First Trimester Pregnancy Complications

Transcription

1 First Trimester Pregnancy Complications Diagnosis and Management Mark Deutchman MD University of Colorado Objectives Correlation of clincal, ultrasound and serum hcg findings to make a diagnosis Make sense of treatment options for early pregnancy loss MVA workshop 1 2 Early Pregnancy Bleeding Miscarriage: occurs in up to 20% of clinically recognized pregnancies More common in all pregnancies Ectopic pregnancy Gestational trophoblastic disease Cervical bleeding Causes unrelated to pregnancy Discriminatory Criteria Based on history, quantitative hcg laboratory data and diagnostic ultrasound findings Provides tool to distinguish normal intrauterine pregnancy from miscarriage and ectopic pregnancy 3 4 Discriminatory Findings* Patterns of hcg Change Menstrual Age Embryologic event Laboratory and transvaginal sonographic findings 3-4 weeks Implantation site Decidual thickening 4 weeks Trophoblast Peritrophoblastic flow on color flow Doppler 4-5 week Gestational Sac Must be present if βhcg > mIU/mL (varies with sonographer experience and ultrasound quality) 5-6 weeks Yolk Sac Must be present if gestational sac mean diameter >10mm 5-6 weeks Embryo Seen when gestational sac mean Barnhart KT. Ectopic diameter is > 18mm pregnancy. NEJM 5-6 weeks Cardiac activity Must be present if embryonic crownrump 2009;361: length >5mm * Adapted from Paspulati RM, Bhatt S, Nour S. Sonographic evaluation of first-trimester bleeding. Radiol Clin North Am Mar;42(2):

2 Normal Gestational Sac Interdecidual Sign SAC Uterus Round shape Interdecidual location Echogenic rind 5 th menstrual week, transvaginal scan 7 8 Mean Sac Diameter (mm) + 30 = Menstrual age (days) Yolk Sac to 7 Week Embryo with Heartbeat GA by Crown-Rump Length 11 Menstrual age* (weeks) = CRL (cm) *Accurate between 8 and 13 weeks 12 2

3 Abnormal Diagnoses Spontaneous Abortion Complete Incomplete Missed Subchorionic Hemorrhage Ectopic Pregnancy Heterotopic Pregnancy Gestational trophoblastic disease SAB - Clinical Course Missed menses, pregnancy symptoms Positive hcg Vaginal bleeding hcg falls or plateaus Lower abdominal cramping, backache Products of conception passed Doppler Detection of Fetal Heartbeat Float Test for Chorionic Villi Listen after 9-10 weeks with handheld Doppler Sensitivity enhanced by elevating uterus during bimanual exam Source: Advanced Life Support in Obstetrics. AAFP Missed Abortion Anembyronic Pregnancy Embryo w/o heartbeat Completed Miscarriage U = empty uterus CX = cervix B = bladder

4 Subchorionic Hemorrhage Ectopic Pregnancy E= Embryo YS = Yolk sac SCH = subchorionic hemorrhage Pregnancy outside the uterus Usually in fallopian tube Occurs in >1:100 pregnancies Second most common cause of maternal mortality Early diagnosis critical! Risk Factors for Ectopic Diagnosis of Ectopic History of previous ectopic pregnancy Prior tubal surgery Prior tubal infection(s) Progestin-only contraception Contraceptive IUD In utero DES exposure Many occur in women with Failure of hcg to double in hours Ultrasound (transvaginal) IUP rules out ectopic No gestational sac + hcg>1800 highly suggestive Gestational sac / embryo outside of uterus confirms ectopic Pitfalls: pseudogestational sac, ruptured corpus luteum Laparoscopy gold standard no risk factors! Ectopic Pregnancy Extrauterine Mass Pseudosac of Ectopic Pregnancy Uterus Extrauterine mass

5 Extrauterine Signs of Ectopic Finding Risk of Ectopic No mass or free fluid 20% Any free fluid 71% Echogenic mass 85% Moderate to large amount of fluid 95% Echogenic mass with fluid 100% Free Pelvic Fluid Mahony et.al.jum1985;4: Management Options Surgical: Dilation and Curettage (D&C) Manual Vacuum Aspiration (MVA) Medical Misoprostol (off label use) Expectant wait for spontaneous completion Miscarriage Management Resource Guide Overview of the Miscarriage Management Training Initiative Overview of miscarriage management in outpatient settings Papaya Workshop Support Staff Training Implementing outpatient miscarriage management services Resources Management of Miscarriage 50% loss when bleeding present Presence of fetal heartbeat is reassuring Majority do not require medical or surgical intervention Identify patients at risk for bleeding, infection Routine antibiotics are not indicated Address contraceptive needs 29 Expectant and Medical Treatment In incomplete miscarriage, both expectant and medical treatment with misoprostol are highly successful. In missed abortion, medical treatment with misoprostol and surgical treatment are more effective than expectant treatment. Women treated with misoprostol have more bleeding but less pain than those treated surgically. Women treated expectantly have more outpatient visits than those treated with misoprostol. Surgery is associated with more trauma and infectious complications than misoprostol treatment. 30 5

6 Expectant Management Reasonable criteria for offering: <13 weeks gestation Stable vital signs No evidence infection Patient preference Natural history: Most expel within 1st 2 wks after diagnosis Prolonged follow-up may be needed Acceptable and safe to wait up to 4 wks post-diagnosis Slide credit: Sarah Prager, MD Univ. Wash Dept. Ob-Gyn 31 Expectant Management Overall success rate 81% Success rates vary by type of miscarriage (helpful for counseling) Incomplete/inevitable abortion 91% Embryonic demise 76% Anembryonic pregnancies 66% Slide credit: Sarah Prager, MD Univ. Wash Dept. Ob-Gyn Data: Luise C, Ultrasound Obstet Gynecol Problem: Define Success Cited criteria: Endometrial thickness < 15mm No bleeding Negative urine hcg Problems with these criteria: hcg may be + for weeks EM thickness is poor predictor Reasons to Intervene Persistent gestational sac Clinical symptoms Cramping, bleeding, infection Patient preference No data on elapsed time Slide credit: Sarah Prager, MD Univ. Wash Dept. Ob-Gyn Slide credit: Sarah Prager, MD Univ. Wash Dept. Ob-Gyn Misoprostol (off-label use) Typical dosages: 600 micrograms orally 600 to 800 micrograms vaginally May repeat in 24 hours Fewer gastrointestinal side effects when given vaginally than when given orally Highly efficacious and well-accepted by Medical Management Pooled Success Rate Data Placebo 16 60% Single dose misoprostol 25 88% mcg Repeat dose x 1 if incomplete 80 88% at 24 hours Success rate depends on type of miscarriage 100% with incomplete abortion 87% for all others Slide credit: Sarah Prager, MD Univ. Wash Dept. Ob-Gyn women 35 Data: Wood SL, Obstet Gynecol 2002; Bagratee JS, Hum Reproduct 2004; 36 Blohm F, BJOG: Int J Obstet Gynecol

7 Surgical Management Suction D&C (EVA) Manual Vacuum Aspiration (MVA) Infection Prophylaxis Periabortal antibiotics decrease infection risk 42% No strong evidence on what to use Doxycycline (2 14 doses) Metronidazole: Bacterial vaginosis Trichomoniasis Suspicious discharge Sawaya GF, Obstet Gynecol 1996; Prieto JA, Obstet Gynecol Method Outcome Comparison Factor Success rate Resolution within 48 hrs Infection risk.2 3% Comparison of Methods Surgical > Medical Medical Expectant Surgical > Medical > Expectant Expectant = Medical = Surgical Patient Satisfaction Meta-analysis: high satisfaction with medical management Caution: Few studies looked at satisfaction Satisfaction depended on choice: If women randomized 55-74% satisfied If women chose 84-88% satisfied Both were independent of method Unsuccessful expectant resulting in surgical showed most profound anxiety & depression Nanda K, Cochrane Database Syst Rev 2006; Nielsen S, Br J Obstet Gynaecol 1999; Shelly JM, Aust. NZ J Obstet Gynaecol 2005; Sotiriadis A, Obstet Gynecol 2005; Tinder J, (MIST) BMJ, Cost Medical management most cost effective (2 studies) Misoprostol vs. expectant vs. surgical: $1000 vs. $1172 vs. $2007 Expectant management most cost effective (MIST) Expectant vs. medical vs. surgical: 1086 vs vs Suction D & C Patient selection: Unstable Significant medical morbidity Infected Very heavy bleeding Patient prefers immediate therapy Doyle NM, Obstet. Gynecol 2004; You JH, Hum Reprod 2005; Petrou S, BJOG

8 Outpatient MVA Advantages Avoid repeated exams that often occur in hospital Simplify scheduling and reduce wait time - Average OR waiting time in UK-based study: 14 hours, with 42% of women not satisfied Save resources; less cost Avoid cumbersome OR protocols - Prolonged NPO and discharge criteria Less anesthesia required Outpatient Management Cautions Uterine anomalies Coagulation problems Active pelvic infection Extreme anxiety Any medically unstable condition Demetroulis 2001; Lee and Slade 1996 Blumenthal and Remsburg. Int J Gynecol Obstet 1994;45: Manual Vacuum Aspiration MVA Device MVA Cannulas MVA Procedure Patient selection and counseling Confirm diagnosis Prep and apply tenaculum Perform paracervical block Dilate cervix and Insert cannula Generate vacuum, connect to cannula Activate vacuum and aspirate Source: IPAS instruction manual

9 Post-MVA Care Source: IPAS Instruction Manual Rhogam at time of diagnosis or surgery Pelvic rest for 2 weeks No evidence for delaying conception Initiate contraception upon completion of procedure (even IUDs!) Expect light-moderate bleeding for 2 weeks Menses return after 6 weeks Negative ßhCG values after 2 4 weeks Appropriate grief counseling 49 Goldstein R, Am J Obstet. Gynecol 2002; Wyss P, J Perinat Med 1994; Grimes D, Cochrane Database Syst Rev Papaya MVA Workshop 51 First Trimester Pregnancy Loss Conclusions Clinical, ultrasound and serum hcg findings are used to diagnose first trimester pregnancy loss. Expectant, medical and surgical management methods all have their place. Medical management can be used in the majority of cases. MVA is an efficacious, cost-effective and wellaccepted method for surgical management. 52 9