Early pregnancy problems

Alero Awala
Consultant Obstetrician and Gynaecologist
Watford General Hospital
EPU:Aims & Objectives
 To provide an efficient pregnancy diagnostic
service to women with early pregnancy problems
 Appropriate follow up
 To ensure an efficient use of acute unit beds by
prompt and appropriate clinical management
 To ensure women are aware of their treatment
options and can make informed decisions
 Provision of up to date information
EPU referrals:
 Positive pregnancy test
 First trimester: 5+4-12+6 weeks
 Bleeding and or pain in the first trimester
 Previous history of ectopic pregnancy (6+)
 Previous history of molar pregnancy (8+)
 History of recurrent miscarriages
 ?RPOCs
SCANS
 Early Pregnancy Unit is based at WGH only
 EPU performs scans up to 12+6/40
 13/30 – 19+6/40 to be referred to ultrasound:
• For HH and SACH patients GP’s an refer to relevant
hospital if they only want a scan.
• Non pregnant gynae scans – scan form to maternity
ultrasound – will be done a routine outpatient unless
admitted.
Scan Reports
 The number of sacs and diameter
 Features of the sac
 Haematoma
 Yolk sac
 Fetal pole and CRL in mm
 Fetal heart beat
 Adnexae
4 week gestation
 Eccentrically sited
gestation sac MSD 2-3mm
 bHCG range <1500 iu/L
 This sac was 2.3mm MSD
4 -5 week gestation  Gestation sac with
double decidual sign
 bHCG range 1050 to
6530 (mean 2320 iu/L)
 This sac measures
6.4mm MSD
6 week gestation
 Gestation sac 10mm
 Fetal pole visible
2 - 3mm
 Cardiac pulsations can be
seen
 Mean bHCG 16,870iu/L
 This fetal pole CRL 1.6mm
8 week gestation
 Gestation sac




25mm
Embryo measures
CRL16mm
Can identify limb
buds
Mean bHCG
85,560iu/L
CRL 15.3mm
10 week gestation
 Fetus measures




31mm CRL
Active movements
seen
Limbs present
bHCG levels not
relevant
CRL 35.8mm
12 week gestation
 Fetus measures
54mm CRL
 Structurally
formed, gross
anomolies can be
seen
 Placenta identified
Early Scan Features
 4-5wks: Eccentrically placed GS 2-3mm
 5 wks: Double decidual sign
 5-6 wks: GSD: >5mm+, yolk sac
 6 wks: GSD: >10mm, fetal node: 2-3 mm, FHB
 7wks: GSD: 20mm
Early Pregnancy Failures
 Incidence:
 15-20% clinically recognized pregnancies
 Estimated 30% if non-clinically recognized pregnancies
are included*
 80% occur in first trimester
 Ectopic pregnancy rates 1.1/1000???
* Wilcox NEJM 1988
RCOC miscarriage guidelines
Diagnosed miscarriage
 Empty gestation sac MSD >25mm
 Fetal pole CRL > 7mm with no cardiac pulsations
Uncertain viability
 Gestation sac < 25mm
 Fetal pole <7mm
To be rescanned in no less than 7 days
Types of miscarriage
 Missed miscarriage
 Anembryonic pregnancy
 Inevitable miscarriage
 Complete miscarriage <15mm ET
 Incomplete miscarriage >15mm ET
Management of miscarriage
 NICE recommends using expectant management
for 7 – 14 days as first line unless;
 Significant risk of haemorrhage (ie late first trimester)
 Previous adverse/traumatic experience
 Evidence of infection
 Pt choice
 Medical management as second line
 Surgical management
Miscarriages 2012
 3331 scans performed in EPU, including 841 follow up
scans
 982 women diagnosed with a miscarriage (29.5%)
 147 women had medical management
 Expectant: 623
 Surgical: 212
 Medically managed



Missed miscarriage 86
Anembryonic pregnancy 30
Incomplete miscarriage 34
Medical management of
miscarriage

 Incomplete miscarriage:
 RPOC < 25mm manage conservatively
 RPOC > 25mm and < 45mm treat with 600mcg Misoprostol stat as
outpatient
 RPOC > 45mm 600mcg Misoprostol stat as INPATIENT
 Missed miscarriage:
 Empty gestation sac < 33mm MSD and/or CRL < 9 weeks gestation
(23mm) 800mcg Misoprostol stat as outpatient
 Empty gestation sac > 33mm and/or CRL > 9 weeks (CRL 23mm) and < 12
weeks (CRL 54mm) gestation 800mcg Misoprostol stat as INPATIENT
 All women to repeat urinary pregnancy test three weeks after
miscarriage: if positive to be reviewed in GDAU to see if rescan clinically
indicated.
Outcomes: Medical management




66% miscarry within a week (48% in days 1-3)
Pain score: 67% moderate, 14 moderate and 14% none
Blood loss: 34% mild, 33% moderate and 19% excessive
Pt satisfaction survey: .90% were satisfied with the
process
 Failure rates
 Incomplete miscarriage 100% successful
 Missed miscarriage 2.32%
 Anembryonic pregnancy 13.3%
Pregnancy of unknown location
(PUL)
 Positive pregnancy test with no signs of IUP or EP on
TVS or Laparoscopy
 31% of all women attending a standard EPU, 10% with
a experienced sonographer
 WGH: 8-10% PUL rate
Ectopic pregnancy
 Total Ectopic pregnancies: 131
 Medical management: 49
 Surgical Management: 81
 Expectant: 1
 All Rh Neg patients had Anti D (apart from the pt
managed expectantly)
 New NICE guidelines only surgically managed pts will
receive Anti D from 2013
Outcomes
 Medical management (49)
 6 patients were PUL
 One negative laparoscopy
 1 scar ectopic



3 patient required repeat methotrexate (none ruptured)
1 patient ruptured and required laparoscopic salpingectomy
1 failed medical management
Increased from 2011 (28 managed medically)
Continued
 Rupture rate: 2.3%
 Quoted risk of rupture following methotrexate is 7%
 Need for repeat methotrexate: 6.81%
 Expectant management (right adnexal mass and HCG
of 49, progesterone 6) managed successfully, mass had
resolved within 10 days and HCG had fallen to 27
 One pt developed abnormal LFTs following repeat
methotrexate: resolved within 2 weeks
Surgical management (81 pts)




2 sets of twin ectopic pregnancies (1 live)
1 ovarian ectopic
1 live 9 week cornual ectopic
9 patients presented as ruptured ectopics
› EBL: 500mls to 3000mls
1 patient admitted to ITU with ARDS (>3000ml EBL)
› 8 managed laparoscopically, 1 laparotomy
 28 patients presented as leaking ectopic pregnancies,
EBL: 100- 300mls
 2 laparotomies (1 converted from laparoscopy)
 1 negative laparoscopy: Pt went on to receive
methotrexate (HCG Plateaued)
2011 summary
 108 ectopic pregnancies managed
 80 managed surgically
 28 managed medically

4 ruptured (14%)
 None managed expectantly
 2012 figures demonstrate a marked improvement
When to use BhCG




USS ?complete miscarriage: Paired HCG levels
Paired BhCG to compare rise – ideally should be >63% rise
over 48 hours.
Patients under 6 weeks gestation (first line)
If <1000 repeat after 48 hours
If first BhCG >1000 don’t repeat, refer for scan.
 PUL: to aid in diagnosis i.e. ?ectopic , ?Intra uterine
 Medical management of ectopic pregnancy (Methotrexate)
 Suspected molar pregnancy
Molar pregnancy (GTD)
 Non viable pregnancy caused by an imbalance of
genetic material
 Normal egg is fertilised by 2 sperm or an empty egg is
fertilised by a single sperm
 Incidence: 1;500-600 pregnancies (1500/yr in the UK)
 Commoner in teenagers and women >45 years and
previous history (10x increased risk)
 Complete mole: No foetus and an abnormal placenta
 Incomplete mole: some normal placental tissue forms
along with an abnormal foetus (twin pregnancy:
Normal and abnormal foetus co-exist)
Molar Pregnancies WHHT
 2011
› 18 molar pregnancies
› 2 found following medical management
› All counselled and registered with The Trophoblastic centre
› 1 patient fell pregnant within 3 months of diagnosis
› 1 post partum choriocarcinoma
 2012
› 15 molar pregnancies
› Including 4 complete moles
› 1 managed medically
› All counselled and registered with the Trophoblastic centre
New NICE Guidance CG154
 Change nomenclature: ERPOC now to be called
surgical management of miscarriage
 Anti D for women having surgical management of
ectopics or miscarriage or threatened miscarriage after
12 weeks only
 Misoprostol only for medical management of
miscarriage <12 weeks

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