First trimester abortion

Background

• Estimates are up to 15% of pregnancies end in a 1st trimester abortion usually due to fetal chromosomal abnormalities

Types

Complete Abortion

• No IUP + closed os + POC have been expelled
• 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 discharge or frank bleeding
• If <11wk >90% go to term
• If between 11 and 20wk 50% go to term

Inevitable Abortion

• Open os + bleeding

Incomplete Abortion

• Passage of only portion of POC + open os

Missed Abortion

• Fetal death at <20wk w/o passage of any fetal tissue for 4wk after fetal death
• Closed os

Septic abortion

• Evidence of infection during any stage of abortion
• Most commonly caused by retained products of conception

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)

• Ectopic pregnancy
• Subchorionic hematoma
• First Trimester Abortion
  • Complete Abortion
  • Incomplete Abortion
  • Inevitable Abortion
  • Missed Abortion
  • Septic abortion
  • Threatened Abortion
• Gestational trophoblastic disease
  • Consider when pregnancy-induced hypertension is seen before 24 wks of gestation
• Heterotopic pregnancy
• Implantation bleeding
• Molar pregnancy
• Non-pregnancy related bleeding
  • Cervicitis
  • Fibroids
  • Implantation bleeding

Diagnosis

Workup

• Pelvic or Trans-abdominal ultrasound to assess fetal dating and heart rate
• Type and Screen/ABO
• Hemoglobin

Evaluation

• See Vaginal Bleed Pregnant (less than 20wks)

Management

• RhoGam if Rh Negative
• IVF and/or PRBCs if severe bleeding
• Misoprostol only for < 12 wks gestation, high success rate for the following
  • Incomplete AB: 600 mcg PO single dose
  • Missed AB: 800 mcg vaginally single dose
  • Supportive care with anti-emetic and NSAIDs for misoprostol side effects
• D&C and OB/gyn c/s may be necessary if medical management fails or continuous products/vaginal bleeding > 7-14 days

Disposition

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

See Also

• Vaginal Bleeding (Main)
• Vaginal Bleed Pregnant (less than 20wks)

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