1. Early Pregnancy Problems
Feras Izzat
Consultant Gynaecologist – EGU/EPAU Lead
University Hospitals Coventry & Warwickshire NHS Trust

2. Introduction Ectopic Pregnancy
Bleeding in early pregnancy and miscarriage
Gestational Trophoblastic Disease

3. Ectopic Pregnancy

4. Definition Pregnancy occurring outside uterine cavity
Approx 11/1000 of pregnancies – rate increasing
Maternal mortality in 1/2500 ectopic pregnancies (11 deaths in most recent report)

5. Site Tubal Non Tubal Ovary Abdominal cavity Cervix CS Scar
Interstitial 2.4%
Isthmic 12%
Ampullary 70%
Fimbrial 11.1%
Non Tubal
Ovary
Abdominal cavity
Cervix
CS Scar

6. Risk factors Previous PID Previous ectopic pregnancy
Previous tubal surgery (e.g. sterilisation, reversal)
Pregnancy in the presence of IUCD
POP
ART (IVF)

7. 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

8. Signs Abdominal tenderness Adnexal tenderness / mass
Shock – tachycardia, hypotension, pallor
None

9. Diagnosis Ultrasound Serum βhCG & Progesterone Laparoscopy
Empty uterus, adnexal mass, free fluid, occasionally live pregnancy outside of uterus
Serum βhCG & Progesterone
Laparoscopy

10. Ultrasound

11. Ultarsound Trans-Vaginal Ultrasonography
Sensitivity 100%, specificity 98.2%.
The positive predictive value 98%, and the negative predictive value was 100%
FH seen in 23%
Timor-Tritsch et al, 1990 Am J Obstet Gynecol.

12. Left Ectopic on laparoscopy

13. Management Conservative Medical Surgical - Laparoscopy
hCG <1000 , Progesterone < 5 stable, success 70%
Medical
Methotrexate – hCG <4000 mass < 3cm, success 84%. Susequent IUP 54% recurrent EP 8%
Surgical - Laparoscopy
Salpingectomy, IUP 38.3%, EP 9.8
Salpingotomy, IUP 61.1%, EP 15.5
Yao et al, Fertility Sterility 1997

14. PUL
Pregnancy of unknown location (PUL) - positive pregnancy test with no signs of intra- or extrauterine pregnancy on transvaginal sonography (TVS).
15-20% of all EPAU scans
Management should be expectant if stable with an initial serum progesterone (<20) and a hCG ratio 0h/48h of <0.87
Condous et al, Ultrasound Obstet Gynecol 2006

15. Bleeding in Early Pregnancy & Miscarriage

16. Definitions
Threatened miscarriage Vaginal bleeding at < 24 weeks gestation
Delayed (silent) miscarriage Gestational sac with/without fetus present (but no FH)
Recurrent miscarriage 3 or more consecutive miscarriages (with or without a known cause)

17. Miscarriage
Approximately 30% of pregnant women will experience bleeding in early pregnancy
At least 50% of women with threatened miscarriage will have continuing pregnancy
Miscarriage occurs in 15-20% of clinically diagnosed pregnancies

18. Causes of miscarriage Genetic abnormalities 85%
Maternal illness e.g. diabetes, Thyroid disease
Phospholipid / Lupus – 15% recurrent miscarriages
Uterine abnormalities
‘Cervical incompetence’
Progesterone deficiency?

19. History
LMP
When?
Amount?
Pain?
Timing of Pain

20. Examination ABC (vital signs) Abdominal Vaginal (speculum) Cx state
Amount of bleeding

21. Cusc’o speculum Sim’s speculum

22. 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

23. Ultrasound
Expect to see viable fetus from around 6.5 weeks transabdominally, 5.5 weeks transvaginally
Diagnosis can be made on TVS only
CRL ≥ 7mm
Empty GS with a mean diameter ≥ 25 mm

24. Gestational sac

25. Very early..

26. Normal 8-9 wk pregnancy

27. Empty sac

28. 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

29. Management of incomplete miscarriage
Conservative 76% success
Medical mifipristone & misoprostol – 82% success
Nielsen et al, BJOG 1999
Surgical (ERPC) No difference in satisfaction rate than medical – 95%
Chipchase et al, BJOG 1995

30. Recurrent miscarriage
Loss of 3 or more consecutive pregnancies
Affects 1% of women in reproductive age group
Investigations can identify up to 50% with a cause
Women aged <=30 years have a subsequent miscarriage rate of 25% which rises to 52% in women aged >=40 years.
The risk of a subsequent miscarriage is 29% after 3 miscarriages, this rises to 53% in 6 or more previous miscarriages
Clifford et al, Human Reproduction 1997

31. Gestational Trophoblastic Disease

32. GTD The abnormal proliferation of gestational trophoblast tissue
Spectrum of disease
Pre-Malignant
Partial Molar Pregnancy
Complete Molar Pregnancy
Malignant
Invasive mole
Choriocarcinoma
Placental site trophoblastic tumours

33. Molar Pregnancy 1 in 1000 live births Partial Complete
Partial moles are triploid with 2 sets of paternal and 1 set of maternal chromosomes
An embryo often present that dies at 8-9 weeks
0.5% need chemotherapy for invasive disease
Complete
No fetal pole, diplod chromosomes paternally derived – androgenetic
No embryo
Chemo therapy rate 8-20%

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

36. Diagnosis
Ultrasound
Histology after surgical evacuation

39. Complete mole at hysterectomy

40. Follow-up Monitor via regional centre – London, Sheffield, Dundee
CM – 8-20% risk of invasive disease
PM – 0.5%
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