1. Early Pregnancy Loss

2. Definition
Nonviable intrauterine pregnancy charactized by empty gestational sac or embryo/fetus <13 weeks with no fetal heart activity
10% of all pregnancies
50% are generally chromosomal abnormalities

3. Signs and Symptoms First trimester cramping/bleeding
DDx: early pregnancy loss, viable intrauterine pregnancy, ectopic pregnancy
A pelvic exam is important before testing

4. Testing Ultrasound is the prefered method to determine viabilty
HCG levels are important in interpreting ultrasound findings and for serial follow up

6. Beta HCG
Discriminatory zone mIU/ml is associated with a gestational sac in singleton pregnancies
A rise of < 50% in 48 hours is associate with an abnormal pregnancy with a sensitivity of 99%

7. Treatment Options
Expectant
Medical treatment
Surgical treatment

8. Expectant May take up to 8 weeks 80% success What is success
HCG < 5 mIU/ml
Endometrial stripe of < 3 cm
Return of normal menstrual function
Patient needs to be prepared for moderate to heavy bleeding with cramps and may need a suction currettage

9. Medical Treatment
Goal is to shorten the time to complete explusion as compared to expectant
85% success with complete expulsion with in 3 days for 70% of patients
Patient should expect moderate to heavy bleeding and cramping issues as well as possible suction currettage

11. Surgical Suction curettage has replaced sharp curetting
It is immediate and 99% successful
Clinically important intrauterine adhesions are a rare complication

12. Complications of all treatments
Incomplete requiring curettage
Infection 2%
Transfusion 1%

13. Rh Negative Mother
Give micrograms rhogam within 72 hrs of diagnosis of early pregnancy loss

14. Subsequent Pregnancy
No evidenced based data on when it is safe to get pregnant again
BCP or IUD can be started as soon as you are sure the process is complete
Consider workup for recurrent EPL after the 2nd consecutive EPL
No proven treatment for threatened abortion
Progesterone in first trimester after at least 3 EPL may be beneficial

15. Am I ready to do office gyn?
Case Studies
Am I ready to do office gyn?

16. Sally is a 23 y/o GoPo complaining of irregular bleeding
Gyn Hx: sexually active uses condoms most times
PE: 105 lb
Abdomen soft nontender
Pelvic exam: no vaginal bleeding, Cervix is closed nontender, uterus normal, adenexa neg
This scenario is about BCP for DUB
Be sure to do pg test in this age group

17. Test Results Quantative Beta HCG < 1
Ultrasound normal uterus, endometrium, and ovaries
What next? Birth control pills. Discuss what kind, how to start, what to expect

18. What if Ultrasound Shows
uterus 11x9x8 cm with multiple leiomyoma about 2-3 cm in diameter, endometrial thickness 6 mm, normal ovaries
Discuss how one would find if fibroids are the cause of her bleeding
1. trial of birth control pills
2. submucous leiomyoma including diagnostic techniques of sonohystogram and hysteroscopy

19. Test: STD negative pregnancy test negative
Sally returns after 3 months on her new birth control pill still having breakthrough bleeding
Pelvic exam is normal
Test: STD negative pregnancy test negative
Do sonohysterogram or hysteroscopy to rule out a polyp

20. Judy is a 30 y/o G2P2 for annual exam on Ortho Tricyclen Lo
Social hx: married, monogamous
She is complaining that she had regular periods for a while but now having breakthrough bleeding for 6 months
Exam: Normal
Differential diagnosis?
Diagnosis to discuss: BTB on BCP
Discuss logic of switching birth control pills

21. Mary is a 45 y/o G3P3 status post tubal ligation
Menstral formula: 2 weeks/3 days heavy on day 1
PMH: negative
Pelvic exam: Cervix normal, pap done
Uterus 6 weeks size, irregular, firm, nontender
Ovaries not enlarged, nontender
Tests: CBC – normal TSH – normal
ultrasound 3 cm serousal leiomyoma, endometrial thickness 11 mm ( make point endometrial thickness is of no help)
Be sure they do endometrial biopsy before going on to next slide

22. Guidelines for Endometrial Biopsy
All women with history of AUB of 2-3 yrs duration
All women > 45 yrs old with AUB
All women who do not respond to treatment
Discuss how to do biopsy if time allows

23. Endometrial Biopsy Results
Complex hyperplasia with atypia
Complex hyperplasia
Simple hyperplasia
Proliferative endometrium
Secretory endometrium
Complex hyperplasia with atypia refer for hysterectomy
Progesterone for complex and simple hyperplasia
BCP for proliferative and secretory

24. Vicki is a 60 y/o complaining of 3 days of light bleeding 3 weeks ago
PMH: Illnesses: diabetes controlled on diet
mild hypertension
Meds: Atenolol
Continuous hormone replacement therapy
Exam: 5’4”, 175 lb
Pelvic: vagina slightly atrophic
cervix stenotic, pap done
uterus NS/NS
adenexa negative
Discuss testing but not treatment. Move on to next slide once they mention endometrial thickness

25. Endometrial thickness
< 4 mm generally atrophic endometrium
> 4 mm you can’t rule out cancer
If > 4 mm, endo bx is simplest solution. Something that you can do

26. 60 yr old menopausal female complaining of incontinence
PI: leaking urine for several months now worse
PMH: TAH/BSO for benign disease age 45
Lumbar disk fusion 1 years ago
PE: Pelvic – 1st degree cystocoele and 1st degree rectocoele
Any additional history or physical information? Discuss signs and symptoms of SUI verses urge incontinence
Next step, I want them to do residual check as opposed to cysto, cmg, uroflow studies

27. Urine culture positive > 100,000 e-coli
Complaining of urgency, frequency, nocturia, sudden loss of large amounts of urine
Residual urine 10 ml
Urine culture positive > 100,000 e-coli
D.Dx and next steps
Management of OAB

28. Loss of urine with coughing, sneezing, laughing, squatting, jumping
Residual 50 ml and culture negative
Residual > 200 ml
Management of stress incontinence
Overflow incontinence can imitate SUI

29. 22 yr old female complaining of amenorrhea for 1 yr
PI: LMP 1 yr ago prior menstral formula 28d/5d
BC: none
Gyn Hx delivered a baby 2 yrs ago
PMH: Schizophrenic on anti-psychotic med
Soc Hx: Occasionally sexually active without condoms
PE: Thin female, no distress
Breasts bilateral milky discharge
Pelvic exam normal
D. Dx
Tests: PG test, Prolactin, TSH

30. Prolactin 100 ng/ml., TSH 5.5 uU/ml.,
Prolactin, TSH normal
MRI to rule out microadenoma
Perhaps an MRI but yield low. May be the anti-psychotic med
Maybe anovulatory with frequent stimulation and residual obstetrical effects