Management of abnormal uterine bleeding

JodySteinauer,MD,MASDept.Ob/Gyn&ReproductiveSciencesUniversityofCalifornia,SanFrancisco

Disclosures

July4,2017.Ihavenodisclosures.

The Questions

• Toomuch– abnormaluterinebleeding– Differentialandapproachtowork‐up

• Toomuch– fibroids

• Toofast:She’shemorrhaging—whatdoIdo?

• Sideeffect:duetohormonalcontraception

1:AUBand2:fibroids1:AUBand2:fibroids

4:Contraceptivesideeffects4:Contraceptivesideeffects 5:Bleedinginpregnancy5:Bleedinginpregnancy

3:Acutehemorrhage3:Acutehemorrhage

Case 1

A46year‐oldwomanreportsherperiodshavebecomeincreasinglyirregularandheavyoverthelast6‐8months.Sometimestheycome2timespermonthandsometimesthereare2monthsbetween.LMP2monthsago.Shebleeds10dayswithclotsandfrequentlybleedsthroughpadstoherclothes.Shealsohasdiabetesandisobese.

1. FSH2. Testosterone&DHEAS3. Urinehcg4. TSH5. Transvaginal Ultrasound(TVUS)6. EndometrialBiopsy(EMB)

Q1: Which is the first test should you order in this patient? Step 1: Pregnant?

Pregnant• Ectopic• SpontaneousAbortion• ThreatenedAbortion• MolarPregnancy• Trauma• Othercauses

NotPregnant• Anovulation***• Anatomic/structural**• Neoplastic*• Infectious• Iatrogenic• Non‐gynecologic

* = Most likely for this patient

Terminology: What is abnormal?

• Normal:Cycle=28days(21‐35);Length=2‐7days;heaviness=self‐defined

• Toolittlebleeding:amenorrheaoroligomenorrhea

• Toomuchbleeding:Menorrhagia(regulartimingbutheavy(accordingtopatientor>80cc)ORlongflow(>7days)

• Irregularbleeding:Metrorrhagia,intermenstrual orpost‐coitalbleeding

• IrregularandExcessive:Menometrorrhagia

• Preferredtermfornon‐pregnantheavyand/orirregularbleeding=AbnormalUterineBleeding(AUB)

Bradley, AJOG, 2016

Pathophysiology: Anovulatory Bleeding

Bricks&MortarEstrogen=Bricks,buildendometrium

Progesterone(P)=Mortar,stabilizes,onlyhavePifovulate

Normalmenses:WithdrawalofPcauseswalltofalldown,allatonce(orderlybleed)

Anovulation: NoPsowhenwallgrowstootall,itfalls.Itisheavywhenwallistall.Brickscanalsofallintermittently&incompletely–irregularly,irregular

Abnormal Uterine Bleeding Reference:  AUB Differential 

Uterus:Polyp,adenomyosis,leiomyoma,atrophy

Cervix:polyp,atrophy,trauma

Vagina:atrophy,trauma

Uterus:Polyp,adenomyosis,leiomyoma,atrophy

Cervix:polyp,atrophy,trauma

Vagina:atrophy,trauma

Uterus:Hyperplasia,malignancy

Cervix:Dysplasia,malignancy

Ovary:hormoneproducingtumor

Uterus:Hyperplasia,malignancy

Cervix:Dysplasia,malignancy

Ovary:hormoneproducingtumor

Uterus:Endometritis,PID

Cervix:Cervicitis

Vagina:Vaginitis(eg Trich)

Uterus:Endometritis,PID

Cervix:Cervicitis

Vagina:Vaginitis(eg Trich)

Coagulopathy(vWD),severerenalorliverdz,

GIorGUsource

Coagulopathy(vWD),severerenalorliverdz,

GIorGUsource

AnovulationAnovulation

NotPregnantNotPregnant

PALM-COEINPALM-COEIN

AnatomicAnatomic

NeoplasticNeoplastic

InfectiousInfectious

Non‐GynecologicNon‐Gynecologic

History and Physical Examination

• Hx:bleedingpattern,symptomsofanemia,sexual&reproductivehistory,chronicmedicalillness,medication

• Acutev.chronic

• PE:signsofhypovolemia andanemia,thyroidexamination,gynecologicexam,abdominalexamination,(screeningforcervicaldysplasiaandSTI)– Obesity:upto60%ofwomenwhodonotovulateareobese–increasedestradiol&testosterone;elevatedinsulindisorderedfolliculardevelopment

Initial Work‐up:  Menometrorrhagia

• Always:Urinepregnancy

• Usually:TSH

• Maybe:Hct,r/ocoagulopathy

• Maybe:EMB(EndometrialBiopsy)

• Maybebutlater:Transvaginal Ultrasound

• Usuallynotnecessary:FSH,LH,Testosterone,Estradiol

A Rational Approach to EMB

Post‐Menopause:ALLwomenWITHANY BLEEDING(except4‐6monthsafterHT)

Recentonsetirregularbleeding: Considertreatingfirstandifbleedingnormalizes,noneedforEMB

>50: Allwomenwithrecurrent,irregular bleeding(considernotdoingifperiodslightandspacingout)

45‐50: Recurrentirregularbleedingplus>1riskfactorOR>6mosmenometrorrhagia (considernotdoingifperiodslightandspacingout)

<45:Longhx (>2yr?)ofuntreatedanovulatory bleedingorfailedmedicalmanagement

EMBisnotperfectlysensitivesofurtherevaluationmandatoryif:

1.PersistentAUBafternegativeEMB

2.PersistentAUBafter3‐6monthsofmedicaltherapy

Do all women with AUB need an ultrasound?

AlthoughTVUS isthebestimagingchoiceforpelvicpathology(ie betterthanMRI,CT)….• 80%withheavymenstrualbleedinghavenoanatomicpathology

• Incidentalfindingssuchasfunctionalovariancystsandsmallfibroids(~50%)areoftenfoundleadingtoanxietyandunnecessarytreatments

• SO….treatfirst,TVUSiftreatmentfails

What about U/S instead of EMB for post‐menopausal bleeding?

Transvaginal Ultrasound

• Measureendometrialstripe

• Abnormal=>4mm(or5)

• Non‐specific:myomas,polypsalsocausethickEM

• Operatorskillmandatory

• NOTUSEFULPRE‐MENOPAUSE

TVUS EMB

96% Sensitivity 94%

61% Specificity 99%

99% NPV 99%

40‐50% Furtherw/unecessary

?<5%

CanofferpatientchoiceaslongaseitherisquicklyavailableandpatientunderstandsshemayneedEMBafterU/S

CanofferpatientchoiceaslongaseitherisquicklyavailableandpatientunderstandsshemayneedEMBafterU/S

TVUS vs EMB to Detect Cancer (in post‐menopausal women)

Q2: You decide to do a urine pregnancy test and check her TSH – which is the most appropriate next test?

1. FSH2. Testosterone&DHEAS3. Serumbeta‐HCG4. Transvaginal Ultrasound5. EndometrialBiopsy

Q2: You decide to do a urine pregnancy test and check her TSH – which is the most appropriate next test?

1. FSH2. Testosterone&DHEAS3. Serumbeta‐HCG4. Transvaginal Ultrasound5. EndometrialBiopsy

A46year‐oldwomanreportsherperiodshavebecomeincreasinglyirregularandheavyoverthelast6‐8months.Sometimestheycome2timespermonthandsometimesthereare2monthsbetween.LMP2monthsago.Shebleeds10dayswithclotsandfrequentlybleedsthroughpadstoherclothes.Shealsohasdiabetesandisobese.

A46year‐oldwomanreportsherperiodshavebecomeincreasinglyirregularandheavyoverthelast6‐8months.Sometimestheycome2timespermonthandsometimesthereare2monthsbetween.LMP2monthsago.Shebleeds10dayswithclotsandfrequentlybleedsthroughpadstoherclothes.Shealsohasdiabetesandisobese.

EMB=“Disordered Proliferative” How do I stop the bleeding?

MedicalNSAID’sE+Ppill,patch,ringOralProgestinProgestinIUDIMProgestinGnRH agonistTranexamic Acid

SurgicalEndometrialablation

D&C/Hysteroscopy

Hysterectomy

Disorderedproliferative=Anovulation

Treatment of AUB: NSAIDs

• Suppressprostaglandinsynthesis,increaseplateletaggregation,andreducemenstrualbloodloss

• Reducesbloodlossby40%• Usealoneorwithothertreatments• Prescribe5daysATC

– Ibuprofen,mefenamic acid,naproxen

Treatment of AUB: CHC

• CHC– pill,patch,ring– improvecyclecontrol,decreasemenstrualbloodlossby40%whenusedtraditionallyorcontinuously– OneCOC(withestradiol)approvedbyFDAforheavymenstrualbleeding

– COCsoftenusedtotreatacuteandchronicAUB– Fewstudiessupportupto70%decreasedEBLwithCOCandonestudywithvaginalring

Bradley, AJOG, 2016

Treatment of AUB: Progestins

• Oralprogestin– IfovulatoryAUB=HMB:daily ordays5‐26“extendeduse”progestindecreasesbloodloss(MPA2.5‐10mgqd,norethindrone 2.5‐5mgqd,NETA5TID)

– Lowsatisfactionwithextendeduse– Ifanovulatory:cyclic progestin‐12‐14d/monthimprovesmensesinhalfofwomen

• Injectableprogestin– 50%amenorrheaafter1year,irreg.bleedinginfirstfewmonthsand50%atoneyear

• Intrauterineprogestin– Significantdecreaseinbloodloss,superiortootherprogestinsandCHCs

Bradley, AJOG, 2016; Heikinheimo, Best Practice & Research Clin Ob Gyn, 2017.

First Line Hormonal Treatments

• Firstchoice:Levonorgestrel IUD– >80%reductioninbloodloss,decreasedcramping,prevents/treatshyperplasia,highlyeffectivebirthcontrol

– Bloodlossandsatisfactioncomparabletoablation,satisfactioncomparabletohysterectomy

– Veryfewcontraindications

• 2nd choice:combinedcontraceptives(pill,patch,ring)ororalprogestin(cyclicv.daily)orprogestininjection– Decreasesirregularperimenopausal bleeding– Anytypeok,20mcgestrogenpreferredforwomen>40– Estrogencontraindications:smokers>35,HTN,complicatedDM,multipleRFforCAD,h/oDVT,migraineswithaura

Where do you find the US MEC and SPR?

Medical Condition

Birth Control Methods

MEC Category

Treatment of AUB: Tranexamic Acid

• ApprovedbyFDAfortreatmentofovulatory AUB• Preventsplasmaformation,fibrindegradation,andclotdegradation

• InRCT’s,moreeffectivethanplacebo,NSAID,cyclicprogestin

• Dose:1.0‐1.3gevery6‐8hoursx5days

• Risks:TheoreticriskofVTE– contraindicatedinhistoryoforriskfactorsforVTE– notwithCHC

• Sideeffects:Minimal

Surgical Treatments

• D&C,Hysteroscopy:– Notreallyatreatment– Temporaryreductioninbleeding– Curativeiffibroidorpolypremoved

• EndometrialAblation– Reducesbutdoesn’teliminatemenses– ~25%repeatablationorhysterectomyin5years– Mustruleoutcancerfirst– Can’tbedonein>12weekuteriorforwomenwhowantfertility

Perimenopausal/Anovulatory Bleeding: Summary

R/opregnancy,thyroiddz

EMBifmeetscriteria

Treatfirstasifanovulatory bleeding:– NSAIDs+– Hormones(Levo IUD,CHC,DMPA)

Ifpersists:– U/Stocheckforanatomiccauses(andEMBifnotalreadydone)

– Discusssurgicaloptionsforbleedingrefractorytomedicalmanagement.

Case 2:  Is it the fibroids?

SamehistoryasCase1exceptshehasfibroids….Onexaminationheruterusis16weeks’size

• Verycommon 80%ofhysterectomyspecimens(doneforanyreason)and~75%haveonU/Satage50

• About50%areasymptomatic

• Growslowlyuntilmenopauseandthendecreaseby~50%(canstillcausebleedingpost‐menopause)

Fibroid Symptoms

• Bleeding– Usuallynormal ormenorrhagia(heavybutregular).Fibroidsstretchendometrium=morebleeding

– Occasionallymenometrorrhagia ifsubmucous orintracavitary(Fibroidsdistortendometriumsoitcan’tbestable)

• Pressure(notpain)• Dysmenorrhea

Heavy,irregularbleedingHeavy,irregularbleeding

NoeffectNoeffectHeavy,regularbleedingHeavy,regularbleeding

Is the bleeding due to the fibroids? 

• Fibroidsarecommoninlater40s• Anovulationiscommoninlater40s• Theincreasedbleedingseentypicallyduetoincreasedvolumeordistortionoftheendometrium

• Therefore:Thintheendometriumbytreatingasanovulatory bleeding.

Treatment of AUB and Fibroids

• LNG‐IUD:approvedbyFDAforwomenwithfibroidsunlessdistorteduterinecavity

• Combinedhormonalcontraception• NSAIDS• Tranexamic acid• GnRHagonisttoshrinkfibroidsbeforesurgery,orbridgetomenopause

• (SPRMS– investigational)

AUB with Known Fibroids: Work‐up and Treatment

• R/ocancer(using“rationalemb algorithm”)andpregnancy(don’tblamefibroidsforthebleeding)

• NSAID’sandLNGIUD,CHC,tranexamicacid

• Ifnobetter,blamethefibroids!(LNGIUD>CHC)

• +/‐ Lupron‐‐asabridgetomenopauseorpre‐optoshrinktoobtainlessinvasiverouteofhysterectomy

• Othertx (hysteroscopic resectionif<3cm,myomectomy,MR‐guidedfocusedu/s,RFA,UAE,hysterectomy)

Case 3: Acute Hemorrhage

41yearoldwomanpresentswithdizzinessandheavyvaginalbleedingfor2weeksstraight.

Priortothis,occasionalirregularperiodsbutnothinglikethis!Hemoglobin=9

Acute AUB Treatment

ABC’sandStopthebleeding!• ConsiderEDfortransfusion

• Medicalmanagement– Estrogen– Rapidendometrialgrowth,vasospasmofarteries,plateletaggregation,increasingclottingsupportivefactors

• CEE25mgIVq4‐6hoursfor24hours,followedbyprogestinorCOCfor10‐14days

• COC:1tabTIDx7daysthentaper– Progestin:medroxyprogesteroneacetate20mgTIDx7days– Tranexamicacid1.3gTIDx5days

• Otheroptions:D&C,foley bulbtamponade,emergencyhysterectomy

Bradley, AJOG, 2016

COC Taper

• Don’twanttogive2‐4COC’sperdayandthenstopsuddenlyb/cwillhavelargewithdrawalbleed

• Taper:3x4days,2x4daysthen1 perdayfor1‐2months(60+pillsrequired).

• Instructnottotakeplacebosandgiveatleast3packsofpillsatonce.

• Givewithanti‐emetic,splitbid(i.e.2bidratherthan4allatonce)

Case 4:  Because of her contraceptive…

• A32year‐oldwomanhasrecentlyinitiatedthebirthcontrolpill.

• Shehashadspottingfor30straightdays!Sheisannoyed.

Case 4:  Because of the injection…

• A32year‐oldwomanhasrecentlyinitiatedthecontraceptiveinjection.

• Shehashadspottingfor30straightdays!Sheisannoyed.

Case 4:  Because of the implant…

• A32year‐oldwomanhasrecentlyinitiatedthecontraceptiveimplant.

• Shehashadspottingfor30straightdays!Sheisannoyed.

Case 4:  Because of the IUD…

• A32year‐oldwomanhasrecentlyinitiatedthelevonorgestrel IUD.

• Shehashadspottingfor30straightdays!Sheisannoyed.

Condom Pill InjectionLNGimplant

n=705 n=1637 n=579 n=66%Reportingthefollowingreasons

Tooexpensive 2.2 3.2 2.1 1

Toodifficultormessytouse 15.2 5.7 1.2 10.4Partnerunsatisfied 38.6 2.8 2.6 1.2Experiencedsideeffects 17.9 64.6 72.3 70.6Worriedaboutsideeffects 2 13.1 4.2 4.2

Didnotlikethechangesinmenstrualperiods 1.5 12.7 33.7 19.3

Experiencedcontraceptivefailure 7.5 10.4 5.7 8.3Worriedabouteffectiveness 13.2 3 2.2 0NoprotectionagainstSTIs 1.1 2.1 1.3 0Otherhealthproblems/doctor'sadvice 2.5 8.5 5.7 9.2Methoddecreasedsexualpleasure 37.9 4.1 8.2 1.1Toodifficulttoobtain 1.5 1.8 2 0Otherreason 15.4 10.6 8.1 10.2

Moreau C, Contraception, 2005.

Reasons for dissatisfaction leading to contraceptive discontinuation

Mechanism for Abnormal Bleeding with Hormonal Contraceptives

IrregularbleedingIrregularbleeding

Transitionfromthicktothinendometrium

Transitionfromthicktothinendometrium

Fragileandsuperficial

bloodvesselsinendometrium

Fragileandsuperficial

bloodvesselsinendometrium

Unstableendometrialstromaandglands

Unstableendometrialstromaandglands

Alteredendometrialremodeling

Alteredendometrialremodeling

COCs: Setting Expectations

• Unscheduledbleeding– 10‐30%inthefirstmonth– Lessthan10%bythethirdmonth

• Amenorrhea– Lessthan2%inthefirstyear– Upto5%after1year

Speroff L & Darney PD, Clinical Guide for Contraception 4th Ed, 2011

COCs: General Counseling

• Takepillatthesametimeeachday– Inconsistentpilluseassociatedwithincreasedriskofunscheduledbleeding1

• Stopsmoking!– Smokersmorelikelytoexperienceunscheduledbleeding/spotting1

– Amongsmokers,bleedingmorelikelytopersist

Rosenberg, Contraception, 1996.

CyclicUse ExtendedCycle

COCs: Regimens Treating Bleeding on Cyclic COCs

• Supplementalestrogen1– OralCEE1.25mgx7days– Oralestradiol2mgx7days

• IncreasedoseofestrogenifwomanusingCOCwith< 20mcgestrogen– SeveralCOCscontaining20mcgethinylestradiolresultedin:

• Higherratesofearlytrialdiscontinuation• Increasedriskofbleedingdisturbances2

• Switchtovaginalring

1. Speroff L & Darney PD, Clinical Guide for Contraception 4th Ed, 2011.2. Gallo MF, Cochrane, 2013.

Double or triple the birth control pill?

Treating Bleeding on Extended COCs

• DiscontinuetheCOCsfor3‐4consecutivedays1

– A3‐dayhormonefreeintervalwasassociatedwithgreaterresolutioninbreakthroughbleeding/spottingincomparisontocontinuingactivepills2

– Afterthefirst21days

1. Godfrey EM, Contraception, 2012; 2. Sulak PJ, AJOG, 2006.

DMPA: Setting Expectations

• Abnormalbleedingiscommoninthefirstyear• Ratesofunscheduledbleeding1

– Upto70%inthefirstyear– Approximately10%afterthefirstyear

• Amenorrheaismorelikelyovertime1

Within3months

After1year At5years

Rateofamenorrhea 12% 46% 80%

1. Speroff L & Darney PD, Clinical Guide for Contraception 4th Ed, 2011.

Summary: Injection Bleeding

EnhancedCounseling• Bleedingpatterns• Reassurance

EnhancedCounseling• Bleedingpatterns• Reassurance

ContinueDMPA• Moreinjections,lessbleeding

ContinueDMPA• Moreinjections,lessbleeding

TREAT• NSAIDsx5‐7days• Estrogen(COCsorsupplementalestrogenx10‐20d)

• Tranexamicacid

TREAT• NSAIDsx5‐7days• Estrogen(COCsorsupplementalestrogenx10‐20d)

• Tranexamicacid

DMPA

Etonogestrel Implant: Setting Expectations

• Mostwomenexperienceareductionofmenstrualbleeding1

• Bothersomebleedingreportedin25%ofpatients2

– 6.7%reportedfrequentbleeding– 17.7%prolongedbleeding

• Ratesofamenorrhea3

– Approximately20%infirstyear– 30‐40%after1year

1. Mansour D, Contraception, 2011. 2. Mansour D, Eur J Contracept Reprod Health Care, 2008 3. Speroff L & Darney PD, Clinical Guide for Contraception 4th Ed, 2011.

Contraceptive Implant: Bleeding Patterns

• Numberofunscheduledbleedingdays:

– IsHIGHESTinthefirst3months

– DECREASESoverthefirstyear

– PLATEAUSinthesecondandthirdyear

1. Flores JB, Int J Gynaecol Obstet, 2005.

Contraceptive Implant: Bleeding Patterns

• Moreunpredictablebleedingpattern1– Amenorrheamaynotbesustainedifachieved

– “Favorable”patterninthefirst3monthspredictsacontinuedfavorablepattern

– Forthosewithan“unfavorable”bleedingpattern,50%reportimprovementovertime

1. Mansour D, Eur J Contracept Reprod Health Care, 2008.

Treating Implant Bleeding

EXPECTANTMANAGEMENTfor6‐12months

EXPECTANTMANAGEMENTfor6‐12months

Supplementalestrogen

Supplementalestrogen

COCs10‐20daysCOCs

10‐20days

Oralestrogen‐1.25mgCEE2mgestradiol

Oralestrogen‐1.25mgCEE2mgestradiol

Transdermalestrogen0.1mg/day

Transdermalestrogen0.1mg/day

NSAIDsx5‐7days

NSAIDsx5‐7days

USSelectedPracticeRecommendationfor

ContraceptiveUse,2013

Where do you find the US MEC and SPR?

LNG‐IUS: Setting Expectations

• Unscheduledspottingorlightbleedingiscommon,especiallyduringthefirst3–6months

• ForLNG52/5,spottingwaspresentin25%oftheusersat6monthsanddecreasedovertime.1

1. Hidalgo M, Contraception, 2002.

IUD Comparison

Bedsider.org

4/5 years

“52/5”

“52/4”

“19.5/5”

“13.5/3”

LNG‐IUS: Setting Expectations

• LNG52/5andLNG52/4– 79‐97%reductioninbleeding– 33%oligo/amenorrheainfirst3months,70%2years– Amenorrheaat1yr:20%– Amenorrheaat3yrs:40%

• LNG19.5/5– Amenorrheaat1yr:12%– Amenorrheaat3yrs:20%

• LNG13.5/3– Amenorrheaat1yr:6%– Amenorrheaat3yrs:12%

Treating LNG IUD Bleeding

• Pre‐insertioncounseling– Discussbleeding/spottinginfirst3‐6months

– Discussamenorrhea

• Providereassuranceasbleedinglikelytoimprove

• CheckIUDlocation• NSAIDsATCq4wks mayhelp,noevidenceforestrogen

Irregular Bleeding by Contraceptive Ratesofirregularbleeding

COCs • 10‐30%infirstmonthofuse• <10%bythethirdmonthofuse

VaginalRing • Lesscommonin comparisontoCOCs• Upto6%infirstyear

Patch • SimilartoCOCs exceptslightlyhigherrateofspottinginfirst2cycles

Injectable • 70%in first year• 10% afterthefirstyear

Implant • Upto25% infirst2years

Cu‐IUD • Lessirregularbleedingcompared toLNG‐IUS

LNG‐IUS • Upto25% at6months• 8‐11%at18‐24months

Amenorrhea by Contraceptive

RATESOFAMENORRHEAWithin 1st year At1year Beyond

COCs <2% Upto5%

VaginalRing SimilartoCOCs

Patch SimilartoCOCs

Injectable 12% 46% 80%at5years

Implant 21% 30‐40%

Cu‐IUD 0% 0% 0%

LNG‐52/5&4 20% 40% at3years

LNG‐19.5/5 12% 20% at3years

LNG‐13.5/3 6% 12%at3years

US Selected Practice Recommendation for Contraceptive Use, 2016

US Selected Practice Recommendation for Contraceptive Use, 2016

Case :  Early Pregnancy

• A35year‐oldwomanat8weeks’gestationpresentstoyourofficewithspotting.

Evaluation

• History– Riskfactorsforectopicpregnancy

• Physicalexam– Vitalsigns– Abdominalandpelvicexam

• Ultrasound– Transvaginal oftennecessary

• Lab– Rhfactor– HemoglobinorHematocrit– β‐hCG whenindicated

Isthepregnancydesired?Isthepregnancydesired?

Case 5: Bleeding in Early Pregnancy

• Keepthepatientinformed.– Providereassurancethatnotallvaginalbleeding&cramping= anabnormality,butavoidguaranteesthat“everythingwillbeallright”

– Assurethatyouareavailable

• Whatdoesthebleedingmean?– Upto20%chanceofectopicpregnancy– 50%ongoingpregnancywithclosedcervicalos– 85%ongoingpregnancywithviableIUPonsono– 30%ofnormalpregnancieshavevaginalbleeding

Ectopic Pregnancy 

• 1‐2%ofallpregnancies• Upto20%ofsymptomaticpregnancies• ½ofectopicpatientshavenoriskfactors• Mortalityhasdeclined:0.5/100,000

– 6%ofpregnancy‐relateddeaths

• Earlydiagnosisimportant• Concernaboutmanagementerrors

Early Pregnancy Loss (EPL)

• 15‐20%ofclinicallyrecognizedpregnancies

• 1in4womenwillexperienceEPL

• Includesallnon‐viablepregnanciesinfirsttrimester=miscarriage

Pregnancy of Unknown Location

• Whenthepregnancytestispositiveandnosignsofintrauterineorextrauterine pregnancyonu/s– Wetrytofollowthesewomenuntiladiagnosisismade– Wehavetoweighriskofectopicpregnancy(EP)– Sometimesnofinaldiagnosis‐ bothEPLandEPmayresolvespontaneously

• Morecommonlyencounteredinsymptomaticearlypregnancy,butcanalsobeencounteredinasymptomaticwomen,especiallywhenu/searly

Simplified Workup of Bleeding &/or Pain

1. Whereisthepregnancy? U/S(sameday)2. Ifthepregnancyundesired? uterineaspiration3. Ifdesiredandwecan’ttellwhereitis:Isitnormal

orabnormal? quantitative(serial)Beta‐HCG– IfBhcg abovethreshold(>3,000)andnoIUP=Abnormal– MostlikelyanabnormalIUP

IUP=Intrauterine pregnancy

Simplified Workup of Bleeding &/or Pain

1. Whereisthepregnancy? U/S(sameday)2. Ifthepregnancyundesired? uterineaspiration3. Ifdesiredandwecan’ttellwhereitis:Isitnormal

orabnormal? quantitative(serial)Beta‐HCG– IfBhcg abovethreshold(>3,000)andnoIUP=Abnormal– SerialbetaHCGs:

• IfBhcg drops>50%in48hours=Abnormal• IfBhcg rises>50%in48hours=Mostlikelynormal(canbeEP)– Continuetofollowandrepeatu/s

• Ifbetween=Mostlikelyabnormal(stillcanbenormal)–Continuetofollowandrepeatu/s

4. Ifpregnancyclearlyabnormal,ifundesiredordesiresdefinitivedx uterineaspiration

IUP=Intrauterine pregnancy

Conclusions

• Diagnosis:thinkofpregnancy,thenanovulation• Work‐up:Alwaysruleoutpregnancy.Ifirregular:TSH,PLN.?HCT,?EMB,TVUSifinitialtx fails.

• Treatment:allbleedingtreatedsimilarly• NSAID’splushormones.Persistentabnormalbleedingrequirescontinuedwork‐upevenifEMBand/orultrasoundarenegative.

• Hormonalorcopperbirthcontrol:setexpectations

ThankstoRebeccaJacksonandSaraWhetstoneforsharingslides!ThankstoRebeccaJacksonandSaraWhetstoneforsharingslides!

• HCG2000‐ 3000– Non‐viablepregnancymostlikely,2Xectopic– Ectopicis19xmorelikelythanviablepregnancy– Foreachviablepregnancy:

• 19ectopicpregnancies• 38nonviablepregnancies

– 2%chanceofviablepregnancy

• HCG>3000– Ectopic70xmorelikelythanviablepregnancy

0.5%chanceviableIUP

In women with desired pregnancy consider beta hcg cut-off of >= 3000.

Society of Radiologists in Ultrasound: No Gestational Sac Slides for Reference Only