Chapter 79 Spontaneous and Elective Abortion
Clinical Case Problem 1: Bleeding in the Middle of the Night
Select the best answer to the following questions
2. She follows your advice. The next day you see the patient and her husband in your office. She appears tearful but calm. Her temperature is 98.4° F, blood pressure is 120/80 mm Hg, pulse is 80 beats/minute, and respiratory rate is 16 breaths/minute. She reports that since she spoke to you, she has passed a few dime-sized clots but no obvious tissue. She continues to have lower abdominal cramping. You perform a speculum examination, which reveals some blood in the vaginal vault and a small amount of tissue protruding from an open, dilated cervical os. A bimanual examination reveals a 6-week-size uterus with minimal tenderness but no peritoneal signs. The most likely diagnosis is
3. All of the following would be appropriate management strategies except
4. The patient chooses expectant management. She returns to your office in 2 weeks for another evaluation. She reports passing tissue 48 hours after you examined her in the office. Since then, she has had only minimal spotting, and her pregnancy symptoms of nausea and breast tenderness have resolved. An ultrasound examination reveals a thickened, heterogeneous endometrial stripe and no evidence of an intrauterine pregnancy. What issues should be discussed during this office visit?
Clinical Case Problem 2: An Unplanned Event
5. Which of the following is the most appropriate next step in management?
6. The patient’s pregnancy options could include all the following except
7. The following statements about mifepristone (the medication abortion pill) and emergency contraceptive pills (ECPs) are true except
8. Which of the following is true regarding unintended pregnancy and elective abortion in the United States?
Answers
1. a. This patient is most likely experiencing an early pregnancy loss (also called a spontaneous abortion, nonviable pregnancy, or early pregnancy failure), which is defined as a spontaneous pregnancy loss at less than 20 weeks of gestation based on the last menstrual period. Because the patient appears to be hemodynamically stable on the basis of your phone conversation, it is reasonable to have her evaluated first thing in the morning in your office. Furthermore, you already have preexisting documentation of an intrauterine pregnancy, which makes the possibility of an ectopic pregnancy highly unlikely. The concomitant presence of an ectopic and intrauterine pregnancy (referred to as a heterotopic pregnancy) is possible but is a very rare occurrence, with an incidence of 1:30,000 pregnancies. Reports estimate that heterotopic pregnancies are on the rise, with an incidence as high as 1:2600 pregnancies among certain high-risk subgroups, such as women who have undergone assisted reproductive interventions (e.g., in vitro fertilization).
Although sending the patient to the emergency department immediately is a possible option, this will likely cause unnecessary waiting and anxiety for the couple. An immediate D&C is not necessary, given the fact that the patient is stable and not bleeding excessively. Most early pregnancy losses can be managed safely and effectively in the family medicine setting; a consultation with an obstetrician-gynecologist is not mandatory and will depend on the clinician’s level of clinical comfort. Telling the patient to take ibuprofen and follow up at her next prenatal visit is not appropriate in the setting of undiagnosed first-trimester bleeding.
2. d. The patient is experiencing an incomplete abortion. The terminology to describe nonviable pregnancies was devised before the advent of ultrasonography and can be confusing. Traditionally, nonviable pregnancies are divided into different categories based on physical examination findings: (1) a threatened abortion refers to vaginal bleeding, with or without cramping, in the presence of a closed cervix; (2) an inevitable abortion refers to a dilated cervical os without the passage of tissue; (3) an incomplete abortion refers to a dilated cervical os with the passage of some but not all products of conception; and (4) a complete abortion refers to the complete expulsion of the products of conception. Recurrent spontaneous abortion refers to three or more consecutive pregnancy losses. In clinical trials, an embryonic or fetal demise has been sonographically defined as an embryonic pole or crown-rump length between 5 and 40 mm without cardiac activity. An anembryonic pregnancy (commonly called a blighted ovum) refers to a gestational sac with a mean diameter between 16 and 45 mm without evidence of a fetal pole, inadequate growth of the gestational sac, or an increase in β-hCG levels of less than 15% during a 2-day period in the presence of a yolk sac visualized on ultrasound examination.
3. d. Traditionally, clinicians performed immediate D&Cs to treat spontaneous abortions. Recent evidence provides support for the role of expectant management and medical management instead of surgical intervention. Expectant management allows the patient time to complete the process of spontaneous abortion on her own. This process can occur during the course of 2 to 4 weeks, depending on the patient’s clinical symptoms and the patient’s and clinician’s level of comfort with waiting. Clinicians can monitor the progress of an ongoing pregnancy loss with serial β-hCG levels or ultrasound examination. The β-hCG level should double approximately every 48 hours in a viable intrauterine pregnancy. A rise of less than 50% is associated with an abnormal pregnancy. A change of less than 15% is considered to be a plateau, which is most predictive of an ectopic pregnancy. For incomplete spontaneous abortions, the success rate of expectant management is excellent at 82% to 96%. However, the success rate of expectant management declines with anembryonic pregnancy or fetal or embryonic death (25% to 76%).
Medical management with misoprostol is another option for women. Misoprostol is a prostaglandin that causes cervical softening and uterine contractions. Based on a large, randomized trial, an initial dose of 800 μg of misoprostol by vaginal insertion was associated with a complete expulsion rate of 84% by day 8. Women with an anembryonic pregnancy or embryonic or fetal demise required a second dose of misoprostol for successful completion more often than did women with incomplete or inevitable abortions.
If the patient desires a surgical evacuation of the uterus for emotional reasons, providers who are trained in doing uterine aspiration (with either a hand-held manual vacuum aspirator or an electrical vacuum aspirator) can do so safely in the outpatient setting with local anesthesia. An exploratory laparoscopy would be inappropriate in the setting of an uneventful incomplete spontaneous abortion.
4. c. Women and their partners may experience a range of emotions after an early pregnancy loss. If the pregnancy was a desired one, feelings of grief, guilt, and loss are common. Clinicians should inquire about these emotions and assure patients that they are not “responsible” for the miscarriage’s occurring. If the pregnancy was not a desired one, women may feel a sense of relief because they have avoided the need for an elective termination. Regardless of the situation, clinicians should offer support and appropriate preventive care at the time of the follow-up visit. Women and their partners should be asked about whether another pregnancy is desired and, if so, how soon. A tailored contraceptive plan or preconception counseling should be offered, if appropriate. A thickened endometrial stripe is commonly seen after a medication abortion and does not require intervention if the patient is otherwise asymptomatic. Genetic counseling is not necessary after a single spontaneous abortion. Recurrent spontaneous abortion (three or more consecutive abortions) deserves further investigation. Avoidance of discussing the pregnancy loss is unlikely to help the patient “get over” the event any quicker.
5. b. The most appropriate next step is to inquire how the patient is feeling about being pregnant. Given her body language and tearfulness, it would be presumptive to assume she is happy about the pregnancy and wants to begin prenatal care. Simple, open-ended questions asked in a nonjudgmental manner are useful for engaging the patient in a discussion (e.g., How are you feeling about this? and What does being pregnant right now mean for you and those involved in your life?). There is good reason to believe that the patient is 6 weeks pregnant on the basis of history, examination, and urine pregnancy test. A serum β-hCG level is not necessary to confirm pregnancy diagnosis. A false-positive result from a high-sensitivity (able to detect as low as 25 mIU/mL of β-hCG) urine pregnancy test is rare. Although ultrasound examination may be indicated at some point, depending on the patient’s clinical course, it is not the next most appropriate step in management.
6. e. Clinicians who care for women of reproductive age should be knowledgeable about various pregnancy options and resources for patients who present with unintended pregnancy. Potential options include (1) continuing the pregnancy and becoming a parent; (2) continuing the pregnancy and pursuing adoption for the baby; (3) undergoing a medication abortion; and (4) undergoing a surgical, or aspiration, abortion. There are several medication abortion agents currently in clinical use, including methotrexate (an antimetabolite), mifepristone (an antiprogestin), and misoprostol (a prostaglandin analogue). A detailed comparison of medication abortion protocols is beyond the scope of this chapter.
In 2000, the Food and Drug Administration (FDA) approved a medication abortion protocol using oral mifepristone (RU-496) and oral misoprostol in women who are up to 49 days pregnant. On the basis of large, randomized controlled trials, several evidence-based medication abortion protocols have extended the gestational age limit up to 56 to 63 days, depending on the route of misoprostol administration. Traditionally, D&C was used to perform first-trimester abortions. This procedure has largely been replaced by aspiration abortion, which involves removal of the pregnancy through suction with either a hand-held syringe (manual vacuum aspirator) or an electric vacuum. Aspiration abortion has provided a safe alternative to D&C because there is no sharp curettage of the endometrium involved. It is unethical to force a woman to pursue a pregnancy option (regardless if it is continuing or ending a pregnancy) solely on the basis of her partner’s desires. In ideal circumstances, the decision should involve both the patient and her partner (if there is a partner actively involved).
7. c. Mifepristone (RU-486) is not available without a prescription. Providers must register with the distributor of RU-486 to obtain the pills. In contrast, Plan B, a progestin-only dedicated ECP product, was approved in 2006 by the FDA as a dual-status medication for emergency contraception, meaning that it is available without prescription to women aged 18 years or older and by prescription only to females younger than 18 years. ECPs do not disrupt an implanted pregnancy and are therefore not abortifacients as defined by the FDA, the National Institutes of Health, the American Medical Women’s Association, and the American College of Obstetricians and Gynecologists. Mifepristone, an antiprogestin, is an abortifacient and causes bleeding (that can be heavy and associated with clots) and cramping. Progestin-only ECPs are associated with mild side effects, including nausea, vomiting, and menstrual changes. Most commonly, ECPs may cause early-onset or delayed menses, depending on when they are taken in the menstrual cycle. Intermenstrual spotting is less commonly associated with ECPs.
Adolescents living in certain states need to obtain parental consent before using mifepristone for medication abortion. Currently, there are no states or federal laws that require minors to obtain parental consent before using contraception (including emergency contraception). In fact, Title X and Medicaid, two federal programs that fund family planning services in the United States, prohibit parental consent requirements for teens seeking contraception.
8. b. The United States has one of the highest abortion rates (19.6/1000 women of reproductive age in 2008) among developed countries, which can be attributed in large part to relatively high rates of unintended pregnancy and a lack of widespread contraceptive use among those at highest risk for unplanned pregnancy. Half of all pregnancies in the United States are unintended, and half of unintended pregnancies end in elective abortion. Therefore, one of four pregnancies in the United States ends in an elective termination. In 2008, approximately 1.2 million abortions were performed. The majority of abortions (88%) occur in the first trimester (12 weeks of gestational age or less). The mortality rate from abortion in the United States has decreased significantly since the legalization of abortion in 1973 to approximately 1 in 1 million for early abortions (8 weeks or less). To place this risk in perspective, the risk of death associated with carrying a pregnancy to term is 12 times greater. The risk of mortality from a legal abortion increases with increasing gestational age (e.g., 1/11,000 at 21 weeks or more).
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