eve espey, md, mph. understand steps in diagnosis in women with bleeding, cramping and a positive...

Eve Espey, MD, MPH

Understand steps in diagnosis in women with bleeding, cramping and a positive pregnancy test

Initiate appropriate management for miscarriage,

ectopic and threatened abortion

Understand medical and surgical approaches to the management of miscarriage and ectopic pregnancy

Don’t nuke a normal pregnancy or miss an ectopic

Place an IUD immediately after D&C for miscarriage

“We’ve got a gal here with bleeding, pain and a positive pregnancy test”

Normal pregnancy Miscarriage Ectopic

Ultrasound Quantitative hCG Experience Common sense Luck!

One of the top reasons OB-GYNs are sued: MTX given to a normal intrauterine pregnancy

Ectopic pregnancy still causes maternal mortality

Dealing with miscarriage in a sensitive way is paramount to women

Uterus outline

Sub-chorionic bleed

Embryo

Yolk sac

Gestational sac

Choriodecidual reaction

5 weeks ----> Gestational sac (5mm)

6 weeks ----> Yolk sac

7 weeks ----> Cardiac motion

17 y/o G2P0 presents with bleeding, cramping, positive pregnancy test

Differential◦ Normal pregnancy◦ Miscarriage◦ Ectopic?

Sac = 5 4/7 weeks

Day 0 = 1,700 Day 2 = 4,400 Rise = 158% Likely diagnosis?

The AVERAGE hCG rise over 48 hours in a normal pregnancy is 124%

Day 0 = 1,700Day 2 = 2,200Rise = 29%Likely diagnosis?

The MINIMUM hCG rise over 48 hours in a normal pregnancy is 53%

J Clin Endocrinol Metab 1979;49:917

J Clin Endocrinol Metab 1979

15% of women with IUP have an “abnormal” rise in hCG in the first 40 days

17% of ectopic pregnancies have a normal rise in hCGs over 48 hours at least once in early pregnancy

Kadar et al.Obstet Gynecol 1981;58:162

32 y/o G2P1 at 7 weeks from LMP

Presents with bleeding, cramping, positive pregnancy test

hCG = 5,277

Transvaginal U/S◦ Beta HCG = 1500 - 2000 mIu/ml

Transabdominal U/S◦ Beta HCG = 3,600 mIu/ml

If HCG > discriminatory zone and no gestational sac seen, consider ectopic pregnancy till proven otherwise

Most common cause of maternal death in early pregnancy 20 deaths per year in the US

1970 17,800 cases Fatality 35/10,000 1992 108,800 cases Fatality 3.4/10,000

Risk factors:◦ Prior tubal sterilization 10%◦ Hx Salpingitis.....4X◦ Linear salpingostomy.....10X◦ Ovulation induction.....4X◦ Most cases have no known risk factor!◦ Minority race

Laparoscopy◦ Salpingostomy

5-20% persistent ectopic Monitor with hCG to 0 Treat with MTX

◦ Salpingectomy Laparotomy Medical management Expectant management

Single, two or multi-dose regimens Reported success: 71%-94% Patient selection

◦ Stable◦ No IUP on ultrasound or villi on D&C◦ Labs normal: AST, WBC, platelets, creatinine

Relative contraindications◦ hCG > 5,000◦ Cardiac activity in the tube◦ Sac > 3.5 cm

Day 0: hCG, CBC, Platelets, Rh, AST, Cr Day 0: MTX 50mg/m2 IM Day 4: Quantitative hCG Day 7: Quantitative hCG

◦ If HCG does not decrease by at least 15% from Day 4, repeat MTX

Weekly hCG until < 5

If pretreatment Bhcg >5000 failure rate is around 14%

If pretreatment Bhcg <5000, failure rate is around 3.7%

Consider two-dose regimen if Bhcg >5000

Author Tx IUP Repeat ectopic

Sherman 1982 Salpingectomy 72% 6% Sherman 1982 Salpingostomy 83% 6% Stovall 1993 Medical 70% 9%

Miscarriage

About 25% of women experience a miscarriage.

Approximately 15% of clinically recognized pregnancies spontaneously abort in the first or early second trimester.

Up to 33% of all pregnancies end in miscarriage.

Expectant management

Misoprostol D&C

◦ Suction◦ MVA

Treatemtent Success rates

Placebo 16-60%

Single dose misoprostol 25-88%

Repeat dose x 1 if incomplete at 24 hours

80-88%

Success rate depends on type of miscarriage-100% with incomplete abortion- 87% for all others

Wood SL, Obstet Gynecol 2002; Bagratee JS, Hum Reproduct 2004; Blohm F, BJOG: Int J Obstet Gynecol 2005

Gestational sac or CRL up to 10 weeks◦ No embryo or no fetal cardiac activity

Rh, hematocrit 800 mcg misoprostol x 2 doses

◦ Intravaginal home administration x 1 dose◦ Repeat after 24 hours if no tissue

Ibuprofen + Tylenol with codeine If no passage within a week, RTC for

options

“Vocal local” Oral analgesia + paracervical block

◦ Ibuprofen 800 mg ◦ Percocet and 1 mg lorazepam

IV sedation + paracervical block + ◦ Fentanyl 50-100 mcg ◦ Midazolam 1-2 mg

Regional anesthesia (spinal) General anesthesia or deep sedation

31 y/o G3P2 presents to ER with “severe LLQ pain” and positive pregnancy test◦ Benign pelvic exam, + hCG◦ Ultrasound: “No IUP, left

adnexal mass with surrounding echogenic fluid and free fluid in pelvis concerning for ruptured ectopic”

hCG = 1,003

Ectopic pregnancy vs. early IUP Offered methotrexate Patient declined: desired

pregnancy Plan: Repeat hCG in 48 hours

Continued pain, back to emergency room HR 93, BP 148/71, bilateral adnexal

tenderness and rebound Ultrasound: “Small hypoechoic focus in

uterus, possible pseudosac. Left adnexal mass with interval development of heterogeneous material/free fluid”

hCG: 1,419 (55% rise)

Laparoscopy◦ 400 cc hemoperitoneum, “no active

bleeding site determined”◦ Attempted salpingostomy followed by left

salpingectomy◦ Discharged on POD #1

Pathology sent on Day #1 Checked on Day #7 Pathology

◦ Gross: Sectioning through this area demonstrates “presumed villi”

◦ Microscopic diagnosis: “No chorionic tissue, no evidence of intratubal gestation

Patient called: “final pathology negative for POCs” hCG: 9,417 Triage ultrasound: “Gestational sac measuring 6

weeks, minimal free fluid, right ovary 2.9 cm, circumferential flow, hypoechoic cystic structure within ovary measuring 2 cm, no embryonic pole, no embryonic fetal heart motion.”

Diagnosis: Presumed ongoing ectopic Radiology ultrasound was ordered but not available

since it was the weekend. Given a concerning picture for ectopic, methotrexate was recommended

IM MTX 50 mg/m2 Day #11

◦ hCG = 15,168 – not checked, F/U day #14 (7 days after MTX given)

Day #14◦ Ultrasound: 6 ½ week IUP with positive fetal heart motion in the 120s◦ Patient counseled re MTX in setting of normal IUP

Day #18 ◦ Ultrasound: CRL consistent with 6 ½ weeks with FHM ranging from 0-

100 bpm Day #25

◦ Ultrasound: CRL consistent with 6 ½ weeks with no FHM◦ Requests misoprostol for management

Day #30◦ Empty uterus, Paragard IUD placed

“Offered” MTX (instead of dx LSC) on Day 0 with a desired pregnancy

Laparoscopy: No active bleeding? Checked pathology on Day 7 Incorrect interpretation of hCG of 9,417 with

no fetal heart motion MTX given based on an inadequate U/S Day #11 hCG not checked till Day #14

hCG and pathology follow-upBeta book systemContinuity of physician teams seeing the patient Context—patient course, hCGs and U/S

Ovulation may occur within 10 days

Don’t forget contraception

Half of pregnancies are unintended

May wish to delay another pregnancy even if intended

> 700 women undergoing D&C (abortion and miscarriage) from 5-12 weeksRandomized to immediate vs. delayed IUD insertionNo significant difference in expulsion risk:

◦ 4.5% immediate◦ 2.7% delayed

No increase in other complications

Bednarek, NEJM 2011

Be meticulous in follow-up of first trimester complications

Consider misoprostol and MVA for treatment Don’t forget the IUD!