OUTLINE

CONTENT

early pregnancy q Definition

ese two are v Miscarriage
from the 1sttrimester q Etiology / Risk Factors
the most andthestart of2ndtrimester
common
q Types
v Ectopic Pregnancy
q Clinical Presentation
q Investigation
q Diagnosis
q Management

DEFINITION A 03or
ten teacher
T
hacker ETIOLOGY
Miscarriage/Abortion:/Early pregnancy loss:

↑
A pregnancy that ends spontaneously before 24 weeks. tenteachers
fetal
§ Chromosomal abnormalities. (50%)
-spontaneous or induced termination of pregnancy before fetal viability. (William)
§ Medical/Endocrine disorders.diabetes thyriod autoimmune
-pregnancy termination or loss before 20 weeks gestation or with a fetus delivered

f
weighting < 500g. (WHO) somehospitalsdon'tresuscitateounces survivalarein
iethebaby is lessthangouge of
Noth § Uterine abnormalities. bicornate
-First Trimester vs Second Trimester pregnancy loss § Infections.
atinizweeks is coweeks § Drugs/Chemicals.
nonviableintrauterinepregnancy up to
Incidence:
20 weeks ofgestation toptodate Categaroya
Antipsychotics

Spontaneous abortion occurs in 10-15% of clinically recognizable pregnancies.

anypregnantfemale
 CLINICAL PRESENTATION
RISK FACTORS

SYMPTOMS SIGNS
§ Increase maternal age.
discovered
§ Smoking, alcohol, excessive caffeine intake. • Asymptomatic Clinically By Speculum: d
certin allowedamount it as aforeign bodyandtries
§ Obesity. DM HIV • Amenorrhea notgetting a periodcanclueto Pregnancy
• Cervical dilatation toexpel it thisthecause of
abdominalpain

§ Previous early pregnancy loss, previous stillbirth. • Vaginal bleeding (most common) • Product of conception located in
the cervical os
§ African race. g• Lower abdominal pain
§ Assisted reproductive techniques.
belike IVF

CLASSIFIC ATION

‫ ﻧﻔﺲ اﻟﺸﻲ ﻣﻤﻜﻦ ﯾﺼﯿﺮ ﻓﻲ اﻟﺸﮭﻮر اﻻﺧﯿﺮة وﯾﺴﻤﻰ‬: ‫ﻣﻌﻠﻮﻣﮫ اﺿﺎﻓﯿﺔ‬

‫طﻠﻖ ﻛﺎذب وھﻮ ﻋﺒﺎرة ﻋﻦ اﻧﮫ ﯾﺪرب اﻟﺮﺣﻢ ﻟﻼﻧﻘﺒﺎﺿﺎت واﻟﻄﻠﻖ اﻟﺤﻘﯿﻘﻲ‬
CLASSIFICATION (CONT’D)
X
‫ ﻣﻊ‬vaginal spotting of blood ‫ ﯾﻜﻮن‬:‫اﺣﻤﺪ ﻏﺎزي‬.‫د‬
‫ﻣﺎ ﯾﻔﯿﺪ اﺳﺘﻌﻤﺎل اﻟﻤﺜﺒﺎت وﻻ اي ﺷﻲ‬ Septic abortion:
‫اﻟﻢ ﻓﻲ اول اﻟﺸﮭﻮر وﯾﻜﻮن ﻏﺎﻟﺒﺎ ً ﻻﻧﮫ اﻟﺮﺣﻢ ﻣﻮ ﻣﺘﻘﺒﻞ اﻟﺠﻨﯿﻦ‬ 25-50% of threatened abortions eventually result in loss of the pregnancy.
94% will produce live baby (Hacker)
ststertheatoseon
Refers to any abortion, spontaneous or induced, that is complicated by
survive

308rad Patientgravidaepara uterine infection.

+/- FHstage
orears
abortion
rediscovered
can Q came in a vaginalbleedingand

LL
a
d
withvest
intrauterinepregnancy

e mm onclosed
examination
cervix
what'syourdiagnosis

shecanspontanasyabat
inthe
knowing
 Read
DIFFERENTIAL DIAGNOSIS

Diagnosed
by
exudingthe § Physiologic bleeding (spotting, due to implantation of placenta)
rest
§ Abortion Most Important to rule out

§ Abnormal pregnancy (ectopic, molar)

§ Trauma (post-coital or after pelvic exam)
§ Genital lesion (e.g. cervical polyp, neoplasms)
Medical or
eg coagulation Ibleeding disorders

INVESTIGATION
ULTRASOUND O
Transvaginal: for early
pregnancy, why?
Sequence of Events in early pregnancy said
§ Ultrasound (transabdominal/transvaginal) Bcz, the fetus is too small
and we need to get closer to
visualising him. Gestational sac
normalPregnancy § Beta Human Chorionic Gonadotropin (β-hcg)
it
Also bcz, the uterus is down
in the pelvis.
g j
hrs be
doublesevery48 helpful in ectopicpregnancies Transabdominal: for late Yolk sac (nutritional source)
pregnancy why? fetalpole
Bcz, the fetus becomes large
§ Blood test enough to see him from the
abdomen and he will push Fetal pole (first stage of embryo)
- Hemoglobin the uterus upwards, so we o
can’t see him from the
in case of - Blood group & save serum vagina. Embryo with cardiac activity
transfusions
- +/- cross match
youcan usedoppler
 ULTRASOUND (CONT’D) DIAGNOSIS

Measurement by ultrasound:

• Gestational sac à MSD

• Fetal pole/Embryo à CRL
• Fetal heart à by Doppler
Ionceembryoforms

MANAGEMENT MANAGEMENT (CONT’D)

The most important step is:

ABC (ensure that the patient is hemodynamically stable)
Three main options
vital signs etc

Expectant Medical Surgical

he Patient has the
right to choose MANAGEMENT (CONT’D)

Expectant Medical Surgical

contractions
pauses
-Avoidance of surgery -Misoprostol prostaglandin E1 -Indication: persistent excessive bleeding,
& medical treatment analogue (single/repeated) hemodynamic instability, patient’s favour • Picture
vaginal/sublingual
-Method:
Vacuum aspiration or Sharp curettage
under local in outpatient or general in OR
Dilation and curettage
toeliminatesourceofinfectioncabs suave
especially c urettage
-Risks: uterine perforation, cervical
trauma/incompetence, pelvic infection Hegar Uterine Dilator Uterine
Curette
medication

makesurethere'snoremainsby
y an
uterine
scrapping was
MANAGEMENT (CONT’D)

When the patient is Rh negative and does not have Rh (anti-D)

antibodies:
prophylactic RhO-GAM should be administered within 72hr

anti D ‫ ﻧﻌﻄﯿﮭﻢ‬Rh(-ve) ‫اﻟﻤﺮﺿﻰ اﻟﻠﻲ‬

prophylactic RhO-GAM ‫واﻟﻠﻲ م ﻋﻨﺪھﻢ ﻛﻠﮭﻢ ﻧﻌﻄﯿﮭﻢ‬
 RECURRENT MISCARRIAGE
COUNSELLING

so
v No matter how well-prepared a couple is for a pregnancy loss, the event has a Definition: loss of 3 or more consecutive pregnancies
significant psychological impact.
(2 or more in Uptodate)

v Couples should be reassured that the loss was not precipitated by anything that they
did or did not, and that they were nothing they could have done to prevent it.

Incidence: 1% of couples
v Give the patient follow up visit.

RECURRENT MISCARRIAGE (CONT’D) RECURRENT MISCARRIAGE (CONT’D)

Etiology:
• Genetic: chromosomal translocations Investigation:
• Anatomical: congenital, fibroids, intrauterine adhesions, cervical incompetence • Rule out systemic disease: antiphospholipid antibodies, SLE, thyroid function, DM
• Endocrine: DM, hypothyroidism • Uterus imaging
• Immunological: SLE, Antiphospholipid antibody syndrome • Product of conception for cytogenic analysis
• Environmental: smoking, alcohol, drugs, radiation • Parental chromosomal analysis/ peripheral blood karyotyping
• Maternal Infection
• Advanced maternal age
 DEFINITION

Ectopic is an implantation of pregnancy outside the normal uterine cavity.

ECTOPIC PREGNANCY Heterotopic pregnancy: simultaneous development of two pregnancies:

one within and one outside the uterine cavity. thesametime
at
veryvery rare

Incidence: one in 80 pregnancies are ectopic (in USA)

CLASSIFIC ATION (CONT’D)

CLASSIFICATION

Cornual/ common
most infallopian
Site tube
4 usuallythisis the
site offertilization
common rig itisnaw
Most
Tubal Ectopic
/Infundibular
Pregnancy
Ectopic
Pregnancy Non-tubal Ectopic
Pregnancy
 so Pg y

ETIOLOGY & RISK FACTORS POTENTIAL OUTCOME OF

ECTOPIC PREGNANCY
• Fallopian tube damage:
- Pelvic infection (PID)or
couldeffectcinia If a patient had a pervious
ectopic pregnancy and got it
- Previous ectopic surgically removed the scar in
the site of surgery could cause

manykinda tubal another ectopic pregnancy to

surgery
- Previous tubal surgery (tubal ligation) happen Ectopic Pregnancy
- Functional: increase maternal age, smoking can damageCollin
- External tubal scarring/distorion: Previous abdominal surgery (CS, appendectomy), Endometriosis,
uterine fibroid
Spontaneous Tubal abortion
resolution Ruptured Ectopic

• Infertility, Infertility treatment (ovulation induction, IVF)

• Use of contraception (IUCD, conception on OCP)

type ofcothatprevents
At typesofpregnancy
so ie pregnancydoes occur it can ttherisk ofectopic

CLINICAL PRESENTATION

SYMPTOMS SIGNS

• Asymptomatic • Abdominal, Pelvic, Adnexal tenderness

foundinnormal
• Amenorrhea • Cervical motion tenderness not
pregnancy

Classic it onetoinsinuation
happens

• Lower abdominal pain • Pelvic/Adnexal/Cul-de-sac Mass

Traid
n i see • Vaginal bleeding/spotting • Mild elevation in temperaturenotreliablehappens
duetoinelanamation
se s ectopic
bein
egnanymust • Slightly open cervix with blood or decidual
y u tissue.
 CLINICAL PRESENTATION (CONT’D) INVESTIGATION

For ruptured Ectopic § Serial Serum bhcg:

rupture ectopic à massive intraperitoneal bleeding à Acute sign & symptoms In normally developing intrauterine pregnancy (66%): Bhcg doubles (53%) x 48hr

In ectopic pregnancies:
SYMPTOMS SIGNS
- 60% show an initial increase (not doubling)
• Sudden severe abdominal pain • Hypovolemic shock, (tachycardia, hypotension,
diaphoresis) - 40% show a decrease.
• Nausea, vomiting
• Distended abdomen, slightly enlarged uterus
• Dizziness
• Acute Abdomen: § Blood test
• Loss of consciousness,
-guarding & rigidity - Hemoglobin
• Shoulder tip pain (diaphragmatic
irritation) bleedingcouldbesoextensive -rebound tenderness - Blood group & save serum
andreachthe diaphragmwhich
affectsthephrenicnerve supplied - +/- cross match
bybrachialplexus

INVESTIGATION (CONT’D) INVESTIGATION (CONT’D)

betterthantrans an to
abdominal as structureweneed
INTRAUTERINE PREGNANCY
exam are near betterview ECTOPIC PREGNANCY
§yTransvaginal Ultrasound: True Gestational sac Pseudogestational sac
- Empty uterus • Ecentrically located • Centrally located
- Adnexal mass • Round-shaped • Oval-shaped
naveto
irritation

- Dilated thick-walled fallopian tubes • Two hyperechoic rings • Single layer

- Extrauterine gestational sac (yolk sac/embryo) (double-decidual sign)
• Irregular margins
- Ring of fire by color Doppler signorBupresence • Smooth margins • Avascular
- Moderate to significant Free fluidblood • High peripheral blood
flow
- “pseudodecidual sac” in the uterus
bedue B Hey released
being
the uterusgive a reaction by creating it
 THE DISCRIMINATORY ZONE

Discriminatory zone is defined as the lowest bhcg level in which ultrasound should detect
INVESTIGATION (CONT’D)
evidence of an intrauterine pregnancy.

TRANS-VAGINAL US TRANS-ABDOMINAL US § Other investigations:

• bhCG: 1500 to 2000 mIU/mL - Progesterone level

• bhCG: 5000 to 6000 mIU/mL
Not actually

f
• gestational sac: 4.5-5 weeks - Coldocentesis (hemoperitoneum)
done in
15 • yolk sac: 5-6 weeks clinical - Dilatation and curettage
of • fetal pole with cardiac motion: 5.5-6 weeks. Practice - Laparoscopy
dad

The absence of intrauterine pregnancy with bchg above the discriminary zone signifies an
abnormal pregnancy ( ectopic, abortion ..)

DIFFERENTIAL DIAGNOSIS
POTENTIAL CLINIC AL PRESENTATION
OF ECTOPIC PREGNANCY

Ectopic Pregnancy
ovarian
torsion
LibYids
Acutely Ruptured Possible ectopic
ectopic Probable ectopic (pregnancy of
unknown origin)

tutti think broadly

 POSSIBLE ECTOPIC
PROBABLE ECTOPIC
PREGNANCY OF UNKNOWN
(PREGNANCY OF UNKNOWN ORIGIN)
ORIGIN/LOCATION
• Hx: present with notable pelvic pain & vaginal • Hx: Missed menses/abnormal LMP, symptoms are more
spotting/bleeding subtle (mild lower abdominal pain, vaginal
• Ex: Hemodynamically stable, generally have other clinical bleeding/spotting)
§ + ve pregnancy test
signs, such as tenderness of the abdomen with adnexal or • Ex: < 50% found to have adnexal mass on Often is
cervical motion tenderness. palpated on the side opposite the ectopic pregnancy & § No Intrauterine pregnancy
• positive pregnancy test represents a corpus luteum in that ovary. The uterus is
soft & either of normal size/slightly enlarged. § No Extrauterine pregnancy
• US: variable amount of free fluid may be detected in the
cul-de-sac. Only occasionally will the ectopic • positive pregnancy test
pregnancy be seen on ultrasound as a “double- • US: thin, triple-layered endometrial (lining) may be
ring” sign in the adnexa, but a corpus luteal cyst is seen, or it may be thickened because of hCG, may be a
** Need to determine the location of pregnancy by serial
often present. small amount of fluid seen in the cul-de-sac measurement of bhcg & U/S till reach the discriminatory zone
• Other diseases with similar symptoms has been rule out
• surgical exploration is generally recommended

Read LyI Read

 Read MANAGEMENT

Management of Rupture ectopic :

Ruptured ectopic Is a surgical emergency
à Always ABC !!!
- Two Large-bore intravenous lines
- fluid resuscitation
- Blood transfusion
à Surgery: dialated
extremis

- In the hemodynamically unstable patientà laparotomy is usually required. usually we need to act

J quick sois our

laparotomy
- in less compromised patients à Laparoscopy may be performed. safest quickestoption
- Generally, tubal damage after rupture is so extensive that salpingectomy is required.
bit norupture orit'sanearlystageofrupturewecanremovetheectopicpregnancyalone
t here's

surethere'snoremaints
make
However

MANAGEMENT (CONT’D)

MANAGEMENT (CONT’D)
Expectant Management: Nodoctor likes to take this step
Criteria:
I 04 ON
• Hemodynamic stable.
Management of unruptured Ectopic
Pregnancy • Asymptomatic.
• Counselled properly, reliable & in easy reach of hospital.
• BhCG titers <200 mIU/mL & declining nightreachresolution
a
• Size of gestational sac < 3cm, no cardiac activity veryhardtorupture
Expectant Medical Surgical
• Only tubal ectopic pregnancies
it
mightreachresolution
normalabortion
** Patient require serial bhcg till undetectable
 MANAGEMENT (CONT’D)
MANAGEMENT (CONT’D)

used incancertreatment
Medical Management: Cytotoxicualso
Medication: Methotrexate (folic acid antagonist which inhibit DNA synthesis & cell replication)
Criteria:
• Hemodynamically stable Dose: 50 mg/m2
• No evidence of acute intr-abdominal bleeding
• Minimal symptoms Protocols:
(1) the single-dose/flexible-dose protocol,
• Size of ectopic <3cm if cardiac activity present , < 4cm if cardiac activity absent
(2) the two-dose protocol,
• Serum bhcg <3000 IU/I (<5000 IU/I ) y (3) the fixed multidose protocol.
• In facility with follow up
• No contraindication to treatment
• Desire for future fertility

MANAGEMENT (CONT’D)
MANAGEMENT (CONT’D)

Follow up:
• Serum bhcg on day 4, 7, 11 then weekly till undebatable
• Need to fall 15% between day 4 & 7

if it didn't
happen

Side effects:
of medical
• Stomatitis failure
• Conjunctivitis
• GI upset management
• Photosensitive skin reaction we either doanotherdose or
• Abdominal pain
surgery
• Hair loss
 MANAGEMENT (CONT’D)
MANAGEMENT (CONT’D)

Patients being treated with MTX should be instructed to avoid:

• Folate supplements,
Surgical Management:
• Nonsteroidal anti-inflammatory agents.
Method: Laparoscopy/Laparotomy
• Alcohol.
lessinvasive
snort stay
hospital
d
• Sunlight exposure
Surgery: Salpingectomy vs Salpingosotmy vs Salpingotomy
• Vigorous physical exercise.
• Sexual activity 9Patientmightgetpregnantn bnegwill
increase

beaog sa i wi am i jog bag

breastfeeding

** After an ectopic, pregnancy should be avoided for at least 3 months to permit

the fallopian tube to normalize & to allow complete elimination of MTX
Gtonotelect
thefetus

MANAGEMENT (CONT’D)

Salpingectomy Salpingostomy Salpingotomy

Removal of the tube with the small opening over the site of small opening over the site
ectopic pregnancy the ectopic then product of of the ectopic then product
conception is extracted, the of conception is extracted,
incision is left open/healed by the incision is closed
secondary intension

* Standard of choice • In case absent/damaged contralateral tube

• Who desire fture fertility
Salpingectomy
• when there has been significant
* Associated with higher rate of subsequent ectopic dueto thescar
damage to the tube
* Must be followed with quantitative bhcg to monitor regression of the pregnancy Salpingostomy
• does not desire future fertility
• when there is a high likelihood of
retained products of conception.
 MANAGEMENT (CONT’D)

For all ectopic/ miscarriage who are Rh-ve women, should receive:
Anti-d Rh-immunoglobulin prophylaxis to prevent alloimmunization in
future pregnancy
• 50ug (250IU)
• As soon as possible & within 72hr
Miscarriage, also known as spontaneous abortion, refers to the loss of a pregnancy before the fetus is able to survive independently outside the uterus. It typically
occurs within the first 20 weeks of gestation. Miscarriages are relatively common and can be emotionally distressing for individuals and couples involved.

i
Etiology / Risk Factors:
MANAGEMENT (CONT’D)
1. Chromosomal abnormalities: The majority of miscarriages are caused by chromosomal abnormalities in the fetus, which usually occur spontaneously and are not
related to parental factors.
2. Advanced maternal age: The risk of miscarriage increases with advancing maternal age, especially after the age of 35.
3. Hormonal
For all imbalances: Certainwho
ectopic/ miscarriage hormonal imbalances,
are Rh-ve such as
women, should low levels of progesterone, can increase the risk of miscarriage.
receive:
4. Maternal
Anti-dmedical conditions:prophylaxis
Rh-immunoglobulin Conditions like diabetes,
to prevent thyroid disorders,
alloimmunization in autoimmune diseases, and polycystic ovary syndrome (PCOS) can increase the risk of
miscarriage.
future pregnancy
5. Uterine abnormalities:
• 50ug (250IU) Structural abnormalities of the uterus, such as uterine fibroids or septate uterus, may contribute to miscarriages.
6. Infections: Infections like bacterial vaginosis, sexually transmitted infections (STIs), and certain viral infections can increase the risk of miscarriage.
• As soon as possible & within 72hr
7. Lifestyle factors: Smoking, alcohol consumption, drug use, and excessive caffeine intake have been associated with an increased risk of miscarriage.
8. Previous history of miscarriage: Women who have previously experienced one or more miscarriages are at a slightly higher risk of subsequent miscarriages.

Types of Miscarriage:
1. Threatened miscarriage: Vaginal bleeding occurs, but the cervix remains closed, and the pregnancy may continue normally.
2. Inevitable miscarriage: Vaginal bleeding and cramping occur, and the cervix begins to dilate, indicating that miscarriage is likely to occur.
3. Incomplete miscarriage: Some fetal or placental tissue is passed out of the uterus, but some remains inside.
4. Complete miscarriage: All fetal and placental tissue is expelled from the uterus.
5. Missed miscarriage: The fetus has died, but the products of conception are not expelled from the uterus. There may be no symptoms, and the diagnosis is usually
made during a routine ultrasound.

Clinical Presentation:
The common signs and symptoms of miscarriage include vaginal bleeding, abdominal or pelvic cramping, back pain, passage of tissue or clot-like material from the
vagina, and a decrease in the intensity of pregnancy symptoms (such as breast tenderness or morning sickness).

Investigation and Diagnosis:

If a miscarriage is suspected, the following investigations may be performed:
1. Pelvic examination: To check for any signs of bleeding or abnormalities in the uterus or cervix.
2. Ultrasound: An ultrasound scan can confirm the diagnosis of miscarriage and determine if there is any remaining fetal or placental tissue.
3. Blood tests: Blood tests may be performed to measure hormone levels, such as human chorionic gonadotropin (hCG), and to assess the overall health of the
mother.

Management:
The management of miscarriage depends on the type and stage of the miscarriage, as well as the individual's preferences and clinical circumstances. Options
include:
1. Expectant management: Allowing the miscarriage to progress naturally without medical or surgical intervention, with close monitoring for any complications.
2. Medical management: The use of medications, such as misoprostol, to induce the expulsion of the remaining pregnancy tissue.
3. Surgical management: A procedure called dilation and curettage (D&C) may be performed to remove the remaining tissue from the uterus.
4. Emotional support: Psychological support and counseling are essential to help individuals and couples cope with the emotional impact of a miscarriage.

It is important to consult with a healthcare provider for proper evaluation, diagnosis, and management in case of a suspected miscarriage.