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![Page 1: Early Pregnancy Problems Jacqueline Woodman (Medical Education Lead) Feras Izzat (EPAU Lead) University Hospitals Coventry & Warwickshire NHS Trust.](https://reader033.fdocuments.net/reader033/viewer/2022052702/56649f3c5503460f94c5b6a4/html5/thumbnails/1.jpg)
Early Pregnancy ProblemsJacqueline Woodman (Medical Education Lead)Feras Izzat (EPAU Lead)University Hospitals Coventry & Warwickshire NHS Trust
![Page 2: Early Pregnancy Problems Jacqueline Woodman (Medical Education Lead) Feras Izzat (EPAU Lead) University Hospitals Coventry & Warwickshire NHS Trust.](https://reader033.fdocuments.net/reader033/viewer/2022052702/56649f3c5503460f94c5b6a4/html5/thumbnails/2.jpg)
• Early pregnancy
• Ectopic pegnancy
• Miscarriage
• Trophoblastic disease
Contents
![Page 3: Early Pregnancy Problems Jacqueline Woodman (Medical Education Lead) Feras Izzat (EPAU Lead) University Hospitals Coventry & Warwickshire NHS Trust.](https://reader033.fdocuments.net/reader033/viewer/2022052702/56649f3c5503460f94c5b6a4/html5/thumbnails/3.jpg)
Early pregnancyEarly pregnancy
Pregnancy up to 12 weeks gestation.
Amenorrhea
Urine pregnancy test positive
Pregnancy symptoms
USS- fetus transabdominal scan from 6.5 weeks and TV
scan from 5.5 weeks
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Ectopic Pregnancy
![Page 5: Early Pregnancy Problems Jacqueline Woodman (Medical Education Lead) Feras Izzat (EPAU Lead) University Hospitals Coventry & Warwickshire NHS Trust.](https://reader033.fdocuments.net/reader033/viewer/2022052702/56649f3c5503460f94c5b6a4/html5/thumbnails/5.jpg)
DefinitionDefinition
• Pregnancy implanted
outside uterine cavity
• Approx 11/1000 of
pregnancies – rate
increasing
• Maternal mortality in
1/2500 ectopic
pregnancies
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Site
• Outside uterine cavity (Cervical, CS scar)
• Commonest- tubal
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Risk factorsRisk factors
• Previous PID
• Previous ectopic pregnancy
• Previous tubal surgery (e.g. sterilisation, reversal)
• Pregnancy in the presence of IUCD
• POP
• Assisted reproduction
• Smoking
• Maternal age >40y
• Up to 50% have no risk factors
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SymptomsSymptoms
• 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
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SignsSigns
• Abdominal tenderness
• Adnexal tenderness / mass
• Shock – tachycardia, hypotension, pallor
• None
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Outcomes
• Unlikely to continue beyond few months and exceptional to reach period of viability
• Resolve spontaneously
• Catastrophic rupture- intraabdominal haemorrhage
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DiagnosisDiagnosis
• History and examination
• Ultrasound– Empty uterus, adnexal mass, free fluid, occasionally live
pregnancy outside of uterus
• Serum βhCG - serial– Slow rising, plateau
• Laparoscopy
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Ultrasound
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Beta hCG levels
• Level don’t inform location of pregnancy!!!
• 1) levels may suggest if pregnancy is advanced enough to be seen on scan
• 2) serial- failing or progressing
• 3) if ectopic- management option
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Left Ectopic on laparoscopy
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ManagementManagement
• Conservative – Self resolving with close watch
• Medical– Methotrexate
• Surgical– Laparoscopic salpingectomy / salpingotomy– Laparotomy
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True / False
• Ectopic pregnancy is pregnancy outside the uterus.
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True / False
• Ectopic pregnancy is pregnancy outside the uterus. F
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True / False
• Ectopic pregnancy is pregnancy outside the uterus. F
• Pregnancy conceived with IUCD in situ is at increased risk of ectopic pregnancy.
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True / False
• Ectopic pregnancy is pregnancy outside the uterus. F
• Pregnancy conceived with IUCD in situ is at increased risk of ectopic pregnancy. T
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True / False
• Ectopic pregnancy is pregnancy outside the uterus. F
• Pregnancy conceived with IUCD in situ is at increased risk of ectopic pregnancy. T
• Once ectopic pregnancy is diagnosed, surgical management is recommended.
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True / False
• Ectopic pregnancy is pregnancy outside the uterus. F
• Pregnancy conceived with IUCD in situ is at increased risk of ectopic pregnancy. T
• Once ectopic pregnancy is diagnosed, surgical management is recommended. F
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True / False
• Ectopic pregnancy is pregnancy outside the uterus. F
• Pregnancy conceived with IUCD in situ is at increased risk of ectopic pregnancy. T
• Once ectopic pregnancy is diagnosed, surgical management is recommended. F
![Page 23: Early Pregnancy Problems Jacqueline Woodman (Medical Education Lead) Feras Izzat (EPAU Lead) University Hospitals Coventry & Warwickshire NHS Trust.](https://reader033.fdocuments.net/reader033/viewer/2022052702/56649f3c5503460f94c5b6a4/html5/thumbnails/23.jpg)
True / False
• Ectopic pregnancy is pregnancy outside the uterus. F
• Pregnancy conceived with IUCD in situ is at increased risk of ectopic pregnancy. T
• Once ectopic pregnancy is diagnosed, surgical management is recommended. F
• Smoking is not a risk factor for ectopic pregnancy.
![Page 24: Early Pregnancy Problems Jacqueline Woodman (Medical Education Lead) Feras Izzat (EPAU Lead) University Hospitals Coventry & Warwickshire NHS Trust.](https://reader033.fdocuments.net/reader033/viewer/2022052702/56649f3c5503460f94c5b6a4/html5/thumbnails/24.jpg)
True / False
• Ectopic pregnancy is pregnancy outside the uterus. F
• Pregnancy conceived with IUCD in situ is at increased risk of ectopic pregnancy. T
• Once ectopic pregnancy is diagnosed, surgical management is recommended. F
• Smoking is not a risk factor for ectopic pregnancy. F
![Page 25: Early Pregnancy Problems Jacqueline Woodman (Medical Education Lead) Feras Izzat (EPAU Lead) University Hospitals Coventry & Warwickshire NHS Trust.](https://reader033.fdocuments.net/reader033/viewer/2022052702/56649f3c5503460f94c5b6a4/html5/thumbnails/25.jpg)
True / False
• Ectopic pregnancy is pregnancy outside the uterus. F
• Pregnancy conceived with IUCD in situ is at increased risk of ectopic pregnancy. T
• Once ectopic pregnancy is diagnosed, surgical management is recommended. F
• Smoking is not a risk factor for ectopic pregnancy. F
• hCG doubling in 48h excludes ectopic pregnancy. F
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True / False
• Ectopic pregnancy is pregnancy outside the uterus. F
• Pregnancy conceived with IUCD in situ is at increased risk of ectopic pregnancy. T
• Once ectopic pregnancy is diagnosed, surgical management is recommended. F
• Smoking is not a risk factor for ectopic pregnancy. F
• hCG doubling in 48h excludes ectopic pregnancy. F
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True/False
• Ectopic pregnancy is pregnancy outside the uterus. F
• Pregnancy conceived with IUCD in situ is at increased risk of ectopic pregnancy. T
• Once ectopic pregnancy is diagnosed, surgical management is recommended. F
• Smoking is not a risk factor for ectopic pregnancy. F
• hCG doubling in 48h excludes ectopic pregnancy. F
• Slow rising hCG increases possibility of ectopic pregnancy
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True/False
• Ectopic pregnancy is pregnancy outside the uterus. F
• Pregnancy conceived with IUCD in situ is at increased risk of ectopic pregnancy. T
• Once ectopic pregnancy is diagnosed, surgical management is recommended. F
• Smoking is not a risk factor for ectopic pregnancy. F
• hCG doubling in 48 h excludes ectopic pregnancy. F
• Slow supoptimal rise in HCG increases possibility of ectopic pregnancy. T
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Bleeding in Early Pregnancy & Miscarriage
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Miscarriage
• UK definition- Loss of intrauterine pregnancy before 24 weeks of gestation
• WHO definition- expulsion of fetus weighing 500g or less and less than 22 completed weeks gestation.
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MiscarriageMiscarriage
• Miscarriage occurs in 15-20% of clinically diagnosed pregnancies
• Once fetal heart is seen, the risk of miscarriage is less than 5%
• At least 50% of women with threatened miscarriage will have continuing pregnancy
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DefinitionsDefinitions
• Threatened miscarriage Vaginal bleeding at < 24 weeks gestation, FH+
• Inevitable miscarriage Internal cervical os open in association
with bleeding
• Incomplete miscarriage Products of conception remaining in uterus
• Complete miscarriage Uterus empty
• Delayed (silent) miscarriage Gestational sac with/without fetus present
(but no FH)
![Page 33: Early Pregnancy Problems Jacqueline Woodman (Medical Education Lead) Feras Izzat (EPAU Lead) University Hospitals Coventry & Warwickshire NHS Trust.](https://reader033.fdocuments.net/reader033/viewer/2022052702/56649f3c5503460f94c5b6a4/html5/thumbnails/33.jpg)
Remember
• Miscarriage not abortion or termination
• It is loss/end of pregnancy, except in threatened miscarriage where it is continuing but increased risk of ending.
• Early miscarriage- <12 weeks
• Late miscarriage- >12 weeks
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Causes
Fetal
• Chromosomal
• Malformations
• Placental
• Multiple pregnancy
Maternal
• Disease- Diabetes, hyperthyroidism
• Age
• BMI
• Infection
• Uterine/ cevical anamolies
• Previous miscarriage
• trauma
![Page 35: Early Pregnancy Problems Jacqueline Woodman (Medical Education Lead) Feras Izzat (EPAU Lead) University Hospitals Coventry & Warwickshire NHS Trust.](https://reader033.fdocuments.net/reader033/viewer/2022052702/56649f3c5503460f94c5b6a4/html5/thumbnails/35.jpg)
Examination
• ABC (vital signs)
• Abdominal
• Vaginal (speculum)– Cx state
– Amount of bleeding
![Page 36: Early Pregnancy Problems Jacqueline Woodman (Medical Education Lead) Feras Izzat (EPAU Lead) University Hospitals Coventry & Warwickshire NHS Trust.](https://reader033.fdocuments.net/reader033/viewer/2022052702/56649f3c5503460f94c5b6a4/html5/thumbnails/36.jpg)
Cusco speculum Sims speculum
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InvestigationsInvestigations
Ideally in dedicated ‘Early Pregnancy Assessment Unit’
• Ultrasound
• Measurement of serum βhCG
• Determination of blood & Rhesus group
• FBC, G&S and admit if significant bleeding
• Psychological support
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UltrasoundUltrasound
• Expect to see viable fetus from around 6.5 weeks transabdominally, 5.5 weeks transvaginally
• Other possible appearances – ‘POC’ Incomplete miscarriage
– Empty uterus Not pregnantToo early gestationExtrauterine pregnancyComplete miscarriage
– Empty sac Non-viable pregnancyToo early gestation
– Fetal pole with no FH If tiny, may be very early gestation
Delayed miscarriage
![Page 39: Early Pregnancy Problems Jacqueline Woodman (Medical Education Lead) Feras Izzat (EPAU Lead) University Hospitals Coventry & Warwickshire NHS Trust.](https://reader033.fdocuments.net/reader033/viewer/2022052702/56649f3c5503460f94c5b6a4/html5/thumbnails/39.jpg)
Gestational sac
![Page 40: Early Pregnancy Problems Jacqueline Woodman (Medical Education Lead) Feras Izzat (EPAU Lead) University Hospitals Coventry & Warwickshire NHS Trust.](https://reader033.fdocuments.net/reader033/viewer/2022052702/56649f3c5503460f94c5b6a4/html5/thumbnails/40.jpg)
Very early..
![Page 41: Early Pregnancy Problems Jacqueline Woodman (Medical Education Lead) Feras Izzat (EPAU Lead) University Hospitals Coventry & Warwickshire NHS Trust.](https://reader033.fdocuments.net/reader033/viewer/2022052702/56649f3c5503460f94c5b6a4/html5/thumbnails/41.jpg)
Normal 8-9 wk pregnancy
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Empty sac
![Page 43: Early Pregnancy Problems Jacqueline Woodman (Medical Education Lead) Feras Izzat (EPAU Lead) University Hospitals Coventry & Warwickshire NHS Trust.](https://reader033.fdocuments.net/reader033/viewer/2022052702/56649f3c5503460f94c5b6a4/html5/thumbnails/43.jpg)
Measurement of Measurement of ββhCGhCG
• 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 βhCG of 1500-2000
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Management of Incomplete MiscarriageManagement of Incomplete Miscarriage
• Conservative- unsuitable if infection + , heavy bleeding
review after 1-2 weeks, can continue up to 6-8 weeks
risk of unplanned intervention , transfusion due to bleeding, failure
• Medical – Misoprostol 600-800mcg (UPTafter 3 weeks)
risk of bleeding, failure
• Surgical (ERPC) Suction curettage usually under GA- first line if infection, heavy
bleeding. Risks of bleeding ,infection, perforation, failure
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True or False1. Miscarriage is defined as expulsion of fetus <500g.2. 1 in 3 pregnancies end in a miscarriage3. Commonest cause of miscarriage is chromosomal
abnormalities.4. Term an embryonic pregnancy should be preferred over
early fetal demise5. There are no risks with expectant management of
miscarriage6. Mifepristone is anti estrogen7. Misprostol is licensed for medical management of
miscarriage
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True or False1. Miscarriage is defined as expulsion of fetus <500g. ✔2. 1 in 3 pregnancies end in a miscarriage. ✗3. Commonest cause of miscarriage is chromosomal
abnormalities.✔4. Term an embryonic pregnancy should be preferred over
early fetal demise. ✗5. There are no risks with expectant management of
miscarriage.✗6. Mifepristone is anti estrogen.✗7. Misprostol is licensed for medical management of
miscarriage.✗
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Gestational Trophoblastic Disease
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Hydatidiform MoleHydatidiform Mole
• Disordered placental proliferation
• 1-3 in 1000 pregnancies
• Partial Mole– Associated with fetus, triploid
• Complete Mole– No fetal pole, diploid chromosomes paternally derived –
androgenetic
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Increased rates
• Southeast Asia (8/1000)
• Extremes of reproductive age (>40 X5-10)
• Previous molar pregnancy
• Low carotene diet
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PresentationPresentation
• Vaginal bleeding
• Excessive N&V ‘Hyperemesis gravidarum’
• Uterus large for dates
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DiagnosisDiagnosis
• Ultrasound (Snow storm appearance)
• Histology after surgical evacuation
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Snowstorm appearance
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Complete mole at hysterectomy
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Management
• Suction evacuation
• Avoid cervical ripening
• Above will cure 99.5% of PHM, 84% of CHM
• Avoid hysteroscopy- increase the likelihood of chemotherapy
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Follow-upFollow-up
• Monitor via regional centre – London, Sheffield, Dundee
• 3% risk choriocarcinoma following complete mole, less following partial mole
• Choriocarcinoma may follow any subsequent pregnancy – miscarriage, TOP, term delivery
• Choriocarcinoma is curable
• Monitor βhCG levels to check resolution – for 6 months to 2 years
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• Updated and revised nomenclature for description of early pregnancy events. Farquharson etal .Hum Repd 2005
• RCOG Green-top guideline “Tubal pregnancy, management”
• NICE guidance on ectopic pregnancy and miscarriage
• Ectopic pregnancy. J L Tenore: Am Fam Physician 2000.
• Association of early pregnancy units
• Ectopic foundation trust
• Miscarriage Association
References