FIRST TRIMESTER BLEEDING

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FIRST TRIMESTER BLEEDING

• SPONTANEOUS ABORTION
• ?30, usu self-limited
• ECTOPIC PREGNANCY
• ?1, most dangerous
• MOLAR PREGNANCY
• 0.1, cookbook

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SPONTANEOUS ABORTION

• SPONTANEOUS LOSS, PRE-VIABLE
• lt20 WKS, lt500 GM
• 30 PREVALENCE
• 80 1ST TRIMESTER-EARLY

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RISK FACTORS

• AGE
• 10_at_20, 20_at_35, 40_at_40, 80_at_45
• SAB HX
• 5 NSVD/NO SAB, 30-40 IF 3 SABS

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CAUSES

• CHROMOSOMAL ABNS- 50-sporadic
• CONG ANOMALIES
• UTERINE ABNS-fibroids, synechiae, septae
• INFECTIONS
• THROMBOPHILIAS-APS, APC res, prothro, etc
• DM, THYROID
• IATROGENIC-amnio, CVS
• SUBSTANCES-caffeine, tob, meth, coc, NSAIDs

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APPROACH

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

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ECTOPIC? VIABILITY?

• RISK FACTOR ASSESSMENT
• absence doesnt r/o
• UTERINE SIZE-decidua to 8 wks
• HEART TONES- dont settle for 2nd best
• CERVICAL-open suggestive
• TISSUE PASSED-frozen/rush permanent

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ECTOPIC? VIABILITY?

• HCG
• ?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 gt20
• cardiac if fetal pole gt6-7wkCRL gt5mm

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TERMS

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

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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

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INTERVENTION

• DO I NEED TO INSTRUMENT?
• Where/ what instrument?
• How soon?-septic vs bleeding vs missed
• Lams? EGA by sono, blighted ovum
• DO I NEED FROZEN SECTION ?
• Rush permanents vs routine

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OPTIONS

• EXPECTANT
• lt10-12wk, 80-90 res, slower
• SURGICAL
• ?ectopic, septic, BLEEDING, missed,gt10-12
• Fastest
• MEDICAL
• lt10-12, 80-90 res, faster
• Miso 600-800 PV x 1-2

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PREVENT ISOIMMUNIZATION

• REMEMBER RHOGAM 50mcg IM if
  lt 12 WEEKS 300mcg IM
  IF gt 12 WEEKS

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EDUCATION SUPPORT

• ADDRESS GUILT
• ADDRESS GRIEF
• DEFER PREGNANCY gt 3 MONTHS

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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

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MOLAR PREGNANCY

• Aberrant fertilization, fetal origin
• 0.05-0.1 incid (US), chorioca 130,000
• 1120 SE Asians, 11200 Hispanics, prior mole,
  age lt20 gt35, lower parity
• 80-90 benign course
• most metastatic disease curable

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CLASSIFICATION

• HYDATIDIFORM MOLE GTD
• COMPLETE
• PARTIAL
• PERSISTENT/INVASIVE MOLEGTN
• CHORIOCARCINOMAGTN
• PLAC SITE TROPHOBLASTIC TUMOR
• GTN

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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

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CLINICAL FINDINGS

• VAGINAL BLEEDING
• NO FHTS
• SIZE gt DATES
• HIGH HCG- gt100,000 (nl preg peak lt 200,000)
• HYPEREMESIS GRAVIDARUM
• EARLY PREECLAMPSIA lt20Wwks
• THYROTOXICOSIS
• OVARIAN CYTS ( THECA LUTEIN)

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DIAGNOSIS

• SONOGRAPHY
• PATHOLOGY

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W/U

• HCG, Rh, TSH, LFP, BUN/Cr
• CXR
• SONO

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TREATMENT

• Uterine evacuation
• DC, pitocin running?
• Bleeding, perforation, ?ARDS, etc
• Serial HCGs
• q wk till negative then q mo for 6-12mo
• Should drop rapidly be negative lt 90 days
• normal preg usu takes 2-4wk
• effective contraception during follow-up

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Persistent/recurrent HCG rise

• HCG rise x2 wk, stable x 3wk,_at_3mo
• ?new pregnancy
• Worry re GTN/metastatic disease
• 25chorioca, 75 persist/invasive mole
• Pelvic sono
• Consider repeat DC- up to 40 ?neg HCG
• Cbc, coags, liver, renal labs
• CT abd, pelvis, chest, ?head

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High risk features

• Higher HCG
• Time from and characteristics of antecedent
  pregnancy
• Site, size and number of mets
• failure of prior chemo

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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 HCGs after molar pregs

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Remember rhogam

• 300mcg IM with moles

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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

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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

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Risk factors

• Tubal damage
• Prior ectopic
• PID 124 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

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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

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HCG

• gt99 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

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Lower normal limits HCG rise
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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?

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Sonographycontinued

• Gestational sac (vs pseudo sac)
• EGA5wks, singleton 1000-1800
• Fetal pole
• EGA5.5wks, by mean sac diam of 16-20mm
• Cardiac activity
• EGA6wks, by 7 wks minimum EGA or fetal pole
  gt5mm

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DDX

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

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DIAGNOSTIC ALGORITHM
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DIAGNOSTIC ALGORITHM
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DIAGNOSTIC ALGORITHM
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DIAGNOSTIC ALGORITHM
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Treatment options

• Expectant
• Methotrexate
• Surgery

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Expectant

• Selection criteria
• asymptomatic, small ectopic, low falling HCG
• Rationale
• ?incidence tubal SAB, no therapeutic MM
• Concerns
• risk of rupture awaiting resolution

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Methotrexate

• Inclusion criteria
• lt3-4cm, unruptured, no liver, renal, heme dis
  ?no cardiac activity, ?HCG lt5000-15,000
• Education/ consent
• Workup
• CBC/d, AST, BUN/Cr,Type/Rh
• Sono
• DC

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Methotrexateinformed consent

• Alternatives
• nature of treatment follow-up
• failure rate, risk of rupture
• Side-effect profile
• pain, stomatitis, liver, marrow, renal tox
• things to avoid
• NSAIDs, ETOH, folic acid, intercourse

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Methotrexate

• Dose
• 50mg/m2
• Follow-up
• quant HCG 36 days after injection
• Success
• gt15 drop on HCG between day 36
• follow weekly till negative

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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

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Surgery

• Laparoscopy vs laparotomy
• Conservative- maximize fertility
• salpingostomy
• Extirpative- prevent future ectopics
• salpingiectomy