Conceptual plus emphasis on bedside practicality

1. Emergencies in the first 20
weeks of Pregnancy
Dr Goutham B M

2. Case study

3. History
A 28-year-old woman, gravid III Para II, was admitted to the emergency
department at 10 weeks of amenorrhea, with acute abdominal pain, dyspnea
and hypotension. She had no vaginal bleeding. Her current pregnancy occurred
spontaneously. This was a spontaneous conception with no previous fertility
treatment and she did not use any contraception. Her medical history did not
suggest any history of pelvic inflammatory disease, abortions, infertility or
abdominal surgery or trauma.

4. Physical examination and Lab
The physical examination revealed a conscious
woman with discolored conjunctives and
cutaneous paleness, systolic blood pressure of
70 mmHg, shortness of breath, profuse
sweating and a tachycardia, with a weak and
rapid pulse rate of 130 beat per minute.
Abdominal examination was suggestive of an
acute abdomen with severe tenderness,
guarding and rigidity.
Laboratory data on admission showed a white
blood cell count of 7900 cells/mm3, a
hematocrit of 18% and serum hemoglobin
concentration of 9.1 g/dl, with a normal blood
platelet level (390,000/mm3), a blood urea of 45
mg/dL and a creatinine level of 1 mg/dL.
Hemostasis laboratory data, chemistry and
serum lipase were within normal limits

5. Radio diagnosis and its Limitations
After hemodynamic stability, an abdominal
ultrasonography (US) was realized, which
demonstrated free intraperitoneal fluid and a
normal-looking IU gestation with a sac of 33.79
mm in diameter and a crown-rump length (CRL)
of 28 mm, with a positive fetal heart rate
consistent with a fetal age of approximately 10
weeks and 2 days of amenorrhea
The patient became acutely hypotensive with an
associated increase in abdominal girth. This
episode of hypotension was minimally
responsive to fluid resuscitation. A stat
hemogram confirmed an acute decrease in her
hematocrit

6. Approach to Women of
Childbearing age with Positive
UPT

7. Initial Patient
Presentation
Triad of Symptoms (50%)
● Abdominal Pain
● Bleeding per vagina
● Amenorrhea
● Abdominal pain or discomfort is the most common
symptom of ectopic pregnancy and is reported in 90% of
ectopic pregnancies.
● The classic pain of rupture is lateralized, sudden, sharp,
and severe . Shoulder Pain maybe present due to
diaphragmatic irritation
● Any lateral or bilateral abdominal discomfort or tenderness
in a woman of childbearing age requires consideration of
ectopic pregnancy
● Lack of pain in a woman with vaginal spotting or
bleeding does not exclude ectopic pregnancy.
● Bleeding per vaginum (PV) is usually scanty, brownish and
altered which occurs due to withdrawal of hormonal
support on rupture or total abortion of ectopic pregnancy.
● No missed menses are reported in 15% of ectopic
pregnancy cases.
● Dyspepsia, vomiting and loose motions , Syncopal attacks
with sudden unexplained episodes of fainting

8. Focused History
Major Risk Factors for Ectopic Pregnancy
● Pelvic inflammatory disease, history of sexually transmitted
infections
● History of tubal surgery or tubal sterilization
● Conception with intrauterine device in place
● Maternal age 35–44 (age-related change in tubal function)
● Previous ectopic pregnancy
● Assisted reproduction techniques (cause unknown, as tube
is bypassed in implantation)
● Cigarette smoking (may alter embryo tubal transport)
● Prior pharmacologically induced abortion
● Pregnancy in a patient with
prior tubal surgery for
sterilization is assumed to
be an ectopic pregnancy
until proven otherwise

9. Focused Physical Examination
Hemodynamically stable patient :
● Vitals in normal range
● Rule out Cryptic shock
● We can't diagnose or exclude
ectopic pregnancy based on
physical examination ( pelvic
examination )
Hemodynamically unstable patient : SI > 0.9
Patient will be presented in shock - Decompensated state
● Hypotension (<65 mmhg)
● Tachycardia (>100 bpm)
● Tachypnea (>22 cpm)
● Oliguria (<0.5 ml/kg/hr)
● JVP (<8 cm)
● Cool extremities , CFT ( >3 secs) , weak pulse

10. Differential Diagnosis for
UPT positive patient
having atleast either one
of the 3 symptoms
● Ectopic pregnancy
● Threatened abortion
● Inevitable abortion
● Molar pregnancy
● Heterotopic pregnancy*
● Implantation bleeding
● Corpus luteum cyst
● Threatened Abortion is presumed when bloody vaginal
discharge or bleeding appears through a closed
cervical os during the first 20 weeks.
● Every woman with an early pregnancy, vaginal bleeding,
and pain should be evaluated. The primary goal is
prompt diagnosis of ectopic pregnancy, and serial
quantitative serum Beta-hCG levels and transvaginal
sonography are integral tools
● No Single Beta-HCG level can reliably distinguish
between a Normal and a pathologic pregnancy
● Serial measurements of Beta - HCG are used to
heighten or lower the suspicion for ectopic pregnancy
but are not diagnostic
● PPROM with gush of vaginal fluid is diagnostic of
inevitable abortion
● Molar pregnancy and corpus luteum cyst can be
diagnosed definitively with US
● Spotting at 7th day after fertilisation is characteristic of
implantation bleeding

11. Diagnosis of
Ectopic
Pregnancy
Multimodality Diagnosis :
● TVS
● Beta-HCG
● Physical findings
The definitive diagnosis of ectopic
pregnancy is made by US, by direct
visualization by laparoscopy, or at
surgery. No single or combination
of laboratory tests has a sufficient
negative or positive predictive value
to completely exclude ectopic
pregnancy or to definitively
establish the diagnosis.

13. Laboratory
Serum Beta-HCG :
● Absolute levels of Beta-HCG tend to be
lower in pathologic pregnancies than in
IUPs but there is much Overlap
● Longer Doubling time indicate ectopic
and other pathologic pregnancies
● HCG levels that fail to increase by 53%
or more in 2 days are suggestive but
not diagnostic of ectopic pregnancy
Serum Progesterone levels :
● <5ng/ml ~ 100% of pregnancies will be
pathologic
● >25ng/ml ~ 97% sensitive for viable IUP
● An empty uterus or non specific fluid
collection on US associated with
progesterone <5ng/ml is highly predictive
of Abnormal IUP or ectopic pregnancy

14. Ultrasonography
● The sequencing of transabdominal versus transvaginal US
is situation and operator dependent
● An empty uterus with embryonic cardiac activity visualized
outside the uterus is diagnostic of ectopic pregnancy
● When US reveals an unequivocal IUP and no other
abnormalities, ectopic pregnancy is effectively excluded
unless the patient is at high risk for heterotopic pregnancy
● Risk of ectopic pregnancy with US findings : Free pelvic
fluid ~86% Adnexal mass with free fluid ~97% ,
Hepatorenal free fluid ~100%

15. The Discriminatory Zone
● The discriminatory zone is the level of β-hCG at which findings of an IUP are
expected on US
● If US fails to reveal a definite IUP or fails to show findings strongly suggestive or
diagnostic of an ectopic pregnancy, the test should be considered indeterminate
and interpreted in light of quantitative serum β-hCG levels
● With transvaginal scanning, the discriminatory zone is often considered to be 1500
mIU/mL. For transabdominal scanning, an IUP should be detectable when the β-hCG
level reaches about 6000 mIU/mL
● Further, decision to intervene on a pregnancy should not be made solely on a single
hCG level; if the patient is hemodynamically stable with a β-hCG greater than the
discriminatory zone and no visible intrauterine or extrauterine pregnancy, watchful
waiting is an appropriate management strategy with close follow-up and strict
return precautions.
● When ectopic pregnancy is suspected, US should be performed even in patients with
low β-hCG levels, because ectopic pregnancy can occur even at very low (<500
mIU/mL) β-hCG levels.

16. Management of ectopic pregnancy
Hemodynamically Stable : Ruled out Rupture
equivocally with US
● Medical Management : Beta-HCG
<5000miu/ml , Mass < 3.5 cms
● Methotrexate + Leucovorin
● Single dose - MTX - 50mg/m2
● Multidose -MTX - 1mg/kg on Day 1,3,5,7
with leucovorin - 0.1 mg/kg on Day 2,4,6,8
● Serial serum Beta HCG on Day 1,4,7 -15%
expected decline after weekly testing until
undetectable
● Laparoscopic Salpingectomy
Hemodynamically unstable : SI >0.9
● Initial resuscitation
● Surgical management : Laparotomy with
Salpingectomy/salpingostomy

17. Ruptured Ectopic Pregnancy Management
1. Secure the airway , and passive leg raising in supine position
2. Intravenous volume resuscitation with Blood products and limited crystalloids
3. Damage control resuscitation : Strategy begins in the Emergency room and continues into
the operating room and into the ICU ,
4. Initial resuscitation is limited to keep SBP around 80-90 mmhg
5. Any delay in Surgery for control of hemorrhage increases mortality ; with uncontrolled
hemorrhage attempting to achieve normal bp may increase mortality
6. Early use of Tranexamic acid limits rebleeding and reduces mortality
7. Thromboelastography - quicker more comprehensive determination of coagulopathy
8. FFP and platelets transfusion indicated based on presence of coagulopathy and
thrombocytopenia respectively
9. Hypotension non responsive to fluids can be started with vasopressors
Noradrenaline Iv infusion - 80mcg/ml - 6-9 ml/hr initially , 1.5-3 ml/hr Maintenance
● STAT LAB : CBC ,S/E , ABG , RFT , PT , APTT , INR , Urinalysis, ABG , ECG Lactate

18. Septic abortion
● A septic abortion is a spontaneous or other abortion complicated by a
pelvic infection.
● with spontaneous or induced abortion, organisms may invade myometrial
tissues and extend to cause parametritis, peritonitis, and septicemia
● Causative agents - Group A strep - Strep Pyogenes , Clostridium
perfringens ,sordelli
● The most common causes are retained products of conception due
to incomplete spontaneous or therapeutic abortion and introduction of
either normal or pathologic vaginal bacteria by instrumentation.

19. Final point
Timely Prompt Diagnosis could
save Lives in these conditions

20. Thanks!
Dr Goutham B M
ajjargoutham@gmail.com