EARLY PREGNANCY

LOSSDILEMMAS

Dr. JYOTI BHASKARDR. SHARDA JAIN

Director of Lifecare IVF

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Content

ULTRASOUND 2

HCG INTERPRETATION3

PREGNANCY OF UNKNOWN LOCATION

4

ANTI D PROPHYLAXIS5

DEFINITIONS1

MANAGEMENT6

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

DEFINITIONS Change in terminology to MISCARRIAGE

Spontaneous/Threatened/Missed/Inevitable/ Complete/Incomplete/Recurrent Miscarriage

Anembryonic / Blighted Ovum

Delayed / Silent Miscarriage

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

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 miscarriageNICE clinical guideline 154, December 2012

What to expect in USG

4 weeks 5 weeks

6 weeks

GS

GS < 20mm No YS

GS < 25 mmNo Fetal Pole

GS >25mmNo embryo

Rescan after 1 weekMISSED MISCARRIAGE

Rescan after 1 weekSecond opinion

CRL

CRL < 7MM NO CA

PUV

CRL > 7MMNO CA

EARLY FETAL LOSS

Rescan after 1 weekMISSED MISCARRIAGE

Rescan after 1 weekSecond opinion

ET

< 15MM > 15MM

HOMOGENOUS MASSIN CAVITY

COMPLETE MISCARRIAGE

INCOMPLETE MISCARRIAGE

EXCLUDE PREGNANCY OF UNKNOWN LOCATION/ ECTOPIC

H.MOLESERUM B HCG

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

HCG DOUBLING TIMEIt 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.

CAUTION15% 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

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

BETA HCG INTERPRETATION

Serum B HCG at 0 and 48 hrs

> 66% increase > 66% increase or < 21-35% decrease

>21-35% decrease

IUP ? Ectopic Pregnancy

? Failing PULMiscarriage

Pregnancy test positive + TVS

Inconclusive result (No evidence of IUP or EP)

Serum HCG measurements every 2-3 days

Falling Complete miscarriage No further scans are necessaryFollow up until hCG <20 IU/L

Rising (doubling)

Repeat TVS when hCG >1000 IU/L

IUPNo further hCG assays

Rescan in one week

Suboptimal rise/plateauing/falling slowly after 2-3 measurements

EP PUL Non-viable IUP

TVS

Role of serum progesterone

Serum progesterone

< 20 nmol/L >60 nmol/L

PPV > 95% to predictPregnancy failure

(Banerjee et al., 2001)

‘Strongly’associated with

viable pregnancies

Viable IUPs reported withlevels < 16nmol/L

Discriminative capacity insufficient to diagnose ectopic pregnancy withcertainty (Mol et al., 1998)

Good at predicting viability but not location

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)

Spontaneous Miscarriage Given to all non-sensitised RhD negative-

With 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).

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).

DO NOT GIVE

Threatened Spontaneous

<12 weeks

NO ANTI D

PROPHYLAXIS

Complete H. MOLE

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 UF2. 100 ug - Vinobulin

3. 300 ug -- Predominantly

MEDICAL MANAGEMENT – Method of Choice

Missed miscarriage Incomplete miscarriage

NO MIFEPRISTONE

VAGINAL MISOPROSTOL

800 MG 600 MG

Surgical Management

Only in

• Persistent excessive bleeding• Haemodynamically unstable• Infected retained tissue• Suspected Gestational trophoblastic tissue

Surgical ManagementVaccum Aspiration – Method of choice

Prior Prostaglandin administration

If infection suspected – delay intervention for 12 hrs for I/V antibiotic

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

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.

Pregnancy of Unknown LocationExpectant 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

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CONTACT US 011-22414049, 42401339

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