative women with first trimester bleeding regardless of how early in pregnancySlide29
Quantitative βhCGCorrelate with gestational age and ultrasound 2 measurements, 48 hours apartShould increase by at least 53%, but may not “double”. If rise not at least 53%, then
99% of time it is not viable
IUP
A rise <35% considered safer definition of non-viable
Falling or plateaued serial quantitative HCGs can diagnose a failing pregnancy
but
not the
location
Barnhart KT,
Obstet
Gynecol
2004;104:50–5
Kirk Human Reproduction Update 2014;20:250-261Slide30
ImagingUltrasound is primary and often only diagnostic approach neededDo not need to wait for the βhCG to do an USWhat if the MCH attending is not credentialed to do first trimester US? MCH-OB back-up can do if available during daylight hoursCan ask OB team to perform first trimester US if not busyIf OB team is unavailable, send patient to Diagnostic ImagingSlide31
Gestational Sac~ 5 weeks Does not confirm IUPDoubliet, 2014 Radiol
Clin
N Am;52:1191-1199Slide32
Yolk Sac~ 5.5 weeksConfirms IUP Unless heterotopic – more on this laterSlide33
Embryonic PoleWill usually see by 6wCardiac motion confirms viabilityMay still be viable even if cardiac motion is not identified (If < 7 mm)Can repeat US in 1 week Would not follow hCGs in this situationSlide34
Empty UterusVery early IUPSABEctopicSlide35
Free FluidEmpty uterus with free fluidSlide36
Ultrasound SummaryYolk sac – diagnoses IUPHeartbeat - diagnoses viable IUPA yolk sac and/or embryo rule out ectopic…..unless heterotopic“Gestational sac” without yolk sac or embryo Does NOT rule out ectopic- may be pseudosac
Abdallah
et al
Ultrasound
Obstet
Gynecol
2011Slide37
Case 228-year-old G3 P1011 presents to OB triage with a positive pregnancy test at home and heavy vaginal bleeding with clots. Dating by last menstrual period of 9 weeks. Ultrasound shows an empty uterus. Pelvic exam shows an open cervical os and some tissue at the os. She is Rh-. What do you do? What is her probable diagnosis?Slide38
Transvaginal ultrasound diagnosis of miscarriageAnembryonic pregnancy: Gestational sac of >25 mm without pole or yolk sac OR if < 25 mm with no change on rescan 7 days later.Missed abortion:Fetal pole of >7 mm by CRL without heart beat or if <7 mm no change in rescan 7 days later.No embryo w/ cardiac activity 11d after GS and YS seen.Slide39
RememberPregnancy dating and sonography are imperfect so diagnosis of spontaneous abortion in a woman with a wanted pregnancy may take two ultrasounds.Be patient.Slide40
Case 332-year-old G1 P0 comes in to your primary care clinic with a little vaginal spotting when she wipes. She is really worried because this is a wanted pregnancy. On ultrasound you see:Slide41
Early Pregnancy
Uterus outline
Sub-chorionic Bleed
Embryo
Yolk Sac
Gestational Sac
Choriodecidual ReactionSlide42
How to rule out ectopicWhen no gestational sac is visible you must consider ectopic.When no yolk sac is present in gestational sac you must consider ectopic. Pseudosac?If pregnancy is unwanted an MVA could be performed in an attempt to get chorionic villi which would rule out ectopic.Slide43
Ectopic Pregnancy1-2% of pregnanciesConsider in all women with pain and bleedingWomen with h/o ectopic, tubal surgery, or tubal pathology are at increased riskIncreased risk if smoker or IVFMost women do not have risk factorsJurkovic BMJ 2011;342:d3397Slide44
Ectopic Presentation10% of women have no symptomsAmount of bleeding classically is spottingAbdominal pain is often absent or late finding, likely due to earlier recognitionMajority of women with abdominal pain in early pregnancy don’t have an ectopicKirk Human Reproduction Update 2014;20:250-261Slide45
Ectopic DiagnosisTVUS sensitivity 98.3% - but not on first US20% may have pseudosac, but still more likely to be normal pregnancy so can’t diagnose by this aloneFree fluid on USEctopics have been identified with βhCG at levels < 100 and > 50,000A single βhCG cannot confirm diagnosisEctopic may have normal rise in HCGNo single pattern to diagnose women with EPKirk Human Reproduction Update 2014;20:250-261Lozeau AFP 205;72:1707-1714Slide46
Pseudosac vs ‘real sac’Slide47
PUL follow-up with serial BhCGReview ectopic warning signs carefully Repeat βhCG in 48 hoursβhCG drop by 13% in 48 hrRisk of needing intervention is low and likely SAB or resolving ectopic. Follow βhCG weekly until BhCG is 0.May need to repeat βhCG again in another 48 hoursNormally rising βhCG – repeat TVUS when above discriminatory zone or on day 7. Abnormally rising βhCG across 3 measurements or symptoms – needs evaluation and repeat US for ectopicSlide48
Heterotopic PregnancyPresence of simultaneous pregnancies at two different implantation sitesUsually intrauterine and ectopic1 in 30,0001 in 3,900 with ARTComplex adnexal mass and fluid in the pelvisSlide49
Heterotopic pregnancyIntrauterine pregnancyRight adnexal massSlide50
What is the discriminatory zone?Serum hCG at which US findings should be detectedThreshold level – refers to the lowest serum hCG at which a gestational sac or fetal pole can be detected1,500-2,000 mIU/mL commonly used a hCG disriminatory zone in practice for seeing gestational sacHowever
, this is value is not conservative enoughSlide51
Traditional HCG and Ultrasound CorrelatesGestational age by LMP
Transabdominal Landmarks
Transvaginal Landmarks
Serum
hCG mIU/ml IRP
< 5 weeks
None
Possible gestational sac
1800
5 - 6 weeks
Gestational sac
Gestational sac, yolk sac
1800 - 3500
7 weeks
5-10 mm embryo
Same as transabdominal, with cardiac activity
>20,000Slide52
Discriminatory zone - reconsideredReviewed 690 1st tri pregnancies with vaginal bleeding and/or pelvic pain with HCG and TVUS50% of the time a gestational sac could be seen when HCG >879 90% of the time GS seen when HCG >191899% discriminatory level was 3510- much higher than currently
used
Connolly Obstet Gynecol 2013;121:65–70Slide53
Use Caution with Discriminatory ValuesHCG >1500 would only detect 80% of viable pregnanciesHCG > 2000 may only diagnose 91% of viable pregnanciesReasons for not visualizing – fibroids, polyps, obesity, adenomyosisUse care when interpreting hCG discriminatory level in hemodynamically stable patients with PULThe
decision to intervene should
not be
based solely on a single hCG
level in a stable patient
.
Connolly Obstet Gynecol 2013;121:65–
70
Ko J Ultrasound Med 2014; 33:465-471Slide54
New Discriminatory Values
Connolly Obstet Gynecol 2013;121:65–70Slide55
If B-HCG below discriminatory levelSerial B-HCGsIf B-HCG in 48 hrs has gone up by 53% then this is a normal pregnancy with 99% confidence but repeat u/s is still indicated until fetal pole is seen and measured for dating.A decreasing B-HCG is abnormal and is most likely a miscarriage.Slide56
Case 418-year-old G1 P0 comes into reproductive health. She thinks she 5-6 weeks pregnant. She is having a little bit of vaginal bleeding. She does not want to be pregnant and on ultrasound you see a small gestational sac with a double decidual ring reaction. There is no yolk sac. Slide57
With her consent you proceed with manual vacuum aspiration (MVA)to find:Slide58
On closer lookSlide59
Case 424-year-old G3 P2 002 at 8 weeks by her last menstrual period comes in with vaginal bleeding and cramping. She has had a lot of nausea with this pregnancy. Her beta-hCG is 12,000 and her ultrasound shows a “starry night” or “cluster of grapes”.Slide60
Partial Hydatiform MoleSebire Gestational Trohoblastic disease in Management of Unintended and Abnormal Pregnancy: Comprehensive Abortion CareSlide61
With her consent you proceed with manual vacuum aspiration (MVA)to find: hydropic villiSlide62
Management of early pregnancy failureUterine curette introduced in 1843D and C advocated in late 18th century to decrease hemorrhage and chance of sepsisDilation and curettage has been standard management for over 50 yearsEdwards and Carson report prompts increased MVA use in USA in 1997Misoprostol introduced for medical management of EPL in 2001-2004Slide63
Potential risks of expectant managementInfectionNeed for emergent uterine aspirationHemorrhage/blood transfusionSlide64
Potential benefits of expectant managementAvoid risks (albeit uncommon) of uterine aspiration including perforationDecrease risk of excess curettage (Asherman’s syndrome)Patient preferenceCostSlide65
Contraindications to expectant managementExcess blood lossInfectionInability to access an emergent uterine aspirationPatient choiceSlide66
Myths of expectant managementAcceptable for limited time onlyDICInfection likelyPreferred by most womenSlide67
Success of expectant management
Group
N
Complete day 7
Complete day 14
Success day 49
Incomplete
221
117 (53%)
185 (84%)
201 (91%)
Missed
138
41 (30%)
81 (59%)
105 (76%)
Anembryonic
92
23 (25%)
48 (52%)
61 (66%)
TOTAL
451
181 (40%)
314 (70%)
367 (81%)
Luise C, et al . BMJ 2002; 324Slide68
How well does miso work for miscarriage?Day 1: 800 mcg miso administered vaginally Day 3: Repeat misoprostol if incomplete - 71% completeDay 8: Aspiration if still incomplete - 84% completeAnembryonic gestation success rate 81%Embryonic or fetal death 88%Incomplete or inevitable abortion 93%Zhang et al NEJM 8/25/05Slide69
UNM Misoprostol Management ProtocolCandidatesNon-viable pregnancy up to 10 weeks gestation diagnosed by ultrasoundEctopic pregnancy has been excludedDictate note & place patient in the beta bookLabsRh screen, Hct, quantitative serum βhCGProcedure800 mcg misoprostol vaginally or buccally Give prescription for 1 dose with a second dose in case tissue does not pass with first doseIbuprofen 800 mg starting at time of misoprostol and then q 6 hrTylenol #3 1-2 tabs q 3-4
hr
prn
severe pain
On MCH Wiki http
://
unmfm.pbworks.com
/w/page/94583924/MCH%20Beta%20BookSlide70
Psychosocial factors in decision making: qualitative studyWomen may need more time and information than usually provided after initial diagnosis to make decisionWomen choosing surgery usually got adequate counselingWomen choosing expectant management needed more info about miscarriage process
Ogden . BJOG 2004; 111:463-7Slide71
Surgical options Sharp curettage (D and C) no longer an acceptable option due to higher complication ratesVacuum aspiration includes manual vacuum aspiration (MVA) vs electrical pump aspirationSlide72
Historical Perspective of MVA use1970-71: Large US study documents safety of vacuum aspiration1971-73: US government funds research to develop non- electric vacuum source1972: First report on MVA use1973: Non-profit organization (IPAS) created to complete development of MVA and
distribute instruments worldwide
1980s: Several manufacturers market MVA
worldwide
1990s: MVA used in >100 countries
1997: Edwards and Carson report prompts
increased MVA use in USSlide73
MVA Instruments and SuppliesSlide74
Manual Vacuum Aspiration (MVA) vs. Electric Vacuum Aspiration (EVA) MVAInexpensiveSmall Portable QuietSpecimen likely to be intactMay require repeated reloading of suction
EVA
More costly but longer life
Bulky
Less portable
Noisy
Fragmentation of specimen possible
Constant suctionSlide75
MVA in ED/labor ward vs. suction D and C (EVA) in ORWaiting time reduced by 52%Procedure time reduced from mean 33 to 19 minutesCosts reduced by 41% ($1404 to $827, P < .01) for all three outcomesBlumenthal PD, Remsburg RE. Int J Gynecol Obstet 1994, 45: 261-267Slide76
MVA for EPL (early pregnancy loss) at University of New MexicoWomen who present with an incomplete abortion, inevitable abortion or missed abortion with heavy bleeding are candidates for MVA in OB triage. Women with missed abortion without heavy bleeding may be scheduled for an outpatient clinic procedure at CRH (925-4455/ ad huc referral)..An ultrasound from Diagnostic Imaging or Women’s Ultrasound may be used to make the diagnosis, as may an ultrasound by a credentialed physician from the departments of either Family Medicine or OB-GYN.Slide77
Misoprostol for early pregnancy lossCandidatesNon-viable pregnancy up to 10 weeks gestation diagnosed by ultrasoundEctopic pregnancy has been excludedLabsRh screen, Hct, quantitative serum βhCGProcedure800 mcg misoprostol vaginally or buccally Give prescription for 1 dose with a second dose in case tissue does not pass with first doseIbuprofen 800 mg starting at time of misoprostol and then q 6 hrTylenol #3 1-2 tabs q 3-4 hr prn severe painSlide78
Side effects of misoprostolBleeding – typically lasts up to 2 weeks with spotting till next periodCramping – usually starts within the first few hours. NSAIDs can be usedFevers and/or chills – common side effect. If lasts >24 hours, evaluate for infectionNausea and vomiting – more common after oral misoprostol. Should resolve in 6 hoursDiarrhea – also more common after oral miso and should resolve in 24 hours. Slide79
Failure to pass tissueIf no passage of tissue occurs (the patient has not bled as much as a period) within 12-24 hours, the patient may use the second vaginal dose of 800 mcg misoprostol. If no passage of tissue occurs by 1-2 weeks consider referral for MVA vs. D&C. May continue expectant management if desired.Slide80
Patient precautions Call for “heavy bleeding” defined as soaking two pads every hour for more than 2 hours. The patient does not need to bring products of conception back to the provider and should not be instructed to do so. The provider seeing the patient should give her instructions for who to call. Slide81
Followup in one week to ensure completionDiagnosis completion by either : 1) follow-up quantitative serum hCG following passage of tissue (a drop of 50%) 2) a transvaginal ultrasound with absence of sac. Note: if one of these criteria has been met, no further follow-up of serum hCGs is warrantedSlide82
Which is better or safer: aspiration, medication or waiting?Cochrane 2010 Compared miso to expectant and miso to aspiration and found each equal Cochrane 2012 Aspiration to expectant managementMore unplanned surgery & transfusions (1.4% vs. 0%) with expectant. Infection and psychological outcomes similar and cost less with expectantSlide83
Antibiotics indicatedYes for uterine aspirationDoxycycline 200 mg the night before (up to 12 hrs) or one hour prior to procedure appears optimalMetronidazole alternative if allergicAntibiotics not needed for misoprostol or expectant managementSFP Guideline Contraception April 2011Slide84
Summary for EPLExpectant management or medical or surgical intervention (MVA or EVA) are appropriate with EPL based on patient choice.Appropriate education and close follow-up essential for expectant management.Incomplete abortions are more likely to have successful expectant management than missed abortions/anembryonic pregnancies.If expectant management unsuccessful by day 14 consider intervention.Slide85
Summary1st trimester bleeding is common.Early normal pregnancy, early abnormal pregnancy or ectopic can be the cause.Ectopic must be ruled out!Women have options of watchful waiting, misoprostol and MVA for EPL.Slide86
MCH Beta Book GuidelinesHelp us manage women with miscarriage, pregnancies of unknown location, and ectopic pregnanciesWomen evaluated in OB triage and continuity clinicsMCH fellows will manage this book under supervision of Nicole Yonke & Larry LeemanSlide87
Beta Book“Beta Book” is a Care Team list, just like the MCH Care Team. Patient should be added by the resident seeing her in triage or clinicInclude contact number, PUL or SABInitial BhCG and follow-up planSlide88
Ectopic PregnanciesAll diagnosed or probable ectopics should be placed in the MCH and OB Beta Book. Patient should have consult by the Ob/Gyn Family Planning ServiceSlide89
Questions?