1. Avoiding the Pitfalls: 1st trimester pregnancy complications
Eve Espey, MD, MPH

2. No financial disclosures

3. Lecture Objectives
Understand steps in diagnosis in women with bleeding, cramping and a positive pregnancy test
Initiate appropriate management for miscarriage, ectopic and threatened abortion
Understand medical and surgical approaches to the management of miscarriage and ectopic pregnancy

4. The punch line… Don’t nuke a normal pregnancy or miss an ectopic
Place an IUD immediately after D&C for miscarriage

5. The ER calls:
“We’ve got a gal here with bleeding, pain and a positive pregnancy test”

6. Puny differential….
Normal pregnancy
Miscarriage
Ectopic

7. Few tools
Ultrasound
Quantitative hCG
Experience
Common sense
Luck!

8. But high impact…
One of the top reasons OB-GYNs are sued: MTX given to a normal intrauterine pregnancy
Ectopic pregnancy still causes maternal mortality
Dealing with miscarriage in a sensitive way is paramount to women

9. Landmarks in Early Pregnancy
Uterus outline
Sub-chorionic bleed
Embryo
Yolk sac
Gestational sac
Choriodecidual reaction
Vaginal Ultrasound
Ultrasound can be useful in identifying an early intrauterine pregnancy before the procedure and its absence after the procedure. In pregnancies < 5 weeks, the gestational sac may be difficult to find. There will be a thick decidual shadow with an intra- or extra- uterine pregnancy.
The features to look for when performing a vaginal ultrasound to determine gestational age for early abortion are:
the presence of the gestational sac
the presence of an embryonic structure
the presence of the yolk sac
the presence of cardiac activity.

10. Transvaginal ultrasound: What you should see, when you should see it
5 weeks > Gestational sac (5mm)
6 weeks > Yolk sac
7 weeks > Cardiac motion
Maintain a healthy skepticism about the date of the LMP

11. Case
17 y/o G2P0 presents with bleeding, cramping, positive pregnancy test
Differential
Normal pregnancy
Miscarriage
Ectopic?
At every step of the workup, I ask residents to consider what the differential is and has an ectopic been ruled out.
Sac = 5 4/7 weeks

12. Miscarriage vs. normal pregnancy? Quantitative hCG approach:
The AVERAGE hCG rise over 48 hours in a normal pregnancy is 124%
Day 0 = 1,700
Day 2 = 4,400
Rise = 158%
Likely diagnosis?

13. What if the quants had been..?
Day 0 = 1,700 Day 2 = 2,200 Rise = 29% Likely diagnosis?
The MINIMUM hCG rise over 48 hours in a normal pregnancy is 53%

14. 1st Trimester hCG J Clin Endocrinol Metab 1979;49:917

15. Caveats
15% of women with IUP have an “abnormal” rise in hCG in the first 40 days
17% of ectopic pregnancies have a normal rise in hCGs over 48 hours at least once in early pregnancy
Kadar et al.Obstet Gynecol 1981;58:162

16. Case 32 y/o G2P1 at 7 weeks from LMP
Presents with bleeding, cramping, positive pregnancy test
hCG = 5,277

17. Discriminatory zone Transvaginal U/S Transabdominal U/S
Beta HCG = mIu/ml
Transabdominal U/S
Beta HCG = 3,600 mIu/ml
If HCG > discriminatory zone and no gestational sac seen, consider ectopic pregnancy till proven otherwise

18. Day 8 hCG = 580 Ultrasound:

19. Oops! Ectopic pregnancy

20. ECTOPIC PREGNANCY
Most common cause of maternal death in early pregnancy
20 deaths per year in the US
,800 cases Fatality /10,000
,800 cases Fatality /10,000
Risk factors:
Prior tubal sterilization 10%
Hx Salpingitis.....4X
Linear salpingostomy X
Ovulation induction.....4X
Most cases have no known risk factor!
Minority race

21. Ectopic: Management options
Laparoscopy
Salpingostomy
5-20% persistent ectopic
Monitor with hCG to 0
Treat with MTX
Salpingectomy
Laparotomy
Medical management
Expectant management

22. Medical management of ectopic pregnancy using Methotrexate:
Single, two or multi-dose regimens
Reported success: 71%-94%
Patient selection
Stable
No IUP on ultrasound or villi on D&C
Labs normal: AST, WBC, platelets, creatinine
Relative contraindications
hCG > 5,000
Cardiac activity in the tube
Sac > 3.5 cm

23. Single dose MTX Day 0: hCG, CBC, Platelets, Rh, AST, Cr
Day 0: MTX 50mg/m2 IM
Day 4: Quantitative hCG
Day 7: Quantitative hCG
If HCG does not decrease by at least 15% from Day 4, repeat MTX
Weekly hCG until < 5

24. Failure…. If pretreatment Bhcg >5000 failure rate is around 14%
Consider two-dose regimen if Bhcg >5000

25. Fertility following treatment for ectopic pregnancy
Author Tx IUP Repeat ectopic
Sherman 1982 Salpingectomy % 6%
Sherman 1982 Salpingostomy 83% 6%
Stovall Medical % 9%

26. Miscarriage

27. Spontaneous abortion About 25% of women experience a miscarriage.
Approximately 15% of clinically recognized pregnancies spontaneously abort in the first or early second trimester.
Up to 33% of all pregnancies end in miscarriage.

28. Management options for miscarriage
Expectant management
Misoprostol
D&C
Suction
MVA

29. Misoprostol for miscarriage Pooled outcomes
Treatemtent
Success rates
Placebo
16-60%
Single dose misoprostol
25-88%
Repeat dose x 1 if incomplete at 24 hours
80-88%
Success rate depends on type of miscarriage
-100% with incomplete abortion
- 87% for all others
Wood SL, Obstet Gynecol 2002; Bagratee JS, Hum Reproduct 2004; Blohm F, BJOG: Int J Obstet Gynecol 2005

30. Misoprostol for miscarriage: Note – off label use!
Gestational sac or CRL up to 10 weeks
No embryo or no fetal cardiac activity
Rh, hematocrit
800 mcg misoprostol x 2 doses
Intravaginal home administration x 1 dose
Repeat after 24 hours if no tissue
Ibuprofen + Tylenol with codeine
If no passage within a week, RTC for options

31. Suction curettage

32. Manual Vacuum Aspirator (MVA)

33. Anesthesia options “Vocal local” Oral analgesia + paracervical block
Ibuprofen 800 mg
Percocet and 1 mg lorazepam
IV sedation + paracervical block +
Fentanyl mcg
Midazolam 1-2 mg
Regional anesthesia (spinal)
General anesthesia or deep sedation
CORE SLIDE

34. A hair-raising tale:
31 y/o G3P2 presents to ER with “severe LLQ pain” and positive pregnancy test
Benign pelvic exam, + hCG
Ultrasound: “No IUP, left adnexal mass with surrounding echogenic fluid and free fluid in pelvis concerning for ruptured ectopic”
hCG = 1,003

35. Day 0 Ectopic pregnancy vs. early IUP Offered methotrexate
Patient declined: desired pregnancy
Plan: Repeat hCG in 48 hours

36. Day 1 assessment Continued pain, back to emergency room
HR 93, BP 148/71, bilateral adnexal tenderness and rebound
Ultrasound: “Small hypoechoic focus in uterus, possible pseudosac. Left adnexal mass with interval development of heterogeneous material/free fluid”
hCG: 1,419 (55% rise)

37. Day #1 management Laparoscopy
400 cc hemoperitoneum, “no active bleeding site determined”
Attempted salpingostomy followed by left salpingectomy
Discharged on POD #1

38. Day #7 Pathology sent on Day #1 Checked on Day #7 Pathology
Gross: Sectioning through this area demonstrates “presumed villi”
Microscopic diagnosis: “No chorionic tissue, no evidence of intratubal gestation

39. Day 7 Patient called: “final pathology negative for POCs” hCG: 9,417
Triage ultrasound: “Gestational sac measuring 6 weeks, minimal free fluid, right ovary 2.9 cm, circumferential flow, hypoechoic cystic structure within ovary measuring 2 cm, no embryonic pole, no embryonic fetal heart motion.”

40. Day #7: Management Diagnosis: Presumed ongoing ectopic
Radiology ultrasound was ordered but not available since it was the weekend. Given a concerning picture for ectopic, methotrexate was recommended
IM MTX 50 mg/m2
Day #11
hCG = 15,168 – not checked, F/U day #14 (7 days after MTX given)

41. Follow-up Day #14 Day #18 Day #25 Day #30
Ultrasound: 6 ½ week IUP with positive fetal heart motion in the 120s
Patient counseled re MTX in setting of normal IUP
Day #18
Ultrasound: CRL consistent with 6 ½ weeks with FHM ranging from bpm
Day #25
Ultrasound: CRL consistent with 6 ½ weeks with no FHM
Requests misoprostol for management
Day #30
Empty uterus, Paragard IUD placed

42. Multiple problems
“Offered” MTX (instead of dx LSC) on Day 0 with a desired pregnancy
Laparoscopy: No active bleeding?
Checked pathology on Day 7
Incorrect interpretation of hCG of 9,417 with no fetal heart motion
MTX given based on an inadequate U/S
Day #11 hCG not checked till Day #14

43. The devil is in the details
hCG and pathology follow-up
Beta book system
Continuity of physician teams seeing the patient
Context—patient course, hCGs and U/S

44. Classic missed opportunity
Ovulation may occur within 10 days
Don’t forget contraception
Half of pregnancies are unintended
May wish to delay another pregnancy even if intended

45. IUD insertion after 1st trimester uterine aspiration
> 700 women undergoing D&C (abortion and miscarriage) from 5-12 weeks
Randomized to immediate vs. delayed IUD insertion
No significant difference in expulsion risk:
4.5% immediate
2.7% delayed
No increase in other complications
Bednarek, NEJM 2011

46. Summary Be meticulous in follow-up of first trimester complications
Consider misoprostol and MVA for treatment
Don’t forget the IUD!