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

2. Contents Early pregnancy Ectopic pegnancy Miscarriage
Trophoblastic disease

3. 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

4. Ectopic Pregnancy

5. Definition Pregnancy implanted outside uterine cavity
Approx 11/1000 of pregnancies – rate increasing
Maternal mortality in 1/2500 ectopic pregnancies

6. Site
Outside uterine cavity (Cervical, CS scar)
Commonest- tubal

7. 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

8. 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

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

10. Outcomes
Unlikely to continue beyond few months and exceptional to reach period of viability
Resolve spontaneously
Catastrophic rupture- intraabdominal haemorrhage

11. 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

12. Ultrasound

13. 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

14. Left Ectopic on laparoscopy

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

16. True / False
Ectopic pregnancy is pregnancy outside the uterus.

17. True / False
Ectopic pregnancy is pregnancy outside the uterus. F

18. True / False Ectopic pregnancy is pregnancy outside the uterus. F
Pregnancy conceived with IUCD in situ is at increased risk of ectopic pregnancy.

19. True / False Ectopic pregnancy is pregnancy outside the uterus. F
Pregnancy conceived with IUCD in situ is at increased risk of ectopic pregnancy. T

20. 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.

21. 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

22. 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

23. 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.

24. 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

25. 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

26. 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

27. 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

28. 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

29. Bleeding in Early Pregnancy & Miscarriage

30. 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.

31. 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

32. 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)

33. 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

34. Causes Fetal Maternal Chromosomal Malformations Placental
Multiple pregnancy
Disease- Diabetes, hyperthyroidism
Age
BMI
Infection
Uterine/ cevical anamolies
Previous miscarriage
trauma

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

36. Cusco speculum Sims speculum

37. 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

38. 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

39. Gestational sac

40. Very early..

41. Normal 8-9 wk pregnancy

42. Empty sac

43. 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

44. 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 mcg (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

45. 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

46. 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.✗

47. Gestational Trophoblastic Disease

48. 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

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

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

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

53. Snowstorm appearance

54. Complete mole at hysterectomy

55. Management Suction evacuation Avoid cervical ripening
Above will cure 99.5% of PHM, 84% of CHM
Avoid hysteroscopy- increase the likelihood of chemotherapy

56. 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

57. 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