First Trimester Complications Dr. Dominick helton University of Toronto Toronto, Ontario, Canada
Objectives To learn how to manage first trimester bleeding in high and low resource settings To learn how to rule out ectopic pregnancy To learn treatment options for missed and incomplete abortions
Case 22 year old female presents to the emergency department with vaginal bleeding LMP about 2 months ago Bleeding as heavy as menses x 3 days Mild lower abdominal cramps
Physical Exam Vital signs stable Abd benign Vaginal Exam moderate amount of blood no tissue visible cervix closed Uterus unable to palpate fundus, non-tender Adnexa non-tender, no masses
Management
First Trimester Bleeding High Resource erum Bhcg CBC Group and screen Trans-vaginal ultrasound Low Resource +/- CBC +/- urine Bhcg +/- Trans-abdominal ultrasound
First Trimester Bleeding Differential Diagnosis Threatened abortion Missed abortion (blighted ovum, anembryonic pregnancy) Incomplete abortion Complete abortion Ectopic pregnancy Induced abortion eptic abortion Non-pregnancy related
Ectopic Pregnancy Rule out ectopic Maternal death Case fatality rate
Ruptured Ectopic Pregnancy Missed menses evere abdominal pain +/- vaginal bleeding Hypotensive Peritonitis
Rule out Ectopic Pregnancy Intra-uterine pregnancy Heterotopic pregnancy Correlate ultrasound findings with Bhcg
IUP
Discriminatory Threshold Trans-vaginal ultrasound - Bhcg 1200 Trans-abdominal ultrasound - Bhcg 6000
Ectopic Pregnancy Likely Ectopic erum Bhcg >1200 and no IUP on trans-vaginal ultrasound erum Bhcg >6000 and no IUP on trans-abdominal ultrasound Bhcg increase Treatment
Low Resource Clinical suspicion for an unruptured ectopic pregnancy Missed menses Risk factors Unilateral pelvic pain Abdominal pain >> vaginal bleeding
Low Resource: Moderate-high suspicion of unruptured ectopic Management Options Ultrasound Observation urgery
Low Resource Assume Intra-Uterine Pregnancy Missed menses Low clinical suspicion for ectopic Tissue passed or removed from cervical os
Low Resource: Viable vs. Non-Viable Pregnancy If mild-moderate vaginal bleeding, then assume viable Expectant management If heavy vaginal bleeding and/or tissue passed then assume non-viable Management options: surgery, oxytocin, misoprostol
Low Resource: Wrong Assumptions About Viability Actually non-viable (missed abortion, incomplete, complete) Expectant management Actually viable pregnancy urgery, oxytocin, misoprostol
High Resource Confirmation of failed pregnancy Ultrasound erial decrease in Bhcg
Management of Missed And Incomplete Abortion Expectant Medical urgical
Misoprostol Prostaglandin analog Causes uterine contractions and cervical ripening Indications: Misuse Missed abortion Incomplete abortion
Misoprostol Dose Missed abortion 800 mcg q3-24 h vaginal or oral (max 2 doses) Incomplete abortion 600 mcg oral x 1 (or same as missed abortion)
Misoprostol When using for presumed miscarriage (missed or incomplete) without ultrasound, always consider the possibility of ectopic All patients require follow up and advice when to seek emergent care
Conclusions The key to decreasing morbidity from ectopic pregnancy is early diagnosis Ultrasound significantly impacts diagnosis and management of patients with first trimester bleeding; advocate for ultrasound in ED If ultrasound is unavailable when managing first trimester bleeding first establish clinical suspicion of ectopic pregnancy, then establish clinical suspicion of viability; be conservative Misoprostol is an important treatment option available to emergency physicians to manage failed pregnancies
Case 22 year old female presents to the emergency department with vaginal bleeding LMP about 2 months ago Bleeding heavier than menses with clots x 3 days Mild lower abdominal cramps Vaginal Exam moderate amount of blood no tissue visible cervix closed uterus small for dates (4-6 week size) Adnexa non-tender, no masses