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Eve Espey, MD, MPH
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
Don’t nuke a normal pregnancy or miss an ectopic
Place an IUD immediately after D&C for miscarriage
“We’ve got a gal here with bleeding, pain and a positive pregnancy test”
Normal pregnancy Miscarriage Ectopic
Ultrasound Quantitative hCG Experience Common sense Luck!
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
Uterus outline
Sub-chorionic bleed
Embryo
Yolk sac
Gestational sac
Choriodecidual reaction
5 weeks ----> Gestational sac (5mm)
6 weeks ----> Yolk sac
7 weeks ----> Cardiac motion
17 y/o G2P0 presents with bleeding, cramping, positive pregnancy test
Differential◦ Normal pregnancy◦ Miscarriage◦ Ectopic?
Sac = 5 4/7 weeks
Day 0 = 1,700 Day 2 = 4,400 Rise = 158% Likely diagnosis?
The AVERAGE hCG rise over 48 hours in a normal pregnancy is 124%
Day 0 = 1,700Day 2 = 2,200Rise = 29%Likely diagnosis?
The MINIMUM hCG rise over 48 hours in a normal pregnancy is 53%
J Clin Endocrinol Metab 1979;49:917
J Clin Endocrinol Metab 1979
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
32 y/o G2P1 at 7 weeks from LMP
Presents with bleeding, cramping, positive pregnancy test
hCG = 5,277
Transvaginal U/S◦ Beta HCG = 1500 - 2000 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
Most common cause of maternal death in early pregnancy 20 deaths per year in the US
1970 17,800 cases Fatality 35/10,000 1992 108,800 cases Fatality 3.4/10,000
Risk factors:◦ Prior tubal sterilization 10%◦ Hx Salpingitis.....4X◦ Linear salpingostomy.....10X◦ Ovulation induction.....4X◦ Most cases have no known risk factor!◦ Minority race
Laparoscopy◦ Salpingostomy
5-20% persistent ectopic Monitor with hCG to 0 Treat with MTX
◦ Salpingectomy Laparotomy Medical management Expectant management
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
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
If pretreatment Bhcg >5000 failure rate is around 14%
If pretreatment Bhcg <5000, failure rate is around 3.7%
Consider two-dose regimen if Bhcg >5000
Author Tx IUP Repeat ectopic
Sherman 1982 Salpingectomy 72% 6% Sherman 1982 Salpingostomy 83% 6% Stovall 1993 Medical 70% 9%
Miscarriage
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.
Expectant management
Misoprostol D&C
◦ Suction◦ MVA
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
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
“Vocal local” Oral analgesia + paracervical block
◦ Ibuprofen 800 mg ◦ Percocet and 1 mg lorazepam
IV sedation + paracervical block + ◦ Fentanyl 50-100 mcg ◦ Midazolam 1-2 mg
Regional anesthesia (spinal) General anesthesia or deep sedation
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
Ectopic pregnancy vs. early IUP Offered methotrexate Patient declined: desired
pregnancy Plan: Repeat hCG in 48 hours
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)
Laparoscopy◦ 400 cc hemoperitoneum, “no active
bleeding site determined”◦ Attempted salpingostomy followed by left
salpingectomy◦ Discharged on POD #1
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
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.”
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)
Day #14◦ 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 0-
100 bpm Day #25
◦ Ultrasound: CRL consistent with 6 ½ weeks with no FHM◦ Requests misoprostol for management
Day #30◦ Empty uterus, Paragard IUD placed
“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
hCG and pathology follow-upBeta book systemContinuity of physician teams seeing the patient Context—patient course, hCGs and U/S
Ovulation may occur within 10 days
Don’t forget contraception
Half of pregnancies are unintended
May wish to delay another pregnancy even if intended
> 700 women undergoing D&C (abortion and miscarriage) from 5-12 weeksRandomized to immediate vs. delayed IUD insertionNo significant difference in expulsion risk:
◦ 4.5% immediate◦ 2.7% delayed
No increase in other complications
Bednarek, NEJM 2011
Be meticulous in follow-up of first trimester complications
Consider misoprostol and MVA for treatment Don’t forget the IUD!