Early Pregnancy ProblemsJacqueline Woodman (Medical Education Lead)Feras Izzat (EPAU Lead)University Hospitals Coventry & Warwickshire NHS Trust

• Early pregnancy

• Ectopic pegnancy

• Miscarriage

• Trophoblastic disease

Contents

Early pregnancyEarly 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

Ectopic Pregnancy

DefinitionDefinition

• Pregnancy implanted

outside uterine cavity

• Approx 11/1000 of

pregnancies – rate

increasing

• Maternal mortality in

1/2500 ectopic

pregnancies

Site

• Outside uterine cavity (Cervical, CS scar)

• Commonest- tubal

Risk factorsRisk 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 >40y

• Up to 50% have no risk factors

SymptomsSymptoms

• 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

SignsSigns

• Abdominal tenderness

• Adnexal tenderness / mass

• Shock – tachycardia, hypotension, pallor

• None

Outcomes

• Unlikely to continue beyond few months and exceptional to reach period of viability

• Resolve spontaneously

• Catastrophic rupture- intraabdominal haemorrhage

DiagnosisDiagnosis

• History and examination

• Ultrasound– Empty uterus, adnexal mass, free fluid, occasionally live

pregnancy outside of uterus

• Serum βhCG - serial– Slow rising, plateau

• Laparoscopy

Ultrasound

Beta hCG levels

• Level don’t 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

Left Ectopic on laparoscopy

ManagementManagement

• Conservative – Self resolving with close watch

• Medical– Methotrexate

• Surgical– Laparoscopic salpingectomy / salpingotomy– Laparotomy

True / False

• Ectopic pregnancy is pregnancy outside the uterus.

True / False

• Ectopic pregnancy is pregnancy outside the uterus. F

True / False

• Ectopic pregnancy is pregnancy outside the uterus. F

• Pregnancy conceived with IUCD in situ is at increased risk of ectopic pregnancy.

True / False

• Ectopic pregnancy is pregnancy outside the uterus. F

• Pregnancy conceived with IUCD in situ is at increased risk of ectopic pregnancy. T

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.

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

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

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.

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

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

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

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

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

Bleeding in Early Pregnancy & Miscarriage

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.

MiscarriageMiscarriage

• 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

DefinitionsDefinitions

• Threatened miscarriage Vaginal bleeding at < 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)

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- <12 weeks

• Late miscarriage- >12 weeks

Causes

Fetal

• Chromosomal

• Malformations

• Placental

• Multiple pregnancy

Maternal

• Disease- Diabetes, hyperthyroidism

• Age

• BMI

• Infection

• Uterine/ cevical anamolies

• Previous miscarriage

• trauma

Examination

• ABC (vital signs)

• Abdominal

• Vaginal (speculum)– Cx state

– Amount of bleeding

Cusco speculum Sims speculum

InvestigationsInvestigations

Ideally in dedicated ‘Early Pregnancy Assessment Unit’

• Ultrasound

• Measurement of serum βhCG

• Determination of blood & Rhesus group

• FBC, G&S and admit if significant bleeding

• Psychological support

UltrasoundUltrasound

• Expect to see viable fetus from around 6.5 weeks transabdominally, 5.5 weeks transvaginally

• Other possible appearances – ‘POC’ Incomplete miscarriage

– Empty uterus Not pregnantToo early gestationExtrauterine pregnancyComplete miscarriage

– Empty sac Non-viable pregnancyToo early gestation

– Fetal pole with no FH If tiny, may be very early gestation

Delayed miscarriage

Gestational sac

Very early..

Normal 8-9 wk pregnancy

Empty sac

Measurement of Measurement of ββhCGhCG

• 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 βhCG of 1500-2000

Management of Incomplete MiscarriageManagement 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

True or False1. Miscarriage is defined as expulsion of fetus <500g.2. 1 in 3 pregnancies end in a miscarriage3. Commonest cause of miscarriage is chromosomal

abnormalities.4. Term an embryonic pregnancy should be preferred over

early fetal demise5. There are no risks with expectant management of

miscarriage6. Mifepristone is anti estrogen7. Misprostol is licensed for medical management of

miscarriage

True or False1. Miscarriage is defined as expulsion of fetus <500g. ✔2. 1 in 3 pregnancies end in a miscarriage. ✗3. Commonest cause of miscarriage is chromosomal

abnormalities.✔4. Term an embryonic pregnancy should be preferred over

early fetal demise. ✗5. There are no risks with expectant management of

miscarriage.✗6. Mifepristone is anti estrogen.✗7. Misprostol is licensed for medical management of

miscarriage.✗

Gestational Trophoblastic Disease

Hydatidiform MoleHydatidiform 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

Increased rates

• Southeast Asia (8/1000)

• Extremes of reproductive age (>40 X5-10)

• Previous molar pregnancy

• Low carotene diet

PresentationPresentation

• Vaginal bleeding

• Excessive N&V ‘Hyperemesis gravidarum’

• Uterus large for dates

DiagnosisDiagnosis

• Ultrasound (Snow storm appearance)

• Histology after surgical evacuation

Snowstorm appearance

Complete mole at hysterectomy

Management

• Suction evacuation

• Avoid cervical ripening

• Above will cure 99.5% of PHM, 84% of CHM

• Avoid hysteroscopy- increase the likelihood of chemotherapy

Follow-upFollow-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 βhCG levels to check resolution – for 6 months to 2 years

• 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

References