Amanda B. Murchison and Melanie D. Altizer
History of present illness
A 19-year-old gravida 1 who is 8 weeks’ pregnant by her last menstrual period, presents to the emergency department with a 1-day history of vaginal spotting. She reports that she had a positive home pregnancy test one week ago. Her periods are typically regular and she has not been using any form of contraception. She denies pelvic cramping, abdominal pain, or fever. She complains of mild nausea but no emesis. She reports that she was diagnosed with chlamydia one year ago and was treated with an antibiotic. She has no other medical problems and is not taking any medication.
Physical examination
General appearance:Well-appearing woman Vital signs:
Temperature: 36.7°C Pulse: 82 beats/min
Blood pressure: 116/72 mmHg Respiratory rate: 16 breaths/min Oxygen saturation: 100% on room air BMI: 20 kg/m2
Cardiovascular:Regular rate and rhythm with no murmurs Lungs:Clear to auscultation
Abdomen:Soft, nontender, nondistended
External genitalia:Normal female external genitalia
Urethra:Urethral meatus appears normal
Vagina:Vaginal mucosa without lesions. There is a small amount of dark blood in the vaginal vault
Cervix:Cervix is without lesions and is closed Uterus:Six to eight weeks’size with no tenderness Adenxa:No adnexal tenderness or masses
Laboratory studies:
Quantitative hCG: 3600 mIU/mL Hb: 12.6 g/dL (normal 12–16 g/dL) Ht: 38% (normal 36–46%)
WBCs: 9500/μL (normal 4000–10 500/μL)
Platelets: 242 000/μL (normal 130 000–400 000/μL) Blood type: A negative
Imaging:An ultrasound is performed. The uterus is anteverted and measures 12 × 8 × 9 cm. It contains an intrauterine gestational sac. Within the gestational sac is a yolk sac and a fetal pole measuring 8.4 mm, which is consistent with a gestational age of 6 weeks and 4 days.
No fetal cardiac activity is present. Both ovaries are normal.
There is no freefluid in the cul-de-sac (Fig. 27.1)
How would you manage this patient?
The patient has a missed abortion. An intrauterine pregnancy was identified on ultrasound with a fetal pole measuring 8.4 mm, but no cardiac activity was seen. This meets diagnostic
Acute Care and Emergency Gynecology, ed. David Chelmow, Christine R. Isaacs and Ashley Carroll. Published by Cambridge University Press.
© Cambridge University Press 2015.
Fig. 27.1 Ultrasound.
criteria for a missed abortion and no further testing is indi- cated. The patient was counseled on the options of expectant, medical, and surgical management and she chose medical management. She was given a prescription for misoprostol 800μg to be placed vaginally and was instructed that the dose could be repeated in 48–72 hours if products of conception were not passed. In addition, a Rh-immunoglobulin injection was administered. She was scheduled for a follow-up appoint- ment in four days. At that time she reported requiring two doses of misoprostol. She described heavy bleeding and cramping that lasted approximately four hours with passage of blood clots followed by bleeding similar to menstrualflow.
She stated that her bleeding had been much lighter for the past 24 hours. A pelvic examination revealed a small amount of blood in the vaginal vault with a closed cervix and small uterus.
A negative home pregnancy test two weeks later confirmed resolution of the pregnancy.
Missed abortion
Approximately 15–20% of clinically recognized pregnancies will end in an early pregnancy loss. If unrecognized pregnan- cies are included, this number increases to as high as 60% [1].
Patients who have a missed abortion may present with vaginal bleeding or pelvic cramping; however, it may also be diagnosed in an asymptomatic woman as an incidentalfinding on routine ultrasound. A physical examination finding of a uterine size less than expected for gestational age would raise suspicion for a missed abortion and an ultrasound would be prudent.
Making the diagnosis of a missed abortion may sometimes be possible in a single clinical encounter or may require subse- quent follow-up with ultrasound or serum beta-human chori- onic gonadotropin (beta-hCG) measurements. The American College of Radiology Appropriateness Criteria guidelines state that a missed abortion may be diagnosed when the mean gestational sac diameter is greater than or equal to 25 mm with no fetal pole, or when a fetal pole is present measuring greater than or equal to 7 mm but no cardiac activity is identified [2].
Our patient had a fetal pole measurement of 8.4 mm with no cardiac activity which met the guidelines for establishing a diagnosis of a missed abortion.
Successful management of a missed abortion requires complete evacuation of the uterus. Treatment options include expectant management, medical management, and surgical management. Not all management options will be appropriate for each patient, but when multiple options are appropriate, the patient should be counseled on the risks and benefits of each. The success of the approach depends on several factors including the presence of symptoms such a bleeding and cramping in addition to the gestational age of the pregnancy.
Expectant management is a reasonable option for women with a gestational age of 13 weeks or less, are hemodynamically stable, and without evidence of infection. The success rate varies from 25 to 76% within 4 weeks. The timing can be unpredictable, leading to patient anxiety [3]. It is important
that patients choosing this option understand that when the miscarriage happens there will be associated bleeding and cramping. Patients should be counseled that if heavy bleeding persists beyond 2–3 hours, they should be evaluated and may possibly need surgical intervention. Expectant management is associated with higher rates of incomplete miscarriage resulting in unplanned surgical intervention. Pelvic infections associated with miscarriage are low in all methods of manage- ment, but some studies show they are lower in patients who chose expectant management. Patients have greater success with expectant management when thorough counseling is provided about appropriate expectations regarding the length of time and symptoms.
Effective and safe medical therapy for missed abortion has afforded women new options for receiving active management in situations where surgical intervention is undesirable to the patient. Patients who choose medical management often want to avoid surgery but desire a more controlled time frame for passage of products of conception. This option should be discussed with patients who are hemodynamically stable and have no sign of a pelvic infection. The most commonly used medication is misoprostol, a prostaglandin E1 analog. It acts as an uterotonic that results in cervical softening and contrac- tions that lead to expulsion of products of conception from the uterine cavity. The risk of a major complication from the use of misoprostol is rare. However, medical management of a missed abortion can result in incomplete passage of tissue resulting in hemorrhage that requires emergent surgical inter- vention. The most studied regimen has been misoprostol 800μg vaginally once and repeated on day 3 if expulsion is incomplete [1]. A multicenter, randomized trial by Creinin et al. [4] showed that using this regimen in missed abortions of 10 weeks, 6 days’ gestation or less (determined by crown rump length of ≤40 mm) resulted in a 71% success rate of pregnancy evacuation with the first dose of misoprostol and an 84% success if an additional dose was required and used.
Many patients are comfortable placing the misoprostol vagin- ally, but a simple trick for patients that are less comfortable with this idea is to have them load the medication in a tampon applicator to assist with proper placement. Also consider pre- scribing a nonsteroidal anti-inflammatory drug (NSAID) or a small amount of narcotic pain medication when patients elect for expectant or medical management as passage of products of conception will be associated with moderate to severe cramping. Patients should be counseled to contact their phys- ician if they experience heavy bleeding, consisting of soaking a menstrual pad every hour for 2 consecutive hours, or fever that persists beyond 24 hours. Misoprostol use can be associated with short-term elevations in temperature [1].
Some patients will elect for surgical management while others will require surgery as a result of failed expectant or medical management. Many patients experience anxiety asso- ciated with the uncertainty as to when they will start bleeding and how much discomfort will be associated with a miscar- riage. Benefits of surgical intervention include a scheduled
Case 27: Vaginal spotting at eight weeks’gestation
timing as well as potentially decreased amounts of bleeding and discomfort. Dilation and curettage also produces a surgical specimen for pathologic evaluation. Surgical management is usually accomplished by a suction dilation and curettage or dilation and evacuation. Risks of surgical management include complications from anesthesia, uterine perforation, intrauter- ine adhesion formation, cervical trauma, infection, and the risk of retained products. Prompt surgical intervention is the cor- rect treatment when the patient is hemodynamically unstable or has evidence of infection (septic abortion) [5]. The use of ultrasound guidance during the procedure is optional, but no studies have been conducted determining its effectiveness in preventing uterine perforation or determining complete emptying of the uterine cavity.
There have been no randomized trials to define the optimal follow-up of patients after treatment for a missed abortion.
Consider a follow-up visit in three to seven days after medical management and one to two weeks after expectant or surgical management. This visit may include a history, pelvic exam, and possibly an ultrasound to evaluate the uterine cavity.
Women who are Rh(D) negative and not sensitized should be given Rh(D)-immunoglobulin following surgical treatment or upon diagnosis of missed abortion when expectant or medical management is selected as the treatment option [6].
Gestations of 12 weeks or less can be treated with a dose of 50μg. Pregnancies of greater gestational age should receive the
standard 300μg dose. There is no harm in using the larger dose at earlier gestation ages.
Key teaching points
An intrauterine pregnancy should be seen by transvaginal ultrasound by the time the beta-human chorionic gonadotropin (beta-hCG) level is between 1000 and 2000 mIU/mL. This will vary by institution and is mostly dependent on the resolution of transvaginal imaging available.
An early failed pregnancy diagnosis can be made when the mean gestational sac measurement is 25 mm or greater and no fetal pole is present.
An early failed pregnancy diagnosis can be made when a fetal pole is present measuring 7 mm or greater but no cardiac activity is identified.
Patients with a diagnosis of an early failed pregnancy who are hemodynamically stable, should be counseled on the options of expectant, medical, and surgical management.
The most studied regimen of medical management for an early pregnancy failure has been misoprostol 800μg vaginally repeated on day 3 if expulsion is incomplete.
Patients who are Rh negative should be given Rh immunoglobulin at the time an early pregnancy failure is diagnosed.
References
1. Gariepy A, Stanwood N. Medical management of early pregnancy failure.
Contemporary Obgyn2013;May:
26–33.
2. Lane B, Wong-You-Cheong J, Javitt M, et al. ACR Appropriateness Criteria® first trimester bleeding.Ultrasound Q 2013;29(2):91–6.
3. Zhang J, Gilles JM, Barnhart K, et al.
National Institute of Child Health and
Human Development Management of Early Pregnancy Failure Trial.
A comparison of medical management with misoprostol and surgical management for early pregnancy failure.N Engl J Med2005;353(8):
761–9.
4. Creinin MD, Huang X, WesthoffC, et al; National Institute of Child Health and Human Development Management of Early Pregnancy Failure Trial.
Factors related to successful
misoprostol treatment for early pregnancy failure.Obstet Gynecol 2006;107(4):901–7.
5. Griebel C, Halvorsen J, Golemon T, Day A. Management of spontaneous abortion.Am Fam Physician2005;
72(7):1243–50.
6. American College of Obstetricians and Gynecologists. Medical management of abortion. Practice Bulletin No. 67.
Obstet Gynecol2005;106:871–82.