1. Early Pregnancy Problems Jacqueline Woodman
M.B.,Ch.B.; Dipl Obst; MRCOG; D.Phil (Oxon)

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

3. Bleeding in Early Pregnancy
& Miscarriage

4. Definitions Remember – MISCARRIAGE not ABORTION
Threatened miscarriage Vaginal bleeding at < 24 weeks gestation (cervix closed)
Inevitable miscarriage Bleeding, pregnancy still in uterus (cervix open)
Incomplete miscarriage Retained products of conception in uterus (cervix open)
Complete miscarriage Uterus empty (cervix closed)
Delayed miscarriage Gestational sac with/without fetus present (but no FH), cervix closed

5. 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

6. Causes of miscarriage Genetic abnormalities Progesterone deficiency?
Maternal illness e.g. diabetes
Uterine abnormalities
‘Cervical incompetence’

7. History LMP Bleeding: amount (spotting/gush), clots
Pain: type – crampy/sharp/dull
location: lower abdomen, shoulder tip, back pain
Passed products?

8. Examination ABC (vital signs) stable or cervical shock Abdominal
tender/ rebound tenderness
Vaginal (speculum)
Cervix: open/closed
Amount of bleeding
Products visible? TAKE IT OUT!

9. Speculums
Cusco speculum Sims speculum

10. 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

11. 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

12. Gestational sac

13. Very early..

14. Normal 8-9 wk pregnancy

15. Empty sac

16. Measurement of βhCG Not necessary if diagnosis unequivocal on scan
Useful as part of investigations to diagnose/exclude extrauterine pregnancy/miscarriage
Doubling time approx 2 days in viable pregnancy
Halving time 1-2 days in complete miscarriage
Should see fetal pole with βhCG of

17. Management of Incomplete Miscarriage
Conservative
Risk of bleeding, infection, retained POC needing ERPC, unpredictable
Medical (Prostaglandin e.g. Misoprostol)
Risk of bleeding, retained POC, need for ERPC
Surgical [Evacuation of retained products of conception (ERPC)]
Suction curettage usually under GA, risk of bleeding, infection, perforation of uterus, longer term complications (e.g. Ashermans syndrome)

18. Ectopic Pregnancy

19. Definition Pregnancy occurring outside uterine cavity
Approx 0.5-1% of pregnancies – rate increasing
Maternal mortality in 1/2500 ectopic pregnancies (13 deaths in UK)

20. Site
Fallopian tube
Ovary
Abdominal cavity
Cervix

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

22. 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, back pain

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

24. Diagnosis Ultrasound Serum βhCG Laparoscopy
Empty uterus, adnexal mass, free fluid in POD, rarely live pregnancy outside of uterus
Serum βhCG
Suboptimal rise, plateau
Laparoscopy

25. Ultrasound

26. Left Ectopic on laparoscopy

27. Management Medical Surgical ‘Conservative’ Methotrexate
Laparoscopic salpingectomy / salpingotomy
Laparotomy
‘Conservative’
Self resolving with close watch

28. Gestational Trophoblastic Disease

29. Hydatidiform Mole 1 in 1000 pregnancies Partial Complete
Associated with fetus, triploid
Complete
No fetal pole, diploid chromosomes paternally derived

31. Presentation
Asymptomatic – incidental finding at dating or anomaly USS
Vaginal bleeding
Hyperemesis gravidarum
Uterus large for dates

32. Diagnosis Ultrasound (Snow storm appearance)
Histology after surgical evacuation

33. Snowstorm appearance

34. Hydatidiform Mole after hysterectomy

35. Follow-up Monitor via regional centres – 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
Avoid pregnancy for minimum 6 months or until all clear

36. Hyperemesis Gravidarum

37. Hyperemesis Gravidarum
Nausea/vomiting in pregnancy is normal – ‘morning sickness’
Rarely excessive – hyperemesis gravidarum
Related to level of βhCG

38. Associated Factors UTI Multiple pregnancy Molar pregnancy
Socio-economic factors

39. Investigations Renal function Liver function FBC Urinalysis and MSU
Ultrasound

40. Consequences & Management Dehydration Electrolyte imbalance
Metabolic alkalosis, hypokalaemia,
hypernatremia
Oesophageal tears
(Mallory Weiss)
Thrombosis
DVT/PE/Cerebral sinus
Weight loss
Vitamin deficiency (vit B1- thiamine)
Wernicke's encephalopathy
Psychological impact
IV fluids
Electrolyte replacement
Antiemetics
Thromboprophylaxis
Dietary advice
Vitamin supplementation
Steroids
Antibiotics if UTI
Termination of pregnancy

41. in CONCLUSION GYNAECOLOGICAL EMERGENCIES 1. MISCARRIAGE 2. ECTOPIC
3. PELVIC SEPSIS
4. OVARIAN TORSION