2. CASE
Case 1
• A 23 yo nulliparous woman has had 7 weeks of amenorrhea. She had not
been using contraception. She normally has regular menstrual cycle 28
-30days. Self UPT positive. For the past 2 days, she notice vaginal bleeding
that increase in amount.
Case 2
• A 34 yo woman present with a history of 6 weeks of ammenorrhoea,
abdominal pain and slight vaginal bleeding. She has an irregular menstrual
cycle. She stopped OCP 6 months ago in order to conceive. Recently she
has sometimes been dizzy. Self UPT positive.
3. Bleeding < 12 weeks gestation
History
• Review of menstrual history
• Pain
• Amount of bleeding
• Passed out POC
• Initial US findings
• Anaemic symptoms
Physical Examination
• Haemodynamic stability
• Abdominal examination
• VE & Speculum examination
• identify non-obstetric cause
• Os open or close
• POC
• Bimanual examination
Peritoneal signs
or haemodynamic
instability
Non obstetrics
cause of bleeding
POC visible on
examination
Patient stable, no POC visible or
other causes of bleeding
identified
Resuscitate and
consider
immediate
surgical
intervention
Diagnose and treat
accordingly
Incomplete
miscarriage.
Treat as
indicated
Perform Transvaginal Scan (TVS)
4. Patient stable, no POC visible or other
causes of bleeding identified
Perform TVS
Ectopic pregnancy
or signs suggestive
of ectopic
pregnancy
Viable intrauterine
pregnancy
Non-viable
intrauterine
pregnancy
Intrauterine
pregnancy, viability
uncertain
No intrauterine
or ectopic
pregnancy
Manage ectopic
pregnancy
Threatened
miscarriage
Early pregnancy
loss
Repeat ultrasound
in 7 – 14 days
Intrauterine
pregnancy seen
on previous TVS
Complete
miscarriage
Pregnancy of unknown
location
5. Pregnancy of Unknown Location (PUL)
Haemodynamically Stable Haemodynamically Unstable
Pain No Pain
Serum ß hCG
Consider Laparoscopy
Serum ß hCG at 0 and 48 hours
Laparoscopy or Laparotomy
> 66% increase < 66% increase < 13% decrease > 13% decrease
Normal
Intrauterine
pregnancy
Repeat TVS in 7
days
Probable Ectopic
Pregnancy
Repeat TVS after
7 days
Failing PUL or
possible ectopic
pregnancy
Repeat serum
hCG after 7 days
Failed pregnancy
UPT in 2 weeks,
Repeat serum
hCG if positive
7. EARLY PREGNANCY LOSS
• Early pregnancy loss (EPL) – a nonviable, intrauterine pregnancy
within the first trimester (up to 12+6 weeks from the last menstrual
period)
• EPL includes:
• pregnancies with an empty gestational sac (anembryonic pregnancy or
blighted ovum)
• pregnancies with an embryo or fetus without cardiac activity.
In the first trimester, the terms miscarriage, spontaneous abortion, and early pregnancy loss are used
interchangeably, and there is no consensus on terminology in the literature.
8. EARLY PREGNANCY LOSS
RISK FACTORS:
1. Increasing age
2. Prior pregnancy loss
3. Maternal medical conditions
4. Medication or substance use
5. Environmental factors and exposures
6. Sub-chorionic haematoma
9. EARLY PREGNANCY LOSS
ETIOLOGY:
1. Chromosomal abnormalities
• Approximately 50-70% of miscarriages are associated with chromosomal
abnormalities in the conceptus, with autosomal trisomy, especially trisomy
16, triploidy and monosomy X being the predominant chromosomal
aberrations reported in the first trimester
2. A smaller potentially preventable proportion of miscarriages may
be caused by luteal phase deficiency, while in the remainder, the
cause is not known
11. MISCARRIAGE
EPL
HISTORY EXAMINATION INVESTIGATIONS MANAGEMENT
TYPES BLEEDING PAIN CERVICAL OS UTERINE SIZE IN
RELATION TO GA
UTERUS ON
ULTRASOUND
Threatened Slight None / slight Closed Consistent • Fetus with heart
beat
25% will miscarry
Inevitable Heavy Considerable Open Consistent • Fetus may be alive Miscarriage is
inevitable
Incomplete Heavy +/-
Passed out
POC
Considerable Open Small • Some fetal tissue
*Management of EPL
Complete Slight to
moderate
after heavy
loss
Slight at
presentation
but
considerable
earlier on
Closed Small • Empty
Missed None or slight None Closed Consistent or
small
• Fetus with no
heart beat
• Anembryonic
pregnancy
r
12. EARLY PREGNANCY LOSS
INTRAUTERINE PREGNANCY
– NO FETAL HEART ACTIVITY
ANEMBRYONIC PREGNANCY / BLIGHTED OVUM
- GESTATIONAL SAC, NO FETAL POLE
15. EPL – Principles of Management
1. Confirm diagnosis –
History + Examination + Ultrasound (TVS) ± serum ßhCG
✔ Types of miscarriage
✔ Exclude ectopic pregnancy
✔ Exclude molar pregnancy
2. Control heavy bleeding – Incomplete and complete miscarriage
Intramuscular Ergometrine (syntometrine)
3. Women who are Rh(D) negative and un-sensitized should receive Rh(D)-
immune globulin within 72 hours of evacuation (medical or surgical)
16. EPL – Principles of Management
4. Antibiotic prophylaxis should be given based on individual clinical
indications e.g septic miscarriage
5. Evacuated uterus if incomplete / missed
1. Medical – Prostaglandin
• Efficacy rates are vary
• Prostaglandin may induce evacuation of uterus (esp in missed)
2. Surgical (D&C, S&C, ERPOC) – removal of POC under anaesthesia
3. HPE – chorionic villi
18. The definition of Recurrent Pregnancy Loss varies, e.g:
- Two or more failed clinical pregnancies as documented by US or HPE
- Three consecutive pregnancy losses, which are not required to be intrauterine
> 2 PREVIOUS (consecutive)
1ST
TRIMESTER MISCARRIAGE
Anti-cardiolipin
antibodies
IgG, IgM and Lupus
3D Ultrasound for
uterine malformation
Karyotype of POC from 3rd
miscarriage
Thyroid
function
HbA1c &
OGTT
Parental Karyotype
If indicated
Genetic Counselling
if abnormal
22. HISTORY EXAMINATION INVESTIGATIONS MANAGEMENT
BLEEDING PAIN CERVICA
L OS
UTERINE SIZE IN
RELATION TO GA
UTERUS ON
ULTRASOUND
ECTOPIC
PREGNANCY
None /
slight
None /
slight /
severe ±
referred
pain
Closed /
Tender
on
cervical
mobility
test
Small Empty uterus
- Adnexal mass
- Free fluid
Gold Standard :
Laparoscopy
- Conservative
- Medical
- Surgical
23. MANAGEMENT OF ECTOPIC PREGNANCY
• Confirm Diagnosis:
1. Transvaginal Ultrasound
2. Diagnostic Laparoscopy - gold standard.
- Can proceed with therapeutic procedures
24. MANAGEMENT OF ECTOPIC PREGNANCY
1. EXPECTANT MANAGEMENT
• Patients who have the following criteria are considered a good
candidate:
i. are clinically stable and pain free and
ii. have a tubal ectopic pregnancy measuring less than 35 mm with no visible
heartbeat on transvaginal ultrasound scan and
iii. have serum hCG levels of 1,000 IU/L or less and
iv. are able to return for follow-up.
• repeat hCG levels on days 2, 4 and 7 after the original test
25. MANAGEMENT OF ECTOPIC PREGNANCY
2. MEDICAL TREATMENT - systemic methotrexate to women who:
i. have no significant pain and
ii. have an unruptured tubal ectopic pregnancy with an adnexal mass smaller
than 35 mm with no visible heartbeat and
iii. have a serum hCG level less than 1,500 IU/litre and
iv. do not have an intrauterine pregnancy (as confirmed on an ultrasound
scan) and
v. are able to return for follow-up.
26. MANAGEMENT OF ECTOPIC PREGNANCY
3. SURGICAL TREATMENT
• surgery as a first-line treatment to women who are unable to return for
follow-up after methotrexate treatment or who have any of the following:
i. an ectopic pregnancy and significant pain
ii. an ectopic pregnancy with an adnexal mass of 35 mm or larger
iii. an ectopic pregnancy with a fetal heartbeat visible on an ultrasound scan
iv. an ectopic pregnancy and a serum hCG level of 5,000 IU/litre or more.
Laparoscopy > Laparotomy (unless haemodynamically not stable)
Salpingectomy
Salpingostomy,
Milking the POC (fimbrial pregnancy)
28. Serum ßHCG in management of ectopic
pregnancy
• Serum ßHCG should be undertaken:
1. If there was uncertainty about the diagnosis,
2. If conservative or medical management is planned in a stable
patient,
29. Serum ßHCG:
In 48 hours sample:
1. Doubling of levels – Intrauterine Pregnancy
2. Increase but less than double – Ectopic Pregnancy
3. Level fall and eventually become non-detectable – Failed pregnancy
32. HISTORY EXAMINATION INVESTIGATIONS MANAGEMENT
BLEEDING PAIN CERVICA
L OS
UTERINE SIZE IN
RELATION TO GA
UTERUS ON
ULTRASOUND
Molar
Pregnancy
Slight to
moderate
May pass
out
vesicels
Slight /
none
Closed Consistent or
Large
Classical ‘Snow-
storm’
appearance of
vesicles
- Evacuation of
uterus
- Follow – up
34. CLINICAL FEATURES OF MOLAR PREGNANCY
1. History of amenorrhoea of 8 – 12 weeks
2. Vaginal bleeding (90%) – may vary from spotting to profuse
bleeding
3. Expulsion of grapes like vesicles per vagina (50%)
4. Lower abdominal pain – concealed haemorrhage, uterine
contraction, infection or perforation by invasive mole
5. Uterus is soft doughy and larger than expected GA
35. MOLAR PREGNANCY USUALLY ASSOCIATED
WITH:
1. Excessive uterine enlargement (50%)
2. Theca lutein cysts (25 – 50%)
3. Hyperthyroidism (1 – 2%)
4. Hyperemesis gravidarium (25%)
5. Very early onset of Pre-eclampsia (26%)
6. Marked elevated HCG 100,000 mIU/mL
7. Breathlessness or acute respiratory distress (2%)
36. WHO CLASSIFICATION OF TROPHOBLASTIC DISEASE
• BENIGN
• Hydatidiform Mole
• Complete
• Partial
• MALIGNANT GTD
• Invasive Hydatidiform mole
• Choriocarcinoma
• Placental site tumour
• Trophoblastic tumour – placental site nodule or plaque, Exaggerated
placental site
*The last 3 may follow abortion, ectopic or normal pregnancy*
37. MANAGEMENT OF MOLAR PREGNANCY
1. Evacuation of Uterus - S&C
2. Follow-up - important to detect any persistent trophoblastic disease
(PTD) that may progress to choriocarcinoma.
□ Weekly for 1 months, 2 weekly for 3 months, monthly for 6 months, then 3
monthly till 2 years,
□ Avoid pregnancy.
During Follow up:
✔ History of Vaginal Bleeding, Haemoptysis, Jaundice
✔ Examine Lungs, Liver, abdomen for uterine enlargement
✔ CXR if symptomatic
✔ Ultrasound - Endometrial thickening
✔ Serial Beta HCG - plot graph.
38. Serum ßHCG – Post Evacuation in Molar Pregnancy
√
39. MANAGEMENT OF MOLAR PREGNANCY
3. Indications for chemotherapy:
i. Serum ßHCG plateau in 3 consecutive samples,
ii. Rising Serum ßHCG in 2 consecutive samples,
iii. Heavy vaginal bleeding or evidence of GIT or Intraperitonel bleeding,
iv. HPE – Choriocarcinoma
v. Evidence of metastases in the brain, lungs, liver, vagina and GIT
90. threshold
4ghours
1500 Is 73000
I
97070/607.
→
T 2000
but 23000
^
1500 → 800
1- .
1-
-
no pain (slightly
-
bleeding , slight
-
pass out vesicle
-
examination larger than
actual date
↳ snowstorm
appearance
