Issues in Early Pregnancy

1
Issues in Early Pregnancy

• ACOG District I Medical Student
• Teaching Module 2008

2
When a woman presents with an early pregnancy

• Ask yourself two questions
• Where is this pregnancy?
• Is it viable?

3
Where is this pregnancy?

• In a woman with an early pregnancy you must
  determine if the pregnancy is intrauterine or an
  ectopic, because her life could depend on it!

4
How to you determine location of the pregnancy?

• First determine dating by LMP
• Then perform ultrasound
• If you can see location of the pregnancy, you are
  done!
• If you cannotit becomes more complicated

5
Early pregnancy with unknown location

• Check a serum BHCG
• If it is above the discriminatory zone (DZ)(this
  is different at every hospital) an intrauterine
  pregnancy should be seen
• Then do an ultrasound to see if you see the
  pregnancy

6
Early pregnancy with unknown location

• If BHCGDZ and pregnancy seen in the uterus, you
  are done
• If BHCGDZ and no pregnancy seen in the uterus,
  it is an ectopic until proven otherwise!

7
Ectopic pregnancy

• 2 of all pregnancies
• Risk factors include prior tubal surgery, prior
  ectopic, current IUD use, history of PID, or DES
  exposure
• A woman can present with abdominal pain or
  bleeding or be asymptomatic!

8
Ectopic Pregnancy

• 95 are in the fallopian tube (70 ampulla, 12
  isthmus, 11 fimbria, 2 interstitial/cornual)
• Ovarian occurs about 3 of the time, abdominal 1
  of the time and cervical

Seeber 2006
9
Early pregnancy with unknown location

• If BHCGthe ultrasound consider your patient
• Is she.
• Unstable or stable
• Have pain? Have risk factors for ectopic?
• Your differential diagnosis is intrauterine
  pregnancy just too small to see on ultrasound vs
  ectopic

10
Early pregnancy with unknown location

• Generally, BHCG will double in 48 hours
• If the patient is stable you can have her return
  in 48 hours for repeat BHCG
• If is doubling appropriately, likely normal
  intrauterine pregnancy and can order ultrasound
  when DZ
• If not doubling appropriately consider treatment
  for ectopic (methotrexate or surgery)

11
Now you know locationnow what?

• An ectopic pregnancy can be treated either
  medically with methotrexate or surgically
• The next step with an intrauterine pregnancy is
  determining viability

12
Viability

• When you have an intrauterine pregnancy there are
  several possibilities
• 1- Normal
• 2 - Miscarriage (there are different types!)
• 3 - Molar pregnancy
• A viable pregnancy is an intrauterine pregnancy
  that has cardiac motion-should see by 7-8 weeks

13
Intrauterine pregnancy

• First finding on US is an empty gestational sac
• But cannot say that it is an intrauterine
  pregnancy until you see a yolk sac or a fetal pole

14
Intrauterine Pregnancy
15
Yolk sac by 5 weeks
www.advancedfertility.com
16
Fetal Pole by 6-7 weeks
www.advancedfertility.com
17
Types of nonviable intrauterine pregnancies

• Anembryonic (blighted ovum)
• Threatened abortion
• Inevitable abortion
• Complete abortion
• Missed abortion

18
Anembryonic gestation

• No yolk sac or fetal pole
• Mean gestational sac diameter of 30 mm

www.gloriaspregnancyinfo.com
19
Threatened abortion

• First trimester bleeding
• Fetal pole with a heartbeat
• If there is a heartbeat there is less than 10
  chance of miscarriage

20
Inevitable abortion

• Deformation and/or descent of gestational sac
  with a dilated cervix

21
Complete abortion

• Products of conception completely expelled

22
Missed abortion

• Intrauterine pregnancy with an embryo, but no
  cardiac activity by 8 weeks gestation

23
Now you know the basic issues in early
pregnancy!!
24
Algorithm that might help you
Seeber 2006
25
Sources

• Frishman, Gary, et al. Women and Infants Beta
  book.
• Merz, Eberhard. Ultrasound in Obstetrics and
  Gynecology Vol 1 Obstetrics. Stuttgart Georg
  Thieme Verlag, 2005.
• Mukul, Liberato and Stephanie Teal. Current
  Management of Ectopic Pregnancy. Obstetrics
  Gynecology Clinics of North America. 34 (2007)
  403419.
• Seeber, Beata E, and Kurt T Barnhart. Suspected
  Ectopic Pregnancy. Obstetrics Gynecology. 107
  (2006) 399-413 .
• www.advancedfertility.com
• www.gloriaspregnancyinfo.com