Transcript Slide 1

OB Module
First Trimester Bleeding
Philip Trangmar, MD
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Case Study – at home call
Diana is a 34 year old, G1 P0
Diana did not have a period for 5 weeks and so had a
pregnancy test at home which was positive.
She was very happy with the news.
That was two days ago.
She now phones you at 2am when you are at home on
outpatient call.
She tells you that she has seen spotting. She has mild
abdominal cramping which causes her some discomfort
rather than pain.
However, she is very anxious and is crying.
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What you should be thinking now
What differential diagnoses are you thinking about?
Try to name at least three!
List of dif dx
Does Diana need to be seen tonight; or can you go
back to sleep, telling her to just turn up at the clinic in
the morning?
Clinic
ER
Does the patient need to be seen
tonight?
Bleeding in the first trimester can be a medical
emergency! Even spotting can be enough to warrant a
visit to the ER.
If Diana had not had a positive pregnancy test, then it
would not be considered first trimester bleeding; just a
late period. However, that is not the case here.
HOWEVER, it can be a judgment call if there is no
pain and the patient has only very mild spotting.
Best practice is to play it safe and send her for an
exam tonight. Particularly given her disposition – she
is anxious.
next
What differential diagnoses are you thinking
about for 1st Trimester bleeding?
1. Abortion



Requires positive pregnancy test and usually some bleeding.
May or may not be accompanied by pain
This includes threatened, inevitable, or missed abortions
click here for a description of the different types
2. Ectopic pregnancy



A pregnancy which is not contained in the uterus
Any bleeding is usually accompanied by pain – either moderate or severe
This subject is covered later in the module
3. Molar pregnancy





This is now referred to as Gestational Trophoblastic Disease
This term encompasses several disease processes that originate in the placenta
These include complete and partial moles, placental site trophoblastic tumors,
choriocarcinomas, and invasive moles
Patients usually present with elevated hCG levels
Click here for a web page with more information on hydatidiform moles
4. Infection

STDs and particularly PID can cause vaginal bleeding
5. Trauma

Sexual acts can cause abrasions to the vaginal wall which can result in bleeding
Back
Abortion terminology
Spontaneous



It is defined as a clinically recognized pregnancy (eg, by blood test,
ultrasound) which is then lost before 20 weeks' gestation.
They are sub-classified into:
threatened, inevitable, incomplete, complete or missed
It is the most common complication of pregnancy
Elective

Either medical or surgical termination of the pregnancy
Therapeutic

This is where an elective abortion is given for the medical benefit of the
mother.
Septic


A spontaneous or elective abortion complicated by a pelvic infection
Could be the result of a non-medical/home abortion attempt
Miscarriage


This term is normally only used ‘medically’ where the termination occurs at
greater than 20 weeks.
However, when talking to patients it can be used instead of abortion as
abortion carries with it harsh overtones!
Back
Sub categories of spontaneous abortions
Threatened


Vaginal bleeding during early pregnancy represents a threatened abortion,
On vaginal examination, the cervical os is closed and no tissue is found.
Inevitable


Vaginal bleeding is accompanied by dilatation of the cervix.
Bleeding usually is more severe than with threatened abortion and often is
associated with abdominal pain.
Incomplete



Vaginal bleeding usually is intense and accompanied by abdominal pain.
The cervical os is open and products of conception are being passed.
Ultrasound shows some products of conception are still present in the
uterus.
Complete



Patients usually present with a history of bleeding, abdominal pain, and
tissue passage.
By the time abortion is complete, bleeding and pain usually have subsided.
Diagnosis is confirmed by observation of the aborted fetus +/- vacant
uterus on U/S
Missed


In utero death of the fetus with retained products of conception.
Also known as blighted ovum, anembryonic pregnancy, or fetal demise.
Back
Case Study – in the ER
Diana goes to the ER
It is 3.45am and she gives the ER doctor her history as
stated on the ‘phone to the on-call resident.
She has no further spotting and only mild cramping
She still appears tearful and anxious
After confirming she is pregnant,
what should the next step be?
a.
b.
c.
d.
Bi-manual pelvic exam
Sterile speculum exam
Order an Ultra-sound
Send her home as the bleeding seems to have resolved
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Case Study - next steps
Answer b is correct: Sterile speculum exam
Diana needs to have her bleeding assessed now




She may not be spotting but she may be actively bleeding
This needs to done use a sterile speculum to visualize the cervix
Only then can you assess at what stage is this threatened
abortion
Do a G/C test and wet prep whilst you’re in there! There may be
a reversible cause for her bleeding (infection).
This would now be a good time to think about lab work.
What labs would you order for Diana?
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Labs necessary to order
Serum hCG




This should be done now. We know she is pregnant but it will help
correlate with the ultrasound exam
and again in 48 hours - this second draw is done to ensure that the
pregnancy is progressing
Click here to see expected hCG levels
Progesterone levels. If <10, highly correlated with abnormal
pregnancy (ectopic or miscarraige). If>25, correlated with normal
pregnancy.
CBC and type


We need to see if Diana lost any significant amount of blood and
ascertain her blood group to see if she is Rh negative
STDs

I hope that you did this as part of the pelvic exam as you should have
got Gonorrhea and Chlamydia swabs, as well as a wet prep!
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hCG levels
Weeks of pregnancy
after period
hCG
Week 3 (ie 7d post period)
0 to 5
Week 4 (ie 14d post period)
5 to 426
Week 5
18 to 7340
Week 6
1,080 to 56,500
Weeks 7 to 8
7,650 to 229,000
Weeks 9 to 12
25,700 to 288,000
Weeks 13 to 16
13,300 to 254,000
Weeks 17 to 24
4,060 to 165,400
Weeks 25 to birth
3,640 to 117,000
4/6 weeks post
Less than 5
NB – Because of the variation, this is less useful to pinpoint likely dates.
hCG is more useful for ultrasound correlation.
Ref:http://www.birth.com.au/class.asp?class=6620&page=8
Back
Case Study – patient outcome
Her CBC is normal and she is A pos

This rules out severe blood loss and no Rhogram required
Diana’s hCG levels are 900

This will enable you to assess what should be seen on ultrasound
Micro


Her wet prep was negative for Trich and fungal infections and
she has no clue cells
Her G & C test will not come back until tomorrow
A 2002 study showed clinical judgment is not an
alternative to ultrasound
NOW you can order a stat ultra sound
What would the ultra sound show at this stage?
- 4 weeks and a few days
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Ultrasound findings in 1st trimester
β-HCG
(mIU/ml)
Trans-vaginal findings
Weeks from
LMP
Click for view
Gestational sac (25 mm)
4.5-5
1000
Click for view
Yolk sac
5-5.5
1500-2500
Click for view
Fetal pole
5-6
2000-5000
5.5-6.5
4000-17000
Fetal cardiac activity
The β-hCG level at which an intra-uterine pregnancy (IUP) should be
visualized by transvaginal ultrasound, with near 100% sensitivity, is
1000-2000 mIU/mL.
The level for transabdominal sonography is less certain but has been
suggested to be between 4000 and 6500 mIU/mL.
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Gestational Sac - TVUS
Gestational sac is visible at 4-5 weeks.
The fetal pole is barely visible
Back
Yolk Sac - TVUS
Yolk sac is seen within the gestational sac, and is
visible at 5-6 weeks
Back
Fetal pole - TVUS
Fetal pole is seen below the yolk sac
Back
Case study - current diagnosis
Diana has a closed cervix and no additional blood visualized in
the vaginal vault.
It was too early to show any IUP evidence of a yolk sac.
What type of abortion would you consider classifying Diana W
at this stage? Place cursor over your choice

Complete
Incomplete
Inevitable
Missed
Threatened

Click here if you want to see the definitions again




next
Sub categories of spontaneous abortions
Threatened


Vaginal bleeding during early pregnancy represents a threatened abortion,
On vaginal examination, the cervical os is closed and no tissue is found.
Inevitable


Vaginal bleeding is accompanied by dilatation of the cervix.
Bleeding usually is more severe than with threatened abortion and often is
associated with abdominal pain.
Incomplete



Vaginal bleeding usually is intense and accompanied by abdominal pain.
The cervical os is open and products of conception are being passed.
Ultrasound shows some products of conception are still present in the
uterus.
Complete



Patients usually present with a history of bleeding, abdominal pain, and
tissue passage.
By the time abortion is complete, bleeding and pain usually have subsided.
Diagnosis is confirmed by observation of the aborted fetus +/- vacant
uterus on U/S
Missed


In utero death of the fetus with retained products of conception.
Also known as blighted ovum, anembryonic pregnancy, or fetal demise.
Back
Case Study – patient outcome
Diana’s bleeding and cramping was most likely a
threatened abortion


however, the word abortion is not a word which should be used with
patients
the better understood word for patients is potential miscarriage, but it
is really too early to tell
You tell her that you are going to send her home


she should take Tylenol for her pain and cramping
and start prenatal vitamins if she has not done so already
You advise her to take it easy

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
no strenuous activity or heavy lifting or exercise for the next 7 days
to follow up with a hCG serum level in two days to ensure that the
levels are doubling every 48 hours
Doubling hCG levels are a sign of well being in early pregnancy
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Case Study – patient’s questions
Diana does have several questions for
you



1. What is the chance of her having an
actual miscarriage/abortion?
2. What risk factors are there for
spontaneous abortions?
3. What causes an abortion?
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Abortion Epidemiology
Click here to see
epi statistic slide
You should tell Diana that:
Spontaneous abortions occur in 20-30% of
pregnancies
2/3 of first trimester spontaneous abortions have
chromosomal abnormalities

i.e. these are inevitable as the abnormalities are not
compatible with life
First trimester bleeding is also common: about
25% of pregnancies
50% of these go on to have a normal course of
pregnancy
You can therefore tell Diana that abortions/miscarriages are far from
unusual and that there is a good chance that this will carry to term
Back
Epidemiology of Abortions
Frequency In the US:



Up to an estimated 30% of pregnancies are terminated spontaneously before the
first missed menstrual period and, therefore, usually are not clinically recognized.
Spontaneous abortions occur in an estimated 10-20% of known pregnancies.
They usually occurs between the 7th and 12th weeks of pregnancy
Vaginal bleeding

occurs in approximately 25% of all pregnancies during the first 2 trimesters.
About 50% these cases progress to an actual abortion/miscarriage.
Age:

Age and increased parity affect a woman's risk of a miscarriage. In women
younger than 20 years, miscarriage occurs in an estimated 12% of pregnancies;
in women older than 20 years, miscarriage occurs in an estimated 26% of
pregnancies.
Mortality/Morbidity:

Surveillance data from the US between 1987 and 1990 revealed a total of 1459
pregnancy-related deaths. Spontaneous and induced abortions accounted for
5.6% of these deaths.
Race:

Surveillance data for pregnancy-related deaths between 1987 and 1990
demonstrated that more black mothers died after abortions, both spontaneous
(14%) and induced (7%), than white mothers (8% and 4%, respectively).
Back
Risk factors associated with Abortions
You should tell Diana that the following items cause increased risk of abortions:
Cigarette smoking increases risk of abortion
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Over 14 Cigarettes per day doubles risk over non-smokers

Relative Risk increases 1.2x for each 10 cigs/day
Alcohol abuse increases risk of abortion

Abortion risk doubled for twice weekly alcohol

Abortion risk tripled for daily alcohol use*
Illicit drug use
Uterine surgeries or anomalies
Incompetent cervix (usually second trimester)
IUDs
Ref: http://www.fpnotebook.com/OB9.htm
* Somewhat controversial statement but is the basis for the ACOG
saying not to drink in pregnancy
Apart from smoking, drugs and alcohol, there are no real risk factors
which Diana can influence
Back
Causes of early miscarriage
Genetic or fetal causes

Trisomy; Polyploidy or aneuploidy; translocations
Environmental or maternal causes,
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Smoking, alcohol, drugs
Congenital uterine anomalies; Leiomyoma
Intrauterine adhesions (Asherman's syndrome)
Endocrine
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Progesterone deficiency (luteal phase defect)
Diabetes mellitus (poorly controlled); Hypothyroidism
Luteinizing hormone hypersecretion
Immunologic

Autoimmunity: antiphospholipid syndrome, lupus
Infections

Toxoplasma gondii, Listeria monocytogenes Chlamydia trachomatis,
Ureaplasma urealyticum, Mycoplasma hominis, Herpes simplex,
Treponema pallidum, Borrelia burgdorferi, Neisseria gonorrhoeae
You can inform Diana of the main causes
– and try to see if any may apply at this stage?
Back
Case Study – return visit
Diana returns to visit you in clinic three weeks later

She is 6 weeks post LMP
Looking at her history you note that her hCG had doubled on a
second lab visit

and therefore you had told her that at that time her pregnancy was
progressing well
However, she is now experiencing increased abdominal pain in the
right side and is bleeding
The bleeding is described as more than spotting – a cupful.
What differential diagnoses do you have now?
next
Differential diagnosis of pain and
bleeding at 7 weeks
– the same as 4 weeks
Abortion

click here for review of different types
Molar pregnancy

link to web site
Trauma
Infections
And of course ….
Ectopic pregnancy
What is the next step?
next
Sub categories of spontaneous abortions - 3
Threatened


Vaginal bleeding during early pregnancy represents a threatened abortion,
On vaginal examination, the cervical os is closed and no tissue is found.
Inevitable


Vaginal bleeding is accompanied by dilatation of the cervix.
Bleeding usually is more severe than with threatened abortion and often is
associated with abdominal pain.
Incomplete



Vaginal bleeding usually is intense and accompanied by abdominal pain.
The cervical os is open and products of conception are being passed.
Ultrasound shows some products of conception are still present in the
uterus.
Complete



Patients usually present with a history of bleeding, abdominal pain, and
tissue passage.
By the time abortion is complete, bleeding and pain usually have subsided.
Diagnosis is confirmed by observation of the aborted fetus +/- vacant
uterus on U/S
Missed


In utero death of the fetus with retained products of conception.
Also known as blighted ovum, anembryonic pregnancy, or fetal demise.
Back
Ectopic work up
Since Diana has unilateral pain, your thought process is directed
towards a possible ectopic pregnancy

This means an emergency ultrasound in the ER
Remember on her first visit to the ER the ultrasound was unable to
visualize an Intra-uterine Pregnancy

This was because it was too early
We now do a serum hCG and get 7000
What are the likely findings?
next
Diana’s findings
Remember back to the table on the correlation between hCG and
ultrasound findings
At a hCG level of 7000 you should be able to find, using a
transvaginal ultrasound


a fetal pole
and cardiac activity
If there is no IUP, then you would be looking at


a potential ectopic
or recent complete abortion
Click here to see
hCG table again
next
Ultrasound findings in 1st trimester
β-HCG
(mIU/ml)
Trans-vaginal findings
Weeks from
LMP
Gestational sac (25 mm)
4.5-5
1000
Yolk sac
5-5.5
1500-2500
Fetal pole
5-6
2000-5000
5.5-6.5
4000-17000
Fetal cardiac activity
The β-hCG level at which an intra-uterine pregnancy (IUP) should be
visualized by transvaginal ultrasound, with near 100% sensitivity, is
1000-2000 mIU/mL.
The level for transabdominal sonography is less certain but has been
suggested to be between 4000 and 6500 mIU/mL.
Back
Ectopic work up using ultrasound
Diagnostic of IUP
“Double” gestational sac
Intrauterine fetal pole or yolk sac
Intrauterine fetal heart activity
Click here to see
Ultrasound pictures
Diagnostic of Ectopic Gestation
Ectopic fetal heart activity or
Ectopic fetal pole
Suggestive of Ectopic Gestation
Moderate or large cul-de-sac fluid without IUP
Adnexal mass without IUP
†
Indeterminate
Empty uterus
Nonspecific fluid collections
Echogenic material
Abnormal sac
Single gestational sac
Click here to see
Tubal ectopics
* Modified from Dark RG: Role of pelvic ultrasonography in evaluation of symptomatic first trimester pregnancy, Ann Emerg Med 33:310–320, 1999.
† Complex mass most suggestive of ectopic pregnancy, but cyst can also be seen with ectopic pregnancy.
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Ultrasound of ectopic pregnancy
Same images
Uterus outlined in red, uterine lining in green, ectopic pregnancy yellow.
Fluid in uterus at blue circle - sometimes called a "pseudosac"
Click here for magnified image
Back
Magnified ultrasound image of ectopic
Same images
Tubal pregnancy circled in red, 4.5 mm fetal pole (between cursors) in
green, pregnancy yolk sac blue.
Back
Ectopic pregnancies
Laparoscopic view of
ectopic
Uterus with fallopian
ectopic
Back
Management of ectopic pregnancy
Medical

Methotrexate
It has a very good success rate, but does carry risk and
therefore is generally managed by ob/gyn.
only used in early pregnancy where the patient is
hemodynamically stable
Otherwise it is off to:
Surgery

Laparoscopic approach
next
Methotrexate in Ectopic Pregnancy
The antifolate drug - methotrexate is widely
used to treat ectopic pregnancies without
surgery

Methotrexate, 50 mg/m2 intramuscularly
Misoprostol is not used for ectopic
pregnancy. It is a prostaglandin used to
empty the uterus. It is used after
methotrexate for early medical TABs that
are intrauterine only.
Back
Surgical treatment Ectopic pregnancy
Salpingectomy by laparotomy has long offered almost a 100 percent
cure.
More recently laparoscopic salpingostomy and laparoscopic partial
salpingectomy are thus rapidly replacing laparotomy.
Laparotomy should be performed only when a laparoscopic
approach is too difficult, the surgeon is not trained in operative
laparoscopy, or the patient is hemodynamically unstable.
Approximately 95 percent of laparoscopic salpingostomies are
successful (i.e., no additional procedures are needed).
Of the 93 women evaluated in one study, 86 percent were later
shown to have patent oviducts; 66 percent of 430 women who were
followed subsequently became pregnant, with 23 percent of those
pregnancies being ectopic.
i.e there is a high risk for future Ectopics
Ref: Seifer DB, Gutmann JN, Doyle MB, et al: Persistent ectopic pregnancy following laparoscopic linear
salpingostomy. Obstet Gynecol 76:1121, 1990.
Back
Ultrasound exam of Diana
On a transvaginal ultrasound you find



Gestational sac in utero
Fetal pole at 2cm
No cardiac activity
Cardiac activity should become visible
and begin once the fetal pole reaches
5mm. No cardiac activity at this stage
means:

a non-viable fetus
next
Pelvic exam of Diana
On doing a Pelvic exam you find



blood in vaginal vault
Cervix is partially open
No tissue is seen
What type of abortion would you consider classifying
Diana at now? Place your curser over your choice





Complete
Incomplete
Inevitable
Missed
Threatened
Click here if you want to see the definitions again
next
Sub categories of spontaneous abortions
Threatened


Vaginal bleeding during early pregnancy represents a threatened abortion,
On vaginal examination, the cervical os is closed and no tissue is found.
Inevitable


Vaginal bleeding is accompanied by dilatation of the cervix.
Bleeding usually is more severe than with threatened abortion and often is
associated with abdominal pain.
Incomplete



Vaginal bleeding usually is intense and accompanied by abdominal pain.
The cervical os is open and products of conception are being passed.
Ultrasound shows some products of conception are still present in the
uterus.
Complete



Patients usually present with a history of bleeding, abdominal pain, and
tissue passage.
By the time abortion is complete, bleeding and pain usually have subsided.
Diagnosis is confirmed by observation of the aborted fetus +/- vacant
uterus on U/S
Missed


In utero death of the fetus with retained products of conception.
Also known as blighted ovum, anembryonic pregnancy, or fetal demise.
Back
Management of inevitable
(or incomplete or missed) abortion
Medical

Misoprostol
Surgical

Dilation and curettage
Manual or Standard Vacuum Curettage

Dilation and evacuation
So which would you offer
for Diana?
next
Misoprostol in Missed abortion
The antifolate drug methotrexate is not needed for
a missed AB as it is used to stop growth of a
pregnancy and this pregnancy is already nonviable.
Misoprostol can be used to empty the uterus at
this point: vaginal misoprostol 800 μg, can be
repeated at 24 hours if the patient had not aborted.
Statistics:



Fifty-three percent aborted after the first dose of
misoprostol
an additional 15 percent after the second dose
a total of 92 percent aborted by 35 days
Back
Surgical treatment in Missed or
incomplete abortion
Technique for Manual Vacuum Procedures
After examination to determine uterine position and to be sure that pregnancy is 7 weeks or less, the
cervix is exposed with a speculum, infiltrated with local anesthetic, and grasped with a tenaculum
placed vertically at 12 o'clock.
Four- and 5-mm-diameter cannulas are passed through the cervical canal as dilators, and then a 6-mm
cannula is inserted and attached to the evacuated 50-ml syringe to establish suction.
The 4- and 5-mm cannulas are not large enough to dependably evacuate the uterus in pregnancy, but
are useful as atraumatic dilators and for endometrial biopsies in the nonpregnant state.
The 6-mm cannula is rotated and pushed in and out with gentle strokes, taking care to rotate the
cannula only on the outstroke so as to avoid twisting off the flexible tip by rotating it when it is
pressed against the uterine fundus.
When no more tissue comes through, the cannula is withdrawn, its tip cleared in a sterile fashion, and
it is reinserted and vacuum reestablished for a final, check curettage to
Technique for Standard Vacuum Curettage
Standard vacuum curettage applies essentially the same technique as manual vacuum, but uses
larger cannulas, from 7 to 12 mm, with an electric vacuum pump.
After establishing a paracervical block as above, the operator dilates the cervical canal, using serial
insertion of tapered rods that increase progressively in size.
Dilatation is continued to a diameter 1 mm less than the estimated length of gestation in menstrual
weeks and then a vacuum cannula of that same outside diameter is inserted.
After aspiration is complete, we gently insert a sharp curette and use it as a finger to gently explore
the cavity and prove it empty. Finally, the suction cannula is reintroduced for a final few seconds to
remove any additional tissue remaining.
Back
Diana’s case
The first choice would be medical 

Misoprostol
Or watch and wait. Some women may
choose to remain at home for a miscarraige,
unless bleeding becomes heavy or
concerning.
Only if Diana failed medical treatment
would you need to offer the surgical
route
next
Case study – procedure
Diana decided to go thought with a trial of misoprostol
She was advised that if it did not work, she would likely
require a D&C in any event
next
Case study – bleeding
On the third day Diana passed clots and plenty of
blood.
As this was her first early abortion, there was no need
to have the fetus analyzed for chromosomal
abnormalities.
This would be an indication for a D&C in other
patients.
next
Patient Questions
Diana asks you:


What are the chances of having a
successful next pregnancy?
What if she was 37 YO or she had a history
of previous abortions?
next
Answers
Click here to see
epi statistic slide
In women with an unknown etiology of prior
pregnancy loss, the probability of achieving
successful pregnancies is 40-80%.
As stated earlier, increased age increases
chances of spontaneous abortion.
This is also the case with patients who have
three or more previous abortions
next
Epidemiology of Abortions
Frequency In the US:



Up to an estimated 30% of pregnancies are terminated spontaneously before the
first missed menstrual period and, therefore, usually are not clinically recognized.
Spontaneous abortions occur in an estimated 10-20% of known pregnancies.
They usually occurs between the 7th and 12th weeks of pregnancy
Vaginal bleeding

occurs in approximately 25% of all pregnancies during the first 2 trimesters.
About 50% these cases progress to an actual abortion/miscarriage.
Age:

Age and increased parity affect a woman's risk of a miscarriage. In women
younger than 20 years, miscarriage occurs in an estimated 12% of pregnancies;
in women older than 20 years, miscarriage occurs in an estimated 26% of
pregnancies.
Mortality/Morbidity:

Surveillance data from the US between 1987 and 1990 revealed a total of 1459
pregnancy-related deaths. Spontaneous and induced abortions accounted for
5.6% of these deaths.
Race:

Surveillance data for pregnancy-related deaths between 1987 and 1990
demonstrated that more black mothers died after abortions, both spontaneous
(14%) and induced (7%), than white mothers (8% and 4%, respectively).
Back
Follow up with Diana
Lastly you should address any relevant psychiatric
issues concerning the loss of a baby and look for
potential depression beyond normal grief.
IMPORTANT: reassure her that she did nothing to
cause the miscarriage (unless drugs or alcohol are
involved).
Make a follow up appointment sooner rather than later
if you have any concerns on this point .
Some parents need closure, even with a very pre-term
fetus and wish to see the aborted fetus, following a
D&C.
Some parents may also wish to bury the fetus to aid
with closure.
next
OB Module – First Trimester Bleeding
References
1.
Ultrasound in pregnancy
Christopher Moore, MD, RDMS, RDCS Susan B. Promes, MD, FACEP
Emergency Medicine Clinics of North America
Volume 22 • Number 3 • August 2004
Copyright © 2004 W. B. Saunders Company
http://home.mdconsult.com/das/journal/view/40844780-4/N/14936568?ja=432625&PAGE=1.html&sid=299459631&source=
2.
Table on U/S modified from Dart RG: Role of pelvic ultrasonography in evaluation of symptomatic first trimester pregnancy Ann Emerg Med 33:310–320, 1999.
3.
Threatened miscarriage in general practice: diagnostic value of history taking and physical examination.
Authors Wieringa-de Waard M, Bonsel GJ, Ankum WM, Vos J, Bindels PJ
Source British Journal of General Practice
Date of publication 2002 Oct
Volume 52
Issue 483
Pages 825-9
4.
The accuracy of single serum progesterone measurement in the diagnosis of ectopic pregnancy: a meta-analysis (Structured abstract)
NHS Centre for Reviews and Dissemination
Original article:
Mol B W, Lijmer J G, Ankum W M, van der Veen F, Bossuyt P M. The accuracy of single serum progesterone measurement in the diagnosis of ectopic pregnancy: a
meta-analysis. Human Reproduction. 1998. 13(11). 3220-3227.
5.
Interventions for tubal ectopic pregnancyHajenius PJ, Mol BWJ, Bossuyt PMM, Ankum WM, Van der Veen F
Date of most recent substantive amendment: 24 October 1999
This review should be cited as: Hajenius PJ, Mol BWJ, Bossuyt PMM, Ankum WM, Van der Veen F. Interventions for tubal ectopic pregnancy (Cochrane Review). In: The
Cochrane Library, Issue 3, 2004. Chichester, UK: John Wiley & Sons, Ltd.
6.
The medical management of ectopic pregnancy: a meta-analysis comparing 'single dose' and 'multidose' regimens (Provisional record)
NHS Centre for Reviews and Dissemination
Original article:
Barnhart K T, Gosman G, Ashby R, Sammel M. The medical management of ectopic pregnancy: a meta-analysis comparing 'single dose' and 'multidose' regimens.
Obstetrics and Gynecology. 2003. 101(4). 778-784.
7.
http://www.emedicine.com/emerg/topic5.htm
8.
http://home.mdconsult.com/das/book/41051225-2/view/1007
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OB Module
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