Episode 193: Threatened Abortion

We review threatened abortion and the complexities in its care.
Hosts:
Stacey Frisch, MD
Brian Gilberti, MD



https://media.blubrry.com/coreem/content.blubrry.com/coreem/Threatened_Abortion.mp3



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Tags: OBGYN





Show Notes
Background

* Defined as vaginal bleeding during early pregnancy (before 20 weeks) with a closed cervical os, no passage of fetal tissue, and IUP on ultrasound
* Occurs in 20-25% of all pregnancies.

Initial Assessment and Management

* Priority is to assess patient stability, establish good IV access, FAST may be helpful in identifying some ruptured ectopics early
* Broad differential diagnosis is crucial to avoid mistaking conditions like ectopic pregnancy for other emergencies.
* Importance of a detailed history and physical examination.

Diagnostic Approach

* Essential tests include HCG level, urinalysis, and possibly CBC + blood type/Rh status.
* Rhogam’s use is well-supported in second and third trimester bleeding; however, data is less robust for first trimester bleeding in preventing sensitization
* Importance of interpreting b-HCG with caution and understanding HCG discriminatory zones.
* Use of ultrasound imaging, both bedside and formal, to assess the pregnancy’s status.

Patient Counseling and Management

* Open and honest communication about the prognosis of threatened abortion.
* Addressing psychosocial aspects, including dispelling guilt and myths, and screening for intimate partner violence and mental health issues.
* Recommendations against bedrest and certain activities
* Lack of evidence supporting restrictions on sexual activity.
* Standard pregnancy guidelines: avoiding smoking, alcohol, drug use, and starting prenatal vitamins.

Follow-up and Precautions

* Adopting a wait-and-see approach for stable patients, with scheduled follow-ups for ultrasounds and beta-HCG tests.
* Educating patients on critical warning signs that require immediate medical attention.
* Emphasizing the importance of returning to the hospital if experiencing significant bleeding or other severe symptoms.

Take Home Points

* Threatened Abortion is defined as Experiencing abdominal pain and/or vaginal bleeding during early pregnancy (before 20 weeks), characterized by a closed cervical os and no expulsion of fetal tissue. In these cases, it is important to assess patient stability promptly.
* Keep your differential broad in these cases. The evaluation will in most cases involve a combination of labs and ultrasound imaging. 
* Understand that the Rhogam certainly has a role in second and third trimester vaginal bleeding in the Rh-negative patient, and that there is a dearth of good data on its role in the first trimester – it will ultimately be a decision that is made by you, OBGYN, and the patient.