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Emad R. Sagr, MBBS, FRCSC, FACOG
Consultant OB-Gyn and Gynecology Oncology
Security Forces Hospital
Bleeding in early pregnancy and Ectopic
Pregnancy
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SPONTANEOUS ABORTION
• Definition:
Abortion is termination of pregnancy before the fetus is sufficiently developed to survive (before 24 wks)
Incidence: 15-20%
It is convenient to consider the clinical aspect of spontaneous abortion under 5 sub groups:
1. Threatened 4. Missed
2. Inevitable 5. Recurrent abortion
3. Incomplete 6. Septic Abortion
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Threatened Abortion
• 25% of pregnancies
• This refers only to bleeding from placental site which is not yet severe enough to terminate the pregnancy.
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• Serial qualitative HCG level:
BHCG level – 1000 miu/ml
If gest. Sac seen & BHCG less than 1000 unlikely to survive.
Qualitative BHCG level should ↑ 65% every 48 hours.
• Serum Progesterone level
5 ng/ml associated with none viable fetus
> 25ng/ml associated with alive fetus
Expectant observation
No benefit from use of progesterone or bed rest although it is often advised.
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Inevitable Abortion
• Indicate the pregnancy is doomed to end shortly. Progressive cervical dilation without the passage of tissue. here bleeding is slight but retroplacental
• Pain usually more.
• Dilated internal os. USS – Non viable fetus
• Emergency suction: D & C
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Complete Abortion
• Diagnosed if patient passed tissue but now is only slight pain and P/V bleeding
• Examination confirmed closed Cx.
• Minimal current bleeding
• TVU – empty uterus
• R/O ectopic pregnancy by serial BHCG level
until P.T. -ve
• Anti D injection if patients RH – ve to prevent sensitization
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Incomplete Abortion• If the internal cervical os is open and
patient has passed some tissue.
Management:
Emergency suction and curettage
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Missed Abortion
• It is defined as retention of dead products of conception in utero for several weeks.
• Symptoms of early pregnancy disappear
• Uterus not only has ceased to enlarge but also has become smaller.
• Occasionally serious coagulation defect may develop.
• Abnormal sonographic findings
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Septic Abortion
• Uterine infection at any stage of abortion causes:• Delay in evacuation of uterus
• Delay seeking advice• Incomplete surgical evacuation followed
by infection from vaginal organisms after 48 hours
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• Trauma:• Perforation or cervical tear• Criminal abortion
• Treatment:• Should be active to minimize risk of
septic shock• Cervical & HVS, blood culture• Broad spectrum antibiotic• Evacuation
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Induced Abortion
• Therapeutic abortion – termination of pregnancy before the viability for the purpose of saving the life of the mother. Heart disease, invasive Ca of Cx.
• Elective (voluntary) abortion is the interruption of pregnancy before viability at request of the women but not for reason of maternal health or fetal disease.
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Illegal abortion usually performed in unsterile condition by operators with little or nor medical training.
It is often incomplete and complicated by:
• Hemorrhage
• Infection
• Infertility and tubal occlusions
• Intrauterine infection is frequent complication and septic shock and death are the ultimate consequences.
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Recurrent Miscarriage
• When a woman has had 3 consecutive miscarriage.
• Risk of abortion for next pregnancy:• 1 abortion 15%• 1 Normal pregnancy 15%• 1 Abortion• 1 Normal 25%• 2 Abortion• 2 abortion 40%
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Etiology and Investigation:1. Genetic factors
Karyotyping of both partners will reveal chromosome anomalies
2. Anatomical factorsUterine anomaliesCervical incompetenceHysteroscopy & HSG – Septum / Fibroid
• Endocrine problem
• Immunological factorsCommon in women with antiphopholipid antibodies syndrome, Anticardiolipid ant. & Lupus anticoagulant
• Maternal diseaseSLE, Renal disease
• Environmental factorSmoking / Alcohol
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Abortion Technique
Medical
Surgical
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Ectopic Pregnancy
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Epidemiology• Leading cause of pregnancy-related deaths
during T-1
• 1-2% of all diagnosed pregnancies
• Incidence is • incidence of salpingitis d/t chlamydia or other STI• Improved diagnostic techniques• age
• Most occur in multigravid women • > 50% in women with 3 pregnancies
• 10-15% in nulligravid women
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Mortality
• Causes 15% of maternal deaths
• Overall risk of death 10X > the risk of childbirth; 50X > risk of legal abortion
• Cause of death r/t blood loss (80%), infection (3%), & anesthesia (2%)
• Interstitial & abdominal 5X > risk of death than other sites
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Fallopian Tube Function
• Complex structure • sustains & transports sperm, ovum & early conceptus
for ~ 3 days• Beating cilia & rhythmic contraction of smooth
muscle neg pressure in tube• Zygote undergoes cleavage & held for another 30
hrs. in the ampullary-isthmic region• Developing blastocyst is then transported via the
isthmus into the uterus
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Types of EP
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Sites of EP
Fallopian tubeFallopian tube
AmpullaAmpulla 80%80%
IsthmusIsthmus 12%12%
Fimbrial endFimbrial end 5%5%
Cornual & interstitialCornual & interstitial 2%2%
AbdominalAbdominal 1.4%1.4%
OvarianOvarian 0.2%0.2%
CervicalCervical 0.2%0.2%
Heterotopic Pregnancies: 1 in 30 000
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Risk Factors for EP
• Definite• PID• Previous EP• Any tubal surgery or sterilization procedure• infertility
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Risk Factors for EP
• Probable• Any pelvic surgery• Use of reproductive techniques
• In vitro fertilization• Gamete intrafallopian transfer• Embryo transfer
• Uncertain Association• IUCD• “Superovulating agents”
• Pergonal, Clomiphene citrate
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Classic TRIAD of EP
1. Delayed menses
2. Irregular vaginal bleeding
3. Abdominal pain
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Symptoms of Ectopic Pregnancy
SYMPTOMSYMPTOM PTS WITH PTS WITH SYMPTOMSYMPTOM
Abdominal painAbdominal pain 90-100%90-100%
AmenorrheaAmenorrhea 75-95%75-95%
Vaginal bleedingVaginal bleeding 50-80%50-80%
Dizzininess, faintingDizzininess, fainting 20-35%20-35%
Pregnancy symptomsPregnancy symptoms 10-25%10-25%
Urge to defecateUrge to defecate 5-15%5-15%
Passage of tissuePassage of tissue 5-10%5-10%
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Signs of EP
SIGNSIGN PTS WITH SIGNPTS WITH SIGN
Adnexal tendernessAdnexal tenderness 75-90%75-90%
Abdominal tendernessAbdominal tenderness 80-95%80-95%
Adnexal mass*Adnexal mass* 50%50%
Uterine enlargementUterine enlargement 20-30%20-30%
Orthostatic changesOrthostatic changes 10-15%10-15%
FeverFever 5-10%5-10%
* 20% of masses occur on the side opposite the EP.
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Differential Diagnosis• Complication of IUP
• Abortion• Early pregnancy plus uterine fibroid or ovarian tumour
• Conditions causing acute abd pain• Torsion of ovarian tumour, FT, or subserous pedunculated
fibroid• Salpingo-oophoritis• Pelvic pain with an IUCD in situ• Appendicitis
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Differential Dx – cont’d
• Conditions causing hemoperitoneum• Ruptured corpus luteum• Ruptured follicular cyst• Ruptured endometriotic cyst
• Conditions simulating a pelvic hematoma• Retroverted gravid uterus• Pelvic or tubo-ovarian abcess
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Management of EP
• Pre-operative diagnostic accuracy of EP based on clinical features alone is notoriously poor: ~50%
• 20% of EP occur as surgical emergencies
• Delay is justified only to correct shock
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Acute Management of EP
• Remember your ABCs• Oxygen• Large bore IV(s) crystalloids• Blood
• Labs• CBC, coagulation studies• -hCG
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Usefulness of Quantitaive
-hCG• Assessment of pregnancy viability
• Serial rise usually indicates a normal pregnancy
• Correlation with ultrasonography• With titers > 1500 IU/L, TVUS should ID an IUP• With multiple gestation, a gestational sac will not be
apparent until titer rises a little higher
• Assessment of treatment results• Declining levels are c/w effective medical or surgical Tx; if
levels persist think GTD
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The Importance of TVUS
• Documentation of an intrauterine sac• A viable IUP should be identified when -hCG
> 1500 IU/ml
• Adnexal mass• An EP > 2 cm should be identified
• Adnexal cardiac activity• Detectable when -hCG is ~ 15 000 – 20
000
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U/S – Is it EP or miscarriage?
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Surgical Management of EP
• Radical• Salpingectomy
• Conservative• Salpingotomy • Salpingostomy or segmental resection does not
repeat EP rate • fimbrial evacuation (traumatizes the endosalphinx & is
assoc with rate of recurrent EP (24%) compared with salpingectomy
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Medical Management of EP
Methotrexate (MTX)• 1st used in Japan in 1982
• Antimetabolite that interferes with dihydrofolate reductase
• Considered for low -hCG
• Success rate 67%-94%
• Indications• Hemodynamically stable pt • good F/U• Recurrent EP following Sx intervention
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Methotrexate – cont’d
• Contraindications• Evidence of rupture• Serum -hCG > 5 000 IU/L (varies)• FH detected on U/S• Adnexal mass> 3.5 cm on U/S• Unreliable pt• F/U unavailable• Laparoscopy required to make dx• Solid adnexal masses (germ cell tumour)• Free fluid > 30ml
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Methotrexate Protocol
• Exclude contraindications as well as• No evidence of renal, liver, or hematopoietic disease
(Bilirubin, AST,ALT, urea, Cr, CBC)
• Informed consent• 5% risk of hematoperitoneum 2° to rupture of EP
following MTX
• MTX 50mg/m² body surface area (~1mg/kg) given IV or IM
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Methotrexate Protocol – cont’d
• Pt F/U • repeat serum quantitative -hCG in 3-4 days,
7days, then weekly until < 10 IU/L• If > day-4 level at day-7 repeat MTX• If -hCG fails to fall by at least 25%/week at any
time repeat dose• U/S not required routinely
• Pt should avoid• Alcohol use, sexual I/C, oral folic acid (until HCG
levels are neg)
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Methotrexate Protocol – cont’d
• What to expect• Majority experience some degree of abd pain
(occurs in ~ 50% at day-6)• Shedding of a decidual cast• Moderate vaginal bleeding
• Side effects (usually at higher doses)• Impaired liver function, bone marrow suppression,
neutropenia, stomatitis, hematosalpinx
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Expectant Mx of EP
• Anticipates spontaneous regression of EP• Occurs in ~ 57%• Symptoms, HCG titers, & U/S findings followed• Risk of tubal rupture is 10% if HCG levels < 1000
• Criteria include• Sonographic diameter < 3cm• Initial -hCG < 1 000 IU/ml, no in 2-day period,
subsequent levels • asymptomatic
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Future Fertility following EP
• Subsequent conception rate is ~ 60%
• Incidence of recurrent EP is 15%
• Other factors influencing include:• Age, parity, history of infertility, evidence of
contralateral tubal disease, ruptured EP, IUCD use, salpingitis
• No difference b/t laparoscopy vs laparotomy
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Prevention of EP
• Treat salpingitis early & correctly
• MTX management lowers rate of subsequent EP
• Risk of EP is with all methods of contraception, except progesterone containing IUCDs
• Remember Rh Sensitization• Rhogam for the Rh-neg woman