Early pregnancy dilemmas. DR. Sharda Jain , Dr. Jyoti Bhaskar

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Early pregnancy dilemmas. DR. Sharda Jain , Dr. Jyoti Bhaskar

  1. 1. LOGO EARLY PREGNANCY LOSS DILEMMAS Dr. JYOTI BHASKAR DR. SHARDA JAIN Director of Lifecare IVF
  2. 2. Content 1 2 3 4 DEFINITIONS ULTRASOUND HCG INTERPRETATION PREGNANCY OF UNKNOWN LOCATION 5 ANTI D PROPHYLAXIS 6 MANAGEMENT
  3. 3. SOURCES  Diagnosis and initial management in early pregnancy of ectopic pregnancy and miscarriage NICE clinical guideline 154, Dec 2012  AEPU Guidelines 2007  Management of Early Pregnancy Loss Green Top Guideline No. 25 , 2006  Rhesus D Prophylaxis, The Use of Anti-D Immunoglobulin for (Green-top 22,2011)  Lifecare Centre Experience
  4. 4. DEFINITIONS  Change in terminology to MISCARRIAGE Spontaneous/Threatened/Missed/Inevitable/ Complete/Incomplete/Recurrent Miscarriage Anembryonic / Blighted Ovum Delayed / Silent Miscarriage
  5. 5.  Pregnancy of Unknown Location( PUL) ( 8-31% at first visit) No signs of either Intrauterine or extrauterine pregnancy or RPOC on TVS in a women with positive pregnancy test.  Pregnancy of Uncertain Viability ( PUV) ( 10% at first visit) Intrauterine GS < 20 mm with No YS or FP or Fetal echo < 7mm with No CA
  6. 6. ULTRASOUND  TVS is the method of choice  If unacceptable, do TAS and explain the limitations of this method of scanning  Diagnosis of miscarriage using 1 ultrasound scan cannot be guaranteed to be 100% accurate Diagnosis and initial management in early pregnancy of ectopic pregnancy and miscarriage NICE clinical guideline 154, December 2012
  7. 7. What to expect in USG 5 weeks 4 weeks 6 weeks
  8. 8. GS GS < 20mm No YS GS < 25 mm No Fetal Pole Rescan after 1 week GS >25mm No embryo MISSED MISCARRIAGE Rescan after 1 week Second opinion
  9. 9. CRL CRL < 7MM NO CA PUV Rescan after 1 week CRL > 7MM NO CA EARLY FETAL LOSS MISSED MISCARRIAGE Rescan after 1 week Second opinion
  10. 10. ET < 15MM > 15MM HOMOGENOUS MASS IN CAVITY H.MOLE SERUM B HCG COMPLETE MISCARRIAGE INCOMPLETE MISCARRIAGE EXCLUDE PREGNANCY OF UNKNOWN LOCATION/ ECTOPIC
  11. 11. UNDERSTANDIING HCG MEASUREMENTS USEFUL IN  Screening in women at high risk of ectopic pregnancy  Monitoring during expectant management or medical management of women with pregnancy of unknown location and ectopic pregnancy  Evaluation of conservative surgical treatment of ectopic pregnancy
  12. 12. HCG DOUBLING TIME  It refers to the time taken for the hCG level to double its original value  Serum hCG levels double approximately every two days in early (<8 weeks)  a lesser increase (<66% over 48 hours) is associated with ectopic pregnancy and miscarriage.
  13. 13. CAUTION  15% of normal pregnancies will have abnormal doubling time and 13% of ectopic pregnancies will have a normal doubling time  In multiple pregnancies and heterotropic pregnancies the level of hCG on D2 would be a little higher
  14. 14. DISCRIMINATORY HCG ZONE  Level of hCG above which the gestational sac of an intrauterine pregnancy should be visible on ultrasound.  It usually lies between 1000 – 2400IU/L.  Depends on three factors: i) hCG assay ii) quality of ultrasound iii) the experience of the person Performing USG
  15. 15. BETA HCG INTERPRETATION Serum B HCG at 0 and 48 hrs > 66% increase IUP > 66% increase or < 21-35% decrease ? Ectopic Pregnancy >21-35% decrease ? Failing PUL Miscarriage
  16. 16. Pregnancy test positive + TVS Inconclusive result (No evidence of IUP or EP) Serum HCG measurements every 2-3 days Rising (doubling) Falling Repeat TVS when hCG >1000 IU/L Complete miscarriage No further scans are necessary Follow up until hCG <20 IU/L IUP No further hCG assays Rescan in one week Suboptimal rise/plateauing/falling slowly after 2-3 measurements TVS EP PUL Non-viable IUP
  17. 17. Role of serum progesterone Serum progesterone < 20 nmol/L PPV > 95% to predict Pregnancy failure (Banerjee et al., 2001) Viable IUPs reported with levels < 16nmol/L >60 nmol/L ‘Strongly’ associated with viable pregnancies Discriminative capacity insufficient to diagnose ectopic pregnancy with certainty (Mol et al., 1998) Good at predicting viability but not location
  18. 18. RHESUS ANTI D PROPHYLAXIS  THREATENED MISCARRIAGE - all > 12 weeks - if bleeding persists , given at 6 weekly interval ( RCOG recommendation )  Prudent to administer anti-D as gestation approaches 12 weeks 1. where bleeding is heavy or repeated 2. where there is associated abdominal pain (RCOG Grade C recommendation)
  19. 19. Spontaneous Miscarriage  Given to all non-sensitised RhD negativeWith spontaneous complete or incomplete miscarriage after 12 weeks of pregnancy (RCOG Grade B recommendation) Before 12 weeks not recommended as risk of immunisation is negligible. (RCOG Grade C recommendation).
  20. 20. SPECIAL SITUATIONS -- GIVEN ERPC OR TOP Therapeutic termination of pregnancy, whether by surgical or medical methods, regardless of gestational age (RCOG Grade B recommendation). ECTOPIC PREGNANCY confirmed or suspected ectopic pregnancy (RCOG Grade B recommendation).
  21. 21. DO NOT GIVE Threatened Spontaneous Complete H. MOLE <12 weeks NO ANTI D PROPHYLAXIS
  22. 22. DOSAGE OF ANTI D • UPTO 20 WEEKS -- 250 IU ( 50 ug) • MORE THAN 20 WEEKS – 500 IU ( 100 ug) Available in India 1. 50 ug – Microhogam UF 2. 100 ug - Vinobulin 3. 300 ug -- Predominantly
  23. 23. MEDICAL MANAGEMENT – Method of Choice Missed miscarriage Incomplete miscarriage NO MIFEPRISTONE VAGINAL MISOPROSTOL 800 MG 600 MG
  24. 24. Surgical Management  Only in • • • • Persistent excessive bleeding Haemodynamically unstable Infected retained tissue Suspected Gestational trophoblastic tissue
  25. 25. Surgical Management  Vaccum Aspiration – Method of choice  Prior Prostaglandin administration  If infection suspected – delay intervention for 12 hrs for I/V antibiotic
  26. 26. TAKE HOME MESSAGE  Understand changing management trends  Moved Towards • Treatment on Outpatient basis • Refined and Indicated Diagnostic techniques • Patient centred Therapeutic Interventions  Interpret USG and HCG results wisely and reach a diagnosis  Always be on look out for ectopic pregnancy and PUL
  27. 27.  Follow the latest protocols for Anti D prophylaxis in early pregnancy  Medical management is the treatment of choice  The approach has to be patient centred.
  28. 28. Pregnancy of Unknown Location  Expectant management suitable for majority of women  No consensus on appropriate intervention but no routine role for curettage  Serum hCG and progesterone levels useful, but no role for single hCG measurement
  29. 29. & ADDRESS 35 , Defence Enclave, Opp. Preet Vihar Petrol Pump, Metro pillar no. 88, Vikas Marg , Delhi – 110092 CONTACT US 011-22414049, 42401339 WEBSITE : www.lifecarecentre.in www.drshardajain.com www.lifecareivf.com E-MAIL ID Sharda.lifecare@gmail.com Lifecarecentre21@gmail.com info@lifecareivf.com

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