1. Bleeding in early pregnancy and Ectopic Pregnancy
Emad R. Sagr, MBBS, FRCSC, FACOG
Consultant OB-Gyn and Gynecology Oncology
Security Forces Hospital

2. SPONTANEOUS ABORTION Definition:
Abortion is termination of pregnancy before the fetus is sufficiently developed to survive (before 24 wks)
Incidence: 15-20%
It is convenient to consider the clinical aspect of spontaneous abortion under 5 sub groups:
1. Threatened Missed
2. Inevitable Recurrent abortion
3. Incomplete Septic Abortion

3. Threatened Abortion 25% of pregnancies
This refers only to bleeding from placental site which is not yet severe enough to terminate the pregnancy.

4. Serial qualitative HCG level:
BHCG level – 1000 miu/ml
If gest. Sac seen & BHCG less than 1000  unlikely to survive.
Qualitative BHCG level should ↑ 65% every 48 hours.
Serum Progesterone level
5 ng/ml associated with none viable fetus
> 25ng/ml associated with alive fetus
Expectant observation
No benefit from use of progesterone or bed rest although it is often advised.

5. Inevitable Abortion
Indicate the pregnancy is doomed to end shortly. Progressive cervical dilation without the passage of tissue. here bleeding is slight but retroplacental
Pain usually more.
Dilated internal os. USS – Non viable fetus
Emergency suction: D & C

6. Complete Abortion
Diagnosed if patient passed tissue but now is only slight pain and P/V bleeding
Examination confirmed closed Cx.
Minimal current bleeding
TVU – empty uterus
R/O ectopic pregnancy by serial BHCG level
until P.T. -ve
Anti D injection if patients RH – ve to prevent sensitization

7. Incomplete Abortion
If the internal cervical os is open and patient has passed some tissue.
Management:
Emergency suction and curettage

8. Missed Abortion
It is defined as retention of dead products of conception in utero for several weeks.
Symptoms of early pregnancy disappear
Uterus not only has ceased to enlarge but also has become smaller.
Occasionally serious coagulation defect may develop.
Abnormal sonographic findings

9. Septic Abortion Uterine infection at any stage of abortion causes:
Delay in evacuation of uterus
Delay seeking advice
Incomplete surgical evacuation followed by infection from vaginal organisms after 48 hours

10. Trauma: Treatment: Perforation or cervical tear Criminal abortion
Should be active to minimize risk of septic shock
Cervical & HVS, blood culture
Broad spectrum antibiotic
Evacuation

11. Induced Abortion
Therapeutic abortion – termination of pregnancy before the viability for the purpose of saving the life of the mother. Heart disease, invasive Ca of Cx.
Elective (voluntary) abortion is the interruption of pregnancy before viability at request of the women but not for reason of maternal health or fetal disease.

12. Illegal abortion usually performed in unsterile condition by operators with little or nor medical training.
It is often incomplete and complicated by:
Hemorrhage
Infection
Infertility and tubal occlusions
Intrauterine infection is frequent complication and septic shock and death are the ultimate consequences.

13. Recurrent Miscarriage
When a woman has had 3 consecutive miscarriage.
Risk of abortion for next pregnancy:
1 abortion  15%
1 Normal pregnancy  15%
1 Abortion
1 Normal  25%
2 Abortion
2 abortion  40%

14. Etiology and Investigation:
Genetic factors
Karyotyping of both partners will reveal chromosome anomalies
Anatomical factors
Uterine anomalies
Cervical incompetence
Hysteroscopy & HSG – Septum / Fibroid
Endocrine problem
Immunological factors
Common in women with antiphopholipid antibodies syndrome, Anticardiolipid ant. & Lupus anticoagulant
Maternal disease
SLE, Renal disease
Environmental factor
Smoking / Alcohol

15. Abortion Technique
Medical Surgical

16. Ectopic Pregnancy

17. Epidemiology Leading cause of pregnancy-related deaths during T-1
1-2% of all diagnosed pregnancies
Incidence is 
 incidence of salpingitis d/t chlamydia or other STI
Improved diagnostic techniques
 age
Most occur in multigravid women
> 50% in women with  3 pregnancies
10-15% in nulligravid women

18. Mortality Causes 15% of maternal deaths
Overall risk of death 10X > the risk of childbirth; 50X > risk of legal abortion
Cause of death r/t blood loss (80%), infection (3%), & anesthesia (2%)
Interstitial & abdominal 5X > risk of death than other sites

19. Fallopian Tube Function
Complex structure
sustains & transports sperm, ovum & early conceptus for ~ 3 days
Beating cilia & rhythmic contraction of smooth muscle  neg pressure in tube
Zygote undergoes cleavage & held for another 30 hrs. in the ampullary-isthmic region
Developing blastocyst is then transported via the isthmus into the uterus

20. Types of EP

21. Heterotopic Pregnancies: 1 in 30 000
Sites of EP
Fallopian tube
Ampulla
80%
Isthmus
12%
Fimbrial end 5%
Cornual & interstitial 2%
Abdominal
1.4%
Ovarian
0.2%
Cervical
Heterotopic Pregnancies: 1 in

22. Risk Factors for EP Definite PID Previous EP
Any tubal surgery or sterilization procedure
infertility

23. Risk Factors for EP Probable Uncertain Association Any pelvic surgery
Use of reproductive techniques
In vitro fertilization
Gamete intrafallopian transfer
Embryo transfer
Uncertain Association
IUCD
“Superovulating agents”
Pergonal, Clomiphene citrate

24. Classic TRIAD of EP Delayed menses Irregular vaginal bleeding
Abdominal pain

25. Symptoms of Ectopic Pregnancy
PTS WITH SYMPTOM
Abdominal pain
90-100%
Amenorrhea
75-95%
Vaginal bleeding
50-80%
Dizzininess, fainting
20-35%
Pregnancy symptoms
10-25%
Urge to defecate
5-15%
Passage of tissue
5-10%

26. Signs of EP SIGN PTS WITH SIGN Adnexal tenderness 75-90%
Abdominal tenderness
80-95%
Adnexal mass*
50%
Uterine enlargement
20-30%
Orthostatic changes
10-15%
Fever
5-10%
* 20% of masses occur on the side opposite the EP.

27. Differential Diagnosis
Complication of IUP
Abortion
Early pregnancy plus uterine fibroid or ovarian tumour
Conditions causing acute abd pain
Torsion of ovarian tumour, FT, or subserous pedunculated fibroid
Salpingo-oophoritis
Pelvic pain with an IUCD in situ
Appendicitis

28. Differential Dx – cont’d
Conditions causing hemoperitoneum
Ruptured corpus luteum
Ruptured follicular cyst
Ruptured endometriotic cyst
Conditions simulating a pelvic hematoma
Retroverted gravid uterus
Pelvic or tubo-ovarian abcess

29. Management of EP
Pre-operative diagnostic accuracy of EP based on clinical features alone is notoriously poor: ~50%
20% of EP occur as surgical emergencies
Delay is justified only to correct shock

30. Acute Management of EP Remember your ABCs Labs Oxygen
Large bore IV(s)  crystalloids
Blood
Labs
CBC, coagulation studies
-hCG
-B-hCG secreted by the syncytiotrophoblast & reaches max at 10 weeks

31. Usefulness of Quantitaive -hCG
Assessment of pregnancy viability
Serial rise usually indicates a normal pregnancy
Correlation with ultrasonography
With titers > 1500 IU/L, TVUS should ID an IUP
With multiple gestation, a gestational sac will not be apparent until titer rises a little higher
Assessment of treatment results
Declining levels are c/w effective medical or surgical Tx; if levels persist think GTD
HCG levels q weekly until undetectable (usually 4-6 wks)
progesterone levels usually lower in EP
A value of 25ng/mL or more is 98% of the time assoc with a normal IUP, while < 5ng/mL identifies a nonviable preg, regardless of location
May be useful in help make a decision re the viability of a possible IUP prior to curettage
Great majority of pts will have a level between 10 & 20 (limiting the clinical usefulness)_

32. The Importance of TVUS Documentation of an intrauterine sac
A viable IUP should be identified when -hCG > IU/ml
Adnexal mass
An EP > 2 cm should be identified
Adnexal cardiac activity
Detectable when -hCG is ~ –

33. U/S – Is it EP or miscarriage?

34. Surgical Management of EP
Radical
Salpingectomy
Conservative
Salpingotomy
Salpingostomy or segmental resection  does not  repeat EP rate
fimbrial evacuation (traumatizes the endosalphinx & is assoc with  rate of recurrent EP (24%) compared with salpingectomy
Salpingectomy if:
childbearing completed
2nd EP in same tube
Uncontrolled bleeding
Severely damaged tube

35. Medical Management of EP Methotrexate (MTX)
1st used in Japan in 1982
Antimetabolite that interferes with dihydrofolate reductase
Considered for low -hCG
Success rate 67%-94%
Indications
Hemodynamically stable pt
good F/U
Recurrent EP following Sx intervention

36. Methotrexate – cont’d Contraindications Evidence of rupture
Serum -hCG > IU/L (varies)
FH detected on U/S
Adnexal mass> 3.5 cm on U/S
Unreliable pt
F/U unavailable
Laparoscopy required to make dx
Solid adnexal masses (germ cell tumour)
Free fluid > 30ml

37. Methotrexate Protocol
Exclude contraindications as well as
No evidence of renal, liver, or hematopoietic disease (Bilirubin, AST,ALT, urea, Cr, CBC)
Informed consent
5% risk of hematoperitoneum 2° to rupture of EP following MTX
MTX 50mg/m² body surface area (~1mg/kg) given IV or IM

38. Methotrexate Protocol – cont’d
Pt F/U
repeat serum quantitative -hCG in 3-4 days, 7days, then weekly until < 10 IU/L
If > day-4 level at day-7  repeat MTX
If -hCG fails to fall by at least 25%/week at any time repeat dose
U/S not required routinely
Pt should avoid
Alcohol use, sexual I/C, oral folic acid (until HCG levels are neg)

39. Methotrexate Protocol – cont’d
What to expect
Majority experience some degree of abd pain (occurs in ~ 50% at day-6)
Shedding of a decidual cast
Moderate vaginal bleeding
Side effects (usually at higher doses)
Impaired liver function, bone marrow suppression, neutropenia, stomatitis, hematosalpinx

40. Expectant Mx of EP Anticipates spontaneous regression of EP
Occurs in ~ 57%
Symptoms, HCG titers, & U/S findings followed
Risk of tubal rupture is 10% if HCG levels < 1000
Criteria include
Sonographic diameter < 3cm
Initial -hCG < IU/ml, no  in 2-day period, subsequent levels 
asymptomatic

41. Future Fertility following EP
Subsequent conception rate is ~ 60%
Incidence of recurrent EP is 15%
Other factors influencing include:
Age, parity, history of infertility, evidence of contralateral tubal disease, ruptured EP, IUCD use, salpingitis
No difference b/t laparoscopy vs laparotomy

42. Prevention of EP Treat salpingitis early & correctly
MTX management lowers rate of subsequent EP
Risk of EP is  with all methods of contraception, except progesterone containing IUCDs
Remember Rh Sensitization
Rhogam for the Rh-neg woman
Prg-releasing IUD has a higher rate, probably because its action is limited to a local effect on the endometrium
IUD has been traditionally listed as a risk factor for EP
Previous use doise not increase risk of a subsequent EP
Current use of modern copper-bearing IUDs does NOT increase risk, in fact offers considerable protection
WHP multicenter study, concluded that IUD users were 50% less likely to have an EP when compared to women using no contraception
However, if an IUD user becomes preg, the preg is more likely to be ectopic
~ 3-4% of IUD pregnancies have been ectopi (rare event)