1. FIRST TRIMESTER BLEEDING
SPONTANEOUS ABORTION
?30%, usu self-limited
ECTOPIC PREGNANCY
?1%, most dangerous
MOLAR PREGNANCY
0.1%, cookbook
Cervicitis, ectropion, ect less important, less common and usu obvious
Order of prevalence20-30% vs 1% vs 0.1%, ectopic is most dangerous needs most study
Sab usu handles itself, mole is cookbook

2. SPONTANEOUS ABORTION SPONTANEOUS LOSS, PRE-VIABLE
<20 WKS, <500 GM
30% PREVALENCE
80% 1ST TRIMESTER-”EARLY”
Prevalence varies- recog vs vs very early preg’s

3. RISK FACTORS AGE SAB HX 10%@20, 20%@35, 40%@40, 80%@45
5% NSVD/NO SAB, 30-40% IF 3 SABS

4. CAUSES CHROMOSOMAL ABN’S- 50%-sporadic CONG ANOMALIES
UTERINE ABN’S-fibroids, synechiae, septae
INFECTIONS
THROMBOPHILIAS-APS, APC res, prothro, etc
DM, THYROID
IATROGENIC-amnio, CVS
SUBSTANCES-caffeine, tob, meth, coc, NSAIDs

5. APPROACH ESTABLISH IUP-R/O ECTOPIC-urgent
ESTABLISH VIABILITY-less urgent
CONSIDER INTERVENTION-not all
REMEMBER RHOGAM-all Rh neg
EDUCATE/ SUPPORT/ FOLLOW-UP

6. ECTOPIC? VIABILITY? RISK FACTOR ASSESSMENT
absence doesn’t r/o
UTERINE SIZE-decidua to 8 wks
HEART TONES- don’t settle for 2nd best
CERVICAL-open suggestive
TISSUE PASSED-frozen/rush permanent
Rf-abd/pelvic surg,pid,failed contraception-neg pred value not validated
Decidua to 8wk, fht’s prob 2nd best if sono not avail
Open os, tissue hard-always use path-frozen or rush perm

7. ECTOPIC? VIABILITY? HCG SONOGRAPHY ?serial- not if visualized on sono
?serial sono better if not definitive
SONOGRAPHY
Gest sac/yolk sac- ?normal appearing
Fetal pole if gest sac MSD >20
cardiac if fetal pole >6-7wk=CRL >5mm
Will talk about discrim zone, HCG curve with ectopics more in detail

8. TERMS THREATENED-next slide INEVITABLE-open,SROM,heavy bleeding
INCOMPLETE-
COMPLETE-easiest in retrospect-decresc
MISSED/” BLIGHTED OVUM”
SEPTIC

9. Threatened SAB Vaginal bleeding +/- cramping
30-40% pregnancies bleed; 1/2 SAB
more symptoms, small for dates, subchorionic bleed-poorer prognosis
fetal cardiac activity- better prognosis
Rx- observation
<1-2% risk of loss if fetal cardiac activity

10. INTERVENTION DO I NEED TO INSTRUMENT? DO I NEED FROZEN SECTION ?
Where/ what instrument?
How soon?-septic vs bleeding vs missed
Lam’s? EGA by sono, blighted ovum
DO I NEED FROZEN SECTION ?
Rush permanents vs routine

11. OPTIONS EXPECTANT SURGICAL MEDICAL <10-12wk, 80-90% res, slower
?ectopic, septic, BLEEDING, missed,>10-12
Fastest
MEDICAL
<10-12, 80-90% res, faster
Miso PV x 1-2

12. PREVENT ISOIMMUNIZATION
REMEMBER RHOGAM mcg IM if < 12 WEEKS mcg IM IF > 12 WEEKS

13. EDUCATION & SUPPORT ADDRESS GUILT ADDRESS GRIEF
DEFER PREGNANCY > 3 MONTHS
Work, sex, trauma- 2 yr sib kicking abd– vs meth use and tob
Similar to term IUFD
?some data suggest higher SAB rate if within 3 mo

14. Recurrent SAB ?3 consecutive for therapeutic nihilists
?evid base for recommendations
Outcomes similar- ~70% successful preg
no w/u, + or – w/u , +w/u with or without rx
50% success after 6 consecutive losses
Uterine eval, day 3 FSH, antiphos syn w/u & misc thrombophilia w/u, TSH, ?fast glu, ?ANA, karyotype
Thrombophilia is in –progesterone supps, doxy are both out
3 consecutive
Progest for luteal phase defect, empiric antibiotic for mycoplasma out

15. MOLAR PREGNANCY Aberrant fertilization, fetal origin
% incid (US), chorioca 1:30,000
1:120 SE Asians, 1:1200 Hispanics, prior mole, age <20 >35, lower parity
80-90% benign course
most metastatic disease curable

16. CLASSIFICATION HYDATIDIFORM MOLE =GTD PERSISTENT/INVASIVE MOLE=GTN
COMPLETE
PARTIAL
PERSISTENT/INVASIVE MOLE=GTN
CHORIOCARCINOMA=GTN
PLAC SITE TROPHOBLASTIC TUMOR=
GTN
Last 3 =GTN (vs gtd)- or metastatic gtd

17. Complete & partial mole
No fetal tissue
1 sperm + anuclear ovum- 46XX or 46XY
GTN risk 20%
Fetal tissue
2 sperm + 1 ovum - 69XXY or 69XYY
GTN risk 5%
Not terribly important but check GTN risk

18. CLINICAL FINDINGS VAGINAL BLEEDING NO FHT’S SIZE > DATES
HIGH HCG- >100,000 (nl preg peak < 200,000)
HYPEREMESIS GRAVIDARUM
EARLY PREECLAMPSIA <20Wwks
THYROTOXICOSIS
OVARIAN CYTS ( THECA LUTEIN)

19. DIAGNOSIS
SONOGRAPHY
PATHOLOGY

20. W/U
HCG, Rh, TSH, LFP, BUN/Cr
CXR
SONO

21. TREATMENT Uterine evacuation Serial HCG’s
D&C, pitocin running?
Bleeding, perforation, ?ARDS, etc
Serial HCG’s
q wk till negative then q mo for 6-12mo
Should drop rapidly& be negative < 90 days
normal preg usu takes 2-4wk
effective contraception during follow-up

22. Persistent/recurrent HCG rise
=HCG rise x2 wk, stable x
?new pregnancy…
Worry re GTN/metastatic disease
25%chorioca, 75% persist/invasive mole
Pelvic sono
Consider repeat D&C- up to 40% neg HCG
Cbc, coags, liver, renal labs
CT abd, pelvis, chest, ?head

24. High risk features Higher HCG
Time from and characteristics of antecedent pregnancy
Site, size and number of mets
failure of prior chemo

25. GTN Occurs 50% after nl preg, 25% after mole, 25% after ectopic/SAB
Vag bleeding or amenorrhea esp prolonged postpartum,very bloody tumors check HCG
Serial HCG’s after molar pregs

26. Remember rhogam
300mcg IM with moles

27. ECTOPIC PREGNANCY Implantation outside endometrial cavity
High prevalence related to PID prevalence
98-99% tubal- usu rupturing 6-10 wks
cornual, cervical, ovarian, abdominal rare

28. High index of suspicion
Assume all female patients are pregnant until proven otherwise
?9-50yrs, sexual hx reliability, contraceptive failure
Assume all pregnant patients are ectopic until proven otherwise
danger of preexisting diagnosis of SAB

29. Risk factors Tubal damage Failed contraception Misc.
Prior ectopic
PID 1:24 pregs
pelvic surg- appi, cystectomy, section, TL
Failed contraception
IUD, progesterone only methods, TL, emergency?
Misc.
extrinsic mass, infert, smoking at conception
Absence of risk factors does not rule out ectopic

30. Clinical Presentation -an evolution-
Pregnancy
amenorrhea, N, V, frequency, rising HCG
Failing pregnancy
vag bleeding, ?tissue, flat/ falling HCG
Growing/ rupturing ectopic
pain (colic, peritoneal irritation, referred), mass, hemodynamic instability, fluid in belly
Variable because it is an evolution

31. HCG >99% ectopics positive absolute values correlate poorly w/ EGA
relative rise helpful early in gestation
abnormal rise signifies abnormal gestation
note 20-30% of ectopics have normal rise

32. Lower normal limits HCG rise
Newest literature give 53% as the lowest 2 day rise in normal pregnancies

33. Sonography Primary-Verify or rule out IUP-?heterotopic
Also ectopic cardiac, complex mass, free fluid
“Discriminatory zone”
Endovaginal vs. transabdominal
Availability
Indication-low thresholds symptoms-All?
Depend on heterotopic being rare-1:30,000 prob ~ or 4000 even w/o fert rx’s
Availability evolution
Indication all cramp/bleed-?all 1st tri r/o ectopic, dating- decr postdates induction

34. Sonography continued Gestational sac (vs pseudo sac) Fetal pole
EGA~5wks, singleton
Fetal pole
EGA~5.5wks, by mean sac diam of 16-20mm
Cardiac activity
EGA~6wks, by 7 wks “minimum EGA” or fetal pole >5mm
Twins double the discrim zone- more hormone for lesser gest age

35. DDX SAB Molar preg IUP complicated by: ovarian cyst complication
fibroid degeneration, torsion
appendicitis
etc.

36. DIAGNOSTIC ALGORITHM Peritoneal signs, hemodynamic instability
RF’s, sono-empty ut, blood in morrison’s pouch,+/-adnexal mass

37. DIAGNOSTIC ALGORITHM
Empty DDx is completed SAB- minimally symptomatic and rapidly falling HCG in the setting of cramping and bleeding usually for some time

38. DIAGNOSTIC ALGORITHM
Ectopic precautions- pain, incr bleeding, lightheadedness,etc

39. DIAGNOSTIC ALGORITHM
No instrumentation if very likely completed SAB: crescendo-decrescendo, no rf’s, low hcg
Playing with fire otherwise
Or rush permanents instead of frozen or in addition to frozen

40. Treatment options
Expectant
Methotrexate
Surgery

41. Expectant Selection criteria Rationale Concerns
asymptomatic, small ectopic, low falling HCG
Rationale
?incidence tubal SAB, no therapeutic M&M
Concerns
risk of rupture awaiting resolution

42. Methotrexate Inclusion criteria Education/ consent Workup
<3-4cm, unruptured, no liver, renal, heme dis ?no cardiac activity, ?HCG < ,000
Education/ consent
Workup
CBC/d, AST, BUN/Cr,Type/Rh
Sono
D&C

43. Methotrexate informed consent
Alternatives
nature of treatment & follow-up
failure rate, risk of rupture
Side-effect profile
pain, stomatitis, liver, marrow, renal tox
things to avoid
NSAID’s, ETOH, folic acid, intercourse

44. Methotrexate Dose Follow-up Success 50mg/m2
quant HCG 3&6 days after injection
Success
>15% drop on HCG between day 3&6
follow weekly till negative

45. ALT METHOTREXATE 1mg/kg IM every other day to 4 doses
Quant HCG with leucovorin rescue on alternate days
Stop when 15% drop in HCG
?higher efficacy, less lost sleep

46. Surgery Laparoscopy vs laparotomy Conservative- maximize fertility
salpingostomy
Extirpative- prevent future ectopics
salpingiectomy