Transcript Early Pregnancy Problems

Early Pregnancy
Problems
Jacqueline Woodman
M.B.,Ch.B.; Dipl Obst; MRCOG; D.Phil (Oxon)
Introduction
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Bleeding in early pregnancy and miscarriage
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Ectopic Pregnancy
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Gestational Trophoblastic Disease
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Hyperemesis Gravidarum
Bleeding in Early Pregnancy
& Miscarriage
Definitions
Remember – MISCARRIAGE not ABORTION
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Threatened miscarriage
Vaginal bleeding at < 24 weeks gestation (cervix closed)
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Inevitable miscarriage
Bleeding, pregnancy still in uterus (cervix open)
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Incomplete miscarriage
Retained products of conception in uterus (cervix open)
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Complete miscarriage
Uterus empty (cervix closed)
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Delayed miscarriage
Gestational sac with/without fetus present (but no FH),
cervix closed
Miscarriage
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Approximately 30% of pregnant women will
experience bleeding in early pregnancy
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At least 50% of women with threatened
miscarriage will have continuing pregnancy
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Miscarriage occurs in 15-20% of clinically
diagnosed pregnancies
Causes of miscarriage
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Genetic abnormalities
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Progesterone deficiency?
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Maternal illness e.g. diabetes
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Uterine abnormalities
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‘Cervical incompetence’
History
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LMP
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Bleeding: amount (spotting/gush), clots
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Pain: type – crampy/sharp/dull
location: lower abdomen, shoulder tip,
back pain
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Passed products?
Examination
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ABC (vital signs)
stable or cervical shock
Abdominal
tender/ rebound tenderness
Vaginal (speculum)
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Cervix: open/closed
Amount of bleeding
Products visible? .............TAKE IT OUT!
Speculums
Cusco speculum
Sims speculum
Investigations
Ideally in dedicated ‘Early Pregnancy Assessment Unit’
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Ultrasound
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Measurement of serum βhCG
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Determination of blood & Rhesus group
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FBC, G&S and admit if significant bleeding
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Psychological support
Ultrasound
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Expect to see viable fetus from around 6.5 weeks transabdominally,
5.5 weeks transvaginally
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Other possible appearances
 ‘POC’
Incomplete miscarriage
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Empty uterus
Not pregnant
Too early gestation
Extrauterine pregnancy
Complete miscarriage
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Empty sac
Non-viable pregnancy
Too early gestation
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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
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Not necessary if diagnosis unequivocal on scan
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Useful as part of investigations to diagnose/exclude extrauterine
pregnancy/miscarriage
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Doubling time approx 2 days in viable pregnancy
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Halving time 1-2 days in complete miscarriage
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Should see fetal pole with βhCG of 1500-2000
Management of Incomplete
Miscarriage
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Conservative
Risk of bleeding, infection, retained POC needing ERPC,
unpredictable
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Medical (Prostaglandin e.g. Misoprostol)
Risk of bleeding, retained POC, need for
ERPC
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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
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Pregnancy occurring outside uterine cavity
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Approx 0.5-1% of pregnancies – rate increasing
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Maternal mortality in 1/2500 ectopic pregnancies
(13 deaths 1997-1999 in UK)
Site
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Fallopian tube
Ovary
Abdominal cavity
Cervix
Risk factors
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Previous PID
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Previous ectopic pregnancy
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Previous tubal surgery (e.g. sterilisation, reversal)
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Pregnancy in the presence of IUCD
Symptoms
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Acute
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Low abdominal pain – peritoneal irritation by
blood
Vaginal bleeding – shedding of decidua
Shoulder tip pain – referred from diaphragm
Fainting - hypovolaemia
Chronic (Atypical)
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Asymptomatic, gastrointestinal symptoms, back
pain
Signs
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Shock – tachycardia, hypotension, pallor
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Abdominal tenderness
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Adnexal tenderness
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Adnexal mass
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None
Diagnosis
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Ultrasound
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Serum βhCG
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Empty uterus, adnexal mass, free fluid in POD,
rarely live pregnancy outside of uterus
Suboptimal rise, plateau
Laparoscopy
Ultrasound
Left Ectopic on laparoscopy
Management
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Medical
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Surgical
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Methotrexate
Laparoscopic salpingectomy / salpingotomy
Laparotomy
‘Conservative’
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Self resolving with close watch
Gestational Trophoblastic
Disease
Hydatidiform Mole
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1 in 1000 pregnancies
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Partial
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Associated with fetus, triploid
Complete
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No fetal pole, diploid chromosomes paternally
derived
Presentation
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Asymptomatic – incidental finding at dating or
anomaly USS
Vaginal bleeding
Hyperemesis gravidarum
Uterus large for dates
Diagnosis
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Ultrasound (Snow storm appearance)
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Histology after surgical evacuation
Snowstorm appearance
Hydatidiform Mole after
hysterectomy
Follow-up
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Monitor via regional centres – London, Sheffield, Dundee
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3% risk choriocarcinoma following complete mole, less following partial mole
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Choriocarcinoma may follow any subsequent pregnancy – miscarriage, TOP,
term delivery
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Choriocarcinoma is curable
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Monitor βhCG levels to check resolution – for 6 months to 2 years
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Avoid pregnancy for minimum 6 months or until all clear
Hyperemesis Gravidarum
Hyperemesis Gravidarum
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Nausea/vomiting in pregnancy is normal –
‘morning sickness’
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Rarely excessive – hyperemesis gravidarum
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Related to level of βhCG
Associated Factors
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UTI
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Multiple pregnancy
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Molar pregnancy
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Socio-economic factors
Investigations
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Renal function
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Liver function
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FBC
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Urinalysis and MSU
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Ultrasound
Consequences
&
 Dehydration
Management
 Electrolyte imbalance
Metabolic alkalosis, hypokalaemia,
hypernatremia
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IV fluids
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Electrolyte replacement
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Antiemetics
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Thromboprophylaxis
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Dietary advice
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Vitamin supplementation
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Steroids
 Oesophageal tears
(Mallory Weiss)
 Thrombosis
DVT/PE/Cerebral sinus
 Weight loss
 Vitamin deficiency (vit B1- thiamine)
Wernicke's encephalopathy
 Psychological impact
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Antibiotics if UTI
Termination of pregnancy
in CONCLUSION
GYNAECOLOGICAL EMERGENCIES
1. MISCARRIAGE
2. ECTOPIC
3. PELVIC SEPSIS
4. OVARIAN TORSION