Early Pregnancy Problems

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Early Pregnancy Problems

• Feras Izzat
• Consultant Gynaecologist EGU/EPAU Lead
• University Hospitals Coventry Warwickshire NHS
  Trust

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Introduction

• Ectopic Pregnancy
• Bleeding in early pregnancy and miscarriage
• Gestational Trophoblastic Disease

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• Ectopic Pregnancy

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Definition

• Pregnancy occurring outside uterine cavity
• Approx 11/1000 of pregnancies rate increasing
• Maternal mortality in 1/2500 ectopic pregnancies
  (11 deaths in most recent report)

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Site

• Tubal
• Interstitial 2.4
• Isthmic 12
• Ampullary 70
• Fimbrial 11.1
• Non Tubal
• Ovary
• Abdominal cavity
• Cervix
• CS Scar

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Risk factors

• Previous PID
• Previous ectopic pregnancy
• Previous tubal surgery (e.g. sterilisation,
  reversal)
• Pregnancy in the presence of IUCD
• POP
• ART (IVF)

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Symptoms

• Acute
• Low abdominal pain peritoneal irritation by
  blood
• Vaginal bleeding shedding of decidua
• Shoulder tip pain referred from diaphragm
• Fainting - hypovolaemia
• Chronic (Atypical)
• Asymptomatic, gastrointestinal symptoms

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Signs

• Abdominal tenderness
• Adnexal tenderness / mass
• Shock tachycardia, hypotension, pallor
• None

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Diagnosis

• Ultrasound
• Empty uterus, adnexal mass, free fluid,
  occasionally live pregnancy outside of uterus
• Serum ßhCG Progesterone
• Laparoscopy

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Ultrasound
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Ultarsound

• Trans-Vaginal Ultrasonography
• Sensitivity 100, specificity 98.2.
• The positive predictive value 98, and the
  negative predictive value was 100
• FH seen in 23
• Timor-Tritsch et al, 1990 Am J Obstet Gynecol.

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Left Ectopic on laparoscopy
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Management

• Conservative
• hCG lt1000 , Progesterone lt 5 stable, success 70
• Medical
• Methotrexate hCG lt4000 mass lt 3cm, success 84.
  Susequent IUP 54 recurrent EP 8
• Surgical - Laparoscopy
• Salpingectomy, IUP 38.3, EP 9.8
• Salpingotomy, IUP 61.1, EP 15.5
• Yao et al, Fertility Sterility 1997

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PUL

• Pregnancy of unknown location (PUL) - positive
  pregnancy test with no signs of intra- or
  extrauterine pregnancy on transvaginal sonography
  (TVS).
• 15-20 of all EPAU scans
• Management should be expectant if stable with an
  initial serum progesterone (lt20) and a hCG ratio
  0h/48h of lt0.87
• Condous et al, Ultrasound Obstet Gynecol 2006

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• Bleeding in Early Pregnancy Miscarriage

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Definitions

• Threatened miscarriage Vaginal bleeding at lt 24
  weeks gestation
• Delayed (silent) miscarriage Gestational sac
  with/without fetus present (but no FH)
• Recurrent miscarriage 3 or more consecutive
  miscarriages (with or without a known cause)

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Miscarriage

• Approximately 30 of pregnant women will
  experience bleeding in early pregnancy
• At least 50 of women with threatened miscarriage
  will have continuing pregnancy
• Miscarriage occurs in 15-20 of clinically
  diagnosed pregnancies

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Causes of miscarriage

• Genetic abnormalities 85
• Maternal illness e.g. diabetes, Thyroid disease
• Phospholipid / Lupus 15 recurrent miscarriages
• Uterine abnormalities
• Cervical incompetence
• Progesterone deficiency?

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History

• LMP
• When?
• Amount?
• Pain?
• Timing of Pain

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Examination

• ABC (vital signs)
• Abdominal
• Vaginal (speculum)
• Cx state
• Amount of bleeding

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• Cusco speculum Sims speculum

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Investigations

• Ideally in dedicated Early Pregnancy
  Assessment Unit
• Ultrasound
• Measurement of serum ßhCG
• Determination of blood Rhesus group
• FBC, GS and admit if significant bleeding
• Psychological support

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Ultrasound

• Expect to see viable fetus from around 6.5 weeks
  transabdominally, 5.5 weeks transvaginally
• Diagnosis can be made on TVS only
• CRL 7mm
• Empty GS with a mean diameter 25 mm

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Gestational sac
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Very early..
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Normal 8-9 wk pregnancy
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Empty sac
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Measurement of ßhCG

• Not necessary if diagnosis unequivocal on scan
• Useful as part of investigations to diagnose /
  exclude extrauterine pregnancy
• Doubling time approx 2 days in viable pregnancy
• Halving time 1-2 days in complete miscarriage
• Should see fetal pole with ßhCG of 1500-2000

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Management of incomplete miscarriage

• Conservative 76 success
• Medical mifipristone misoprostol 82 success
• Nielsen et al, BJOG 1999
• Surgical (ERPC) No difference in satisfaction
  rate than medical 95
• Chipchase et al, BJOG 1995

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Recurrent miscarriage

• Loss of 3 or more consecutive pregnancies
• Affects 1 of women in reproductive age group
• Investigations can identify up to 50 with a
  cause
• Women aged lt30 years have a subsequent
  miscarriage rate of 25 which rises to 52 in
  women aged gt40 years.
• The risk of a subsequent miscarriage is 29 after
  3 miscarriages, this rises to 53 in 6 or more
  previous miscarriages
• Clifford et al, Human Reproduction 1997

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• Gestational Trophoblastic Disease

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GTD

• The abnormal proliferation of gestational
  trophoblast tissue
• Spectrum of disease
• Pre-Malignant
• Partial Molar Pregnancy
• Complete Molar Pregnancy
• Malignant
• Invasive mole
• Choriocarcinoma
• Placental site trophoblastic tumours

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Molar Pregnancy

• 1 in 1000 live births
• Partial
• Partial moles are triploid with 2 sets of
  paternal and 1 set of maternal chromosomes
• An embryo often present that dies at 8-9 weeks
• 0.5 need chemotherapy for invasive disease
• Complete
• No fetal pole, diplod chromosomes paternally
  derived androgenetic
• No embryo
• Chemo therapy rate 8-20

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Presentation

• Vaginal bleeding
• Excessive NV Hyperemesis gravidarum
• Uterus large for dates

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Diagnosis

• Ultrasound
• Histology after surgical evacuation

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Complete mole at hysterectomy
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Follow-up

• Monitor via regional centre London, Sheffield,
  Dundee
• CM 8-20 risk of invasive disease
• PM 0.5
• Choriocarcinoma may follow any subsequent
  pregnancy miscarriage, TOP, term delivery
• Choriocarcinoma is curable
• Monitor ßhCG levels to check resolution for 6
  months to 2 years

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