Vandana Sharma, M.D
April 30, 2004
Pt. 27 yr.. old G3 P2002, walks into clinic
with vaginal bleeding
What would you ask her?
What tests would you order?
What follow-up would she need?
Bleeding in the first trimester
Cervical or vaginal Pathology
Maternal Exposure to Teratogens
Types of Spontaneous Abortions
Blighted ovum or Anembryonic Pregnancy
– Failure or absence of an embryo at a very early stage of
Pregnancy that ends spontaneously
before the fetus has reached a viable
Corresponds to a gestational age of 20
to 22 weeks.
History of Amenorrhea
– spotting or heavy
– intermittent or constant
– light or dark
– brief or lengthy (several weeks in duration)
– heavier and more persistent bleeding (carries a poor
Most common complication of early pregnancy.
Approximately 10 to 20 percent of clinically
recognized pregnancies under 20 weeks of
gestation will undergo spontaneous abortion.
– 80 percent of these occur in the first 12 weeks of
Loss of unrecognized or sub clinical pregnancies
is much higher - between 50% and 75%
Over all 12% of clinically recognized pregnancies
ended in spontaneous abortion.
Quantitative beta hCG
Plays an important role in the diagnosis and
management of first trimester bleeding
Criteria for Definite diagnosis of nonviable IU
– Absence of fetal cardiac activity with C-R length of
– Absence of a fetal pole when the mean sac diameter is
>25 mm by transabdominal US or >18 mm by the
Additional finding- predictive of impending
An abnormal Yolk sac - large for gestational age,
irregular, free floating in the gestational sac or
Fetal HR <100 bpm at 5-7 wks gestation
Small mean sac size
Large subchorionic hematoma
Pre and post Counseling
Panic and anxiety
As effective as medical or surgical treatment.
Early pregnancy Failure <13 week gestation.
Stable Vital signs
No evidence of infection
Majority of expulsions occur in the first 2 weeks of
Uterine cavity evaluation by ultrasound
Surgical evacuation is needed if retained tissue is > 15mm.
Failure Spontaneous expulsion - Medical or surgical
Prostaglandin E1 analog
– Oral - Low success rate
– vaginal - High success rate
Recommendation: Misoprostol 400mcg every 4 hrs for 4 doses
Combination of a progesterone antagonist
– Side effects
– Less Expensive
– Low incidence of side effects when used
– Ready availability
– Conventional treatment for first or early second trimester
– Evidence of incomplete abortion
– Heavy bleeding
– Intrauterine sepsis
– Patient’s preference
– Documented Fetal demise or blighted ovum.
– Minimal, uterine perforation, interauterine adhesions, cervical
trauma, infection and Anesthesia risks.
Examination of Tissue
Crucial and underutilized skill in the management
of first trimester bleeding problem.
The main issue is whether the tissue is placenta -
proving that pregnancy was intrauterine. Placental
villi have a characteristic appearance best
described as frond like or “seaweed floating under
In all cases the tissue should be submitted for
formal pathologic examination. In certain
situations tissue is submitted for genetic studies.
One third of the products of conception from
spontaneous abortions occurring at or before eight
weeks of gestation are blighted. If embryo is
found, there is 50% probability of it being
Approximately 50% of miscarriages are
Earlier the gestational age at abortion, the higher
the incidence of chromosomal defects.
Post Abortion Care
Immediate Care after D&C
– Observation for Hemorrhage or change in vital
– Women who are Rh(D) negative
– doxycycline 100 mg bid on the day of the
– Methylergonovine maleate 0.2 mg every 4 hours
for five doses
– Pelvic rest - nothing per vagina for two wks
Post Abortion Family Planning
Pregnancy can be deferred for two to three
months however there is no greater risk of
adverse outcome with a shorter pregnancy
Contraception - Any type including IUD
may be started immediately.
Grief counseling is appropriate as needed.
Take Home Points
Always do vaginal exam with sterile
If not confident about passage of complete
tissue, perform ultrasound
Counseling and emotional support is
Follow up on regular basis