Early Pregnancy Problems

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Early Pregnancy Problems

• Jacqueline Woodman (Medical Education Lead)
• Feras Izzat (EPAU Lead)
• University Hospitals Coventry Warwickshire NHS
  Trust

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Contents

• Early pregnancy
• Ectopic pegnancy
• Miscarriage
• Trophoblastic disease

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Early pregnancy

• Pregnancy up to 12 weeks gestation.
• Amenorrhea
• Urine pregnancy test positive
• Pregnancy symptoms
• USS- fetus transabdominal scan from 6.5 weeks and
  TV scan from 5.5 weeks

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• Ectopic Pregnancy

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Definition

• Pregnancy implanted outside uterine cavity
• Approx 11/1000 of pregnancies rate increasing
• Maternal mortality in 1/2500 ectopic pregnancies

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Site

• Outside uterine cavity (Cervical, CS scar)
• Commonest- tubal

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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
• Assisted reproduction
• Smoking
• Maternal age gt40y
• Up to 50 have no risk factors

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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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Outcomes

• Unlikely to continue beyond few months and
  exceptional to reach period of viability
• Resolve spontaneously
• Catastrophic rupture- intraabdominal haemorrhage

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Diagnosis

• History and examination
• Ultrasound
• Empty uterus, adnexal mass, free fluid,
  occasionally live pregnancy outside of uterus
• Serum ßhCG - serial
• Slow rising, plateau
• Laparoscopy

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Ultrasound
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Beta hCG levels

• Level dont inform location of pregnancy!!!
• 1) levels may suggest if pregnancy is advanced
  enough to be seen on scan
• 2) serial- failing or progressing
• 3) if ectopic- management option

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Left Ectopic on laparoscopy
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Management

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

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True / False

• Ectopic pregnancy is pregnancy outside the
  uterus.

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True / False

• Ectopic pregnancy is pregnancy outside the
  uterus. F

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True / False

• Ectopic pregnancy is pregnancy outside the
  uterus. F
• Pregnancy conceived with IUCD in situ is at
  increased risk of ectopic pregnancy.

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True / False

• Ectopic pregnancy is pregnancy outside the
  uterus. F
• Pregnancy conceived with IUCD in situ is at
  increased risk of ectopic pregnancy. T

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True / False

• Ectopic pregnancy is pregnancy outside the
  uterus. F
• Pregnancy conceived with IUCD in situ is at
  increased risk of ectopic pregnancy. T
• Once ectopic pregnancy is diagnosed, surgical
  management is recommended.

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True / False

• Ectopic pregnancy is pregnancy outside the
  uterus. F
• Pregnancy conceived with IUCD in situ is at
  increased risk of ectopic pregnancy. T
• Once ectopic pregnancy is diagnosed, surgical
  management is recommended. F

22
True / False

• Ectopic pregnancy is pregnancy outside the
  uterus. F
• Pregnancy conceived with IUCD in situ is at
  increased risk of ectopic pregnancy. T
• Once ectopic pregnancy is diagnosed, surgical
  management is recommended. F

23
True / False

• Ectopic pregnancy is pregnancy outside the
  uterus. F
• Pregnancy conceived with IUCD in situ is at
  increased risk of ectopic pregnancy. T
• Once ectopic pregnancy is diagnosed, surgical
  management is recommended. F
• Smoking is not a risk factor for ectopic
  pregnancy.

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True / False

• Ectopic pregnancy is pregnancy outside the
  uterus. F
• Pregnancy conceived with IUCD in situ is at
  increased risk of ectopic pregnancy. T
• Once ectopic pregnancy is diagnosed, surgical
  management is recommended. F
• Smoking is not a risk factor for ectopic
  pregnancy. F

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True / False

• Ectopic pregnancy is pregnancy outside the
  uterus. F
• Pregnancy conceived with IUCD in situ is at
  increased risk of ectopic pregnancy. T
• Once ectopic pregnancy is diagnosed, surgical
  management is recommended. F
• Smoking is not a risk factor for ectopic
  pregnancy. F
• hCG doubling in 48h excludes ectopic pregnancy. F

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True / False

• Ectopic pregnancy is pregnancy outside the
  uterus. F
• Pregnancy conceived with IUCD in situ is at
  increased risk of ectopic pregnancy. T
• Once ectopic pregnancy is diagnosed, surgical
  management is recommended. F
• Smoking is not a risk factor for ectopic
  pregnancy. F
• hCG doubling in 48h excludes ectopic pregnancy. F

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True/False

• Ectopic pregnancy is pregnancy outside the
  uterus. F
• Pregnancy conceived with IUCD in situ is at
  increased risk of ectopic pregnancy. T
• Once ectopic pregnancy is diagnosed, surgical
  management is recommended. F
• Smoking is not a risk factor for ectopic
  pregnancy. F
• hCG doubling in 48h excludes ectopic pregnancy. F
• Slow rising hCG increases possibility of ectopic
  pregnancy

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True/False

• Ectopic pregnancy is pregnancy outside the
  uterus. F
• Pregnancy conceived with IUCD in situ is at
  increased risk of ectopic pregnancy. T
• Once ectopic pregnancy is diagnosed, surgical
  management is recommended. F
• Smoking is not a risk factor for ectopic
  pregnancy. F
• hCG doubling in 48 h excludes ectopic pregnancy.
  F
• Slow supoptimal rise in HCG increases possibility
  of ectopic pregnancy. T

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• Bleeding in Early Pregnancy Miscarriage

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Miscarriage

• UK definition- Loss of intrauterine pregnancy
  before 24 weeks of gestation
• WHO definition- expulsion of fetus weighing 500g
  or less and less than 22 completed weeks
  gestation.

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Miscarriage

• Miscarriage occurs in 15-20 of clinically
  diagnosed pregnancies
• Once fetal heart is seen, the risk of miscarriage
  is less than 5
• At least 50 of women with threatened miscarriage
  will have continuing pregnancy

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Definitions

• Threatened miscarriage Vaginal bleeding at lt 24
  weeks gestation, FH
• Inevitable miscarriage Internal cervical os open
  in association with bleeding
• Incomplete miscarriage Products of conception
  remaining in uterus
• Complete miscarriage Uterus empty
• Delayed (silent) miscarriage Gestational sac
  with/without fetus present
• (but no FH)

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Remember

• Miscarriage not abortion or termination
• It is loss/end of pregnancy, except in threatened
  miscarriage where it is continuing but increased
  risk of ending.
• Early miscarriage- lt12 weeks
• Late miscarriage- gt12 weeks

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Causes

• Fetal

• Maternal

• Chromosomal
• Malformations
• Placental
• Multiple pregnancy

• Disease- Diabetes, hyperthyroidism
• Age
• BMI
• Infection
• Uterine/ cevical anamolies
• Previous miscarriage
• trauma

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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
• 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

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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- unsuitable if infection , heavy
  bleeding
• review after 1-2
  weeks, can continue up to 6-8 weeks
• risk of unplanned
  intervention , transfusion due to bleeding,
  failure
• Medical Misoprostol 600-800mcg (UPTafter 3
  weeks)
• risk of bleeding, failure
• Surgical (ERPC) Suction curettage usually under
  GA- first line if infection, heavy bleeding.
  Risks of bleeding ,infection, perforation,
  failure

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True or False

• Miscarriage is defined as expulsion of fetus
  lt500g.
• 1 in 3 pregnancies end in a miscarriage
• Commonest cause of miscarriage is chromosomal
  abnormalities.
• Term an embryonic pregnancy should be preferred
  over early fetal demise
• There are no risks with expectant management of
  miscarriage
• Mifepristone is anti estrogen
• Misprostol is licensed for medical management of
  miscarriage

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True or False

• Miscarriage is defined as expulsion of fetus
  lt500g. ?
• 1 in 3 pregnancies end in a miscarriage. ?
• Commonest cause of miscarriage is chromosomal
  abnormalities.?
• Term an embryonic pregnancy should be preferred
  over early fetal demise. ?
• There are no risks with expectant management of
  miscarriage.?
• Mifepristone is anti estrogen.?
• Misprostol is licensed for medical management of
  miscarriage.?

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• Gestational Trophoblastic Disease

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Hydatidiform Mole

• Disordered placental proliferation
• 1-3 in 1000 pregnancies
• Partial Mole
• Associated with fetus, triploid
• Complete Mole
• No fetal pole, diploid chromosomes paternally
  derived androgenetic

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Increased rates

• Southeast Asia (8/1000)
• Extremes of reproductive age (gt40 X5-10)
• Previous molar pregnancy
• Low carotene diet

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Presentation

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

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Diagnosis

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

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Snowstorm appearance
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Complete mole at hysterectomy
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Management

• Suction evacuation
• Avoid cervical ripening
• Above will cure 99.5 of PHM, 84 of CHM
• Avoid hysteroscopy- increase the likelihood of
  chemotherapy

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Follow-up

• Monitor via regional centre 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

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References

• Updated and revised nomenclature for description
  of early pregnancy events. Farquharson etal .Hum
  Repd 2005
• RCOG Green-top guideline Tubal pregnancy,
  management
• NICE guidance on ectopic pregnancy and
  miscarriage
• Ectopic pregnancy. J L Tenore Am Fam Physician
  2000.
• Association of early pregnancy units
• Ectopic foundation trust
• Miscarriage Association