Emad R. Sagr, MBBS, FRCSC, FACOG Consultant OB-Gyn and Gynecology Oncology

1. Bleeding in early pregnancy and Ectopic Pregnancy Emad R. Sagr, MBBS, FRCSC, FACOG Consultant OB-Gyn and Gynecology Oncology Security Forces Hospital

2. SPONTANEOUS ABORTION • Definition: Abortion is termination of pregnancy before the fetus is sufficiently developed to survive (before 24 wks) Incidence: 15-20% It is convenient to consider the clinical aspect of spontaneous abortion under 5 sub groups: 1. Threatened 4. Missed 2. Inevitable 5. Recurrent abortion 3. Incomplete 6. Septic Abortion

3. Threatened Abortion • 25% of pregnancies • This refers only to bleeding from placental site which is not yet severe enough to terminate the pregnancy.

4. Serial qualitative HCG level: BHCG level – 1000 miu/ml If gest. Sac seen & BHCG less than 1000  unlikely to survive. Qualitative BHCG level should ↑ 65% every 48 hours. • Serum Progesterone level 5 ng/ml associated with none viable fetus > 25ng/ml associated with alive fetus Expectant observation No benefit from use of progesterone or bed rest although it is often advised.

5. Inevitable Abortion • Indicate the pregnancy is doomed to end shortly. Progressive cervical dilation without the passage of tissue. here bleeding is slight but retroplacental • Pain usually more. • Dilated internal os. USS – Non viable fetus • Emergency suction: D & C

6. Complete Abortion • Diagnosed if patient passed tissue but now is only slight pain and P/V bleeding • Examination confirmed closed Cx. • Minimal current bleeding • TVU – empty uterus • R/O ectopic pregnancy by serial BHCG level until P.T. -ve • Anti D injection if patients RH – ve to prevent sensitization

7. Incomplete Abortion • If the internal cervical os is open and patient has passed some tissue. Management: Emergency suction and curettage

8. Missed Abortion • It is defined as retention of dead products of conception in utero for several weeks. • Symptoms of early pregnancy disappear • Uterus not only has ceased to enlarge but also has become smaller. • Occasionally serious coagulation defect may develop. • Abnormal sonographic findings

9. Septic Abortion • Uterine infection at any stage of abortion causes: • Delay in evacuation of uterus • Delay seeking advice • Incomplete surgical evacuation followed by infection from vaginal organisms after 48 hours

10. Trauma: • Perforation or cervical tear • Criminal abortion • Treatment: • Should be active to minimize risk of septic shock • Cervical & HVS, blood culture • Broad spectrum antibiotic • Evacuation

11. Induced Abortion • Therapeutic abortion – termination of pregnancy before the viability for the purpose of saving the life of the mother. Heart disease, invasive Ca of Cx. • Elective (voluntary) abortion is the interruption of pregnancy before viability at request of the women but not for reason of maternal health or fetal disease.

12. Illegal abortion usually performed in unsterile condition by operators with little or nor medical training. It is often incomplete and complicated by: • Hemorrhage • Infection • Infertility and tubal occlusions • Intrauterine infection is frequent complication and septic shock and death are the ultimate consequences.

13. Recurrent Miscarriage • When a woman has had 3 consecutive miscarriage. • Risk of abortion for next pregnancy: • 1 abortion  15% • 1 Normal pregnancy  15% • 1 Abortion • 1 Normal  25% • 2 Abortion • 2 abortion  40%

14. Etiology and Investigation: • Genetic factors Karyotyping of both partners will reveal chromosome anomalies • Anatomical factors Uterine anomalies Cervical incompetence Hysteroscopy & HSG – Septum / Fibroid • Endocrine problem • Immunological factors Common in women with antiphopholipid antibodies syndrome, Anticardiolipid ant. & Lupus anticoagulant • Maternal disease SLE, Renal disease • Environmental factor Smoking / Alcohol

15. Abortion Technique Medical Surgical

16. Ectopic Pregnancy

17. Epidemiology • Leading cause of pregnancy-related deaths during T-1 • 1-2% of all diagnosed pregnancies • Incidence is  •  incidence of salpingitis d/t chlamydia or other STI • Improved diagnostic techniques •  age • Most occur in multigravid women • > 50% in women with  3 pregnancies • 10-15% in nulligravid women

18. Mortality • Causes 15% of maternal deaths • Overall risk of death 10X > the risk of childbirth; 50X > risk of legal abortion • Cause of death r/t blood loss (80%), infection (3%), & anesthesia (2%) • Interstitial & abdominal 5X > risk of death than other sites

19. Fallopian Tube Function • Complex structure • sustains & transports sperm, ovum & early conceptus for ~ 3 days • Beating cilia & rhythmic contraction of smooth muscle  neg pressure in tube • Zygote undergoes cleavage & held for another 30 hrs. in the ampullary-isthmic region • Developing blastocyst is then transported via the isthmus into the uterus

20. Types of EP

21. Sites of EP Heterotopic Pregnancies: 1 in 30 000

22. Risk Factors for EP • Definite • PID • Previous EP • Any tubal surgery or sterilization procedure • infertility

23. Risk Factors for EP • Probable • Any pelvic surgery • Use of reproductive techniques • In vitro fertilization • Gamete intrafallopian transfer • Embryo transfer • Uncertain Association • IUCD • “Superovulating agents” • Pergonal, Clomiphene citrate

24. Classic TRIAD of EP • Delayed menses • Irregular vaginal bleeding • Abdominal pain

25. Symptoms of Ectopic Pregnancy

26. Signs of EP * 20% of masses occur on the side opposite the EP.

27. Differential Diagnosis • Complication of IUP • Abortion • Early pregnancy plus uterine fibroid or ovarian tumour • Conditions causing acute abd pain • Torsion of ovarian tumour, FT, or subserous pedunculated fibroid • Salpingo-oophoritis • Pelvic pain with an IUCD in situ • Appendicitis

28. Differential Dx – cont’d • Conditions causing hemoperitoneum • Ruptured corpus luteum • Ruptured follicular cyst • Ruptured endometriotic cyst • Conditions simulating a pelvic hematoma • Retroverted gravid uterus • Pelvic or tubo-ovarian abcess

29. Management of EP • Pre-operative diagnostic accuracy of EP based on clinical features alone is notoriously poor: ~50% • 20% of EP occur as surgical emergencies • Delay is justified only to correct shock

30. Acute Management of EP • Remember your ABCs • Oxygen • Large bore IV(s)  crystalloids • Blood • Labs • CBC, coagulation studies • -hCG

31. Usefulness of Quantitaive -hCG • Assessment of pregnancy viability • Serial rise usually indicates a normal pregnancy • Correlation with ultrasonography • With titers > 1500 IU/L, TVUS should ID an IUP • With multiple gestation, a gestational sac will not be apparent until titer rises a little higher • Assessment of treatment results • Declining levels are c/w effective medical or surgical Tx; if levels persist think GTD

32. The Importance of TVUS • Documentation of an intrauterine sac • A viable IUP should be identified when -hCG > 1500 IU/ml • Adnexal mass • An EP > 2 cm should be identified • Adnexal cardiac activity • Detectable when -hCG is ~ 15 000 – 20 000

33. U/S – Is it EP or miscarriage?

34. Surgical Management of EP • Radical • Salpingectomy • Conservative • Salpingotomy • Salpingostomy or segmental resection  does not  repeat EP rate • fimbrial evacuation (traumatizes the endosalphinx & is assoc with  rate of recurrent EP (24%) compared with salpingectomy

35. Medical Management of EPMethotrexate (MTX) • 1st used in Japan in 1982 • Antimetabolite that interferes with dihydrofolate reductase • Considered for low -hCG • Success rate 67%-94% • Indications • Hemodynamically stable pt • good F/U • Recurrent EP following Sx intervention

36. Methotrexate – cont’d • Contraindications • Evidence of rupture • Serum -hCG > 5 000 IU/L (varies) • FH detected on U/S • Adnexal mass> 3.5 cm on U/S • Unreliable pt • F/U unavailable • Laparoscopy required to make dx • Solid adnexal masses (germ cell tumour) • Free fluid > 30ml

37. Methotrexate Protocol • Exclude contraindications as well as • No evidence of renal, liver, or hematopoietic disease (Bilirubin, AST,ALT, urea, Cr, CBC) • Informed consent • 5% risk of hematoperitoneum 2° to rupture of EP following MTX • MTX 50mg/m² body surface area (~1mg/kg) given IV or IM

38. Methotrexate Protocol – cont’d • Pt F/U • repeat serum quantitative -hCG in 3-4 days, 7days, then weekly until < 10 IU/L • If > day-4 level at day-7  repeat MTX • If -hCG fails to fall by at least 25%/week at any time repeat dose • U/S not required routinely • Pt should avoid • Alcohol use, sexual I/C, oral folic acid (until HCG levels are neg)

39. Methotrexate Protocol – cont’d • What to expect • Majority experience some degree of abd pain (occurs in ~ 50% at day-6) • Shedding of a decidual cast • Moderate vaginal bleeding • Side effects (usually at higher doses) • Impaired liver function, bone marrow suppression, neutropenia, stomatitis, hematosalpinx

40. Expectant Mx of EP • Anticipates spontaneous regression of EP • Occurs in ~ 57% • Symptoms, HCG titers, & U/S findings followed • Risk of tubal rupture is 10% if HCG levels < 1000 • Criteria include • Sonographic diameter < 3cm • Initial -hCG < 1 000 IU/ml, no  in 2-day period, subsequent levels  • asymptomatic

41. Future Fertility following EP • Subsequent conception rate is ~ 60% • Incidence of recurrent EP is 15% • Other factors influencing include: • Age, parity, history of infertility, evidence of contralateral tubal disease, ruptured EP, IUCD use, salpingitis • No difference b/t laparoscopy vs laparotomy

42. Prevention of EP • Treat salpingitis early & correctly • MTX management lowers rate of subsequent EP • Risk of EP is  with all methods of contraception, except progesterone containing IUCDs • Remember Rh Sensitization • Rhogam for the Rh-neg woman