Early Pregnancy Loss

Definition Nonviable intrauterine pregnancy charactized by empty gestational sac or embryo/fetus <13 weeks with no fetal heart activity 10% of all pregnancies 50% are generally chromosomal abnormalities

Signs and Symptoms First trimester cramping/bleeding DDx: early pregnancy loss, viable intrauterine pregnancy, ectopic pregnancy A pelvic exam is important before testing

Testing Ultrasound is the prefered method to determine viabilty HCG levels are important in interpreting ultrasound findings and for serial follow up

Beta HCG Discriminatory zone 1500-2000 mIU/ml is associated with a gestational sac in singleton pregnancies A rise of < 50% in 48 hours is associate with an abnormal pregnancy with a sensitivity of 99%

Treatment Options Expectant Medical treatment Surgical treatment

Expectant May take up to 8 weeks 80% success What is success HCG < 5 mIU/ml Endometrial stripe of < 3 cm Return of normal menstrual function Patient needs to be prepared for moderate to heavy bleeding with cramps and may need a suction currettage

Medical Treatment Goal is to shorten the time to complete explusion as compared to expectant 85% success with complete expulsion with in 3 days for 70% of patients Patient should expect moderate to heavy bleeding and cramping issues as well as possible suction currettage

Surgical Suction curettage has replaced sharp curetting It is immediate and 99% successful Clinically important intrauterine adhesions are a rare complication

Complications of all treatments Incomplete requiring curettage Infection 2% Transfusion 1%

Rh Negative Mother Give 50-300 micrograms rhogam within 72 hrs of diagnosis of early pregnancy loss

Subsequent Pregnancy No evidenced based data on when it is safe to get pregnant again BCP or IUD can be started as soon as you are sure the process is complete Consider workup for recurrent EPL after the 2nd consecutive EPL No proven treatment for threatened abortion Progesterone in first trimester after at least 3 EPL may be beneficial

Am I ready to do office gyn? Case Studies Am I ready to do office gyn?

Sally is a 23 y/o GoPo complaining of irregular bleeding Gyn Hx: sexually active uses condoms most times PE: 105 lb Abdomen soft nontender Pelvic exam: no vaginal bleeding, Cervix is closed nontender, uterus normal, adenexa neg This scenario is about BCP for DUB Be sure to do pg test in this age group

Test Results Quantative Beta HCG < 1 Ultrasound normal uterus, endometrium, and ovaries What next? Birth control pills. Discuss what kind, how to start, what to expect

What if Ultrasound Shows uterus 11x9x8 cm with multiple leiomyoma about 2-3 cm in diameter, endometrial thickness 6 mm, normal ovaries Discuss how one would find if fibroids are the cause of her bleeding 1. trial of birth control pills 2. submucous leiomyoma including diagnostic techniques of sonohystogram and hysteroscopy

Test: STD negative pregnancy test negative Sally returns after 3 months on her new birth control pill still having breakthrough bleeding Pelvic exam is normal Test: STD negative pregnancy test negative Do sonohysterogram or hysteroscopy to rule out a polyp

Judy is a 30 y/o G2P2 for annual exam on Ortho Tricyclen Lo Social hx: married, monogamous She is complaining that she had regular periods for a while but now having breakthrough bleeding for 6 months Exam: Normal Differential diagnosis? Diagnosis to discuss: BTB on BCP Discuss logic of switching birth control pills

Mary is a 45 y/o G3P3 status post tubal ligation Menstral formula: 2 weeks/3 days heavy on day 1 PMH: negative Pelvic exam: Cervix normal, pap done Uterus 6 weeks size, irregular, firm, nontender Ovaries not enlarged, nontender Tests: CBC – normal TSH – normal ultrasound 3 cm serousal leiomyoma, endometrial thickness 11 mm ( make point endometrial thickness is of no help) Be sure they do endometrial biopsy before going on to next slide

Guidelines for Endometrial Biopsy All women with history of AUB of 2-3 yrs duration All women > 45 yrs old with AUB All women who do not respond to treatment Discuss how to do biopsy if time allows

Endometrial Biopsy Results Complex hyperplasia with atypia Complex hyperplasia Simple hyperplasia Proliferative endometrium Secretory endometrium Complex hyperplasia with atypia refer for hysterectomy Progesterone for complex and simple hyperplasia BCP for proliferative and secretory

Vicki is a 60 y/o complaining of 3 days of light bleeding 3 weeks ago PMH: Illnesses: diabetes controlled on diet mild hypertension Meds: Atenolol Continuous hormone replacement therapy Exam: 5’4”, 175 lb Pelvic: vagina slightly atrophic cervix stenotic, pap done uterus NS/NS adenexa negative Discuss testing but not treatment. Move on to next slide once they mention endometrial thickness

Endometrial thickness < 4 mm generally atrophic endometrium > 4 mm you can’t rule out cancer If > 4 mm, endo bx is simplest solution. Something that you can do

60 yr old menopausal female complaining of incontinence PI: leaking urine for several months now worse PMH: TAH/BSO for benign disease age 45 Lumbar disk fusion 1 years ago PE: Pelvic – 1st degree cystocoele and 1st degree rectocoele Any additional history or physical information? Discuss signs and symptoms of SUI verses urge incontinence Next step, I want them to do residual check as opposed to cysto, cmg, uroflow studies

Urine culture positive > 100,000 e-coli Complaining of urgency, frequency, nocturia, sudden loss of large amounts of urine Residual urine 10 ml Urine culture positive > 100,000 e-coli D.Dx and next steps Management of OAB

Loss of urine with coughing, sneezing, laughing, squatting, jumping Residual 50 ml and culture negative Residual > 200 ml Management of stress incontinence Overflow incontinence can imitate SUI

22 yr old female complaining of amenorrhea for 1 yr PI: LMP 1 yr ago prior menstral formula 28d/5d BC: none Gyn Hx delivered a baby 2 yrs ago PMH: Schizophrenic on anti-psychotic med Soc Hx: Occasionally sexually active without condoms PE: Thin female, no distress Breasts bilateral milky discharge Pelvic exam normal D. Dx Tests: PG test, Prolactin, TSH

Prolactin 100 ng/ml., TSH 5.5 uU/ml., Prolactin, TSH normal MRI to rule out microadenoma Perhaps an MRI but yield low. May be the anti-psychotic med Maybe anovulatory with frequent stimulation and residual obstetrical effects