First TrimesterPregnancy

Complications

ALSO

First Trimester Bleeding

Spontaneous abortion/miscarriage Ectopic pregnancy Trophoblastic disease Cervical polyps Friable cervix Trauma Cervical cancer

1st Trimester Labs

Quantitative bhCG +Correlate with GA and US +2 meas, 2-3 days apart, shld. double +Falling or plateauing signals problem

Progesterone +Single level early in preg predictive *<5 ng/ml likely predicts poor outcome *>25 ng/ml assoc. with living IUP

Lab and US Correlates

Gest. Age byLMP

Transabd.Landmarks

Transvag.Landmarks

Serum bhCGMIU/ml IRP

<5 weeks None PossibleGestational. Sac

1800

5-6 weeks Gestational Sac Gest. Sac,Yolk sac

1800-3500

7 weeks 5-10 mm embryo Same as Transabw cardiac act.

>20,000

First Trimester US Indications

Suspected miscarriage Vaginal bleeding Gest. Age (if uncertain, or size/date discrepancy) Adjunct to procedures (ex. CVS) Suspected multiple gestation Suspected hydatidiform mole Suspected ectopic pregnancy IUD localization Suspected uterine abnormality Evaluation of maternal pelvic masses

First Trimester US

Best when performed in combination with H & P and relevant labs

Often used as primary tool in evaluating first trimester complications

Transvaginal and transabdominal should be obtained

Definitions

+Spontaneous Abortion

*Involuntary loss during first 20 wks

+Threatened Abortion

*Ut bleeding, closed Cx, no prods of conception passed

+Incomplete Abortion

*Some, but not all products have passed

+Inevitable Abortion

*Cx dilated, no products passed

Definitions

+Missed Abortion

*Dead fetus, no products passed, Cx closed

+Septic Abortion

*Incomplete Ab + ascending infection

+Blighted Ovum

*Identifiable sac & placental tissue, but no embryo

+Decidua

*Endometrium of pregnancy passed as part of SAB

Pathophysiology of Abortion

*Major genetic anomaly*Internal environmental factors -Uterine: anomalies leiomyoma, incompetent Cx -Maternal DES exposure -Luteal phase defect -Immunologic factors*External environmental factors -Substance use (tobacco, EtOH, cocaine) -Irradiation -Infection -Occupational chemical exposure*Advanced maternal age

Clinical Course

Missed menses, pregnancy Sxs Positive bhCG Vag bleeding bhCG falls or plateaus Lower abdominal cramps, backache Products of conception passed >8wks oft won’t pass products spont.

Physical exam

*Abdominal exam

-Pain location, rebound, distension

-Speculum exam

-Assess dilation

*Bimanual exam

-Uterine size, adnexal tenderness

Fetal Heart Tones

Listen after 9-10 weeks with Doppler

Sensitivity enhanced by elevating uterus during bimanual exam

Float Test for Chorionic Villi

Any tissue passed should be examined. If an intact gestational sac, embryo or fronds of chorionic villi are seen, spont. Abortion is proven and ectopic is ruled out (except in heterotopic pregnancy)

To look for villi, rinse and float the tissue with saline.

Passed tissue should be submitted for pathol. Exam.

If tissue is seen at cervical os, abortion is enevitable. May gently remove it with ring forceps.

When Dx is uncertain by clinical findings, transvaginal scan is essential for accurate diagnosis

Management of Spont. Abortion

50% loss when bleeding present Presence of FHTs reassuring Majority do no require medical or surgical

intervention Identify patients at risk for bleeding,

infection

Ectopic Pregnancy

Pregnancy outside uterus (usually in fallopian tube)

Occurs in >1:100 pregnancies Second most common cause of maternal

mortality Early diagnosis critical!

Risk Factors for Ectopic

H/O previous ectopic H/O tubal surgery H/O tubal infections Progestin-only contraception IUD In utero DES exposure Many occur in pts w/o risk factors

Pathophysiology and Symptomatology I

Conception Implantation Normal

in tube hCG

Amenorrhea Symptoms

of Pregnancy

Pathophysiology and Symptomatology II

Diminished Placental hCG Erosionblood supply death falls thru tube

Loss of Bleeding & Painsymptoms Sloughing

Pathophysiology & Symptomatology III

Intraperitoneal Shock Death hemorrhage

Abd. pain, Syncope Deathshoulder pain, Orthostaticsilent, doughy signs abdomen

Diagnosis of Ectopic

*Failure of hCG to double in 48-72 hs

*Low progesterone

*US (transvaginal)

-IUP R/O ectopic

-No gestational sac + hCG >1800 highly suggestive

-Gest. Sac/embryo outside of uterus confirms

-Pitfalls: Pseudogestational sac, ruptured corpus luteum

*Laparoscopy = Gold standard

Culdocentesis

18 or 20 gauge needle passed through the posterior fornix and aspirated for fluid.

Nonclotting body fluid with hematocrit >15% represents active intraperitoneal bleeding.

Expectant managementCriteria Minimal pain or bleeding Reliable F/U No evidence of tubal rupture hCG < 1000 and falling Adnexal mass <3cm or not detected No embryonic heartbeat

Medical Management:Methotrexate*Safe, effective, less costly than surgery

*Equal or better fertility preservation

*Criteria for use

-Stable VS, few Sxs

-No CI to drug

-Absence of embryonic cardiac activity

-Ectopic mass <= 4cm

-hCG < 5000

Methotrexate dosing

Single dose IM regimen with 1 mg/kg or 50mg/m2

Obtain serum hCG on 4th and 7th day post-treatment

Follow level until reaches 5 (3-4 wks) Document progesterone drop to 1.5 Surgical consultation if need more than one

dose

Surgical Management

*Mainstay of treatment

*Conservative-conservation of tube

*Extirpative-removal of tube

*Criteria for selecting surgery

-Unstable VS or hemoperitoneum

-Uncertain Dx

-Advanced ectopic pregnancy

-Unreliable FU

-CI to expectant or methotrexate

Trophoblastic Disease

*Incidence = 1:1000-1500 pregnancies

*Predisposing factors

-Previous molar disease

-Pregnancy at ends of reproductive life

*Complete hydatidiform mole

-Placental proliferation in absence of fetus; 46XX

-Placental villi swollen, grape-like

*Partial mole

-Molar placenta + nonviable fetus, 69XXY

*Recurrence metastatic choriocarcinoma

Clinical Manifistations

Vaginal bleeding 1st/early 2nd trimester Higher than expected hCG levels Ut size > dates w/o heart tones Hyperemesis Early PIH Thyrotoxicosis Ovarian enlargement

Treatment of trophoblastic disease

*Prompt evacuation of the uterus

*Serial hCG

*One year contraception

*Recurrence

-Occurs in 20% with complete mole

-Invades myometrium or becomes metastatic

-Treated with methotrexate

*Most can conceive, carry normal pregnancy