Early pregnancy abnormalities

Early pregnancy abnormalities
Presentation lecture by:Angela F. Hawk

Goals of the talk:
* Differential diagnosis/work up for first trimester bleeding
* Different types of first trimester pregnancy loss
* Ectopic pregnancies: diagnosis and management
* Miscellaneous other oddities of the first trimester

First trimester bleeding
* Occurs in 20-40% women
* Etiology often unknown, goal = exclusion
* Prognosis: association b/w FTB and adverse outcome (SAB, PTD, PPROM, IUGR)
o Worse prognosis with heavier bleeding or extending into second trimester
o PTD frequency with no, light, or heavy FTB was 6, 9.1, and 13.8% respectively
o Spontaneous loss frequency prior to 24 WG was 0.4, 1.0, and 2.0 % respectively
o Vaginal bleeding in >1 trimester associated with 7 fold increased in PPROM
Evaluation – part I

* History
o Extent (amt, associated signs/sx, pain)
o Past history (previous ectopic, prior SABs, medical disorders, risk factors)
* Eval part II – physical
o Vital signs
o Tissue if available (clot vs POC)
o Abdominal exam (+/- dopplers)
o Speculum exam (external and internal) – look for lacerations, warts, vaginitis, cervical polyps, fibroids, ectropion, cervicitis, neoplastic process
o Bimanual exam – assess adnexal/cervical tenderness, adnexal masses, uterine enlargement

Ultrasound
* Cornerstone of evaluation
* Most useful with positive preg test where IUP not previously seen
* Uses: location of pregnancy (intra- or extrauterine), viability (+/- FCA), other rare findings (GTD, partial loss of multiple gestation)

Laboratory evaluation
* HCG levels – useful only with serial measurements
* No role in monitoring once viable IUP has been verified by ultrasonography
* Less useful: progesterone, estrogen, inhibin A, Papp-A)
* Always get type and screen and give rhogam if applicable

Differential diagnosis
* Abortion (threatened, inevitable, complete, incomplete, missed)
* Ectopic pregnancy
* Vanishing twin
* Trauma, wounds, vaginitis, vaginal/cervical neoplasia, warts, polyps, fibroids, ectropion
* Physiologic/implantation (diagnosis of exclusion)

Miscarriage

* SAB = most COMMON complication of early pregnancy
* 8-20% of clinically recognized pregnancies under 20 wks undergo SAB, 80% of these will be <12 wks
* Low risk of loss after 15 wks (0.6%) if fetus chromosomally normal
* Loss of unrecognized/subclinical pregnancies occurs in 13-26% of all pregs
o Unlikely to be recognized without daily UPTs

Early loss – the data
Types of miscarriage
* Threatened: closed cervix, uterus appropriately sized, FCA present if gestational age sufficiently advanced
* Inevitable: cervix dilated, increased bleeding with cramps/ctx, POC can be at os
* Complete/incomplete
* Missed: in utero death of embryo prior to 20th wk with retention of pregnancy for prolonged period of time. Cervix closed, +/- bleeding
* Septic abortion: rare with SABs, foreign bodies ie IUDs, invasive procedures, legal EABs; common complication of illegal EABs.

Ultrasound and SABs
* Definitive diagnosis of SAB when:
o Absence of FCA with CRL >5mm
o Absence of fetal pole when mean sac diameter >25 mm (TAUS) or >18 mm (TVUS)
o Absence of yolk sac 32 days post IVF
* Promising findings for lack of SAB
o Yolk sac b/w 22-32 days from IVF associated with +FCA in 94% pregs
o Positive FCA…. But age matters! Women <36 +FCA associated with SAB in only 4.5% pregs. 36-39 y/o SAB rate 10%, women >40 y/o SAB rate 29%.

You might worry when…
* YS abnormal (irregular, LGA, free floating)
* Slow fetal heart rate (ie HR <85 bmp at 6-8 wks associated with 0% survival)
* Small sac (MSS-CRL <5 mm)
* Subchorionic hematoma (ie double SAB rate with women with large -- >25% of gest sac volume -- subchorionic hematomas in study of first trimester bleeders)
* Management
* Threatened: expectant
* Complete: ideally nothing, but difficult to distinguish clinically/ radiologically so consider D&C
* Septic: stabilize pt, obtain blood and endometrial cultures, broad spectrum Abx (gent + clinda +/- amp), D&C
* 3 options for incomplete, inevitable, and missed ABs
* Surgical: D&C – use this if bleeding heavy, suction curettage is best. Data on Abx (doxycycline) post SABs limited. Has shown 42% decrease in infection with EABs
* Medical: Miso (some studies show expulsion in 71% by day 3, 84% by day 8)
* Expectant: use if stable vital signs, no evidence of infection. Can be used for up to one month

Ectopic pregnancy
* 3 classic symptoms: abdominal pain (99%), amenorrhea (74%), vaginal bleeding (56%)
* Occur with both ruptured and unruptured cases
* Clinical manifestations often appear 6-8 wks after LMP but can appear later
* Often see above symptoms with breast tenderness, frequency urination, and nausea
* Shoulder pain (blood irritating diaphragm), urge to defecate (blood pooling in cul-de-sac) can also be seen with ruptured ectopic pregnancies
* 50% women asymptomatic before rupture with no identifiable risk factors

Differential diagnosis abdominal pain (a very limited list)
* UTIs
* Nephrolithiasis
* Diverticulitis
* Appendicitis
* Ovarian neoplasms
* Endometriosis
* Endometritis
* PID
* IBS
* Fibroids
* Gastroenteritis
* Interstitial cystitis
* Pregnancy miscellaneous!

Risk factors - high
Risk factors – moderate
Risk factors - low

Initial evaluation
Ectopic preg: ultrasound pics
hCG monitoring
Discriminatory zone
Management – above the DZ
Management: below DZ
Uncommon ectopic cases
Cervical pregnancy
Natural history
Management
Gestational trophoblastic disease
Epidemiology
Clinical manifestations
* Vaginal bleeding
* Enlarged uterus
* Pelvic pressure/pain
* Theca lutein cysts
* Anemia
* Hyperemesis gravidarum
* Hyperthyroidism
* Preeclampsia prior to 20 wks gestation
* Vaginal passage of hydropic vesicles
Complete moles
Partial moles
Management
References

Early pregnancy abnormalities.ppt