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Early Pregnancy Problems

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Early Pregnancy Problems Feras Izzat Consultant Gynaecologist EGU/EPAU Lead University Hospitals Coventry & Warwickshire NHS Trust Ultrasound Left Ectopic on ... – PowerPoint PPT presentation

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Title: Early Pregnancy Problems


1
Early Pregnancy Problems
  • Feras Izzat
  • Consultant Gynaecologist EGU/EPAU Lead
  • University Hospitals Coventry Warwickshire NHS
    Trust

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

3
  • Ectopic Pregnancy

4
Definition
  • Pregnancy occurring outside uterine cavity
  • Approx 11/1000 of pregnancies rate increasing
  • Maternal mortality in 1/2500 ectopic pregnancies
    (11 deaths in most recent report)

5
Site
  • Tubal
  • Interstitial 2.4
  • Isthmic 12
  • Ampullary 70
  • Fimbrial 11.1
  • Non Tubal
  • Ovary
  • Abdominal cavity
  • Cervix
  • CS Scar

6
Risk factors
  • Previous PID
  • Previous ectopic pregnancy
  • Previous tubal surgery (e.g. sterilisation,
    reversal)
  • Pregnancy in the presence of IUCD
  • POP
  • ART (IVF)

7
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

8
Signs
  • Abdominal tenderness
  • Adnexal tenderness / mass
  • Shock tachycardia, hypotension, pallor
  • None

9
Diagnosis
  • Ultrasound
  • Empty uterus, adnexal mass, free fluid,
    occasionally live pregnancy outside of uterus
  • Serum ßhCG Progesterone
  • Laparoscopy

10
Ultrasound
11
Ultarsound
  • Trans-Vaginal Ultrasonography
  • Sensitivity 100, specificity 98.2.
  • The positive predictive value 98, and the
    negative predictive value was 100
  • FH seen in 23
  • Timor-Tritsch et al, 1990 Am J Obstet Gynecol.

12
Left Ectopic on laparoscopy
13
Management
  • Conservative
  • hCG lt1000 , Progesterone lt 5 stable, success 70
  • Medical
  • Methotrexate hCG lt4000 mass lt 3cm, success 84.
    Susequent IUP 54 recurrent EP 8
  • Surgical - Laparoscopy
  • Salpingectomy, IUP 38.3, EP 9.8
  • Salpingotomy, IUP 61.1, EP 15.5
  • Yao et al, Fertility Sterility 1997

14
PUL
  • Pregnancy of unknown location (PUL) - positive
    pregnancy test with no signs of intra- or
    extrauterine pregnancy on transvaginal sonography
    (TVS).
  • 15-20 of all EPAU scans
  • Management should be expectant if stable with an
    initial serum progesterone (lt20) and a hCG ratio
    0h/48h of lt0.87
  • Condous et al, Ultrasound Obstet Gynecol 2006

15
  • Bleeding in Early Pregnancy Miscarriage

16
Definitions
  • Threatened miscarriage Vaginal bleeding at lt 24
    weeks gestation
  • Delayed (silent) miscarriage Gestational sac
    with/without fetus present (but no FH)
  • Recurrent miscarriage 3 or more consecutive
    miscarriages (with or without a known cause)

17
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

18
Causes of miscarriage
  • Genetic abnormalities 85
  • Maternal illness e.g. diabetes, Thyroid disease
  • Phospholipid / Lupus 15 recurrent miscarriages
  • Uterine abnormalities
  • Cervical incompetence
  • Progesterone deficiency?

19
History
  • LMP
  • When?
  • Amount?
  • Pain?
  • Timing of Pain

20
Examination
  • ABC (vital signs)
  • Abdominal
  • Vaginal (speculum)
  • Cx state
  • Amount of bleeding

21
  • Cusco speculum Sims speculum

22
Investigations
  • Ideally in dedicated Early Pregnancy
    Assessment Unit
  • Ultrasound
  • Measurement of serum ßhCG
  • Determination of blood Rhesus group
  • FBC, GS and admit if significant bleeding
  • Psychological support

23
Ultrasound
  • Expect to see viable fetus from around 6.5 weeks
    transabdominally, 5.5 weeks transvaginally
  • Diagnosis can be made on TVS only
  • CRL 7mm
  • Empty GS with a mean diameter 25 mm

24
Gestational sac
25
Very early..
26
Normal 8-9 wk pregnancy
27
Empty sac
28
Measurement of ßhCG
  • Not necessary if diagnosis unequivocal on scan
  • Useful as part of investigations to diagnose /
    exclude extrauterine pregnancy
  • Doubling time approx 2 days in viable pregnancy
  • Halving time 1-2 days in complete miscarriage
  • Should see fetal pole with ßhCG of 1500-2000

29
Management of incomplete miscarriage
  • Conservative 76 success
  • Medical mifipristone misoprostol 82 success
  • Nielsen et al, BJOG 1999
  • Surgical (ERPC) No difference in satisfaction
    rate than medical 95
  • Chipchase et al, BJOG 1995

30
Recurrent miscarriage
  • Loss of 3 or more consecutive pregnancies
  • Affects 1 of women in reproductive age group
  • Investigations can identify up to 50 with a
    cause
  • Women aged lt30 years have a subsequent
    miscarriage rate of 25 which rises to 52 in
    women aged gt40 years.
  • The risk of a subsequent miscarriage is 29 after
    3 miscarriages, this rises to 53 in 6 or more
    previous miscarriages
  • Clifford et al, Human Reproduction 1997

31
  • Gestational Trophoblastic Disease

32
GTD
  • The abnormal proliferation of gestational
    trophoblast tissue
  • Spectrum of disease
  • Pre-Malignant
  • Partial Molar Pregnancy
  • Complete Molar Pregnancy
  • Malignant
  • Invasive mole
  • Choriocarcinoma
  • Placental site trophoblastic tumours

33
Molar Pregnancy
  • 1 in 1000 live births
  • Partial
  • Partial moles are triploid with 2 sets of
    paternal and 1 set of maternal chromosomes
  • An embryo often present that dies at 8-9 weeks
  • 0.5 need chemotherapy for invasive disease
  • Complete
  • No fetal pole, diplod chromosomes paternally
    derived androgenetic
  • No embryo
  • Chemo therapy rate 8-20

34
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35
Presentation
  • Vaginal bleeding
  • Excessive NV Hyperemesis gravidarum
  • Uterus large for dates

36
Diagnosis
  • Ultrasound
  • Histology after surgical evacuation

37
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38
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39
Complete mole at hysterectomy
40
Follow-up
  • Monitor via regional centre London, Sheffield,
    Dundee
  • CM 8-20 risk of invasive disease
  • PM 0.5
  • Choriocarcinoma may follow any subsequent
    pregnancy miscarriage, TOP, term delivery
  • Choriocarcinoma is curable
  • Monitor ßhCG levels to check resolution for 6
    months to 2 years

41
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