FIRST TRIMESTER BLEEDING

• SPONTANEOUS ABORTION– ?30%, usu self-limited

• ECTOPIC PREGNANCY– ?1%, most dangerous

• MOLAR PREGNANCY– 0.1%, cookbook

SPONTANEOUS ABORTION

• SPONTANEOUS LOSS, PRE-VIABLE

• <20 WKS, <500 GM

• 30% PREVALENCE

• 80% 1ST TRIMESTER-”EARLY”

RISK FACTORS

• AGE– 10%@20, 20%@35, 40%@40, 80%@45

• SAB HX– 5% NSVD/NO SAB, 30-40% IF 3 SABS

CAUSES

• CHROMOSOMAL ABN’S- 50%-sporadic• CONG ANOMALIES• UTERINE ABN’S-fibroids, synechiae, septae• INFECTIONS• THROMBOPHILIAS-APS, APC res, prothro, etc• DM, THYROID• IATROGENIC-amnio, CVS• SUBSTANCES-caffeine, tob, meth, coc, NSAIDs

APPROACH

• ESTABLISH IUP-R/O ECTOPIC-urgent

• ESTABLISH VIABILITY-less urgent

• CONSIDER INTERVENTION-not all

• REMEMBER RHOGAM-all Rh neg

• EDUCATE/ SUPPORT/ FOLLOW-UP

ECTOPIC? VIABILITY?

• RISK FACTOR ASSESSMENT– absence doesn’t r/o

• UTERINE SIZE-decidua to 8 wks

• HEART TONES- don’t settle for 2nd best

• CERVICAL-open suggestive

• TISSUE PASSED-frozen/rush permanent

ECTOPIC? VIABILITY?

• HCG– ?serial- not if visualized on sono– ?serial sono better if not definitive

• SONOGRAPHY– Gest sac/yolk sac- ?normal appearing– Fetal pole if gest sac MSD >20– cardiac if fetal pole >6-7wk=CRL >5mm

TERMS

• THREATENED-next slide

• INEVITABLE-open,SROM,heavy bleeding

• INCOMPLETE-

• COMPLETE-easiest in retrospect-decresc

• MISSED/” BLIGHTED OVUM”

• SEPTIC

Threatened SAB

• Vaginal bleeding +/- cramping

• 30-40% pregnancies bleed; 1/2 SAB

• more symptoms, small for dates, subchorionic bleed-poorer prognosis

• fetal cardiac activity- better prognosis

• Rx- observation

INTERVENTION

• DO I NEED TO INSTRUMENT?– Where/ what instrument?– How soon?-septic vs bleeding vs missed– Lam’s? EGA by sono, blighted ovum

• DO I NEED FROZEN SECTION ?– Rush permanents vs routine

OPTIONS

• EXPECTANT– <10-12wk, 80-90% res, slower

• SURGICAL– ?ectopic, septic, BLEEDING, missed,>10-12– Fastest

• MEDICAL– <10-12, 80-90% res, faster– Miso 600-800 PV x 1-2

PREVENT ISOIMMUNIZATION

• REMEMBER RHOGAM 50mcg IM if < 12 WEEKS 300mcg IM IF > 12 WEEKS

EDUCATION & SUPPORT

• ADDRESS GUILT

• ADDRESS GRIEF

• DEFER PREGNANCY > 3 MONTHS

Recurrent SAB

• ?3 consecutive for therapeutic nihilists• ?evid base for recommendations• Outcomes similar- ~70% successful preg

– no w/u, + or – w/u , +w/u with or without rx– 50% success after 6 consecutive losses

• Uterine eval, day 3 FSH, antiphos syn w/u & misc thrombophilia w/u, TSH, ?fast glu, ?ANA, karyotype

• Thrombophilia is in –progesterone supps, doxy are both out

MOLAR PREGNANCY

• Aberrant fertilization, fetal origin

• 0.05-0.1% incid (US), chorioca 1:30,000

• 1:120 SE Asians, 1:1200 Hispanics, prior mole, age <20 >35, lower parity

• 80-90% benign course

• most metastatic disease curable

CLASSIFICATION

• HYDATIDIFORM MOLE =GTD – COMPLETE– PARTIAL

• PERSISTENT/INVASIVE MOLE=GTN

• CHORIOCARCINOMA=GTN

• PLAC SITE TROPHOBLASTIC TUMOR=

GTN

Complete & partial mole

• No fetal tissue• 1 sperm + anuclear

ovum- 46XX or 46XY• GTN risk 20%

• Fetal tissue• 2 sperm + 1 ovum -

69XXY or 69XYY• GTN risk 5%

CLINICAL FINDINGS

• VAGINAL BLEEDING• NO FHT’S• SIZE > DATES• HIGH HCG- >100,000 (nl preg peak < 200,000)• HYPEREMESIS GRAVIDARUM• EARLY PREECLAMPSIA <20Wwks• THYROTOXICOSIS• OVARIAN CYTS ( THECA LUTEIN)

DIAGNOSIS

• SONOGRAPHY

• PATHOLOGY

W/U

• HCG, Rh, TSH, LFP, BUN/Cr

• CXR

• SONO

TREATMENT

• Uterine evacuation– D&C, pitocin running?– Bleeding, perforation, ?ARDS, etc

• Serial HCG’s – q wk till negative then q mo for 6-12mo– Should drop rapidly& be negative < 90 days– normal preg usu takes 2-4wk

• effective contraception during follow-up

Persistent/recurrent HCG rise

• =HCG rise x2 wk, stable x 3wk,+@3mo• ?new pregnancy…• Worry re GTN/metastatic disease

– 25%chorioca, 75% persist/invasive mole

• Pelvic sono• Consider repeat D&C- up to 40% neg HCG • Cbc, coags, liver, renal labs• CT abd, pelvis, chest, ?head

High risk features

• Higher HCG

• Time from and characteristics of antecedent pregnancy

• Site, size and number of mets

• failure of prior chemo

GTN

• Occurs 50% after nl preg, 25% after mole, 25% after ectopic/SAB

• Vag bleeding or amenorrhea esp prolonged postpartum,very bloody tumors check HCG

• Serial HCG’s after molar pregs

Remember rhogam

• 300mcg IM with moles

ECTOPIC PREGNANCY

• Implantation outside endometrial cavity

• High prevalence related to PID prevalence

• 98-99% tubal- usu rupturing 6-10 wks

• cornual, cervical, ovarian, abdominal rare

High index of suspicion

• Assume all female patients are pregnant until proven otherwise– ?9-50yrs, sexual hx reliability, contraceptive

failure

• Assume all pregnant patients are ectopic until proven otherwise– danger of preexisting diagnosis of SAB

Risk factors

• Tubal damage– Prior ectopic– PID 1:24 pregs– pelvic surg- appi, cystectomy, section, TL

• Failed contraception– IUD, progesterone only methods, TL, emergency?

• Misc.– extrinsic mass, infert, smoking at conception

• Absence of risk factors does not rule out ectopic

Clinical Presentation-an evolution-

• Pregnancy– amenorrhea, N, V, frequency, rising HCG

• Failing pregnancy– vag bleeding, ?tissue, flat/ falling HCG

• Growing/ rupturing ectopic – pain (colic, peritoneal irritation, referred), mass,

hemodynamic instability, fluid in belly

HCG

• >99% ectopics positive

• absolute values correlate poorly w/ EGA

• relative rise helpful early in gestation

• abnormal rise signifies abnormal gestation

• note 20-30% of ectopics have normal rise

Lower normal limits HCG rise

Interval (days)

Increase in HCG (percent)

1 2 3

29 66(53) 114

4 5

174 255

Sonography

• Primary-Verify or rule out IUP-?heterotopic– Also ectopic cardiac, complex mass, free fluid

• “Discriminatory zone”

• Endovaginal vs. transabdominal

• Availability

• Indication-low thresholds symptoms-All?

Sonographycontinued

• Gestational sac (vs pseudo sac)– EGA~5wks, singleton 1000-1800

• Fetal pole– EGA~5.5wks, by mean sac diam of 16-20mm

• Cardiac activity– EGA~6wks, by 7 wks “minimum EGA” or fetal

pole >5mm

DDX

• SAB

• Molar preg

• IUP complicated by:– ovarian cyst complication– fibroid degeneration, torsion– appendicitis– etc.

DIAGNOSTIC ALGORITHM

S U R G E R Y

S U R G IC A LE M E R G E N C Y

DIAGNOSTIC ALGORITHM

IU P V S E M P TY

S O N O G R A M

? S U F F IC IE N T H C G

DIAGNOSTIC ALGORITHM

S E R IA L Q U A N TSE C TO P IC P R E C A U TIO N S

S O N O A T D IS C R IM IN A TO R Y Z O N E

? IN S U F F IC IE N T H C GR IS IN G H C G

DIAGNOSTIC ALGORITHM

C H O R IO N IC V IL L IV S

D E C ID U A

U TE R IN E E V A C U A TIO NF R O Z E N S E C TIO N

F L A T/ F A L L IN G H C GU N D E S IR E D P R E G N A N C Y

P R O G E S TE R O N E < 5

Treatment options

• Expectant

• Methotrexate

• Surgery

Expectant

• Selection criteria– asymptomatic, small ectopic, low falling HCG

• Rationale– ?incidence tubal SAB, no therapeutic M&M

• Concerns– risk of rupture awaiting resolution

Methotrexate

• Inclusion criteria– <3-4cm, unruptured, no liver, renal, heme dis ?

no cardiac activity, ?HCG <5000-15,000

• Education/ consent

• Workup– CBC/d, AST, BUN/Cr,Type/Rh– Sono– D&C

Methotrexateinformed consent

• Alternatives

• nature of treatment & follow-up– failure rate, risk of rupture

• Side-effect profile– pain, stomatitis, liver, marrow, renal tox

• things to avoid– NSAID’s, ETOH, folic acid, intercourse

Methotrexate

• Dose– 50mg/m2

• Follow-up– quant HCG 3&6 days after injection

• Success– >15% drop on HCG between day 3&6– follow weekly till negative

ALT METHOTREXATE

• 1mg/kg IM every other day to 4 doses

• Quant HCG with leucovorin rescue on alternate days

• Stop when 15% drop in HCG

• ?higher efficacy, less lost sleep

Surgery

• Laparoscopy vs laparotomy

• Conservative- maximize fertility– salpingostomy

• Extirpative- prevent future ectopics– salpingiectomy