Early Preg. problems Flashcards
when the embryonic pole could be visualized
from around day 35
How the sac appears by ultrasound
hypochoic structure with an echogenic rim, eccentric - usually at or near the uterine fundus from as early as day 28-31.
When can we distinguish cranial and caudal ends of CRL
once CRL >5mm
when the true CRL may be measured
Once CRL >18mm from the time limb buds develop.
optimal timing for an ultrasound scan for viability
49 days
How to distinguish between early pregnancy and miscarriage by TVUS
- if CRL <7mm/no FHR-> repeat 1 w
- if CRL >7mm/no FHR-> another opinion now (miscarriage) &/or repeat 1 w
- if GS & no F.pole: GS< 25 mm -> rescan 1 w – GS >25 mm -> another opinion now (miscarriage) &/or repeat 1 w
if by TAS no visible Heart beat when CRL is measured or no visible fetal pole and the mean GS is measured?
repeat scan minimum of 14 days later before making diagnosis.
in expectant management of threatened miscarriage
- if bleeding gets worse or presisit beyond 14 d -> reassess
- if bleeding stops: continue ANC
- if bleeding and pain stop means complete miscarrage: UPT after 3 w
MOde of management of Missed Miscarrage
- Expectant (7-14 days)
- Medical (mifepristone and misoprostol) UPT after 3 w
- Surgical (manual under LA or surgical under GA)
Indications of medical management in Missed miscarrage
- If at increased risk of haemorrhage (e.g. in the late 1st trim) or
- previous traumatic experience with
pregnancy (e.g, SB, miscarriage or APHge) or - increased risk from of Hge (e.g. coagulopathies or is unable t o have a blood transfusion) or there is evidence
of infection.
expectant management of Missed miscarrage
for 7-14 days
- if complete expulsion-> home upt after 3 w
- if no expulsion or deteriorating symptoms -> discuss all 3 options of management
when to give progesterone support in case of threatened miscarrage
in case of Hx of previous miscarriages
- vaginal micronised progesterone 400 mg x2/d
after confirmed FHB continue P4 until 16 w of preg.
When to diagnose miscarrage by TVS
- CRL> 7mm w/o HB
- GS > 25 mm w/o embryo
difference betweeen missed miscarriage and anembryonic miscarriage
- MM: dead embryo or fetus
- Anemb. preg.: no embryo has developed within the GS
How many of pregnncy miscarry
20%
Medical management of missed miscarriage
200 mg O Mifepristone
48 hr later
800 ug Misoprostol (V,O,SL)
success rate 60-83%
Best mode of intake of misoprostol
oral or vaginal are more effective than sublingual
Medical management of incomplete miscarraige
Single dose Misoprostol 600 ug (V,O,SL)
success rate 99%
MAx. daily dose of Misoprostol
1st trim.: 2400
13-17 w: 1600
18-26w: 800
What proportion of miscarriages occur after the identification of fetal heart activity?
<5%
incidence of Ectopic pregnancy
1.1%
maternal mortality incidence from ectopic pregnancy
2:10000
leading cause o f
pregnancy- related first trimester death
Incidence of GTN after therapeutic abrotion
1 in 20000
Classic features of Molar Pregnancy
- Irregular Vaginal Bleeding
- Hyperemesis
- Execessive Uterine Enlargement
- Early failed Pregnancy
Rarely:
- Hypothyroidism
- early onset PE
- Abd. distension d.t. theca lectin cyst
Very rare:
- Acute rep. failure
-Neuro: seizures d.t. metastasis
U/S of complete mole
5-7 w: polypoid mass
>8 w: thickened cystic appearance of the villous tissue w/o GSac
Soft markers on U/S of partial mole
Cystic Spaces in placenta
Ratio of transverse to AP dimension of Gsac is >1.5
resemble anembryonic preg. or delayed missed abortion.
Is US and clinical diagnosis confirmatory
No.
Histopathology is confirmatory
Should tissues be sent after all miscarriages to histo.
Only if the fetal tissue wasn’t identified at any stage of pregnancy.
Or if not sent, can ask her to do urine pregnancy. test after 3 weeks.
Should tissue be sent to histo after therapeutic abortion?
Not req. if fetal parts are identified & do a UPT after 3 weeks
How many cases of GTD are unrecognized prior to removal?
0.027000000000000003
TTT of choice for Complete and partial mole
Suction curetage under US guidance.
In Partial Mole if fetal parts doesn’t allow suction-> medical evacuation
Risk of developing GTN, if medical management used compared to surgical management
16 times
Risk of requiring chemo for GTN post complete mole or partial mole?
Complete: 13-16%
Partial: 0.5-1%
Can prior Cx preparation done?
Yes
Can oxytocin infusion be used prior to completion of removal
No, fear of risk of embolism.
only used in severe Haemorrhage
When is a repeat surgery indicated
If acute hemodynamic compromise d.t. persistent bleeding w/ retained products on US –> repeat surgery
repeat surgery shouldn’t be done w/o referral to GTD center.
Where are GTD centers?
LONDON
DUNDEE
SHEFFIELD
Should Anti-D be given
In partial mole : Yes
In Complete mole: No d.t. poor vascularization of chorionic villi and no anti-D
If no histopathology available, given to all patients
How do you follow up post partial mole pregnancy
Stop F/up once bhCG is normal on 2 samples 4 weeks apart.
How do you follow up post complete mole pregnancy
If bhCG normalizes within 56 days or 8 weeks-> f/up for 6 month since evacuation
If bhCG normalizes after 8 weeks or 56 days -> f/up for 6 months since normalization
Incidence of GTD if chemo not required in previous preg
1 in 4011
should you investigate for GTN after all non molar preg
NO
Only if vaginal bleeding persistent >8 w after pregnancy event-> do UPT
If -ve –> <1% risk of GTN
Histopath. of early complete molar ectopic pregnancy. is similar to
choriocarcinoma
Complication of twin pregnancy, one viable & one molar
Early fetal loss
Preterm birth
PE
MEMORIZE FIGO SCORING 2000
How do u treat GTN
By scoring:
<6 Low risk: Single Agent IM MTX
>7 High risk: Multiple agent IV EMA CO
What are EMA CO?
- Etoposide
- MTX
- Dactinomycin
- Cyclophosphamide
- Vincristine
Cure Rate of GTN
Low risk: MTX: 100%
High Risk: EMA CO: 95%
when can women conceive after molar pregnancy.
Post molar: not before f/up is complete.
Post GTN: not before 1 year after complete chemotherapy
Pregnancy rate if chemotherapy is given for GTN
0.8
Does chemo inc. risk of premature menopause
increased risk
can estrogen & fertility drugs & HRT be used
yes, provided bhCG levels returned to normal
Is PSTT & ETT chemo-sensitive?
No they are chem-resistant
TTT of PSTT & ETT
Hysterectomy
Most important prognostic factor in ttt of PSTT & ETT
Time of diagnosis from index pregnancy:
- If >4 years: 100% mortality
- If <4 years: Long term survival
What is ectopic pregnancy
Pregnancy outside of uterine cavity
Incidence of ectopic pregnancy
11/1000
How many presenting to EPU have ectopic pregnancy
2-3%
Risk factors of ectopic pregnancy
ART
TUBAL DAMAGE
PREVIOUS ECTOPIC
PREVIOUS INFECTION like PID
PREVIOUS SURGERY
SMOKING
Best diagnostic tool for ectopic pregnancy
TVS
Laparoscopy is no longer gold standard
In diagnosing of Ectopic pregnancy, Rate of false negative laparoscopies
3 - 4.5%
US findings of tubal ectopic
Empty uterine cavity
Presence of sac in adnexa separate form ovary 50-60%
Extrauterine gest sac 20-40-%
G sac with yolk sac and fetal pole with or without cardiac activity 15-20%
Pseudosac
Echogenic fluid in POD 28-36%
what does ehcoegenic fluid signify
Haemopertonuem
Majority Cases: blood from fibril end of the tube meaning tubal abortion
In others: ruptured tubal pregnancy
Which blood investigation done in diagnosis of ectopic pregnancy
Beta hcg
In all types of ectopic preg., bhcg has only prognostic value, no diagnostic value.
Ways you can manage a tubal Ectopic?
Expectant
Medical
Surgical
Criteria of Expectant management
No pain
hemodynamically stable
no hemoperitoneum
sac <30mm
no cardiac activity
bhcg <1500
woman’s consent
ability to f/up
When is expectant mx discontinued?
- women withdraw consent
- significant pain
- hemodynamically unstable
- rising bhcg to >2000
In expectant mx, till what level of bhcg women followed up
less than 20
Success rate of expectant management
57-100% depending on initial bhcg level.
Overall 72%
If bhcg <1000 = 80-90%
Criteria of medical management
No pain
hemodynamically stable
no hemoperitoneum
sac <35 mm
no cardiac activity
bhcg 1500-5000
woman’s consent
ability to f/up
no IU pregnancy
No sensitivity to MTX
How do u f/up post MTX
BhCG on day 4 & 7
If decreased by >15% -> weekly levels till <15
if decreases by <15% –> reevaluate by US
Percaution along w/ MTX
Avoid Alcohol and Folate
Baseline Inv.: CBC, BG, urine, LFT, U&E
MTX common side effects and adverse effects
Common:
- Mild elevated LFTs
- Stomatitis
- Bloating, excessive flatulence
Adverse:
- GI ulcers
- Pneumonitis
-Pulmonary fibrosis
- Liver cirrhosis
- Renal Failure
- Bone Marrow suppression
MTX contraindications
Hemodynamic instability
presence of IU preg.
Breastfeeding
If unable to comply with f/up
Sensitivity to MTX
Chronic liver disease
Pre existing blood dyscrasia
Activity pulmonary disease
Immunodeficiency
Peptic ulcer disease
Which surgery is done for tubal ectopic
- Salpingotomy (if fertility reducing factors= preferred)
- Salpingectomy (preferred)
either laparoscopic (preferred) or open
Success rate of medical mx
65-95%
rate f persistent trophoblast after salpingectomy or salpingotomy
Salpingectomy <1%
Salpingotomy 7% - range of 3.9 -11%
If no fertility reducing factors, repeat ectopic after surgery
Salpingectomy 5%
Salpingotomy 8%
Rates of intrauterine pregnancy >90% in both
If fertility reducing factors, rate of IU preg after surgery
Salpingectomy 75%
Salpingotomy 40%
US criteria for diagnosing CX preg
- Empty uterine cavity
- barrel shaped CX
- Gsac present below the level of int. cx os
- absence of sliding sign
- blood flow around the gsac using color doppler
Incidence of cx pregnancy
<1% of all ectopic pregnancies
Does Cx preg. managed medically or surgically
Medical - 1st line
Surgical only when life threatening bleeding
Criteria for risk of failure of medical mx of cx pregnancy
Gsac >9weeks
Cardiac activity
CRL >10 mm
BhcG >10000
Prevelrnce of Caesarean scar pregnancy
1 in 2000
Inv. of choice in diagnosis of CS pregnancy
U/S
if non conclusive: MRI
US diagnostic criteria of CS ectopic preg.
- Empty uterine cavity
- Gsac or sold mass of trophoblast located anteriorly at the level of int. os embedded at site of previous lower uterine segment CS scar
- thin or absent layer of myometrium between Gsac and bladder
- Empty endocervical canal
Management of CS scar ectopic
Medical: MTX (local or sys.)
associated w/ high risk hmge d.t. degeneration of highly vascular placenta
Surgical: Suction evacuation or open, laparoscopic or hysteroscopic excision of scar pregnancy w/ repair
Can expectant mx be done in CS scar pregnancy?
If small, non viable scar pregnancy.
If pregnancy is partially implanted into the scar and grows into uterine cavity. the woman must be counseled of risks, huge, morbidly adherent placentation, and she declined termination of pregnancy
Incidence of interstitial pregnancy
1 - 6.3% of all ectopic
US criteria for interstitial pregnancy?
- empty uterine cavity
- products of conception/gsac located laterally in interstitial part of the tube and surrounded by <5mm of myometrium in all imaging planes
- The interstitial line sign, which is a thin echogenic line extending from the central uterine cavity echo to the periphery of the interstitial sac.
Mx of interstitial pregnancy
surgical by cornual resection
Pharma: MTX
Incidence of Cornual Pregnancy
1 in 76000
US of cornual preg.
- Visualization of a single interstitial portion of Fallopian tube in the main uterine body.
- GSac/product of conception seen mobile and separate from the uterus and completely surrounded by myometrium
- A vascular pedicle adjoining the gestational sac to the unicornuate uterus
Mx of Cornual Preg.
Excision of the rudimentary horn via laparoscopy or laparotomy (to avoid recurrence)
DD of ovarian pregnancy
- Corpus luteal cyst
- tubal ectopic pregnancy stuck to ovary
- 2nd corpus luteum
- ovarian germ cell tumor
How we confirm diagnosis of Ovarian pregnancy
Surgical and histology
Mx of Ovarian Pregnancy
Surgical: enucleation or wedge resection.
If Ovarian pathology or excessive bleeding: Oophorectomy
Medical: If high risk for surgery or if persistently raised BhCG or persistent trophoblast.
Diagnosis of early and late abdominal pregnancy
US & MRI respectively
US criteria of abdominal pregnancy
- no intrauterine Gsac
- no evident dilated tube or complex adnexal mass
- Gestational cavity surrounded by loops of bowel & separated from them by peritoneum
- a wide mobility similar to fluctuation of the sac particularly evident w/ pressure of trasvagifnal probe towards the posterior cut-de-sac
Mx of Abdominal Pregnancy
Early: laparoscopic removal
LAte: Laparotomy and manage
when will you suspect heterotopic pregnancy?
Heterotopic pregnancy should be considered in all women presenting after assisted reproductive technologies, in women with an intrauterine pregnancy complaining of persistent pelvic pain and in those women with a persistently raised b-hCG level following miscarriage or termination of pregnancy.
Management of Heterotopic preg.
Medical: If intrauterine is non viable
Surgical: removal in both stable and unstable patients
Expectant: if hetero is nonviable
Do RH-ve women need to take Anti-D after Surgical ectopic evacuation
YES
250 IU
Incidence of Ectopic pregnancy
1% of all pregnancies
Rate of maternal mortality due to ectopic pregnancy
0.2/1000
Common sites for ectopic pregnancy
Tubal 98%
Others( abdomen, ovaries, cx, cs scar)
What is heterotopic pregnancy
Both IUP and extrauterine pregnancy
Incidence of heterotopic pregnancy
1/4000 natural pregnancy
1/100 pregnancy after ART
Ectopic pregnancy triad
Amenorrhea
Lower abdominal or pelvic pain 5-14w (often unilateral)
Vaginal bleeding 5-14w (intermittent, bright or dark red)
Uncommon symptoms of Ectopic Pregnancy
fainting or dizziness
breast tenderness
gastrointestinal symptoms (vomiting or diarrhoea)
shoulder-tip pain (referred pain due to peritoneal irritation)
urinary symptoms
passage of tissue
rectal pressure or pain on defecation.
Could ectopic pregnancy be asymptomatic
found incidentally on an early pregnancy scan.
Abdominal examination of ectopic pregnancy
tenderness, rebound tenderness, guarding, rigidity, or distension.
Vaginal examination of ectopic pregnancy
cervical and/or adnexal tenderness.
General examination of ectopic pregnancy
cardiovascular shock in cases of ruptured ectopic.
Common signs of ectopic pregnancy
pelvic, adnexal, and abdominal tenderness
Less common signs of ectopic preganncy
cervical motion tenderness, rebound tenderness or peritoneal signs
pallor
abdominal distention
enlarged uterus
tachycardia (> 100 beats per minute) or hypotension (< 100/60 mmHg)
shock or collapse
orthostatic hypotension.
Pelvic examination when suspecting ruptured ectopic pregnancy
Not done.
usually difficult and information gained is limited because of generalized haemoperitoneum and pain.
It could cause total rupture of the ectopic pregnancy and it may delay management.
Risk factors for ectopic pregnancy:
- previous ectopic pregnancy
- Prior tubal, pelvic or abdominal surgery.
- History of an STI
- previous elective termination of pregnancy
- history of infertility
- history of PID
- history of IUCD.
- endometriosis.
- About a third of women have no known risk factors.
Complications of ectopic pregnancy
- Tubal rupture (depends on the site of implantation, usually after 6 weeks)
-
intra-abdominal bleeding, shock.
• Death is rare (leading cause of pregnancy-related death in the first trimester.)
• Tubal infertility.
• Psychological– grief, anxiety, or depression. Distress is commonly at its worst 4–6 weeks after pregnancy loss and may last 6–12 months.
Prognosis of ectopic pregnancy if untreated
• Spontaneous tubal miscarriage – occurs in about 50% of ectopic pregnancies and the woman may have no symptoms. Some spontaneous tubal abortions may bleed, but the bleeding is self-limiting.
• Ruptured ectopic – intra-abdominal bleeding, shock, death.
• Chronic ectopic pregnancy.
DD of ectopic pregnancy (pregnancy related)
*pain or bleeding in early pregnancy
• Miscarriage.
• Molar pregnancy.
• Early intrauterine pregnancy.
• Ruptured corpus luteal cyst.
• Degeneration of a fibroid.
DD OF ectopic pregnancy (non pregnancy related(
• Cervicitis, cervical ectropion, or polyps.
• Vaginitis.
• Cancer of the cervix, vagina, or vulva.
• UTI, urethral bleeding, renal colic.
• Irritable bowel syndrome, haemorrhoids.
• Appendicitis.
• PID.
• Torsion/degeneration of a fibroid.
• Ovarian cyst (torsion, rupture, or bleeding).
• Musculoskeletal pain.
• Adhesions.
First thing to do in assessing suspected Ectopic Pregnancy
Urine pregnancy test even when symptoms are nonspecific.
• Beware of atypical symptoms.
• Exclude the possibility of ectopic pregnancy, even in absence of risk factors, because about a third of women will have no known risk factors.
In assessing EP, after positive pregnancy test:
If there is Pain and abdominal tenderness or pelvic tenderness, or cervical motion tenderness.
Urgent referral to EPAU/A&E
In assessing EP, after positive pregnancy test:
If there is no Pain and abdominal tenderness or pelvic tenderness, or cervical motion tenderness.
If there is:
• Pain.
• Pregnancy of ≥ 6 weeks.
• Pregnancy of uncertain gestation.
⬇️
Refer to EPAU/A&E
If bleeding but not in pain and pregnancy <6 weeks:
Expectant management and repeat test after 7-10 days, return if the case worsen then refer to EPAU/A&E
Women EP who are haemodynamically unstable, or in whom there is significant concern about the degree of pain or bleeding.
Urgent referral to A&E
EPAU OR A&E
Early pregnancy assessment unit
Accident and emergency
Does a negative pregnancy test exclude EP
almost always positive.
A negative pregnancy test in a woman with clinical features of ectopic pregnancy does not absolutely exclude an ectopic pregnancy; but does make the diagnosis highly unlikely.
In such cases, due to the rare possibility of a false-negative pregnancy test result, repeat urine pregnancy test or perform serum β-hCG.
In what cases do we have positive serum bhcg
- pregnancy
- posterior cranial fossa germ cell tumor
- placental trophoblastic tumors.
Does serum hcg is a confirmatory test for EP
hCG levels are a measurement of trophoblastic proliferation only and should not be used for a confirmatory diagnosis.
Final confirmation can be provided only by either an USS or a negative pregnancy test.
Investigation for EP
- urine pregnancy test (if negative)
- serum Bhcg
- TVS
- color doppler (not shown to increase detection rates of EP)
Discriminatory zone – a serum hCG level (at which it is assumed that all viable IUPs will be visualized by TVS)
1000–2400 IU/L
Do we use serum progesterone measurements as an adjunct to diagnose either viable IUP or ectopic pregnancy
No
