Bleeding in early pregnancy and Ectopic Pregnancy Emad

Bleeding in early pregnancy and Ectopic Pregnancy Emad R. Sagr, MBBS, FRCSC, FACOG Consultant OB-Gyn and Gynecology Oncology Security Forces Hospital

SPONTANEOUS ABORTION • Definition: Abortion is termination of pregnancy before the fetus is sufficiently developed to survive (before 24 wks) Incidence: 15 -20% It is convenient to consider the clinical aspect of spontaneous abortion under 5 sub groups: 1. Threatened 4. Missed 2. Inevitable 5. Recurrent abortion 3. Incomplete 6. Septic Abortion

Threatened Abortion • 25% of pregnancies • This refers only to bleeding from placental site which is not yet severe enough to terminate the pregnancy.

• Serial qualitative HCG level: BHCG level – 1000 miu/ml If gest. Sac seen & BHCG less than 1000 unlikely to survive. Qualitative BHCG level should ↑ 65% every 48 hours. • Serum Progesterone level 5 ng/ml associated with none viable fetus > 25 ng/ml associated with alive fetus Expectant observation No benefit from use of progesterone or bed rest although it is often advised.

Inevitable Abortion • Indicate the pregnancy is doomed to end shortly. Progressive cervical dilation without the passage of tissue. here bleeding is slight but retroplacental • Pain usually more. • Dilated internal os. USS – Non viable fetus • Emergency suction: D & C

Complete Abortion • Diagnosed if patient passed tissue but now is only slight pain and P/V bleeding • Examination confirmed closed Cx. • Minimal current bleeding • TVU – empty uterus • R/O ectopic pregnancy by serial BHCG level until P. T. -ve • Anti D injection if patients RH – ve to prevent sensitization

Incomplete Abortion • If the internal cervical os is open and patient has passed some tissue. Management: Emergency suction and curettage

Missed Abortion • It is defined as retention of dead products of conception in utero for several weeks. • Symptoms of early pregnancy disappear • Uterus not only has ceased to enlarge but also has become smaller. • Occasionally serious coagulation defect may develop. • Abnormal sonographic findings

Septic Abortion • Uterine infection at any stage of abortion causes: • Delay in evacuation of uterus • Delay seeking advice • Incomplete surgical evacuation followed by infection from vaginal organisms after 48 hours

• Trauma: • Perforation or cervical tear • Criminal abortion • Treatment: • • Should be active to minimize risk of septic shock Cervical & HVS, blood culture Broad spectrum antibiotic Evacuation

Induced Abortion • Therapeutic abortion – termination of pregnancy before the viability for the purpose of saving the life of the mother. Heart disease, invasive Ca of Cx. • Elective (voluntary) abortion is the interruption of pregnancy before viability at request of the women but not for reason of maternal health or fetal disease.

Illegal abortion usually performed in unsterile condition by operators with little or nor medical training. It is often incomplete and complicated by: • Hemorrhage • Infection • Infertility and tubal occlusions • Intrauterine infection is frequent complication and septic shock and death are the ultimate consequences.

Recurrent Miscarriage • When a woman has had 3 consecutive miscarriage. • Risk of abortion for next pregnancy: • • • 1 abortion 1 Normal pregnancy 1 Abortion 1 Normal 2 Abortion 2 abortion 15% 25% 15% 40%

Etiology and Investigation: 1. Genetic factors Karyotyping of both partners will reveal chromosome anomalies 2. Anatomical factors Uterine anomalies Cervical incompetence Hysteroscopy & HSG – Septum / Fibroid 3. Endocrine problem 4. Immunological factors Common in women with antiphopholipid antibodies syndrome, Anticardiolipid ant. & Lupus anticoagulant • Maternal disease SLE, Renal disease • Environmental factor Smoking / Alcohol

Abortion Technique Medical Surgical

Ectopic Pregnancy

Epidemiology • Leading cause of pregnancy-related deaths during T-1 • 1 -2% of all diagnosed pregnancies • Incidence is • incidence of salpingitis d/t chlamydia or other STI • Improved diagnostic techniques • age • Most occur in multigravid women • > 50% in women with 3 pregnancies • 10 -15% in nulligravid women

Mortality • Causes 15% of maternal deaths • Overall risk of death 10 X > the risk of childbirth; 50 X > risk of legal abortion • Cause of death r/t blood loss (80%), infection (3%), & anesthesia (2%) • Interstitial & abdominal 5 X > risk of death than other sites

Fallopian Tube Function • Complex structure • sustains & transports sperm, ovum & early conceptus for ~ 3 days • Beating cilia & rhythmic contraction of smooth muscle neg pressure in tube • Zygote undergoes cleavage & held for another 30 hrs. in the ampullary-isthmic region • Developing blastocyst is then transported via the isthmus into the uterus

Types of EP

Sites of EP Fallopian tube Ampulla Isthmus Fimbrial end Cornual & interstitial Abdominal Ovarian Cervical Heterotopic Pregnancies: 1 in 30 000 80% 12% 5% 2% 1. 4% 0. 2%

Risk Factors for EP • Definite • • PID Previous EP Any tubal surgery or sterilization procedure infertility

Risk Factors for EP • Probable • Any pelvic surgery • Use of reproductive techniques • In vitro fertilization • Gamete intrafallopian transfer • Embryo transfer • Uncertain Association • IUCD • “Superovulating agents” • Pergonal, Clomiphene citrate

Classic TRIAD of EP 1. Delayed menses 2. Irregular vaginal bleeding 3. Abdominal pain

Symptoms of Ectopic Pregnancy SYMPTOM PTS WITH SYMPTOM Abdominal pain 90 -100% Amenorrhea 75 -95% Vaginal bleeding 50 -80% Dizzininess, fainting 20 -35% Pregnancy symptoms 10 -25% Urge to defecate 5 -15% Passage of tissue 5 -10%

Signs of EP SIGN PTS WITH SIGN Adnexal tenderness 75 -90% Abdominal tenderness 80 -95% Adnexal mass* 50% Uterine enlargement 20 -30% Orthostatic changes 10 -15% Fever 5 -10% * 20% of masses occur on the side opposite the EP.

Differential Diagnosis • Complication of IUP • Abortion • Early pregnancy plus uterine fibroid or ovarian tumour • Conditions causing acute abd pain • • Torsion of ovarian tumour, FT, or subserous pedunculated fibroid Salpingo-oophoritis Pelvic pain with an IUCD in situ Appendicitis

Differential Dx – cont’d • Conditions causing hemoperitoneum • Ruptured corpus luteum • Ruptured follicular cyst • Ruptured endometriotic cyst • Conditions simulating a pelvic hematoma • Retroverted gravid uterus • Pelvic or tubo-ovarian abcess

Management of EP • Pre-operative diagnostic accuracy of EP based on clinical features alone is notoriously poor: ~50% • 20% of EP occur as surgical emergencies • Delay is justified only to correct shock

Acute Management of EP • Remember your ABCs • Oxygen • Large bore IV(s) crystalloids • Blood • Labs • CBC, coagulation studies • -h. CG

Usefulness of Quantitaive -h. CG • Assessment of pregnancy viability • Serial rise usually indicates a normal pregnancy • Correlation with ultrasonography • With titers > 1500 IU/L, TVUS should ID an IUP • With multiple gestation, a gestational sac will not be apparent until titer rises a little higher • Assessment of treatment results • Declining levels are c/w effective medical or surgical Tx; if levels persist think GTD

The Importance of TVUS • Documentation of an intrauterine sac • A viable IUP should be identified when -h. CG > 1500 IU/ml • Adnexal mass • An EP > 2 cm should be identified • Adnexal cardiac activity • Detectable when -h. CG is ~ 15 000 – 20 000

U/S – Is it EP or miscarriage?

Surgical Management of EP • Radical • Salpingectomy • Conservative • Salpingotomy • Salpingostomy or segmental resection does not repeat EP rate • fimbrial evacuation (traumatizes the endosalphinx & is assoc with rate of recurrent EP (24%) compared with salpingectomy

Medical Management of EP Methotrexate (MTX) • 1 st used in Japan in 1982 • Antimetabolite that interferes with dihydrofolate reductase • Considered for low -h. CG • Success rate 67%-94% • Indications • Hemodynamically stable pt • good F/U • Recurrent EP following Sx intervention

Methotrexate – cont’d • Contraindications • • • Evidence of rupture Serum -h. CG > 5 000 IU/L (varies) FH detected on U/S Adnexal mass> 3. 5 cm on U/S Unreliable pt F/U unavailable Laparoscopy required to make dx Solid adnexal masses (germ cell tumour) Free fluid > 30 ml

Methotrexate Protocol • Exclude contraindications as well as • No evidence of renal, liver, or hematopoietic disease (Bilirubin, AST, ALT, urea, Cr, CBC) • Informed consent • 5% risk of hematoperitoneum 2° to rupture of EP following MTX • MTX 50 mg/m² body surface area (~1 mg/kg) given IV or IM

Methotrexate Protocol – cont’d • Pt F/U • repeat serum quantitative -h. CG in 3 -4 days, 7 days, then weekly until < 10 IU/L • If > day-4 level at day-7 repeat MTX • If -h. CG fails to fall by at least 25%/week at any time repeat dose • U/S not required routinely • Pt should avoid • Alcohol use, sexual I/C, oral folic acid (until HCG levels are neg)

Methotrexate Protocol – cont’d • What to expect • Majority experience some degree of abd pain (occurs in ~ 50% at day-6) • Shedding of a decidual cast • Moderate vaginal bleeding • Side effects (usually at higher doses) • Impaired liver function, bone marrow suppression, neutropenia, stomatitis, hematosalpinx

Expectant Mx of EP • Anticipates spontaneous regression of EP • Occurs in ~ 57% • Symptoms, HCG titers, & U/S findings followed • Risk of tubal rupture is 10% if HCG levels < 1000 • Criteria include • Sonographic diameter < 3 cm • Initial -h. CG < 1 000 IU/ml, no in 2 -day period, subsequent levels • asymptomatic

Future Fertility following EP • Subsequent conception rate is ~ 60% • Incidence of recurrent EP is 15% • Other factors influencing include: • Age, parity, history of infertility, evidence of contralateral tubal disease, ruptured EP, IUCD use, salpingitis • No difference b/t laparoscopy vs laparotomy

Prevention of EP • Treat salpingitis early & correctly • MTX management lowers rate of subsequent EP • Risk of EP is with all methods of contraception, except progesterone containing IUCDs • Remember Rh Sensitization • Rhogam for the Rh-neg woman