Early Pregnancy ProblemsFeras IzzatConsultant Gynaecologist – EGU/EPAU LeadUniversity Hospitals Coventry & Warwickshire NHS Trust

IntroductionIntroduction

• Ectopic Pregnancy

• Bleeding in early pregnancy and miscarriage

• Gestational Trophoblastic Disease

Ectopic Pregnancy

DefinitionDefinition

• 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)

SiteSite

• Tubal – Interstitial 2.4%– Isthmic 12%– Ampullary 70%– Fimbrial 11.1%

• Non Tubal– Ovary– Abdominal cavity– Cervix– CS Scar

Risk factorsRisk factors

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

• POP

• ART (IVF)

SymptomsSymptoms

• Acute– 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

SignsSigns

• Abdominal tenderness

• Adnexal tenderness / mass

• Shock – tachycardia, hypotension, pallor

• None

DiagnosisDiagnosis

• Ultrasound– Empty uterus, adnexal mass, free fluid, occasionally live

pregnancy outside of uterus

• Serum βhCG & Progesterone

• Laparoscopy

Ultrasound

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.

Left Ectopic on laparoscopy

ManagementManagement

• Conservative – 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

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

Bleeding in Early Pregnancy & Miscarriage

DefinitionsDefinitions

• 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)

MiscarriageMiscarriage

• 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

Causes of miscarriageCauses of miscarriage

• Genetic abnormalities 85%

• Maternal illness e.g. diabetes, Thyroid disease

• Phospholipid / Lupus – 15% recurrent miscarriages

• Uterine abnormalities

• ‘Cervical incompetence’

• Progesterone deficiency?

History

• LMP

• When?

• Amount?

• Pain?

• Timing of Pain

Examination

• ABC (vital signs)

• Abdominal

• Vaginal (speculum)– Cx state

– Amount of bleeding

Cusc’o speculum Sim’s speculum

InvestigationsInvestigations

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

UltrasoundUltrasound

• 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

Gestational sac

Very early..

Normal 8-9 wk pregnancy

Empty sac

Measurement of Measurement of ββhCGhCG

• 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 1500-2000

Management of incomplete miscarriageManagement 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

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

Gestational Trophoblastic Disease

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

Molar PregnancyMolar Pregnancy

• 1 in 1000 live births

• Partial– 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%

PresentationPresentation

• Vaginal bleeding

• Excessive N&V ‘Hyperemesis gravidarum’

• Uterus large for dates

DiagnosisDiagnosis

• Ultrasound

• Histology after surgical evacuation

Complete mole at hysterectomy

Follow-upFollow-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