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

Contents Early pregnancy Ectopic pegnancy Miscarriage Trophoblastic disease

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

Ectopic Pregnancy

Definition 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 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

Symptoms Acute Chronic (Atypical) 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

Signs 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

Diagnosis History and examination Ultrasound Serum βhCG - serial 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

Management Conservative Medical Surgical 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.

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

Definitions 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 Maternal Chromosomal Malformations Placental Multiple pregnancy 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

Investigations 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

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 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 βhCG 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 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 False Miscarriage is defined as expulsion of fetus <500g. 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

True or False Miscarriage is defined as expulsion of fetus <500g. ✔ 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.✗

Gestational Trophoblastic Disease

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

Increased rates Southeast Asia (8/1000) Extremes of reproductive age (>40 X5-10) Previous molar pregnancy Low carotene diet

Presentation Vaginal bleeding Excessive N&V ‘Hyperemesis gravidarum’ Uterus large for dates

Diagnosis 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-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

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