Early Pregnancy Problems

Jacqueline WoodmanM.B.,Ch.B.; Dipl Obst; MRCOG; D.Phil (Oxon)

Introduction

Bleeding in early pregnancy and miscarriage

Ectopic Pregnancy

Gestational Trophoblastic Disease

Hyperemesis Gravidarum

Bleeding in Early Pregnancy

& Miscarriage

Definitions

Remember – MISCARRIAGE not ABORTION

Threatened miscarriage Vaginal bleeding at < 24 weeks gestation (cervix closed)

Inevitable miscarriage Bleeding, pregnancy still in uterus (cervix open)

Incomplete miscarriage Retained products of conception in uterus (cervix open)

Complete miscarriage Uterus empty (cervix closed)

Delayed miscarriage Gestational sac with/without fetus present (but no FH),

cervix closed

Miscarriage

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 miscarriage

Genetic abnormalities Progesterone deficiency? Maternal illness e.g. diabetes Uterine abnormalities ‘Cervical incompetence’

History LMP Bleeding: amount (spotting/gush), clots Pain: type – crampy/sharp/dull

location: lower abdomen, shoulder tip, back pain

Passed products?

Examination

ABC (vital signs) stable or cervical shock Abdominal tender/ rebound tenderness Vaginal (speculum)

Cervix: open/closed Amount of bleeding Products visible? .............TAKE IT OUT!

Speculums

Cusco speculum Sims speculum

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

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 pregnantToo early gestationExtrauterine pregnancyComplete miscarriage

Empty sac Non-viable pregnancyToo early gestation

Fetal pole with no FH If tiny, may be very early gestation

Delayed miscarriage

Gestational sac

Very early..

Normal 8-9 wk pregnancy

Empty sac

Measurement of βhCG

Not necessary if diagnosis unequivocal on scan

Useful as part of investigations to diagnose/exclude extrauterine pregnancy/miscarriage

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 Miscarriage Conservative

Risk of bleeding, infection, retained POC needing ERPC,

unpredictable

Medical (Prostaglandin e.g. Misoprostol)

Risk of bleeding, retained POC, need for ERPC

Surgical [Evacuation of retained products of conception (ERPC)]

Suction curettage usually under GA, risk of bleeding, infection,

perforation of uterus, longer term complications (e.g. Ashermans

syndrome)

Ectopic Pregnancy

Definition

Pregnancy occurring outside uterine cavity

Approx 0.5-1% of pregnancies – rate increasing

Maternal mortality in 1/2500 ectopic pregnancies

(13 deaths 1997-1999 in UK)

Site

Fallopian tubeOvaryAbdominal cavityCervix

Risk factors

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

Symptoms

AcuteLow abdominal pain – peritoneal irritation by

blood Vaginal bleeding – shedding of deciduaShoulder tip pain – referred from diaphragmFainting - hypovolaemia

Chronic (Atypical)Asymptomatic, gastrointestinal symptoms, back

pain

Signs

Shock – tachycardia, hypotension, pallor

Abdominal tenderness

Adnexal tenderness

Adnexal mass

None

Diagnosis

UltrasoundEmpty uterus, adnexal mass, free fluid in POD,

rarely live pregnancy outside of uterus

Serum βhCGSuboptimal rise, plateau

Laparoscopy

Ultrasound

Left Ectopic on laparoscopy

Management

MedicalMethotrexate

SurgicalLaparoscopic salpingectomy / salpingotomyLaparotomy

‘Conservative’ Self resolving with close watch

Gestational Trophoblastic Disease

Hydatidiform Mole

1 in 1000 pregnancies

PartialAssociated with fetus, triploid

CompleteNo fetal pole, diploid chromosomes paternally

derived

Presentation

Asymptomatic – incidental finding at dating or anomaly USS

Vaginal bleeding Hyperemesis gravidarum Uterus large for dates

Diagnosis

Ultrasound (Snow storm appearance)

Histology after surgical evacuation

Snowstorm appearance

Hydatidiform Mole after hysterectomy

Follow-up

Monitor via regional centres – 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

Avoid pregnancy for minimum 6 months or until all clear

Hyperemesis Gravidarum

Hyperemesis GravidarumNausea/vomiting in pregnancy is normal –

‘morning sickness’

Rarely excessive – hyperemesis gravidarum

Related to level of βhCG

Associated Factors

UTI

Multiple pregnancy

Molar pregnancy

Socio-economic factors

Investigations

Renal function

Liver function

FBC

Urinalysis and MSU

Ultrasound

Consequences &

Management

IV fluids

Electrolyte replacement

Antiemetics

Thromboprophylaxis

Dietary advice

Vitamin supplementation

Steroids

Antibiotics if UTI

Termination of pregnancy

Dehydration

Electrolyte imbalance Metabolic alkalosis, hypokalaemia, hypernatremia

Oesophageal tears (Mallory Weiss)

Thrombosis DVT/PE/Cerebral sinus Weight loss

Vitamin deficiency (vit B1- thiamine) Wernicke's encephalopathy

Psychological impact

in CONCLUSION

GYNAECOLOGICAL EMERGENCIES

1. MISCARRIAGE 2. ECTOPIC3. PELVIC SEPSIS4. OVARIAN TORSION