Early Pregnancy Problems

1. Early Pregnancy Problems Jacqueline Woodman M.B.,Ch.B.; Dipl Obst; MRCOG; D.Phil (Oxon)

2. Introduction • Bleeding in early pregnancy and miscarriage • Ectopic Pregnancy • Gestational Trophoblastic Disease • Hyperemesis Gravidarum

3. Bleeding in Early Pregnancy & Miscarriage

4. 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

5. 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

6. Causes of miscarriage • Genetic abnormalities • Progesterone deficiency? • Maternal illness e.g. diabetes • Uterine abnormalities • ‘Cervical incompetence’

7. History • LMP • Bleeding: amount (spotting/gush), clots • Pain: type – crampy/sharp/dull location: lower abdomen, shoulder tip, back pain • Passed products?

8. 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!

9. Speculums • Cusco speculum Sims speculum

10. 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

11. 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 pregnant Too early gestation Extrauterine pregnancy Complete miscarriage • Empty sac Non-viable pregnancy Too early gestation • Fetal pole with no FH If tiny, may be very early gestation Delayed miscarriage

12. Gestational sac

13. Very early..

14. Normal 8-9 wk pregnancy

15. Empty sac

16. 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

17. 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)

18. Ectopic Pregnancy

19. 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)

20. Site • Fallopian tube • Ovary • Abdominal cavity • Cervix

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

22. Symptoms • 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, back pain

23. Signs • Shock – tachycardia, hypotension, pallor • Abdominal tenderness • Adnexal tenderness • Adnexal mass • None

24. Diagnosis • Ultrasound • Empty uterus, adnexal mass, free fluid in POD, rarely live pregnancy outside of uterus • Serum βhCG • Suboptimal rise, plateau • Laparoscopy

25. Ultrasound

26. Left Ectopic on laparoscopy

27. Management • Medical • Methotrexate • Surgical • Laparoscopic salpingectomy / salpingotomy • Laparotomy • ‘Conservative’ • Self resolving with close watch

28. Gestational Trophoblastic Disease

29. Hydatidiform Mole • 1 in 1000 pregnancies • Partial • Associated with fetus, triploid • Complete • No fetal pole, diploid chromosomes paternally derived

31. Presentation • Asymptomatic – incidental finding at dating or anomaly USS • Vaginal bleeding • Hyperemesis gravidarum • Uterus large for dates

32. Diagnosis • Ultrasound (Snow storm appearance) • Histology after surgical evacuation

33. Snowstorm appearance

34. Hydatidiform Mole after hysterectomy

35. 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

36. Hyperemesis Gravidarum

37. Hyperemesis Gravidarum • Nausea/vomiting in pregnancy is normal – ‘morning sickness’ • Rarely excessive – hyperemesis gravidarum • Related to level of βhCG

38. Associated Factors • UTI • Multiple pregnancy • Molar pregnancy • Socio-economic factors

39. Investigations • Renal function • Liver function • FBC • Urinalysis and MSU • Ultrasound

40. Consequences & Management • 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 • IV fluids • Electrolyte replacement • Antiemetics • Thromboprophylaxis • Dietary advice • Vitamin supplementation • Steroids • Antibiotics if UTI • Termination of pregnancy

41. in CONCLUSION GYNAECOLOGICAL EMERGENCIES 1. MISCARRIAGE 2. ECTOPIC 3. PELVIC SEPSIS 4. OVARIAN TORSION