Early Pregnancy Assessment where do we stand? Prof Hemantha Dodampahala (MS, MRCOG, FRCS) Early pregnancy assessment unit Prof. unit, ward 39 NHSL SLCOG ACADEMIC SESSIONS

SLCOG ACADEMIC SESSIONS Outline Introduction & Terminology Making the diagnosis U/S diagnosis of normal early pregnancy U/S diagnosis of poor outcome U/S indicators of fetal demise U/S diagnosis of ectopic gestation U/S diagnosis of early fetal abnormalities Management Expectant, Medical and Surgical management Recurrent pregnancy loss When to refer SLCOG ACADEMIC SESSIONS

How common is early pregnancy failure? < 6 weeks 50% loss rate 6-10 weeks 15% loss rate > 10 weeks 2% loss rate Knudsen et al., Eur J Obstet Gynecol Reprod Biol 39:31, 1999 SLCOG ACADEMIC SESSIONS

SLCOG ACADEMIC SESSIONS Terminology Definitions not adhered to at all times but important in the cases of recurrent miscarriage Specify the type of loss preclinical- demise before 6wks embryonic loss 6-10wks fetal loss 10-20 wks Beyond 20 wks? SLCOG ACADEMIC SESSIONS

Risk of SA by maternal age Age of Mother Spontaneous miscarriage (SM) <19 11% 20-29 10% 30-34 12% 35-39 21% 40+ 42% Overall Knudsen et al., Eur J Obstet Gynecol Reprod Biol 39:31, 1999 SLCOG ACADEMIC SESSIONS

Effect of Mother’s Reproductive History on Risk of SM No. of Pts No. of SM % of SM Last pregnancy SM 214 40 19 Only SM in past 98 24 Only pregnancy SM 59 12 20 Last pregnancy successful 95 5 All pregnancy successful 73 3 4 Only pregnancy successful 62 Previous TM 32 2 6 Primigravida 87 SLCOG ACADEMIC SESSIONS Regan L et al: Br Med J 299:541,1998

Why is early pregnancy loss so common? Genetic abnormalities Loss < 6 wks 70% Loss 6 – 10 wks 50% Loss > 10 wks 2% Losses due to genetics are: Random loss Increase with maternal age Don’t affect future pregnancy outcomes Luise, Jermy, May et al. BMJ, 324,2003 SLCOG ACADEMIC SESSIONS

Indications for first trimester U/S To confirm viability Infertility Prior losses Bleeding in the first trimester To provide accurate dating Unsure dates Amnio To rule out ectopic pregnancy Pain Prior ectopic Assisted reproductive technology SLCOG ACADEMIC SESSIONS

SLCOG ACADEMIC SESSIONS Estimation of GA Growth Gestational age Gestational Sac 1 mm/day in MSD (up to 8.5 wks) MSD + 30 Embryo 1 mm/day in length EES mm + 42 (most accurate 6.5-10 wks GA) SLCOG ACADEMIC SESSIONS

SLCOG ACADEMIC SESSIONS Sonoembryology SLCOG ACADEMIC SESSIONS

SLCOG ACADEMIC SESSIONS Sonoembryology GS visible at 4-5 wks Yolk sac visible with MSD of 5-10 mm FH or embryo occasionally visible Gestational sac: represents the chorionic cavity a small anechoic area (fluid) surrounded by echogenic ring (decidual reaction and trophoblasts) Intradecidual in location and abuts the endometrial canal (not in the canal) Yolk Sac: Diagnostic of an intrauterine pregancy round or oval with a thick echogenic wall located in the chorionic cavity involved in transfer of nutrients, hematopoeisis and formation of the primitive gut connected to the midgut by the vitteline duct Amnion: develops at 5-6 weeks gestation but difficult to visualize initially SLCOG ACADEMIC SESSIONS

SLCOG ACADEMIC SESSIONS 7 to 8 weeks gestation Embryo and cardiac activity always visible head, body and extremities can be identified physiologic midgut herniation begins in 7th week SLCOG ACADEMIC SESSIONS

SLCOG ACADEMIC SESSIONS 9-12 weeks gestation Human features become more distinct Increased movement Midgut herniation resolves by 11+5 wks NT is measured btw. 11 – 13 weeks SLCOG ACADEMIC SESSIONS

Discriminatory Levels in TVS Threshold Discriminatory Gestational sac 30 days LMP MSD 2-3 mm 4.5 wks LMP Bhcg 1,500 Yolk sac 35-38 days LMP MSD 5-6 mm 6 wks LMP MSD 8 mm Bhcg 7,200 Cardiac activity 42 days LMP MSD 10 mm 1-2 mm embryo 7 wks LMP MSD 16 mm Bhcg 10,000 SLCOG ACADEMIC SESSIONS

Diagnosis of Pregnancy Failure No FH with a > 5 mm embryo No yolk sac with MSD of 8-10 mm No embryo with MSD of 16-18 mm Visible amnion with no embryo Nyberg et. al. 1999 SLCOG ACADEMIC SESSIONS

U/S Predictors of Poor Outcome Embryonic bradycardia Small gestational sac size (“early oligo”) Enlarged or abnormal yolk sac Subchorionic hemorrhage Very small fetus with increased liquor SLCOG ACADEMIC SESSIONS

Embryonic Bradycardia CRL > 5 mm, FH should be > 100 FH gradually rises to a peak of 170-180 at 9-10 wks FH < 100 have been associated with a high rate of SM High FH is not associated with poor outcome SLCOG ACADEMIC SESSIONS

SLCOG ACADEMIC SESSIONS Embryonic heart rate Fetal HR 148/min Fetal HR 99/min SLCOG ACADEMIC SESSIONS

SLCOG ACADEMIC SESSIONS “early oligo” A difference of less than 5mm between MSD and CRL Most significant between 5 and 9 week Associated with a high rate of pregnancy loss (90%) Often seen with early growth delay Bromley 1991 Radiology: this finding is assoiciated with almost 100% demise SLCOG ACADEMIC SESSIONS

SLCOG ACADEMIC SESSIONS Abnormal Yolk Sac Yolk sacs features associated with poor outcome: > 5-6 mm calcified tear drop shaped echogenic Figueras et all APR 2003 Journal of Reproductive Medicine no increased predictive value using 3D for yolk sac and gestational sac volume SLCOG ACADEMIC SESSIONS

Subchorionic hemorrhage Seen in 1-2% of asymptomatic pregnancies, up to 18% of pregnancies with T1 bleeding Poor consensus on significance May be associated with an increased risk of loss, especially if: large occurs before 8 weeks GA occurs in women > 35 associated with vaginal bleeding 15 studies in the literature 14 have small numbers and no controls (n=<30) SLCOG ACADEMIC SESSIONS

SLCOG ACADEMIC SESSIONS Subchorionic hemorrhage SLCOG ACADEMIC SESSIONS

SLCOG ACADEMIC SESSIONS DD of u/s findings Ultrasound Finding Empty Uterus Intrauterine Debris Sac, no embryo Sac, no embryo, no yolk sac Embryo, No FH Embryo, +FH Differential Diagnosis Normal IUP 3-5 wks, SA, ectopic Incomplete SA, blood, ectopic, molar Viable IUP 5-6.5wks, Non-viable IUP, Pseudosac Non-viable IUP (if embryo >5 mm) Viable IUP Draycott & Read, Managed care of early pregnancy problems, Current opinion in Ob Gyn, 1999 SLCOG ACADEMIC SESSIONS

SLCOG ACADEMIC SESSIONS Ectopic gestation Changes leading to improved management of ectopic pregnancy Identify high risk Sensitive Preg Test Early referral Refined high resolution TVS Accurate and rapid estimation of B hCG Lab; Backup results in 24 hours. Min.Invasive Techniques SLCOG ACADEMIC SESSIONS

SLCOG ACADEMIC SESSIONS An audit on ectopic pregnancy 2007 Dodampahala SH, Seneviratne HR, Kaluarachchi AK Early pregnancy assessment unit, professorial Gynaecology ward, ward 39, National Hospital of SriLanka. SLCOG ACADEMIC SESSIONS

SLCOG ACADEMIC SESSIONS An audit on ectopic pregnancy 2007 Dodampahala SH, Seneviratne HR, Kaluarachchi AK Early pregnancy assessment unit, professorial Gynaecology ward, ward 39, National Hospital of SriLanka. SLCOG ACADEMIC SESSIONS

Early fetal malformations SLCOG ACADEMIC SESSIONS

Early fetal malformations SLCOG ACADEMIC SESSIONS

Early fetal malformations SLCOG ACADEMIC SESSIONS

Management of early pregnancy loss Surgical Expectant Medical SLCOG ACADEMIC SESSIONS

SLCOG ACADEMIC SESSIONS Surgical management 80-90% of women with SM have surgical evacuation Surgical evacuation is the treatment of choice in women with: Excessive bleeding Unstable vitals Infection Surgical management doesn’t appear to reduce complications as compared to medical or expectant management D&C accounts for 50-75% of off hours gyn surgery in the ER setting Lack of compelling evidence that D&C is required in women with SA SLCOG ACADEMIC SESSIONS

SLCOG ACADEMIC SESSIONS Expectant management Inevitable or incomplete SM (Nielsen & Halin, 1995) 79% resolved spontaneously within 3 days No increased complication rate Increased duration of bleeding Silent Miscarriage (Jurkovic, Ross & Nicolaides, 1998) 24.7% complete miscarriage 16.5% incomplete, required surgery 58.8% no SA, requested surgery within 48 days With Missed SA only 1/6 of women with have sa within 1 week of diagnosis SLCOG ACADEMIC SESSIONS

SLCOG ACADEMIC SESSIONS Expectant management Best outcomes if: Incomplete SA Earlier gestational age Symptomatic Lowest efficacy is with intact sac and closed cervix May take several weeks to resolve Many women will request surgical evacuation SLCOG ACADEMIC SESSIONS

Fertility and expectant management Blohm et al., 1997 127 with SM 113 responses 76 expectant 37 surgical No difference in cumulative pregnancy rates or in pregnancy outcomes in the 24 months following SM SLCOG ACADEMIC SESSIONS

SLCOG ACADEMIC SESSIONS Expectant management Is effective in properly selected patients Doesn’t impair future fertility Doesn’t increase rate of complications (some studies show decreased rate of infection as compared to D&C) Drawbacks May take several weeks to resolve Days of bleeding increased SLCOG ACADEMIC SESSIONS

SLCOG ACADEMIC SESSIONS Medical management Misoprostil Prostaglandin analogue Stimulates uterine activity Success ranges from 16 to 96% Increased success with (70-96%): Higher doses, vaginal route Incomplete SA Earlier gestational age Clinical follow up without routine US SLCOG ACADEMIC SESSIONS

SLCOG ACADEMIC SESSIONS Misoprostil Regimens There is no “standard” regimen Literature supports higher doses, given vaginally Options: 600 ug vaginally every 12 hours until bleeding starts (max 3 doses) 800 ug vaginally or buccal every 24 hours until bleeding starts (max 2 doses) Tip – have patient wet tables prior to inserting them in the vagina for better absorption. SLCOG ACADEMIC SESSIONS

Patient selection for misoprostil Confirm an intrauterine pregnancy / rule out ectopic Get a baseline B hCG and Rh Consider appropriateness of therapy for the patient Consider need for GYN consult SLCOG ACADEMIC SESSIONS

Preparing your patient Warn your patient that they will have pain and bleeding Discuss the side effects of prostaglandins (nausea, vomiting, diarrhea, fever) Ensure the patient has a way to reach a physician after hours Discuss what to do in the case of excessive bleeding (soaking more than 2 maxi pads/hr x 3 hrs) Arrange for follow up Don’t forget Rhogam SLCOG ACADEMIC SESSIONS

SLCOG ACADEMIC SESSIONS What to expect: Cramping and bleeding usually starts within a few hours of medication Stronger cramps may last 6-8 hours Heavy bleeding may last for several hours Bleeding after this is more like a period Most women will have some spotting for a week or two About 2% will need an emergency D&E SLCOG ACADEMIC SESSIONS

SLCOG ACADEMIC SESSIONS Follow-up 1 week office visit If bleeding has settled, follow B hCG weekly to 0 If persistent heavy bleeding, repeat U/S to rule out retained products and consider D&E SLCOG ACADEMIC SESSIONS

Chances of subsequent loss Number of Prior Losses Miscarriage Risk 11% 1 15% 2 25% 3 45% 4 54% Overall Knudsen et al., Eur J Obstet Gynecol Reprod Biol 39:31, 1991 SLCOG ACADEMIC SESSIONS

Recurrent pregnancy loss (or when to worry) SLCOG ACADEMIC SESSIONS

Causes of recurrent pregnancy loss Affects 0.5-3% of all women Autoimmune 20% Endocrine 20% Anatomic 16% Genetic 3.5% Infectious 0.5% Stephenson, M, Fertility and Sterility, 1996. SLCOG ACADEMIC SESSIONS

SLCOG ACADEMIC SESSIONS When should we worry? Three or more unexplained early (< 10 week losses) Two or more unexplained losses if: Infertility Advanced maternal age Unexplained loss of > 10 weeks (by U/S CRL) embryologic age SLCOG ACADEMIC SESSIONS

SLCOG ACADEMIC SESSIONS THANK YOU SLCOG ACADEMIC SESSIONS