FIRST TRIMESTER BLEEDING • SPONTANEOUS ABORTION – ?30%, usu self-limited • ECTOPIC PREGNANCY – ?1%, most dangerous • MOLAR PREGNANCY – 0.1%, cookbook
FIRST TRIMESTER BLEEDING
• SPONTANEOUS ABORTION– ?30%, usu self-limited
• ECTOPIC PREGNANCY– ?1%, most dangerous
• MOLAR PREGNANCY– 0.1%, cookbook
SPONTANEOUS ABORTION
• SPONTANEOUS LOSS, PRE-VIABLE
• <20 WKS, <500 GM
• 30% PREVALENCE
• 80% 1ST TRIMESTER-”EARLY”
RISK FACTORS
• AGE– 10%@20, 20%@35, 40%@40, 80%@45
• SAB HX– 5% NSVD/NO SAB, 30-40% IF 3 SABS
CAUSES
• CHROMOSOMAL ABN’S- 50%-sporadic• CONG ANOMALIES• UTERINE ABN’S-fibroids, synechiae, septae• INFECTIONS• THROMBOPHILIAS-APS, APC res, prothro, etc• DM, THYROID• IATROGENIC-amnio, CVS• SUBSTANCES-caffeine, tob, meth, coc, NSAIDs
APPROACH
• ESTABLISH IUP-R/O ECTOPIC-urgent
• ESTABLISH VIABILITY-less urgent
• CONSIDER INTERVENTION-not all
• REMEMBER RHOGAM-all Rh neg
• EDUCATE/ SUPPORT/ FOLLOW-UP
ECTOPIC? VIABILITY?
• RISK FACTOR ASSESSMENT– absence doesn’t r/o
• UTERINE SIZE-decidua to 8 wks
• HEART TONES- don’t settle for 2nd best
• CERVICAL-open suggestive
• TISSUE PASSED-frozen/rush permanent
ECTOPIC? VIABILITY?
• HCG– ?serial- not if visualized on sono– ?serial sono better if not definitive
• SONOGRAPHY– Gest sac/yolk sac- ?normal appearing– Fetal pole if gest sac MSD >20– cardiac if fetal pole >6-7wk=CRL >5mm
TERMS
• THREATENED-next slide
• INEVITABLE-open,SROM,heavy bleeding
• INCOMPLETE-
• COMPLETE-easiest in retrospect-decresc
• MISSED/” BLIGHTED OVUM”
• SEPTIC
Threatened SAB
• Vaginal bleeding +/- cramping
• 30-40% pregnancies bleed; 1/2 SAB
• more symptoms, small for dates, subchorionic bleed-poorer prognosis
• fetal cardiac activity- better prognosis
• Rx- observation
INTERVENTION
• DO I NEED TO INSTRUMENT?– Where/ what instrument?– How soon?-septic vs bleeding vs missed– Lam’s? EGA by sono, blighted ovum
• DO I NEED FROZEN SECTION ?– Rush permanents vs routine
OPTIONS
• EXPECTANT– <10-12wk, 80-90% res, slower
• SURGICAL– ?ectopic, septic, BLEEDING, missed,>10-12– Fastest
• MEDICAL– <10-12, 80-90% res, faster– Miso 600-800 PV x 1-2
PREVENT ISOIMMUNIZATION
• REMEMBER RHOGAM 50mcg IM if < 12 WEEKS 300mcg IM IF > 12 WEEKS
EDUCATION & SUPPORT
• ADDRESS GUILT
• ADDRESS GRIEF
• DEFER PREGNANCY > 3 MONTHS
Recurrent SAB
• ?3 consecutive for therapeutic nihilists• ?evid base for recommendations• Outcomes similar- ~70% successful preg
– no w/u, + or – w/u , +w/u with or without rx– 50% success after 6 consecutive losses
• Uterine eval, day 3 FSH, antiphos syn w/u & misc thrombophilia w/u, TSH, ?fast glu, ?ANA, karyotype
• Thrombophilia is in –progesterone supps, doxy are both out
MOLAR PREGNANCY
• Aberrant fertilization, fetal origin
• 0.05-0.1% incid (US), chorioca 1:30,000
• 1:120 SE Asians, 1:1200 Hispanics, prior mole, age <20 >35, lower parity
• 80-90% benign course
• most metastatic disease curable
CLASSIFICATION
• HYDATIDIFORM MOLE =GTD – COMPLETE– PARTIAL
• PERSISTENT/INVASIVE MOLE=GTN
• CHORIOCARCINOMA=GTN
• PLAC SITE TROPHOBLASTIC TUMOR=
GTN
Complete & partial mole
• No fetal tissue• 1 sperm + anuclear
ovum- 46XX or 46XY• GTN risk 20%
• Fetal tissue• 2 sperm + 1 ovum -
69XXY or 69XYY• GTN risk 5%
CLINICAL FINDINGS
• VAGINAL BLEEDING• NO FHT’S• SIZE > DATES• HIGH HCG- >100,000 (nl preg peak < 200,000)• HYPEREMESIS GRAVIDARUM• EARLY PREECLAMPSIA <20Wwks• THYROTOXICOSIS• OVARIAN CYTS ( THECA LUTEIN)
DIAGNOSIS
• SONOGRAPHY
• PATHOLOGY
W/U
• HCG, Rh, TSH, LFP, BUN/Cr
• CXR
• SONO
TREATMENT
• Uterine evacuation– D&C, pitocin running?– Bleeding, perforation, ?ARDS, etc
• Serial HCG’s – q wk till negative then q mo for 6-12mo– Should drop rapidly& be negative < 90 days– normal preg usu takes 2-4wk
• effective contraception during follow-up
Persistent/recurrent HCG rise
• =HCG rise x2 wk, stable x 3wk,+@3mo• ?new pregnancy…• Worry re GTN/metastatic disease
– 25%chorioca, 75% persist/invasive mole
• Pelvic sono• Consider repeat D&C- up to 40% neg HCG • Cbc, coags, liver, renal labs• CT abd, pelvis, chest, ?head
High risk features
• Higher HCG
• Time from and characteristics of antecedent pregnancy
• Site, size and number of mets
• failure of prior chemo
GTN
• Occurs 50% after nl preg, 25% after mole, 25% after ectopic/SAB
• Vag bleeding or amenorrhea esp prolonged postpartum,very bloody tumors check HCG
• Serial HCG’s after molar pregs
Remember rhogam
• 300mcg IM with moles
ECTOPIC PREGNANCY
• Implantation outside endometrial cavity
• High prevalence related to PID prevalence
• 98-99% tubal- usu rupturing 6-10 wks
• cornual, cervical, ovarian, abdominal rare
High index of suspicion
• Assume all female patients are pregnant until proven otherwise– ?9-50yrs, sexual hx reliability, contraceptive
failure
• Assume all pregnant patients are ectopic until proven otherwise– danger of preexisting diagnosis of SAB
Risk factors
• Tubal damage– Prior ectopic– PID 1:24 pregs– pelvic surg- appi, cystectomy, section, TL
• Failed contraception– IUD, progesterone only methods, TL, emergency?
• Misc.– extrinsic mass, infert, smoking at conception
• Absence of risk factors does not rule out ectopic
Clinical Presentation-an evolution-
• Pregnancy– amenorrhea, N, V, frequency, rising HCG
• Failing pregnancy– vag bleeding, ?tissue, flat/ falling HCG
• Growing/ rupturing ectopic – pain (colic, peritoneal irritation, referred), mass,
hemodynamic instability, fluid in belly
HCG
• >99% ectopics positive
• absolute values correlate poorly w/ EGA
• relative rise helpful early in gestation
• abnormal rise signifies abnormal gestation
• note 20-30% of ectopics have normal rise
Lower normal limits HCG rise
Interval (days)
Increase in HCG (percent)
1 2 3
29 66(53) 114
4 5
174 255
Sonography
• Primary-Verify or rule out IUP-?heterotopic– Also ectopic cardiac, complex mass, free fluid
• “Discriminatory zone”
• Endovaginal vs. transabdominal
• Availability
• Indication-low thresholds symptoms-All?
Sonographycontinued
• Gestational sac (vs pseudo sac)– EGA~5wks, singleton 1000-1800
• Fetal pole– EGA~5.5wks, by mean sac diam of 16-20mm
• Cardiac activity– EGA~6wks, by 7 wks “minimum EGA” or fetal
pole >5mm
DDX
• SAB
• Molar preg
• IUP complicated by:– ovarian cyst complication– fibroid degeneration, torsion– appendicitis– etc.
DIAGNOSTIC ALGORITHM
S U R G E R Y
S U R G IC A LE M E R G E N C Y
DIAGNOSTIC ALGORITHM
IU P V S E M P TY
S O N O G R A M
? S U F F IC IE N T H C G
DIAGNOSTIC ALGORITHM
S E R IA L Q U A N TSE C TO P IC P R E C A U TIO N S
S O N O A T D IS C R IM IN A TO R Y Z O N E
? IN S U F F IC IE N T H C GR IS IN G H C G
DIAGNOSTIC ALGORITHM
C H O R IO N IC V IL L IV S
D E C ID U A
U TE R IN E E V A C U A TIO NF R O Z E N S E C TIO N
F L A T/ F A L L IN G H C GU N D E S IR E D P R E G N A N C Y
P R O G E S TE R O N E < 5
Treatment options
• Expectant
• Methotrexate
• Surgery
Expectant
• Selection criteria– asymptomatic, small ectopic, low falling HCG
• Rationale– ?incidence tubal SAB, no therapeutic M&M
• Concerns– risk of rupture awaiting resolution
Methotrexate
• Inclusion criteria– <3-4cm, unruptured, no liver, renal, heme dis ?
no cardiac activity, ?HCG <5000-15,000
• Education/ consent
• Workup– CBC/d, AST, BUN/Cr,Type/Rh– Sono– D&C
Methotrexateinformed consent
• Alternatives
• nature of treatment & follow-up– failure rate, risk of rupture
• Side-effect profile– pain, stomatitis, liver, marrow, renal tox
• things to avoid– NSAID’s, ETOH, folic acid, intercourse
Methotrexate
• Dose– 50mg/m2
• Follow-up– quant HCG 3&6 days after injection
• Success– >15% drop on HCG between day 3&6– follow weekly till negative
ALT METHOTREXATE
• 1mg/kg IM every other day to 4 doses
• Quant HCG with leucovorin rescue on alternate days
• Stop when 15% drop in HCG
• ?higher efficacy, less lost sleep
Surgery
• Laparoscopy vs laparotomy
• Conservative- maximize fertility– salpingostomy
• Extirpative- prevent future ectopics– salpingiectomy