Early pregnancy presentations

Ectopic pregnancy

• 1.5-2% of pregnancies
• 15% have no history of missed menses
• 95% in Fallopian tube
• Risk factors
  • Previous tubal surgery 4.0 (adjusted OR)
  • Previous ectopic 8.3
  • Infertility 2.1-2.7
  • Previous genital tract infection 3.4
  • Previous miscarriage 3.0
  • Current smoker 1.7-3.9
  • Ex-smoker 1.5
  • IUD >2 years 2.9
  • Age >40 2.9
  • Sterilisation 9.3
  • Documented tubal pathology 3.7
  • In utero exposure to diethylstilbestrol (DES)

Presentation

• Classic triad: Abdominal pain, PV bleeding, amenorrhoea
• Pain in 90%
• PV bleeding 50-80%
• DDx of ectopic pregnancy
  • Threatened miscarriage
  • Implantation bleeding (usually 5-6 week mark)
  • Cervicitis
  • Cervical polyp/ectropion/carcinoma
  • Urinary/GI tract bleeding
  • Corpus luteal cyst may present with tender mass
  • Molar pregnancy
  • Heterotopic pregnancy
  • Any other cause of abdominal pain seen in non-pregnant females

Investigation

• Urine hCG
  • Very sensitive and specific but can get false negative if dilute urine
• Serum hCG essentially 100% sensitive and specific
  • Minimum rise in 48 hrs can be as low as 53% in normal pregnancy
  • Median rise of 124% in 2 days
  • Mean doubling time = 1.4-2.1 days up to 6-7 weeks
  • vs. Decline by 21-35% in 2 days if miscarriage
  • Ectopics rise slower but cannot be used to rule in or out

• Heterotopic pregnancy 1/3000 in general population
  • Rising due to IVF and hormone therapy
  • If IUP present, effectively rules out ectopic unless at high risk of ectopic (e.g. previous sterilisation/fallopian surgery) or IVF patient
• USS
  • Embryo with cardiac activity in uterus = viable IUP
  • Embryo without cardiac activity = fetal demise if crown-rump length >5mm (i.e. cardiac activity expected)
  • Empty uterus with embryonic cardiac activity outside the uterus = Ectopic
  • Pelvic mass or free fluid with empty uterus = Ectopic highly likely
  • Pelvic mass + free fluid + empty uterus = 100% ectopic
  • Large free fluid alone = 86% likely ectopic
  • Adnexal mass alone = 70% likely ectopic

• TAUSS
  • Visualises gestational sac, yolk sac and foetal pole one week later than below
• TVUSS
  • Can usually visualise gestational sac, yolk sac and foetal pole at 4.5, 5.5 and 6.0 weeks respectively

• Discriminatory zone (Kader et al.) to detect IUP
  • TVUSS = 1500mIU/mL
  • TAUSS = 6000mIU/mL
  • If no IUP and no abnormal TVUSS findings
    • hCG 2000-3000 = 2% chance of subsequent viable IUP
    • hCG >3000 = 0.5% chance of subsequent viable IUP
  • In QLD
    • If HCG >2000, no IUP on TVUSS and complex adnexal mass or free fluid = High probability of ectopic
    • If hCG >2000, no IUP and no abnormal findings on TVUSS = Consider serum progesterone, repeat hCG at 48-72 hours and if rising then repeat TVUSS at one week (or earlier if clinically indicated)
    • If hCG <2000, repeat hCG at 48-72 hrs and if rising over one week then repeat TVUSS (or earlier if clinically indicated)
    • If HCG declining or sub-optimally rising: No IUP on TVUSS, indicates non-viable ectopic or IUP and needs follow-up
  • Very low values suggest ectopic pregnancy or abnormal IUP
  • Cannot completely exclude or diagnosis ectopic in this way

• Repeat hCG 48-72 hrs apart
  • If >66% rise: Likely IUP (ectopic not excluded)
    • hCG <2000 – Repeat TVUSS in 1-2 weeks
    • hCG >2000 – Repeat TVUSS within 1 week
    • or when mean sac diameter expected to be >25mm (grows 1mm/day)
  • Fall >50%
    • Likely non-viable (IUP or ectopic)
  • Rise 50-66%
    • Repeat TVUSS and if no IUP observed = Likely ectopic

Management

• Surgical
  • Indications: Unstable, signs of rupture, persistent excessive bleeding, heterotopic, CI medical/expectant
  • Laparoscopic salpinostomy preferred method
    • Preserves fallopian for future pregnancy
    • Need ectopic size <5cm in appropriate tubal location
  • Laparotomy (or sometimes laparoscopy) if unstable, too difficult with subsequent saplingotomy or salpingectomy

• Medical
  • Indications: Stable, no rupture, no active bleeding, normal FBC/ELFT, good compliance, geographically close, not breastfeeding
  • Caution if hCG >5000 or ectopic >3cm on TVUSS, foetal cardiac activity or blood transfusion not an option
  • Systemic methotrexate inhibits cell division in rapidly growing tissues
    • 14.3% failure rate if hCG levels >5000 vs. 3.7% if <5000
    • Abdominal pain in 75% usually 3-7 days later. Need USS to rule out rupture
    • Risk factors for failure: Larger tubal diameter, higher initial hCG, severe abdominal pain and fetal cardiac activity
    • Treatment failure in up to 36%
    • 5% need elective or emergency surgical treatment
    • Refrain from sex or pelvic examination for 14-21 days after treatment (until hCG undetectable) as may increase risk of tubal rupture
    • IMI if hCG <3000; IVI if hCG >3000
    • Need to avoid conception for 4 months due to teratogenicity risk

• Expectant
  • Stable, no rupture, low and falling hCG (<1500), minimal free fluid, pain free, tubal mass <3cm, good follow-up
  • Early pregnancy clinic with hCG every 48 hours for 8 days

Spontaneous abortion

• WHO definition = Loss of pregnancy <20 weeks or <500g

Potential miscarriage

• May present with shoulder tip/abdominal pain +- bleeding
• Speculum exam to remove POC
• Urgent hCG, gynae review, USS, FBC, G&H +- surgery
• IDC to empty bladder
• If bleeding continues and ectopic excluded consider Ergometrine 250mcg IV or IM, misoprostol 800-1000mcg PR as per PPH

Early pregnancy loss

• Approximately 20% -40% of all pregnancies
• 75% occur before 8 weeks gestation
• 25% of women who have been pregnant will have suffered a miscarriage by age 39

History

• Menstrual history and LNMP
• Date of positive pregnancy test
• Previous pregnancies and outcomes
• Significant gynae history
• Assisted conception?
• Previous USS or hCG results
• Symptoms of early pregnancy
• Symptoms
  • Bleeding timing, severity
  • Pain (abdominal, shoulder tip)
  • Postural syncope
  • Vomiting
  • Passage of POC

Examination

• Obs
• Abdo
• PV blood loss (check pad)
• PV exam
  • Mandatory to confirm type of abortion, amount and site of bleeding, cervical dilatation and whether any tissue has passed
  • Speculum: Source and amount of bleeding, evidence of pOC
  • Bi-manual: Cervical motion tenderness, state of internal os, adnexal mass
  • Size of uterus relative to menstrual dates (**)

Definition

• Complete miscarriage
  • Only diagnosed by identification of yolk sac in passed products, follow-up serial hCG until negative and TVUSS if clinically indicated to rule out undiagnosed ectopic pregnancy
• Risk factors for miscarriage
  • Fetal
    • Chromosomal, congenital , GTD
  • Maternal
    • Age: 7% in 25-29yo; 43% in 40-43yo
    • Recurrent miscarriage (20-70% risk after 3 losses)
    • Anatomical factors (e.g. uterine septum)
    • Endocrine (e.g. thyroid disease)
    • Immunological (e.g. SLE)
    • Infection (e.g. CMV)
    • Severe acute illness
    • Thrombophilia (e.g. Factor V Leiden)
    • Uncontrolled chronic illness e.g. DM
    • Very high or low pre-pregnancy BMI
    • Drug use, smoking, teratogen exposure, trauma

Potential miscarriage

• Confirm pregnancy
• Physical exam
• Serial hCG
• USS
• FBC, Blood group and hold and antibodies
• MSU as indicated (UTI associated with spontaneous abortion)
• STI screen as indicated

Potential miscarriage

• Viability of IUP
  • Open os or passing POC
  • Fetal heart beat visible = viable
  • No cardiac activity, no foetal pole and mean sac diameter >25mm = non-viable
  • No cardiac activity, no foetal pole and MSD <25mm = Suspicious. Need serial hCG and repeat TVUSS in 7-10 days
  • No cardiac activity, fetal pole present and crown-rump length >7mm = non-viable
  • No cardiac activity, fetal pole present and CRL <7mm = Suspicious as above

Management

• All depends on woman’s preference
• Expectant
  • CI: Haemodynamic instability, suspected gestational trophoblastic disease, IUD (must be removed), evidence of infection
  • GP or early pregnancy clinic in 7-10 days with repeat hCG day 8
  • Consider USS if clinically indicated, to assess for retained POC or hCG not fallen >90% over 7 days

• Medical
  • CI: Instability, suspected GTD, IUD (must be removed), allergy to prostaglandins, evidence of infection, medical CI
  • Misoprostol is drug of choice as OPD or day procedure
  • Follow-up in early pregnancy clinic days 2 and 8
  • hCG day 1 and 8
  • Consider USS if clinically indicated, ? retained POC or hCG not >90% declined at day 7

• Surgical
  • Unsuccessful expectant or medical Rx (or preference)
  • Absolute indications: Instability, persistent bleeding, evidence of retained POC, IUD or suspected GTD
  • Misoprostol for cervical priming

Septic abortion

• Abortion complicated by infection
• Presenting complaints
  • Fever, abdominal pain, PV discharge, PV bleeding and history of recent pregnancy
• Most commonly due to retained POC and/or instrumentation
• Need PV exam and USS + Swabs
• Amp and Gent

Second trimester pregnancy loss

• 1-2% of recognised pregnancies
• Causes
  • Foetal: Chromosomal, congenital
  • Maternal: Previous second trimester loss, uterine malformations, maternal medical illness, PROM, placental complications, cervical insufficiency, infection (10-25%)
• Presentation
  • Intrauterine foetal death
  • Preterm labour or PROM

• Assessment as usual
• Low vaginal and peri-anal swabs
• Maternal investigations as for stillbirth
• Medical management
  • Appropriate for any gestation
  • If cervix closed and membranes intact: Mifepristone + Misoprostol
  • If membranes ruptured and/or dilated cervix: Misoprostol or IV oxytocin
• Surgical management
  • If persistent excessive bleeding, haemodynamic instability, retained POC or suspected GTD
  • Up to 15 weeks

Rhesus immunoglobulin

• 21% rhesus negative in Queensland
• Sensitisation reported at as early as 6 weeks gestation but limited evidence at <12 weeks
• Contraindications
  • Rhesus positive
  • Rhesus negative with preformed anti-D antibodies
  • Woman declines

• Up to 12+6 weeks
  • Threatened miscarriage ONLY if heavy or repeated bleeding, bleeding with abdominal pain, significant abdo trauma
  • Completed Miscarriage
  • Termination of pregnancy
  • Ectopic pregnancy
  • Hydatidiform mole
  • Chorionic villous sampling
• 13+0 weeks and above
  • Chronic villous sampling, amniocentesis, cordocentesis or fetoscopy
  • Trauma considered to cause fetomaternal haemorrhage (even if Kleihauer negative)
  • Each concealed or revealed antepartum haemorrhage
  • External cephalic version
  • Miscarriage or termination of pregnancy

• Quantifying fetomaternal haemorrhage
  • If <12+6 weeks, not required
  • Each 100IU of RhD-Ig protects against 1mL of fetal red cells (2mL whole blood)
  • If Kleihauer negative, further anti-D not required
• Dose of Anti-D
  • Must be administered within 72 hours
  • Singleton pregnancy up to 12+6 = 250IU per sensitising event
  • Multiple pregnancy any gestation = 625IU
  • Gestation uncertain but maybe 13 or more = 625IU
  • Gestation 13+0 or more = 625IU

Gestational trophoblastic disease

• Two pre-malignant diseases
  • Complete hydatidiform mole
  • Partial hydatidiform mole
• Four malignant disorders (gestational trophoblastic neoplasia)
  • Invasive mole/persistent trophoblast neoplasia
  • Choriocarcinoma
  • Placental site trophoblastic tumour (PSTT)
  • Epithelioid trophoblastic tumour (ETT)

• Presentation
  • Abnormal vaginal bleeding
  • Persistent hCG (rising, stable or not declining enough)
• Diagnosis
  • Definitive diagnosis only made by histopathology of POC

Hyperemesis gravidarum

• Morning sickness
  • Nausea: 20% by week 2; 60% by week 8
  • Nausea + Vomiting: 3% by week 2; 25% by week 8
  • Lower risk of miscarriage
• Definition of hyperemesis
  • Persistent severe nausea and vomiting
  • <20 weeks gestation
  • Resulting in dehydration, electrolyte imbalance, ketosis and weight loss of at least 5% pre-pregnancy weight

• 1-2% of pregnancies
• Increased incidence with multiple pregnancy and gestational trophoblastic disease
• Peaks 8-12 weeks
• Resolves by week 20 in 90% of cases
• Need to rule out:
  • UTI
  • Gastroenteritis
  • Appendicitis
  • Hyperthyroidism

• Ix
  • FBC
  • UEC
  • Urinalysis
  • TFT
  • Ketones

• Treatment
  • Replace fluid losses (N/S)
  • Thiamine
  • Pyridoxine 25mg PO TDS
  • Doxylamine 12.5mg PO TDS
  • Metoclopramide 10mg PO/IV TDS
  • Ondansetron 8mg IV TDS (Cat B1)
  • Ginger 1-2g daily (unknown safety but proven effective)
  • Prednisone 50mg daily tapered down

• Admission criteria to SSW/HITH
  • Severe dehydration with intolerance of oral intake
  • Significant electrolyte abnormalities
  • Ketosis
  • Infection

Early pregnancy USS

• hCG >2000
  • 2-3mm gestational sac from 4.5 weeks
  • Not confirmed pregnancy until yolk sac visible at 5.5 weeks
  • Yolk sac visible once gestational MSD >4mm
  • Must see yolk sac if MSD >10mm or = blighted ovum
• hCG 1000 -50 000
  • Foetal pole and foetal cardiac activity visible by MSD 8mm
  • Must see foetal pole and cardiac activity by MSD 18mm or = blighted ovum
  • Heart beat visible with CRL 1.5-3mm (must be by 5mm)

Early pregnancy uss

• CRL >7mm with no FHR = missed miscarriage
• MSD >25mm and no yolk sac or foetal pole – blighted ovum (empty sac miscarriage)
• MSD >10mm should have yolk sac
• MSD >20mm should have foetal pole
• CRL >7mm should have cardiac activity

Last Updated on September 29, 2021 by Andrew Crofton