Early Pregnancy Problems

1
Early Pregnancy Problems
Jacqueline Woodman M.B.,Ch.B. Dipl Obst MRCOG
D.Phil (Oxon)
2
Introduction

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

3
Bleeding in Early Pregnancy Miscarriage
4
Definitions

• Remember MISCARRIAGE not ABORTION
• Threatened miscarriage Vaginal bleeding at lt 24
  weeks gestation (cervix closed)
• Inevitable miscarriage Bleeding, pregnancy still
  in uterus (cervix open)
• Incomplete miscarriage Retained products of
  conception in uterus (cervix open)
• Complete miscarriage Uterus empty (cervix closed)
• Delayed miscarriage Gestational sac with/without
  fetus present (but no FH), cervix closed

5
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

6
Causes of miscarriage

• Genetic abnormalities
• Progesterone deficiency?
• Maternal illness e.g. diabetes
• Uterine abnormalities
• Cervical incompetence

7
History

• LMP
• Bleeding amount (spotting/gush), clots
• Pain type crampy/sharp/dull
• location lower abdomen, shoulder
  tip, back pain
• Passed products?

8
Examination

• ABC (vital signs)
• stable or cervical shock
• Abdominal
• tender/ rebound tenderness
• Vaginal (speculum)
• Cervix open/closed
• Amount of bleeding
• Products visible? .............TAKE IT OUT!

9
Speculums

• Cusco speculum Sims speculum

10
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

11
Ultrasound

• Expect to see viable fetus from around 6.5 weeks
  transabdominally,
• 5.5 weeks transvaginally
• Other possible appearances
• POC Incomplete miscarriage
• Empty uterus Not pregnant
• Too early gestation
• Extrauterine pregnancy
• Complete miscarriage
• Empty sac Non-viable pregnancy
• Too early gestation
• Fetal pole with no FH If tiny, may be very early
  gestation
• Delayed miscarriage

12
Gestational sac
13
Very early..
14
Normal 8-9 wk pregnancy
15
Empty sac
16
Measurement of ßhCG

• Not necessary if diagnosis unequivocal on scan
• Useful as part of investigations to
  diagnose/exclude extrauterine pregnancy/miscarriag
  e
• 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

17
Management of Incomplete Miscarriage

• Conservative
• Risk of bleeding, infection, retained POC
  needing ERPC, unpredictable
• Medical (Prostaglandin e.g. Misoprostol)
• Risk of bleeding, retained POC, need for
  ERPC
• Surgical Evacuation of retained products of
  conception (ERPC)
• Suction curettage usually under GA, risk of
  bleeding, infection, perforation of uterus,
  longer term complications (e.g. Ashermans
  syndrome)

18
Ectopic Pregnancy
19
Definition

• Pregnancy occurring outside uterine cavity
• Approx 0.5-1 of pregnancies rate increasing
• Maternal mortality in 1/2500 ectopic pregnancies
  (13 deaths 1997-1999 in UK)

20
Site

• Fallopian tube
• Ovary
• Abdominal cavity
• Cervix

21
Risk factors

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

22
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, back
  pain

23
Signs

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

24
Diagnosis

• Ultrasound
• Empty uterus, adnexal mass, free fluid in POD,
  rarely live pregnancy outside of uterus
• Serum ßhCG
• Suboptimal rise, plateau
• Laparoscopy

25
Ultrasound
26
Left Ectopic on laparoscopy
27
Management

• Medical
• Methotrexate
• Surgical
• Laparoscopic salpingectomy / salpingotomy
• Laparotomy
• Conservative
• Self resolving with close watch

28
Gestational Trophoblastic Disease
29
Hydatidiform Mole

• 1 in 1000 pregnancies
• Partial
• Associated with fetus, triploid
• Complete
• No fetal pole, diploid chromosomes paternally
  derived

30
(No Transcript)
31
Presentation

• Asymptomatic incidental finding at dating or
  anomaly USS
• Vaginal bleeding
• Hyperemesis gravidarum
• Uterus large for dates

32
Diagnosis

• Ultrasound (Snow storm appearance)
• Histology after surgical evacuation

33
Snowstorm appearance
34
Hydatidiform Mole after hysterectomy
35
Follow-up

• Monitor via regional centres London, Sheffield,
  Dundee
• 3 risk choriocarcinoma following complete mole,
  less following partial mole
• 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
• Avoid pregnancy for minimum 6 months or until all
  clear

36
Hyperemesis Gravidarum
37
Hyperemesis Gravidarum

• Nausea/vomiting in pregnancy is normal morning
  sickness
• Rarely excessive hyperemesis gravidarum
• Related to level of ßhCG

38
Associated Factors

• UTI
• Multiple pregnancy
• Molar pregnancy
• Socio-economic factors

39
Investigations

• Renal function
• Liver function
• FBC
• Urinalysis and MSU
• Ultrasound

40
Consequences Management

• Dehydration
• Electrolyte imbalance
• Metabolic alkalosis, hypokalaemia,
• hypernatremia
• Oesophageal tears
• (Mallory Weiss)
• Thrombosis
• DVT/PE/Cerebral sinus
• Weight loss
• Vitamin deficiency (vit B1- thiamine)
• Wernicke's encephalopathy
• Psychological impact

• IV fluids
• Electrolyte replacement
• Antiemetics
• Thromboprophylaxis
• Dietary advice
• Vitamin supplementation
• Steroids
• Antibiotics if UTI
• Termination of pregnancy

41
in CONCLUSION
GYNAECOLOGICAL EMERGENCIES 1. MISCARRIAGE 2.
ECTOPIC 3. PELVIC SEPSIS 4. OVARIAN TORSION
42
(No Transcript)