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 ABNS- 50%-sporadic

CONG ANOMALIES
UTERINE ABNS-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 doesnt r/o

UTERINE SIZE-decidua to 8 wks

HEART TONES- dont 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
INCOMPLETECOMPLETE-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
Lams? 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 FHTS
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 HCGs
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 HCGs 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)
1
2
3
4
5

Increase in HCG
(percent)
29
66(53)
114
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?

Sonography
continued
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 IC A L
EM ER G EN C Y
SU R G ER Y

DIAGNOSTIC ALGORITHM
? S U F F IC IE N T H C G
SO N O G R AM
IU P V S E M P T Y

DIAGNOSTIC ALGORITHM
? IN S U F F IC IE N T H C G
R IS IN G H C G
S E R IA L Q U A N T S
E C T O P IC P R E C A U T IO N S
S O N O A T D IS C R IM IN A T O R Y Z O N E

DIAGNOSTIC ALGORITHM
F L A T / F A L L IN G H C G
U N D E S IR E D P R E G N A N C Y
PR O G ESTER O N E < 5
U T E R IN E E V A C U A T IO N
F R O Z E N S E C T IO N
C H O R IO N IC V IL L I
VS
D E C ID U A

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

Methotrexate
informed consent
Alternatives
nature of treatment & follow-up
failure rate, risk of rupture

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

things to avoid
NSAIDs, 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