1st Trimester Bleeding Flashcards
1) What % of pregnancies will experience 1st trimester bleeding?
2) What % of pregnancies with 1st trimester bleeding end in miscarriage?
1) 25%
2) 50%
What is the basic differential for 1st trimester bleeding (4 main categories)?
- Early pregnancy loss
- Ectopic pregnancy
- Benign OB causes (subchorionic hemorrhage, implantation bleeding)
- Non-OB causes (vaginal bleeding, intercourse, cervical polyp, UTI, fibroids, etc.)
What percentage of miscarriages occur in the 1st trimester?
80%
In the first 8 weeks of pregnancy, b-hCG should increase _____% every 48 hours
80%
In incomplete abortion and embryonic demise, the overall rate of success of expectant management is ____% at 8 weeks
80%
Step 1 of 1st trimester bleeding: what HISTORY do you need to obtain?
- Pregnancy desired or no
- LMP (or 1st trimester US dating if available)
- Quantification of bleeding (bleeding through 2 thick maxi-pads per hour for 2 hours is bad)
- Blood loss symptoms (presyncope)
- Abdominal cramping or no?
Step 2 of 1st trimester bleeding: what PHYSICAL EXAM do you need to do and what are you looking for (after history)?
- VS: signs of volume depletion (high HR, low BP)
- Speculum exam: cervix open or closed, products visible?, blood visible?, identifiable non-OB causes of bleeding?
**Note that speculum exam only tells us if incomplete abortion or not. Does NOT tell us about viability of pregnancy
Step 3 of 1st trimester bleeding: what STUDIES do you obtain (after history and physical exam)
- Labs: CBC, Rh status, quantitative b-hCG
- Imaging: TVUS
At what GA should we see gestational sac?
4-5 weeks
At what GA should we see yolk sac?
5-6 weeks
1) At what GA should we see cardiac activity?
2) At what crown-rump length should we see cardiac activity?
1) 6.5 weeks
2) 7 mm (if >= 7 mm and no cardiac activity, diagnostic of EPL)
Where can you find a table of findings suggestive of and diagnostic of EPL?
AAFP article, Table 2 (https://www.aafp.org/pubs/afp/issues/2019/0201/p166.html)
If IUP of uncertain viability is seen, what does follow-up look like?
- B-hCG every 48 hours
- TVUS in 7-14 days
If pregnancy of unknown location is diagnosed, what does follow-up look like?
- B-hCG level at 48 hours
- If increased >40%, perform TVUS
- Otherwise, trend to B-hCG <5
At what B-hCG level should you see gestational sac?
1500-3000
Ectopic precautions: Return to clinic if:
1)
2)
3)
4)
1) lightheaded/presyncopal
2) bleeding through 2 maxi-pads per hour for 2+ hours
3) new/worsening abdominal pain, especially if unilateral
4) fever, chills, vomiting
How does mifepristone work?
1) Antiprogesterone:
- decidual breakdown –> blastocyst detachment –> ↓ b-hCG
- ↓ b-hCG –> ↓ progesterone –> further decidual breakdown
2) Also stimulates prostaglandins –> uterine contractions and cervical ripening
How does misoprostol work?
Misoprostol is a prostaglandin analogue that induces uterine contractions and induces cervical ripening
Mifepristone + misoprostol protocol for EPL management
1) mifepristone 200 mg PO once
2) misoprostol 800 mcg PO/buccal/vaginal 10-24 hours after mifepristone
3) if minimal-to-no bleeding 24 hours after first misoprostol, give additional 800 mcg dose
Mifepristone and misoprostol side effects
Mifepristone: basically none (rare N/V)
Misoprostol: nausea (50%), vomiting, diarrhea, HA, hot flashes
Obviously there will be abdominal cramping and vaginal bleeding; this is to be expected. Concerning bleeding is enough to soak 2 pads in an hour –> go to the ED
3 options for EPL management. Also, regardless of management option, what tx should be considered for everyone?
1) Expectant management (80% in first trimester over 8 weeks)
2) Medical management
3) Surgical management
RhoGAM should be given if Rh neg (though some say that if <12w, this isn’t necessary)
Expectant management ____% effective at 1 month for INCOMPLETE abortion
90%
Expectant management ____% effective at 1 month for IUFD
75%
Medical management increases success for management of EPL compared to expectant mangaement in which one: incomplete abortion or IUFD?
IUFD
mife + miso is 84% effective at 2 days, compared with 75% at 1 month with expectant management. Medication doesn’t make much of a difference for incomplete abortion.
What % of patients need to go the ED for evaluation of bleeding for medication management of EPL?
<1%
In general, we don’t recommend expectant management after _____ wks due to increased rate of complications
13 wks
Efficacy of mife + miso for first trimester EPL
~90%
