First Trimester Pregnancy Complications · First Trimester Laboratory Tests •Quantitative hCG Correlate with gestational age and ultrasound 2 measurements, 2-3 days apart – should

First Trimester

Complications of

Pregnancy

Objectives

• Describe hCG and progesterone correlations in the first trimester

• Describe use of first trimester ultrasonography

• Describe diagnosis and management of miscarriage, ectopic pregnancy, and gestational trophoblastic disease

• Describe psychological reactions to early pregnancy loss

First Trimester Bleeding

• Spontaneous miscarriage

• Ectopic pregnancy

• Trophoblastic disease

• Cervical polyps

• Friable cervix

• Trauma

• Cervical cancer

First Trimester Laboratory Tests

• Quantitative hCG

Correlate with gestational age and ultrasound

2 measurements, 2-3 days apart – should double

Falling or plateauing levels signal problem

• Progesterone

Single level in early pregnancy predictive

– <5ng/ml predicts poor outcome

– >25ng/ml associated with living intra-uterine pregnancy

hCG and Ultrasound Correlations

Gestational age by LMP

Trans-abdominal Landmarks

Trans-vaginal Landmarks

Serum hCG mIU/ml IRP

< 5 weeks None Possible gestational sac

1800

5 - 6 weeks Gestational sac Gestational sac, yolk sac

1800 - 3500

7 weeks 5-10 mm embryo Same as trans-abdominal, with cardiac activity

>20,000

First Trimester Ultrasound Indications

• Suspected miscarriage or fetal death

• Vaginal bleeding

• Gestational age (if uncertain, or size/date discrepancy)

• Adjunct to procedures (e.g. CVS) • Suspected multiple gestation • Suspected hydatidiform mole • Suspected ectopic pregnancy • IUD localization • Evaluation of maternal pelvic masses

First Trimester Ultrasound

• Best when performed in combination with history, physical examination and relevant laboratory tests

• Often used as primary tool in evaluating first trimester complications

• Trans-vaginal and trans-abdominal should be obtained

Normal Gestational Sac

• Round shape

• Location in the uterine fundus

• Echogenic “ring” surrounding sac

5th menstrual week, trans-vaginal scan

SAC

Uterus

GA by Crown-Rump Length

Menstrual age* (weeks) = CRL (cm) + 6.5

*Accurate between 8 and 13 weeks

Definitions I

• Spontaneous miscarriage

Involuntary loss before 20 weeks completed weeks of gestation

• Threatened miscarriage

Uterine bleeding, closed cervix, no products of conception passed

• Incomplete miscarriage

Some, but not all, products have passed

Definitions II

• Inevitable miscarriage

Cervix dilated, products not passed

• Missed miscarriage

Fetus dead, but no tissue passed; cervix closed

Often present with absent fetal heart sounds, no uterine growth

• Septic miscarriage

Incomplete miscarriage with ascending infection

Definitions III

• Blighted ovum

Identifiable sac and placental tissue, but no embryo

• Sub-chorionic haemorrhage

Blood between chorion and uterine wall

• Decidua

Endometrium of pregnancy passed as part of miscarriage

Patho-physiology of Miscarriage

• Major genetic anomaly • Internal environmental factors

–Uterine: anomalies, leiomyomata, incompetent cervix

–Maternal DES exposure –Luteal phase defect –Immunological factors

• External environmental factors –Substance use (e.g tobacco, alcohol, cocaine) –Irradiation –Infection –Occupational chemical exposure

• Advanced maternal age

Clinical Course

• Missed menses, pregnancy symptoms

• Positive hCG

• Vaginal bleeding

• hCG falls or plateaus

• Lower abdominal cramping, backache

• Products of conception passed

Examination

• Abdominal examination

Pain location, rebound, distension

• Speculum examination

Identify local causes

• Bimanual examination

Uterine size, adnexal tenderness

Assess cervical dilatation

Fetal Heart Sounds

Listen after 9-10 weeks with Doppler

Sensitivity enhanced by elevating uterus during bimanual examination

Float Test for Chorionic Villi

Management of Miscarriage

• 50% loss when bleeding present

• Presence of fetal heart sounds is reassuring

• Majority do not require medical or surgical intervention

• Give anti-D if indicated

• Identify patients at risk for bleeding, infection

• Address contraceptive needs

Ectopic Pregnancy

• Pregnancy outside the uterus

Usually in fallopian tube

• Occurs in >1:100 pregnancies

• Important cause of maternal mortality

• Early diagnosis critical!

Risk Factors for Ectopic

• History of previous ectopic pregnancy

• Previous tubal surgery (including sterilisation)

• Previous tubal infection(s)

• Progestogen-only contraception

• Contraceptive IUD

• In-utero DES exposure

Many occur in women with no risk factors!

Ectopic Pregnancy: Patho-physiology and Symptomatology I

Conception Implantation in tube

Normal hCG

Amenorrhoea Symptoms of pregnancy

Ectopic Pregnancy: Patho-physiology and Symptomatology II

Diminished blood supply

Placental death

hCG declines

Erosion through tube

Loss of symptoms

Bleeding and sloughing

Pain

Ectopic Pregnancy: Patho-physiology and Symptomatology III

Intra-peritoneal haemorrhage

Shock Death

Abdominal pain, shoulder pain, silent, doughy abdomen

Syncope, orthostatic signs

Death

Diagnosis of Ectopic

• Failure of hCG to double in 48-72 hours

• Low serum progesterone

• Ultrasound (trans-vaginal) Intra-uterine pregnancy rules out ectopic

No gestational sac + hCG>1800 highly suggestive

Gestational sac / embryo outside of uterus confirms ectopic

Pitfalls: pseudo-gestational sac, ruptured corpus luteum

• Laparoscopy – gold standard

Ultrasound Features of Ectopic

Finding________________ Risk of Ectopic

No mass or free fluid 20%

Any free fluid 71%

Echogenic mass 85%

Moderate to large amount

of fluid 95%

Echogenic mass with fluid 100%

Mahony et.al.JUM1985;4:221-228

Expectant Management

• Criteria include:

Minimal pain or bleeding

Reliable follow-up

No evidence of tubal rupture

hCG <1000 and falling

Adnexal mass <3cm, or not detected

No embryonic heartbeat

Medical Management: Methotrexate

• Safe, effective, less costly than surgery

• Equal or better fertility preservation

• Criteria for use:

Stable vital signs, few symptoms

No contra-indication to drug

Absence of embryonic cardiac activity

Ectopic mass <4cm

hCG levels <5000 mIU/ml

Methotrexate Regime

• Single dose IM regimen with 1mg/kg or 50mg/m2

• Obtain serum hCG on 4th and 7th day post- treatment

Follow until level reaches 5mIU/ml (3-4 wks)

Reliable follow-up essential

Surgical Management

• Mainstay of treatment

• Conservative – conservation of tube

• Extirpative – removal of tube

• Criteria for selecting surgery

Unstable vital signs or haemo-peritoneum

Uncertain diagnosis

Advanced ectopic pregnancy

Contraindication to expectant management or Methotrexate

• Incidence = 1:1000 -1500 pregnancies

• Predisposing factors previous molar disease

pregnancy at ends of reproductive life

• Complete hydatidiform mole Placental proliferation in absence of a fetus; 46XX

Placental villi swollen, grape-like

• Partial mole Molar placenta + non-viable fetus; 69XXY

• Recurrence metastatic choriocarcinoma

Trophoblastic Disease

Clinical Manifestations

• Vaginal bleeding 1st/early 2nd trimester

• Higher than expected hCG levels

• Uterine size > dates without heart sounds

• Hyperemesis

• Early pregnancy-induced hypertension

• Thyrotoxicosis

• Ovarian enlargement

Ultrasound of Molar Pregnancy

Treatment of Trophoblastic Disease

• Prompt evacuation of the uterus

• Serial hCG monitoring

• One year of contraception

• Recurrence

Occurs in 20% with complete mole

Invades myometrium or becomes metastatic

Treated with Methotrexate

• Most can conceive, carry normal pregnancy

Psychological Management

• Acknowledge, dispel guilt

• Legitimise grief

• Provide comfort, ongoing support

• Reassure about the future

• Counsel woman how to tell family, friends

• Warn of anniversary phenomenon

• Include partner in psychological care

• Assess level of grief and adjust counselling accordingly

Summary

• Miscarriage can cause significant physical and psychological morbidity

• Ectopic pregnancy is a potential cause of maternal mortality

• Serum hormone testing and ultrasonography important in diagnosis

• Many women can be managed non-surgically