early pregnancy complications…

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Early Pregnancy Early Pregnancy Complications… Complications… Miscarriage Miscarriage Ectopic Ectopic IUCD in situ IUCD in situ Use of Aspirin Use of Aspirin

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Early Pregnancy Complications…. Miscarriage Ectopic IUCD in situ Use of Aspirin. Differential Diagnosis: First Trimester Vaginal Bleeding. Ectopic pregnancy Spontaneous miscarriage Idiopathic bleeding in a viable pregnancy Molar pregnancy Subchorionic hemorrhage - PowerPoint PPT Presentation

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Page 1: Early Pregnancy Complications…

Early Pregnancy Early Pregnancy Complications…Complications…

MiscarriageMiscarriage

EctopicEctopicIUCD in situIUCD in situ

Use of AspirinUse of Aspirin

Page 2: Early Pregnancy Complications…

Differential Diagnosis:Differential Diagnosis:First Trimester Vaginal BleedingFirst Trimester Vaginal Bleeding

Ectopic pregnancyEctopic pregnancy Spontaneous miscarriageSpontaneous miscarriage Idiopathic bleeding in a viable pregnancyIdiopathic bleeding in a viable pregnancy Molar pregnancyMolar pregnancy Subchorionic hemorrhage Subchorionic hemorrhage Infection of the vagina or cervixInfection of the vagina or cervix Cervical abnormalitiesCervical abnormalities

Malignancy, polyps, traumaMalignancy, polyps, trauma

Vaginal traumaVaginal trauma

Page 3: Early Pregnancy Complications…

Ectopic PregnancyEctopic Pregnancy

Any pregnancy that occurs outside of the Any pregnancy that occurs outside of the uterine cavityuterine cavity

Tubal Tubal Ampulla (55%)Ampulla (55%) Isthmus (25%)Isthmus (25%) Fimbria (17%)Fimbria (17%)

CervicalCervical OvarianOvarian Abdominal Abdominal

3%

97%

Page 4: Early Pregnancy Complications…

Ectopic Pregnancy Risk FactorsEctopic Pregnancy Risk FactorsBouyer J, Coste J, Shojaei T, et al. Am J Epidemiol 2003; 157:185Bouyer J, Coste J, Shojaei T, et al. Am J Epidemiol 2003; 157:185

Degree of Risk Risk Factors Odds Ratio

High Previous ectopic 9.3-47

Previous tubal surgery 6.0-11.5

Tubal ligation 3.0-139

Tubal pathology 3.5-25

In-utero DES exposure 2.4-13

Current IUCD use 1.1-45

Moderate Infertility 1.1-28

Previous cervicitis 2.8-3.7

History PID 2.1-3

Multiple sexual partners 1.4-4.8

Smoking 2.3-3.9

Low Previous abdo surgery 0.93-3.8

Vaginal douching 1.1-3.1

Early age intercourse 1.1-2.5

Page 5: Early Pregnancy Complications…

Ectopic Pregnancy - PathophysiologyEctopic Pregnancy - Pathophysiology

Conditions that impair tubal transportConditions that impair tubal transport Chronic salpingitisChronic salpingitis Salpingitis isthmica nodosaSalpingitis isthmica nodosa

Kutluay L, et al. Tubal histopathology in ectopic pregnancies. Eur J Obstet Gynecol Kutluay L, et al. Tubal histopathology in ectopic pregnancies. Eur J Obstet Gynecol Reprod Biol. 1994Reprod Biol. 1994

Conditions that cause premature Conditions that cause premature implantation implantation

Attar E. Endocrinology of ectopic pregnancies. Obstet Gynecol Clin NA. 2004Attar E. Endocrinology of ectopic pregnancies. Obstet Gynecol Clin NA. 2004

Page 6: Early Pregnancy Complications…

Ectopic PregnancyEctopic Pregnancy

History/Exam FindingsHistory/Exam Findings

Pelvic/Abdominal pain (90-100%)Pelvic/Abdominal pain (90-100%)Vaginal bleeding (50-85%)Vaginal bleeding (50-85%)Palpable adnexal mass (40%)Palpable adnexal mass (40%)Normal size uterusNormal size uterus

Page 7: Early Pregnancy Complications…

Ectopic PregnancyEctopic Pregnancy

Suspect Rupture…Suspect Rupture…Significant abdominal tendernessSignificant abdominal tenderness

*Especially if accompanied by:*Especially if accompanied by:HypotensionHypotensionAbdominal guardingAbdominal guardingRebound tendernessRebound tenderness

Page 8: Early Pregnancy Complications…

Ectopic PregnancyEctopic Pregnancy

Diagnostic TestsDiagnostic Tests ββHCGHCG

Does not increase appropriatelyDoes not increase appropriately

Ultrasound- what type Ultrasound- what type and when do we do it? and when do we do it? No intrauterine gestational sac No intrauterine gestational sac Possible adnexal massPossible adnexal mass

Page 9: Early Pregnancy Complications…

Ectopic PregnancyEctopic PregnancyTreatmentTreatment Expectant managementExpectant management

Monitor progress with Monitor progress with ββHCG levelsHCG levels

Medical treatmentMedical treatment Methotrexate – folic acid antagonistMethotrexate – folic acid antagonist

Disrupts rapidly dividing trophoblastic cellsDisrupts rapidly dividing trophoblastic cells

SurgerySurgery Laparoscopy with salpingostomy or salpingectomyLaparoscopy with salpingostomy or salpingectomy Laparotomy – patient unstableLaparotomy – patient unstable

Page 10: Early Pregnancy Complications…
Page 11: Early Pregnancy Complications…

Case 1Case 1

33 yo G3P2 with prior history of chlamydia, LMP 33 yo G3P2 with prior history of chlamydia, LMP 5/52 ago and + UPT. Seen by GP with vague 5/52 ago and + UPT. Seen by GP with vague lower abdominal pain.lower abdominal pain.

ββHCG - 352 IU/lHCG - 352 IU/l

TV USS – TV USS – 8.5mm intrauterine sac compatible with 5/52 8.5mm intrauterine sac compatible with 5/52 pregnancy. No adnexal masses seen.pregnancy. No adnexal masses seen.

Page 12: Early Pregnancy Complications…

Case 2Case 2 24 yo G2P1 LMP 7/52 ago and + UPT. Seen by 24 yo G2P1 LMP 7/52 ago and + UPT. Seen by

GP with vaginal spotting.GP with vaginal spotting.

ββHCG - 5230 IU/lHCG - 5230 IU/l

TV USS – TV USS – No intrauterine pregnancy, 3 cm R adnexal No intrauterine pregnancy, 3 cm R adnexal mass.mass.