1. First Trimester Pregnancy Complications ALSO

2. First Trimester Bleeding 4 Spontaneous abortion/miscarriage 4 Ectopic pregnancy 4 Trophoblastic disease 4 Cervical polyps 4 Friable cervix 4 Trauma 4 Cervical cancer

3. 1st Trimester Labs 4 Quantitative bhCG +Correlate with GA and US +2 meas, 2-3 days apart, shld. double +Falling or plateauing signals problem 4 Progesterone +Single level early in preg predictive * 25 ng/ml assoc. with living IUP

4. Lab and US Correlates

5. First Trimester US Indications 4 Suspected miscarriage 4 Vaginal bleeding 4 Gest. Age (if uncertain, or size/date discrepancy) 4 Adjunct to procedures (ex. CVS) 4 Suspected multiple gestation 4 Suspected hydatidiform mole 4 Suspected ectopic pregnancy 4 IUD localization 4 Suspected uterine abnormality 4 Evaluation of maternal pelvic masses

6. First Trimester US 4 Best when performed in combination with H & P and relevant labs 4 Often used as primary tool in evaluating first trimester complications 4 Transvaginal and transabdominal should be obtained

7. Definitions +Spontaneous Abortion *Involuntary loss during first 20 wks +Threatened Abortion *Ut bleeding, closed Cx, no prods of conception passed +Incomplete Abortion *Some, but not all products have passed +Inevitable Abortion *Cx dilated, no products passed

8. Definitions +Missed Abortion *Dead fetus, no products passed, Cx closed +Septic Abortion *Incomplete Ab + ascending infection +Blighted Ovum *Identifiable sac & placental tissue, but no embryo +Decidua *Endometrium of pregnancy passed as part of SAB

9. Pathophysiology of Abortion *Major genetic anomaly *Internal environmental factors -Uterine: anomalies leiomyoma, incompetent Cx -Maternal DES exposure -Luteal phase defect -Immunologic factors *External environmental factors -Substance use (tobacco, EtOH, cocaine) -Irradiation -Infection -Occupational chemical exposure *Advanced maternal age

10. Clinical Course 4 Missed menses, pregnancy Sxs 4 Positive bhCG 4 Vag bleeding 4 bhCG falls or plateaus 4 Lower abdominal cramps, backache 4 Products of conception passed 4 >8wks oft won’t pass products spont.

11. Physical exam *Abdominal exam -Pain location, rebound, distension -Speculum exam -Assess dilation *Bimanual exam -Uterine size, adnexal tenderness

12. Fetal Heart Tones Listen after 9-10 weeks with Doppler Sensitivity enhanced by elevating uterus during bimanual exam

13. Float Test for Chorionic Villi Any tissue passed should be examined. If an intact gestational sac, embryo or fronds of chorionic villi are seen, spont. Abortion is proven and ectopic is ruled out (except in heterotopic pregnancy) To look for villi, rinse and float the tissue with saline. Passed tissue should be submitted for pathol. Exam. If tissue is seen at cervical os, abortion is enevitable. May gently remove it with ring forceps.

14. When Dx is uncertain by clinical findings, transvaginal scan is essential for accurate diagnosis

15. Management of Spont. Abortion 4 50% loss when bleeding present 4 Presence of FHTs reassuring 4 Majority do no require medical or surgical intervention 4 Identify patients at risk for bleeding, infection

16. Ectopic Pregnancy 4 Pregnancy outside uterus (usually in fallopian tube) 4 Occurs in >1:100 pregnancies 4 Second most common cause of maternal mortality 4 Early diagnosis critical!

17. Risk Factors for Ectopic 4 H/O previous ectopic 4 H/O tubal surgery 4 H/O tubal infections 4 Progestin-only contraception 4 IUD 4 In utero DES exposure 4 Many occur in pts w/o risk factors

18. Pathophysiology and Symptomatology I Conception Implantation Normal in tube hCG Amenorrhea Symptoms of Pregnancy

19. Pathophysiology and Symptomatology II Diminished Placental hCG Erosion blood supply death falls thru tube Loss of Bleeding & Pain symptoms Sloughing

20. Pathophysiology & Symptomatology III Intraperitoneal Shock Death hemorrhage Abd. pain, Syncope Death shoulder pain, Orthostatic silent, doughy signs abdomen

21. Diagnosis of Ectopic *Failure of hCG to double in 48-72 hs *Low progesterone *US (transvaginal) -IUP R/O ectopic -No gestational sac + hCG >1800 highly suggestive -Gest. Sac/embryo outside of uterus confirms -Pitfalls: Pseudogestational sac, ruptured corpus luteum *Laparoscopy = Gold standard

22. Culdocentesis 18 or 20 gauge needle passed through the posterior fornix and aspirated for fluid. Nonclotting body fluid with hematocrit >15% represents active intraperitoneal bleeding.

23. Expectant management Criteria 4 Minimal pain or bleeding 4 Reliable F/U 4 No evidence of tubal rupture 4 hCG < 1000 and falling 4 Adnexal mass <3cm or not detected 4 No embryonic heartbeat

24. Medical Management: Methotrexate *Safe, effective, less costly than surgery *Equal or better fertility preservation *Criteria for use -Stable VS, few Sxs -No CI to drug -Absence of embryonic cardiac activity -Ectopic mass <= 4cm -hCG < 5000

25. Methotrexate dosing 4 Single dose IM regimen with 1 mg/kg or 50mg/m 2 4 Obtain serum hCG on 4th and 7th day post- treatment 4 Follow level until reaches 5 (3-4 wks) 4 Document progesterone drop to 1.5 4 Surgical consultation if need more than one dose

26. Surgical Management *Mainstay of treatment *Conservative-conservation of tube *Extirpative-removal of tube *Criteria for selecting surgery -Unstable VS or hemoperitoneum -Uncertain Dx -Advanced ectopic pregnancy -Unreliable FU -CI to expectant or methotrexate

27. Trophoblastic Disease *Incidence = 1:1000-1500 pregnancies *Predisposing factors -Previous molar disease -Pregnancy at ends of reproductive life *Complete hydatidiform mole -Placental proliferation in absence of fetus; 46XX -Placental villi swollen, grape-like *Partial mole -Molar placenta + nonviable fetus, 69XXY *Recurrence metastatic choriocarcinoma

28. Clinical Manifistations 4 Vaginal bleeding 1st/early 2nd trimester 4 Higher than expected hCG levels 4 Ut size > dates w/o heart tones 4 Hyperemesis 4 Early PIH 4 Thyrotoxicosis 4 Ovarian enlargement

29. Treatment of trophoblastic disease *Prompt evacuation of the uterus *Serial hCG *One year contraception *Recurrence -Occurs in 20% with complete mole -Invades myometrium or becomes metastatic -Treated with methotrexate *Most can conceive, carry normal pregnancy