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Part 1. Cornerstones of diagnosis are:  history and examination  hCG  transvaginal ultrasound.

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Presentation on theme: "Part 1. Cornerstones of diagnosis are:  history and examination  hCG  transvaginal ultrasound."— Presentation transcript:

1 Part 1

2 Cornerstones of diagnosis are:  history and examination  hCG  transvaginal ultrasound

3  Glycoprotein with  and  sub-units linked by disulfide bond (  same in all glycoprotein hormones inc. FSH, LH, TSH;  subunit confers unique biological activity and specificity in radioimmunoassays)  Secreted by syncytiotrophoblast of the chorion  Prevents degradation of the corpus luteum (Corpus luteum produces progesterone and some oestrogen which causes the endometrial glands to prepare for implantation of the blastocyst)

4  Initially rises exponentially and after 6 weeks (> mIU/mL) more slowly  “Doubling time” useful in first 6 weeks  66% considered to be minimal rise in 48 hours for normal intrauterine pregnancy (85% confidence interval ie. 15% normal pregnancies have less than this rise & 15% ectopics have this rise)

5  Plateauing  hCG suggests ectopic  Falling  hCG - rate important Half life less than 1.4 days – rarely ectopic Half life more than 7 days – most predictive of ectopic  Single level – useful only as indication for expected ultrasound findings (depending on quality of ultrasound service)  x higher than normal pregnancy levels in gestational trophoblastic disease

6 25-29 days (from LNMP)Intradecidual sac sign (small gestational sac in decidua) (only 50% early pregnancies)Double sac sign (decidua and membranes) 34 days (earliest) Usual days Gestational sac (  hCG = discriminatory zone on T/A scan) 36 days (earliest) Usual 42 days Yolk sac 43 days (earliest) Usual 45 days Embryo 43 days (earliest) Usual 45 days Embryonic cardiac activity (CRL >5mm,  hCG >25000)

7  Gestational sac >13mm without yolk sac or >17mm without embryo means a non-viable pregnancy

8  Not very useful  >25ng/mL – likely viable intra-uterine pregnancy  <5 ng/mL – abnormal pregnancy but don’t know if intra- or extrauterine  Most between 10 and 20 with early pregnancy bleeding/pain

9  Differential diagnosis: Miscarriage/abortion (intra-uterine pregnancy) Ectopic pregnancy Other – cervical polyps, vaginitis, trauma, foreign body, cervical carcinoma, gestational trophoblastic disease (molar pregnancy)

10

11  Spontaneous: 20-30% of all known pregnancies (80% in 1 st trimester). If pregnancy failure has occurred, usually before 8 weeks  Threatened: 30-40% all pregnancies Small PV loss Uterine size =dates Os closed Fetal heart seen or too early to be seen

12  Missed: Uterine size < dates Os closed May not have bleeding at first Fetal pole with no fetal heart  Inevitable: Heavy PV loss, usually clots Cervix open Initially no products passed  Incomplete: 6 weeks

13  Blighted ovum (fertilised but anembryonic)  Chromosomal anomalies  Embryonic anomalies  Uterine anomalies  IUD  Teratogens (any agent which affects the developing embryo)  Mutagens (any agent which changes the DNA of germ cells)  Maternal disease  Placental abnormalities  Trauma

14  History and examination   hCG +/- ultrasound  (ALWAYS DO A PREGNANCY TEST FOR BLEEDING FEMALE IN REPRODUCTIVE AGE GROUP)  ALWAYS THINK ABOUT ECTOPIC  ALWAYS CHECK BLOOD GROUP

15  Threatened – observe  Missed – suction curettage  Inevitable or incomplete – expectant if stable or suction curettage or misoprostil

16  Next week…


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