Chapter 19: First Trimester Bleeding: Ectopic Pregnancy and Abortion Flashcards
How often does an ectopic happen and where is the most common site?
Ectopic Pregnancy – Blastocyst implantation anywhere other than uterus. 1.5% of reported pregnancies
i) 98% in fallopian tube with 80% in the ampulla
ii) Threat reduced from the past due to transvaginal US and b-hCG testing
Symptoms of an Ectopic
Symptoms
i) Amenorrhea followed by vaginal bleeding and abdominal pain on the affected side
ii) Disturbing findings: Shoulder pain worsened by inspiration (could indicate bleeding into abdomen irritating diaphragm and phrenic nerves)
iii) Passing decidual cast by pregnany patient with no placental villi on pathology means ectopic pregnancy is likely
Causes of Tubal ectopics
(1) Inflammation against tubes stopping normal progress of conception
(a) Salpingitis, salpingitis isthmica nodosa, acute chlamydial infection causing intraluminal inflammation and subsequent fibrin deposition with tubal scarring
(i) Even with negative chlamydial cultures, persistent chlamydial antigens can lead to a hypersensitivity reaction later on (7-14 days) (unlike N. Gonorrhea whose endotoxin causes rapid clinical onset)
(b) Other risk factors: Smoking, prior ectopic, prior tubal surgery, diethylstilbesterol exposure, and advanced age
Outcomes of untreated tubal ectopics
(1) Tubal abortion: Products of conception expelled from fimbriae, which can lead to implantation in the abdomen
(2) Tubal rupture: Hemorrhage leading to surgery
Ruptured ectopic presentation
(1) ¾ of women will have tenderness in pelvis and abdomen, aggravated by cervical manipulation
(2) Pelvic mass with fullness posterolateral to the uterus can be palpated in 20% of women
(a) Soft and elastic initially, harder with hemorrhage
(3) Consider avoiding pelvic examination due to possibility of iatrogenic rupture
(4) Fever may result in response to intraperitoneal blood. 38C indicates infectious cause
(5) Adnexal mass in 1/3 of patients
First trimester bleeding does not always mean ectopic. What must you also consider:
i) Missed abortion, placental polyp, hemorrhage corpus luteal cyst, appendicitis, renal calculus
(1) 20% of normal pregnancies have early bleeding
What are the ways to test for ectopic:
- TVS
- Serial serum bhCG
- Serum progesterone test
- Endometrial curettage
- Culdocentesis
- Laparoscopy
- Pregnancy test
TVS findings with an ectopic
(1) Identify location of ectopic (gestational sac visible at 4.5-5 weeks from LMP
(2) Yolk sac at 5-6 weeks
(3) Fetal pole with heart beat at 5.5-6 weeks
(a) Pseudogestational sac: Fluid collection that mimics appearance of gestation, caused by sloughing of decidua in midline uterine cavity, whereas the normal sac is eccentrically located
How can serial b-hCGs help us with an ectopic?
Serial serum b-hCG (as early as 5 days
(1) Within 60-80 days of last menses, 53% or more increase in b-hCG should occur every 48 hours. Less than this could be ectopic or otherwise abnormal pregnancy
(a) 15% of normal pregnancies can also have this delayed rise in b-hCG
(b) 17% of ectopics have normal increase in b-hCG
How can a serum progesterone test help us with an ectopic?
Serum progesterone test – Doesn’t change between 5-10 weeks, so one value is good for diagnosis
(1) 20: Sensitivity >90% with 40% specificity that there is a healthy pregnancy
Ectopic endometrial curettage findings
Endometrial curettage
(1) Curettage of endometrial cavity, big risk for intrauterine pregnancy
(2) Arias-Stella reaction – Hypersecretory endometrium of pregnancy seen on histology for any pregnancy
How does a culdocentesis help us with ectopic?
(1) Can identify blood in the peritoneal cavity
(2) 18G needle inserted posterior to the cervix between uterosacral ligaments and into cul-de-sac of peritoneal cavity
(3) Aspiration of non-clotting blood = hemoperitoneum
(4) Purulence = infection
Laparoscopy for ectopic:
(1) Look at it! Only 2-5% missed diagnosis
(a) Hematosalpinx – Blood clot in fallopian tube mistaken as unruptured ectopic or tubal abortion
Pregnancy test for ectopic?
Pregnancy test (positive in 90% of ectopics and can be done as early as 14 days)
What is the first medical management for ectopic
Methotrexate – Folic acid antagonist that inhibits binding of dihydrofolate reductase, reducing amount of active intracellular metabolite folinic acid, stopping the growth of rapidly dividing placental, embryonic, and fetal cells
Contraindications for methotrexate
(i) Absolute
1. Brestfeeding, evidence of immunodeficiency, alcoholism, liver disease, blood dyscrasias (anemia, thrombocytopenia, leukopenia), pulmonary disease, PUD, liver/kidney/hematologic dysfunction
(ii) Relative
1. Gestational sac > 3.5 cm, embryonic cardiac motion
Why is it important to check b-hCG for methotrexate use
Initial serum b-hCG 15,000 = 68% success rate
Side effects of methotrexate
Side effects: N/V/D, dizziness, stomatitis. Abdominal pain that can be treated with NSAIDs
How should b-hCG levels change with methotrexate use?
Manage: b-hCG levels at day 4 and 7. 15% or more decline leads to weekly check until undetectable. No decline means surgery or additional dose
If I can’t use methotrexate, what can I use?
Others: Mifepristone (progesterone receptor antagonist), potassium chloride, prostaglandins
Surgical options for a tubal ectopic
You got three options.
(2) Linear salpingostomy: Incision on fallopian tube over site of implantation, removes pregnancy, allows healing via secondary intention
(3) Segmental resection
(4) Salpingectomy if little or no tube remains
Something you should also give mom before removing an ectopic…
Either way, give Rh-negative mother with ectopic pregnancy Rh immunoglobulin to prevent Rh sensitization
What will an ovarian ectopic look like?
a) Ovarian – Cyst with wide echogenic vascular outer ring on or within ovary
Presentation of an interstitial ectopic pregnancy
Interstitial – Cornual pregnancy – Proximal tube segment that lies within muscular uterine wall
i) Swelling lateral to the round ligament
ii) Rupture usually occurs at 8-16 weeks with massive bleeding usually needing hysterectomy since this area was able to expand more to accomadate, to a point
Discuss cervical ectopic and how we confirm it
Cervical – Below the level of the histologic internal os –
Seen in history of dilation and
curettage (70% of cases)
i) Confirmation
(1) Presence of cervical glands opposite the placental attachment site
(2) Portion or entire placenta below either the entrance of uterine vessels or the peritoneal reflection on the anterior and posterior uterine surface
What is a heterotropic pregnancy and what do we do about it?
Heterotropic Pregnancy
i) IUP and ectopic at once!
ii) Potassium chloride injected into ectopic to preserve state of IUP (NO METHOTREXATE)
What do we do about an abdominal pregnancy?
Abdominal pregnancy – Get rid of it, detected long before fetal viability. 10-20% survival
of fetus and up to half of those have substantial deformity
What defines an abortion and what causes them? When do they normally present?
Abortion = loss at less than 20 weeks
a) Half are due to trisomies in first trimester
b) 80% during first 12 weeks
c) Happens spontaneously 15-25% of the time
Second trimester abortions due to what?
Second trimester losses usually due to maternal systemic disease, abnormal placentation, and other anatomy issues
Causes of abortion:
a) Infection - Uncommon cause. Chlamydia, listeria, mycoplasma
b) Endocrine - Thyroid autoantibodies, uncontrolled Type I Diabetes
c) Environment - Smoking, high doses of alcohol in first 8 weeks ,radiation beyond 5 rads
d) Immune - Disorders of blood coag: Factor V leiden, prothrombin G20210A mutation, antithrombin III, protein C and S, and methylene tetrahydrofolate reductase (hyperhomocysteinuria)
Leiomyomas can lead to abortion. What exposure is linked to this scenario?
Diethylstilbesterol exposure can change shape of uterus and cause cervical insufficiency
What is Asherman’s and how do we treat it?
Intrauterine synechiae (Asherman Syndrome) from uterine curettage with destruction and scarring of endometrium past the layer of the basalis, leading to amenorrhea, infertility, cyclic pain, and/or pregnancy loss
(a) Characteristic webbed pattern on hysterogram.
(b) Treat with lysis of synechiae and post-op estrogen at high doses to facilitate endometrial proliferation
What is a threatened abortion
Threatened Abortion: Bleeding in the first trimester without tissue loss. Half of these women proceed to spontaneous abortion
How does miscarriage present?
In cases of miscarriage, we see bleeding first followed by abdominal cramping a few hours to days later.
i) Persistent low back pain, anterior rhythmic cramps, pelvic pressure, or a dull, midline, suprapubic discomfort
What is an inevitable abortion?
Inevitable abortion: Vaginal bleeding and/or the gross rupture of the membranes in the presence of cervical dilation. Uterine contractions begin promptly to expel products of conception
What is an incomplete abortion
Incomplete abortion: Internal cervical os opens and allows passage of blood and some tissue. In some cases, retained placenta remains in the cervical canal and can be removed with forceps or curettage
What is a complete abortion
Complete abortion: Documented pregnancy that resulted in full expulsion of conception material within 20 weeks, with placenta and fetus coming out at 10 weeks together usually
Presentation of a missed abortion
Missed abortion: Retention of a failed IUP for an extended time, usually two menstrual cycles. Patients have an absence of uterine growth and may have amenorrhea or no real change in symptoms.
What is a recurrent pregnancy loss?
Recurrent Pregnancy Loss: More than two consecutive pregnancy losses.
With recurrent first trimester losses what do we look for?
With recurrent first trimester losses, karyotype. 3% chance that mom or dad is an asymptomatic carrier of a chromosomal translocation
How is the immune system related to first trimester losses?
Immune System has a role in 20% of these cases
(1) Antiphospholipid antibodies are a family of autoantibodies that bind to negatively charged phospholipids
(2) Lupus and anticardiolipin also linked
(a) Low dose aspirin along with heparin unfractionated can begin when pregnancy is diagnosed
What typically causes second trimester losses? What do we do about it?
i) Typically due to anatomic issues.
ii) Use laparoscopy, hysterography, operative hysteroscopy to correct issue
What do we do about cervical insufficiency causing second trimester losses?
iii) Cervical insufficiency
(1) Increasing pressure within the uterus causes a weakened cervix to efface and dilate painlessly
(a) Predisposing factors: Uterine anomalies, as well as previous trauma to the cervix
(b) Cervical cerclage used to tie the cervix closed during the early second trimester if cervical insufficiency is deemed the etiology of recurrent second-trimester loss
How do we treat abortion overall?
Treating abortion
a) None needed for threatened abortion or complete
b) Infection, bleeding, significant pain = Complete the abortion
c) Bleeding controlled by making sure conception products are removed from the uterus
d) US to determine need for surgery
e) Curettage for tissue remaining
