eve espey, md, mph. understand steps in diagnosis in women with bleeding, cramping and a positive...
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Eve Espey, MD, MPH
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Understand steps in diagnosis in women with bleeding, cramping and a positive pregnancy test
Initiate appropriate management for miscarriage,
ectopic and threatened abortion
Understand medical and surgical approaches to the management of miscarriage and ectopic pregnancy
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Don’t nuke a normal pregnancy or miss an ectopic
Place an IUD immediately after D&C for miscarriage
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“We’ve got a gal here with bleeding, pain and a positive pregnancy test”
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Normal pregnancy Miscarriage Ectopic
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Ultrasound Quantitative hCG Experience Common sense Luck!
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One of the top reasons OB-GYNs are sued: MTX given to a normal intrauterine pregnancy
Ectopic pregnancy still causes maternal mortality
Dealing with miscarriage in a sensitive way is paramount to women
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Uterus outline
Sub-chorionic bleed
Embryo
Yolk sac
Gestational sac
Choriodecidual reaction
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5 weeks ----> Gestational sac (5mm)
6 weeks ----> Yolk sac
7 weeks ----> Cardiac motion
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17 y/o G2P0 presents with bleeding, cramping, positive pregnancy test
Differential◦ Normal pregnancy◦ Miscarriage◦ Ectopic?
Sac = 5 4/7 weeks
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Day 0 = 1,700 Day 2 = 4,400 Rise = 158% Likely diagnosis?
The AVERAGE hCG rise over 48 hours in a normal pregnancy is 124%
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Day 0 = 1,700Day 2 = 2,200Rise = 29%Likely diagnosis?
The MINIMUM hCG rise over 48 hours in a normal pregnancy is 53%
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J Clin Endocrinol Metab 1979;49:917
J Clin Endocrinol Metab 1979
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15% of women with IUP have an “abnormal” rise in hCG in the first 40 days
17% of ectopic pregnancies have a normal rise in hCGs over 48 hours at least once in early pregnancy
Kadar et al.Obstet Gynecol 1981;58:162
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32 y/o G2P1 at 7 weeks from LMP
Presents with bleeding, cramping, positive pregnancy test
hCG = 5,277
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Transvaginal U/S◦ Beta HCG = 1500 - 2000 mIu/ml
Transabdominal U/S◦ Beta HCG = 3,600 mIu/ml
If HCG > discriminatory zone and no gestational sac seen, consider ectopic pregnancy till proven otherwise
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Most common cause of maternal death in early pregnancy 20 deaths per year in the US
1970 17,800 cases Fatality 35/10,000 1992 108,800 cases Fatality 3.4/10,000
Risk factors:◦ Prior tubal sterilization 10%◦ Hx Salpingitis.....4X◦ Linear salpingostomy.....10X◦ Ovulation induction.....4X◦ Most cases have no known risk factor!◦ Minority race
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Laparoscopy◦ Salpingostomy
5-20% persistent ectopic Monitor with hCG to 0 Treat with MTX
◦ Salpingectomy Laparotomy Medical management Expectant management
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Single, two or multi-dose regimens Reported success: 71%-94% Patient selection
◦ Stable◦ No IUP on ultrasound or villi on D&C◦ Labs normal: AST, WBC, platelets, creatinine
Relative contraindications◦ hCG > 5,000◦ Cardiac activity in the tube◦ Sac > 3.5 cm
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Day 0: hCG, CBC, Platelets, Rh, AST, Cr Day 0: MTX 50mg/m2 IM Day 4: Quantitative hCG Day 7: Quantitative hCG
◦ If HCG does not decrease by at least 15% from Day 4, repeat MTX
Weekly hCG until < 5
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If pretreatment Bhcg >5000 failure rate is around 14%
If pretreatment Bhcg <5000, failure rate is around 3.7%
Consider two-dose regimen if Bhcg >5000
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Author Tx IUP Repeat ectopic
Sherman 1982 Salpingectomy 72% 6% Sherman 1982 Salpingostomy 83% 6% Stovall 1993 Medical 70% 9%
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Miscarriage
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About 25% of women experience a miscarriage.
Approximately 15% of clinically recognized pregnancies spontaneously abort in the first or early second trimester.
Up to 33% of all pregnancies end in miscarriage.
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Expectant management
Misoprostol D&C
◦ Suction◦ MVA
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Treatemtent Success rates
Placebo 16-60%
Single dose misoprostol 25-88%
Repeat dose x 1 if incomplete at 24 hours
80-88%
Success rate depends on type of miscarriage-100% with incomplete abortion- 87% for all others
Wood SL, Obstet Gynecol 2002; Bagratee JS, Hum Reproduct 2004; Blohm F, BJOG: Int J Obstet Gynecol 2005
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Gestational sac or CRL up to 10 weeks◦ No embryo or no fetal cardiac activity
Rh, hematocrit 800 mcg misoprostol x 2 doses
◦ Intravaginal home administration x 1 dose◦ Repeat after 24 hours if no tissue
Ibuprofen + Tylenol with codeine If no passage within a week, RTC for
options
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“Vocal local” Oral analgesia + paracervical block
◦ Ibuprofen 800 mg ◦ Percocet and 1 mg lorazepam
IV sedation + paracervical block + ◦ Fentanyl 50-100 mcg ◦ Midazolam 1-2 mg
Regional anesthesia (spinal) General anesthesia or deep sedation
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31 y/o G3P2 presents to ER with “severe LLQ pain” and positive pregnancy test◦ Benign pelvic exam, + hCG◦ Ultrasound: “No IUP, left
adnexal mass with surrounding echogenic fluid and free fluid in pelvis concerning for ruptured ectopic”
hCG = 1,003
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Ectopic pregnancy vs. early IUP Offered methotrexate Patient declined: desired
pregnancy Plan: Repeat hCG in 48 hours
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Continued pain, back to emergency room HR 93, BP 148/71, bilateral adnexal
tenderness and rebound Ultrasound: “Small hypoechoic focus in
uterus, possible pseudosac. Left adnexal mass with interval development of heterogeneous material/free fluid”
hCG: 1,419 (55% rise)
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Laparoscopy◦ 400 cc hemoperitoneum, “no active
bleeding site determined”◦ Attempted salpingostomy followed by left
salpingectomy◦ Discharged on POD #1
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Pathology sent on Day #1 Checked on Day #7 Pathology
◦ Gross: Sectioning through this area demonstrates “presumed villi”
◦ Microscopic diagnosis: “No chorionic tissue, no evidence of intratubal gestation
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Patient called: “final pathology negative for POCs” hCG: 9,417 Triage ultrasound: “Gestational sac measuring 6
weeks, minimal free fluid, right ovary 2.9 cm, circumferential flow, hypoechoic cystic structure within ovary measuring 2 cm, no embryonic pole, no embryonic fetal heart motion.”
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Diagnosis: Presumed ongoing ectopic Radiology ultrasound was ordered but not available
since it was the weekend. Given a concerning picture for ectopic, methotrexate was recommended
IM MTX 50 mg/m2 Day #11
◦ hCG = 15,168 – not checked, F/U day #14 (7 days after MTX given)
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Day #14◦ Ultrasound: 6 ½ week IUP with positive fetal heart motion in the 120s◦ Patient counseled re MTX in setting of normal IUP
Day #18 ◦ Ultrasound: CRL consistent with 6 ½ weeks with FHM ranging from 0-
100 bpm Day #25
◦ Ultrasound: CRL consistent with 6 ½ weeks with no FHM◦ Requests misoprostol for management
Day #30◦ Empty uterus, Paragard IUD placed
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“Offered” MTX (instead of dx LSC) on Day 0 with a desired pregnancy
Laparoscopy: No active bleeding? Checked pathology on Day 7 Incorrect interpretation of hCG of 9,417 with
no fetal heart motion MTX given based on an inadequate U/S Day #11 hCG not checked till Day #14
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hCG and pathology follow-upBeta book systemContinuity of physician teams seeing the patient Context—patient course, hCGs and U/S
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Ovulation may occur within 10 days
Don’t forget contraception
Half of pregnancies are unintended
May wish to delay another pregnancy even if intended
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> 700 women undergoing D&C (abortion and miscarriage) from 5-12 weeksRandomized to immediate vs. delayed IUD insertionNo significant difference in expulsion risk:
◦ 4.5% immediate◦ 2.7% delayed
No increase in other complications
Bednarek, NEJM 2011
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Be meticulous in follow-up of first trimester complications
Consider misoprostol and MVA for treatment Don’t forget the IUD!