1. EARLY PREGNANCY PAIN AND BLEEDING
Part 1

2. Early pregnancy problems
Cornerstones of diagnosis are:
history and examination
hCG
transvaginal ultrasound

3. Human Chorionic Gonadotrophin (hCG)
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. hCG Interpretation Early Pregnancy
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)
3-100 x higher than normal pregnancy levels in gestational trophoblastic disease

6. Ultrasound Findings (T/V) Early Pregnancy
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
Embryonic cardiac activity
(CRL >5mm, hCG >25000)

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

8. Progesterone Assays 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. Early Pregnancy Bleeding
Differential diagnosis: Miscarriage/abortion (intra-uterine pregnancy) Ectopic pregnancy Other – cervical polyps, vaginitis, trauma, foreign body, cervical carcinoma, gestational trophoblastic disease (molar pregnancy)

10. Abortion

11. Abortion
Spontaneous: 20-30% of all known pregnancies (80% in 1st 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. Abortion
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 usually fetus and placental tissue passed together vs >6 weeks

13. Causes of Miscarriage 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. Management Early pregnancy bleeding
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. Management options Threatened – observe Missed – suction curettage
Inevitable or incomplete – expectant if stable or suction curettage or misoprostil

16. Ectopic Pregnancy
Next week…