AAAAA
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Management:
FIRST TRIMESTER BLEEDING
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I. Abortion--diff types:
Threatened Ab = Bloody d/c from uterus w/o dil. of Cx; may subside & pregnancy may continue to term
Inevitable Ab = Profuse or prolonged uterine bleeding with effaced or dilated Ca; Ab generally proceeds
Missed Ab = Uterine Retention of fetus dead for >8wks; cervix usually closed
Incomplete Ab = Uterus not entirely emptied of contents
Septic Ab = Incomplete Ab + infection.; can lead to sepsis
Induced Ab = just that; don't forget to think of back-alley
Blighted ovum = Identifiable sac + placental tissue but no embryo; doesn't differentiate IUP vs. ectopic
II. 1st trimester spontaneous abortion/threatened abortion--50% of cases of 1st-TM bleeding
Occurs in 15% of diagnosed pregnancies
2/3 have chromosomal abnormality
Risk factors:
Coffee intake
> 6 cups/day (NEJM 341:1639, 1999--JW)
> 24 oz/day coffee ass'd with OR about 1.4 c/w < 5oz after adjusting for other risk factors in a case-control study of 562 women with miscarriage at 6-12wks and 953 controls (NEJM 343:1839, 2000--FP News; JW)
Infection
Poor nutrition
EtOH
Smoking
Severe trauma
"Habitual" = 3x or more (anatomic uterine abnormalities, luteal phase defect, autoimmune disorder, hypercoagulable states)
Management of threatened and/or other forms of spontaneous abortion
Follow serial hCG's to determine fetal viability (should double Q2-3d in wks 4-8)
Consider checking progesterone--Single level in early pregnancy: < 5ng/mL predicts poor outcome; > 25ng/mL ass'd with viable IUP
Surgical treatment vs. expectant management
35 women w/SpAb at < 13wks randomized to suction curettage vs. expectant management w/oral analgesics; no sig. diffs in days of bleeding, days of pain requiring meds, days in which activities were disrupted, time until return of menses, or satisfaction w/tx (Br. J. Obs. Gyn 104:840, 1997-JWWH)
Surgical treatment vs. medical treatment
In study of 604 women presenting with spontaneous abortion and with retained products seen on transvaginal u/s randomized to D & E vs. misoprostol (400mg PO Q4h up to max of 3 doses). Repeat transvaginal u/s at 24h showed retained products in about 50% of misoprostol group, "complications" occurred more often in surgical group (Fertil. Steril. 71:1054, 1999--AFP)
In a trial of 50 women 18-50yo with spontaneous Ab < 12wks gestation randomized to misoprostol 800ug intravaginally (re-administered at 24-48h is products of conception still visible on u/s; D & C done if tissue persisted 72h after initial tx) vs. D & C, 40% of the medical arm eventually had a D & C (Am. J. Obs. Gyn. 187:321, 2002--JW)
In a trial of 169 women with incomplete abortion in 1st trimester randomized to misoprostol 600ug PO x 1 or x 2 doses, there was no diff. in the eventual need for surgical intervention (Obs. Gyn. 103:860, 2004--AFP)
In a study in 652 women with incomplete spontaneous abortion randomized to misoprostol 800 micrograms intravaginally (on day 1 and again on day 3 if expulsion incomplete) vs. vacuum aspiration, 16% in the intravaginal group needed eventual surgical treatment (3% in the surgical group needed repeat aspiration within 30d) (NEJM 353:761, 2005--JW)
Treatment of missed abortion
Expectant management
Curettage
Intravaginal misoprostol (high levels of success in uncontrolled studies, e.g. Am. J. Obs. Gyn. 190:1445, 2004--AFP)
II. Ectopic pregnancy--#1 cause for hypovolemic shock in 1st trimester without evidence of trauma/bleeding
III. Molar pregnancy--20% risk of recurrence
IV. Local lesion (vulva, vagina, Cx, urethra); including trauma and infection
APPROACH TO A PATIENT WITH FIRST TRIMESTER BLEEDING
I. Check vitals (with orthostatics & for signs of shock)
II. If pt. in shock (BP < 90/60, P > 110)
Start IVF
Send blood for type & cross-match 2U, CBC w/plats, PT/PTT, fibrinogen, quant. hCG
Do U/S: if IUP and + FHR then < 1% chance of miscarriage
Do culdocentesis--if blood, prob. ruptured ectopic!
Take immediately to O.R. for laparotomy
Transfuse with RBCs as rapidly as possible
III. If not in shock,
On Px:
CMT suggests various dx's (see "Acute pelvic pain and salpingitis" below)
May see local source for bleeding
Uterine/adnexal tenderness suggests infection
Disruption of rectovag. septum suggests dissecting pelvic abcess
Do vaginal u/s; look for gest. sac (visible in IUP @6wks), fetal heart (after 6wks), adnexal masses, fluid in cul-de-sac
Laparoscopy sometimes indicated
IV. If stable and IUP, see above re: management of spontaneous abortion/threatened abortion
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| frank100
Forum Guru
Topics: 48
Posts: 586
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hmmm, interesting
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