Bleeding in early pregnancy and Ectopic Pregnancy Emad R. Sagr, MBBS, FRCSC, FACOG Consultant OB-Gyn and Gynecology Oncology Security Forces Hospital

SPONTANEOUS ABORTION Definition: Abortion is termination of pregnancy before the fetus is sufficiently developed to survive (before 24 wks) Incidence: 15-20% It is convenient to consider the clinical aspect of spontaneous abortion under 5 sub groups: 1. Threatened 4. Missed 2. Inevitable 5. Recurrent abortion 3. Incomplete 6. Septic Abortion

Threatened Abortion 25% of pregnancies This refers only to bleeding from placental site which is not yet severe enough to terminate the pregnancy.

Serial qualitative HCG level: BHCG level – 1000 miu/ml If gest. Sac seen & BHCG less than 1000  unlikely to survive. Qualitative BHCG level should ↑ 65% every 48 hours. Serum Progesterone level 5 ng/ml associated with none viable fetus > 25ng/ml associated with alive fetus Expectant observation No benefit from use of progesterone or bed rest although it is often advised.

Inevitable Abortion Indicate the pregnancy is doomed to end shortly. Progressive cervical dilation without the passage of tissue. here bleeding is slight but retroplacental Pain usually more. Dilated internal os. USS – Non viable fetus Emergency suction: D & C

Complete Abortion Diagnosed if patient passed tissue but now is only slight pain and P/V bleeding Examination confirmed closed Cx. Minimal current bleeding TVU – empty uterus R/O ectopic pregnancy by serial BHCG level until P.T. -ve Anti D injection if patients RH – ve to prevent sensitization

Incomplete Abortion If the internal cervical os is open and patient has passed some tissue. Management: Emergency suction and curettage

Missed Abortion It is defined as retention of dead products of conception in utero for several weeks. Symptoms of early pregnancy disappear Uterus not only has ceased to enlarge but also has become smaller. Occasionally serious coagulation defect may develop. Abnormal sonographic findings

Septic Abortion Uterine infection at any stage of abortion causes: Delay in evacuation of uterus Delay seeking advice Incomplete surgical evacuation followed by infection from vaginal organisms after 48 hours

Trauma: Treatment: Perforation or cervical tear Criminal abortion Should be active to minimize risk of septic shock Cervical & HVS, blood culture Broad spectrum antibiotic Evacuation

Induced Abortion Therapeutic abortion – termination of pregnancy before the viability for the purpose of saving the life of the mother. Heart disease, invasive Ca of Cx. Elective (voluntary) abortion is the interruption of pregnancy before viability at request of the women but not for reason of maternal health or fetal disease.

Illegal abortion usually performed in unsterile condition by operators with little or nor medical training. It is often incomplete and complicated by: Hemorrhage Infection Infertility and tubal occlusions Intrauterine infection is frequent complication and septic shock and death are the ultimate consequences.

Recurrent Miscarriage When a woman has had 3 consecutive miscarriage. Risk of abortion for next pregnancy: 1 abortion  15% 1 Normal pregnancy  15% 1 Abortion 1 Normal  25% 2 Abortion 2 abortion  40%

Etiology and Investigation: Genetic factors Karyotyping of both partners will reveal chromosome anomalies Anatomical factors Uterine anomalies Cervical incompetence Hysteroscopy & HSG – Septum / Fibroid Endocrine problem Immunological factors Common in women with antiphopholipid antibodies syndrome, Anticardiolipid ant. & Lupus anticoagulant Maternal disease SLE, Renal disease Environmental factor Smoking / Alcohol

Abortion Technique Medical Surgical

Ectopic Pregnancy

Epidemiology Leading cause of pregnancy-related deaths during T-1 1-2% of all diagnosed pregnancies Incidence is   incidence of salpingitis d/t chlamydia or other STI Improved diagnostic techniques  age Most occur in multigravid women > 50% in women with  3 pregnancies 10-15% in nulligravid women

Mortality Causes 15% of maternal deaths Overall risk of death 10X > the risk of childbirth; 50X > risk of legal abortion Cause of death r/t blood loss (80%), infection (3%), & anesthesia (2%) Interstitial & abdominal 5X > risk of death than other sites

Fallopian Tube Function Complex structure sustains & transports sperm, ovum & early conceptus for ~ 3 days Beating cilia & rhythmic contraction of smooth muscle  neg pressure in tube Zygote undergoes cleavage & held for another 30 hrs. in the ampullary-isthmic region Developing blastocyst is then transported via the isthmus into the uterus

Types of EP

Heterotopic Pregnancies: 1 in 30 000 Sites of EP Fallopian tube Ampulla 80% Isthmus 12% Fimbrial end 5% Cornual & interstitial 2% Abdominal 1.4% Ovarian 0.2% Cervical Heterotopic Pregnancies: 1 in 30 000

Risk Factors for EP Definite PID Previous EP Any tubal surgery or sterilization procedure infertility

Risk Factors for EP Probable Uncertain Association Any pelvic surgery Use of reproductive techniques In vitro fertilization Gamete intrafallopian transfer Embryo transfer Uncertain Association IUCD “Superovulating agents” Pergonal, Clomiphene citrate

Classic TRIAD of EP Delayed menses Irregular vaginal bleeding Abdominal pain

Symptoms of Ectopic Pregnancy PTS WITH SYMPTOM Abdominal pain 90-100% Amenorrhea 75-95% Vaginal bleeding 50-80% Dizzininess, fainting 20-35% Pregnancy symptoms 10-25% Urge to defecate 5-15% Passage of tissue 5-10%

Signs of EP SIGN PTS WITH SIGN Adnexal tenderness 75-90% Abdominal tenderness 80-95% Adnexal mass* 50% Uterine enlargement 20-30% Orthostatic changes 10-15% Fever 5-10% * 20% of masses occur on the side opposite the EP.

Differential Diagnosis Complication of IUP Abortion Early pregnancy plus uterine fibroid or ovarian tumour Conditions causing acute abd pain Torsion of ovarian tumour, FT, or subserous pedunculated fibroid Salpingo-oophoritis Pelvic pain with an IUCD in situ Appendicitis

Differential Dx – cont’d Conditions causing hemoperitoneum Ruptured corpus luteum Ruptured follicular cyst Ruptured endometriotic cyst Conditions simulating a pelvic hematoma Retroverted gravid uterus Pelvic or tubo-ovarian abcess

Management of EP Pre-operative diagnostic accuracy of EP based on clinical features alone is notoriously poor: ~50% 20% of EP occur as surgical emergencies Delay is justified only to correct shock

Acute Management of EP Remember your ABCs Labs Oxygen Large bore IV(s)  crystalloids Blood Labs CBC, coagulation studies -hCG -B-hCG secreted by the syncytiotrophoblast & reaches max at 10 weeks

Usefulness of Quantitaive -hCG Assessment of pregnancy viability Serial rise usually indicates a normal pregnancy Correlation with ultrasonography With titers > 1500 IU/L, TVUS should ID an IUP With multiple gestation, a gestational sac will not be apparent until titer rises a little higher Assessment of treatment results Declining levels are c/w effective medical or surgical Tx; if levels persist think GTD HCG levels q weekly until undetectable (usually 4-6 wks) progesterone levels usually lower in EP A value of 25ng/mL or more is 98% of the time assoc with a normal IUP, while < 5ng/mL identifies a nonviable preg, regardless of location May be useful in help make a decision re the viability of a possible IUP prior to curettage Great majority of pts will have a level between 10 & 20 (limiting the clinical usefulness)_

The Importance of TVUS Documentation of an intrauterine sac A viable IUP should be identified when -hCG > 1500 IU/ml Adnexal mass An EP > 2 cm should be identified Adnexal cardiac activity Detectable when -hCG is ~ 15 000 – 20 000

U/S – Is it EP or miscarriage?

Surgical Management of EP Radical Salpingectomy Conservative Salpingotomy Salpingostomy or segmental resection  does not  repeat EP rate fimbrial evacuation (traumatizes the endosalphinx & is assoc with  rate of recurrent EP (24%) compared with salpingectomy Salpingectomy if: childbearing completed 2nd EP in same tube Uncontrolled bleeding Severely damaged tube

Medical Management of EP Methotrexate (MTX) 1st used in Japan in 1982 Antimetabolite that interferes with dihydrofolate reductase Considered for low -hCG Success rate 67%-94% Indications Hemodynamically stable pt good F/U Recurrent EP following Sx intervention

Methotrexate – cont’d Contraindications Evidence of rupture Serum -hCG > 5 000 IU/L (varies) FH detected on U/S Adnexal mass> 3.5 cm on U/S Unreliable pt F/U unavailable Laparoscopy required to make dx Solid adnexal masses (germ cell tumour) Free fluid > 30ml

Methotrexate Protocol Exclude contraindications as well as No evidence of renal, liver, or hematopoietic disease (Bilirubin, AST,ALT, urea, Cr, CBC) Informed consent 5% risk of hematoperitoneum 2° to rupture of EP following MTX MTX 50mg/m² body surface area (~1mg/kg) given IV or IM

Methotrexate Protocol – cont’d Pt F/U repeat serum quantitative -hCG in 3-4 days, 7days, then weekly until < 10 IU/L If > day-4 level at day-7  repeat MTX If -hCG fails to fall by at least 25%/week at any time repeat dose U/S not required routinely Pt should avoid Alcohol use, sexual I/C, oral folic acid (until HCG levels are neg)

Methotrexate Protocol – cont’d What to expect Majority experience some degree of abd pain (occurs in ~ 50% at day-6) Shedding of a decidual cast Moderate vaginal bleeding Side effects (usually at higher doses) Impaired liver function, bone marrow suppression, neutropenia, stomatitis, hematosalpinx

Expectant Mx of EP Anticipates spontaneous regression of EP Occurs in ~ 57% Symptoms, HCG titers, & U/S findings followed Risk of tubal rupture is 10% if HCG levels < 1000 Criteria include Sonographic diameter < 3cm Initial -hCG < 1 000 IU/ml, no  in 2-day period, subsequent levels  asymptomatic

Future Fertility following EP Subsequent conception rate is ~ 60% Incidence of recurrent EP is 15% Other factors influencing include: Age, parity, history of infertility, evidence of contralateral tubal disease, ruptured EP, IUCD use, salpingitis No difference b/t laparoscopy vs laparotomy

Prevention of EP Treat salpingitis early & correctly MTX management lowers rate of subsequent EP Risk of EP is  with all methods of contraception, except progesterone containing IUCDs Remember Rh Sensitization Rhogam for the Rh-neg woman Prg-releasing IUD has a higher rate, probably because its action is limited to a local effect on the endometrium IUD has been traditionally listed as a risk factor for EP Previous use doise not increase risk of a subsequent EP Current use of modern copper-bearing IUDs does NOT increase risk, in fact offers considerable protection WHP multicenter study, concluded that IUD users were 50% less likely to have an EP when compared to women using no contraception However, if an IUD user becomes preg, the preg is more likely to be ectopic ~ 3-4% of IUD pregnancies have been ectopi (rare event)