1 / 46

FIRST TRIMESTER BLEEDING

FIRST TRIMESTER BLEEDING. SPONTANEOUS ABORTION ?30%, usu self-limited ECTOPIC PREGNANCY ?1%, most dangerous MOLAR PREGNANCY 0.1%, cookbook. SPONTANEOUS ABORTION. SPONTANEOUS LOSS, PRE-VIABLE <20 WKS, <500 GM 30% PREVALENCE 80% 1 ST TRIMESTER-”EARLY”. RISK FACTORS. AGE

isanne
Download Presentation

FIRST TRIMESTER BLEEDING

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. FIRST TRIMESTER BLEEDING • SPONTANEOUS ABORTION • ?30%, usu self-limited • ECTOPIC PREGNANCY • ?1%, most dangerous • MOLAR PREGNANCY • 0.1%, cookbook

  2. SPONTANEOUS ABORTION • SPONTANEOUS LOSS, PRE-VIABLE • <20 WKS, <500 GM • 30% PREVALENCE • 80% 1ST TRIMESTER-”EARLY”

  3. RISK FACTORS • AGE • 10%@20, 20%@35, 40%@40, 80%@45 • SAB HX • 5% NSVD/NO SAB, 30-40% IF 3 SABS

  4. CAUSES • CHROMOSOMAL ABN’S- 50%-sporadic • CONG ANOMALIES • UTERINE ABN’S-fibroids, synechiae, septae • INFECTIONS • THROMBOPHILIAS-APS, APC res, prothro, etc • DM, THYROID • IATROGENIC-amnio, CVS • SUBSTANCES-caffeine, tob, meth, coc, NSAIDs

  5. APPROACH • ESTABLISH IUP-R/O ECTOPIC-urgent • ESTABLISH VIABILITY-less urgent • CONSIDER INTERVENTION-not all • REMEMBER RHOGAM-all Rh neg • EDUCATE/ SUPPORT/ FOLLOW-UP

  6. ECTOPIC? VIABILITY? • RISK FACTOR ASSESSMENT • absence doesn’t r/o • UTERINE SIZE-decidua to 8 wks • HEART TONES- don’t settle for 2nd best • CERVICAL-open suggestive • TISSUE PASSED-frozen/rush permanent

  7. ECTOPIC? VIABILITY? • HCG • ?serial- not if visualized on sono • ?serial sono better if not definitive • SONOGRAPHY • Gest sac/yolk sac- ?normal appearing • Fetal pole if gest sac MSD >20 • cardiac if fetal pole >6-7wk=CRL >5mm

  8. TERMS • THREATENED-next slide • INEVITABLE-open,SROM,heavy bleeding • INCOMPLETE- • COMPLETE-easiest in retrospect-decresc • MISSED/” BLIGHTED OVUM” • SEPTIC

  9. Threatened SAB • Vaginal bleeding +/- cramping • 30-40% pregnancies bleed; 1/2 SAB • more symptoms, small for dates, subchorionic bleed-poorer prognosis • fetal cardiac activity- better prognosis • Rx- observation

  10. INTERVENTION • DO I NEED TO INSTRUMENT? • Where/ what instrument? • How soon?-septic vs bleeding vs missed • Lam’s? EGA by sono, blighted ovum • DO I NEED FROZEN SECTION ? • Rush permanents vs routine

  11. OPTIONS • EXPECTANT • <10-12wk, 80-90% res, slower • SURGICAL • ?ectopic, septic, BLEEDING, missed,>10-12 • Fastest • MEDICAL • <10-12, 80-90% res, faster • Miso 600-800 PV x 1-2

  12. PREVENT ISOIMMUNIZATION • REMEMBER RHOGAM 50mcg IM if < 12 WEEKS 300mcg IM IF > 12 WEEKS

  13. EDUCATION & SUPPORT • ADDRESS GUILT • ADDRESS GRIEF • DEFER PREGNANCY > 3 MONTHS

  14. Recurrent SAB • ?3 consecutive for therapeutic nihilists • ?evid base for recommendations • Outcomes similar- ~70% successful preg • no w/u, + or – w/u , +w/u with or without rx • 50% success after 6 consecutive losses • Uterine eval, day 3 FSH, antiphos syn w/u & misc thrombophilia w/u, TSH, ?fast glu, ?ANA, karyotype • Thrombophilia is in –progesterone supps, doxy are both out

  15. MOLAR PREGNANCY • Aberrant fertilization, fetal origin • 0.05-0.1% incid (US), chorioca 1:30,000 • 1:120 SE Asians, 1:1200 Hispanics, prior mole, age <20 >35, lower parity • 80-90% benign course • most metastatic disease curable

  16. CLASSIFICATION • HYDATIDIFORM MOLE =GTD • COMPLETE • PARTIAL • PERSISTENT/INVASIVE MOLE=GTN • CHORIOCARCINOMA=GTN • PLAC SITE TROPHOBLASTIC TUMOR= GTN

  17. No fetal tissue 1 sperm + anuclear ovum- 46XX or 46XY GTN risk 20% Fetal tissue 2 sperm + 1 ovum - 69XXY or 69XYY GTN risk 5% Complete & partial mole

  18. CLINICAL FINDINGS • VAGINAL BLEEDING • NO FHT’S • SIZE > DATES • HIGH HCG- >100,000 (nl preg peak < 200,000) • HYPEREMESIS GRAVIDARUM • EARLY PREECLAMPSIA <20Wwks • THYROTOXICOSIS • OVARIAN CYTS ( THECA LUTEIN)

  19. DIAGNOSIS • SONOGRAPHY • PATHOLOGY

  20. W/U • HCG, Rh, TSH, LFP, BUN/Cr • CXR • SONO

  21. TREATMENT • Uterine evacuation • D&C, pitocin running? • Bleeding, perforation, ?ARDS, etc • Serial HCG’s • q wk till negative then q mo for 6-12mo • Should drop rapidly& be negative < 90 days • normal preg usu takes 2-4wk • effective contraception during follow-up

  22. Persistent/recurrent HCG rise • =HCG rise x2 wk, stable x 3wk,+@3mo • ?new pregnancy… • Worry re GTN/metastatic disease • 25%chorioca, 75% persist/invasive mole • Pelvic sono • Consider repeat D&C- up to 40% neg HCG • Cbc, coags, liver, renal labs • CT abd, pelvis, chest, ?head

  23. High risk features • Higher HCG • Time from and characteristics of antecedent pregnancy • Site, size and number of mets • failure of prior chemo

  24. GTN • Occurs 50% after nl preg, 25% after mole, 25% after ectopic/SAB • Vag bleeding or amenorrhea esp prolonged postpartum,very bloody tumors check HCG • Serial HCG’s after molar pregs

  25. Remember rhogam • 300mcg IM with moles

  26. ECTOPIC PREGNANCY • Implantation outside endometrial cavity • High prevalence related to PID prevalence • 98-99% tubal- usu rupturing 6-10 wks • cornual, cervical, ovarian, abdominal rare

  27. High index of suspicion • Assume all female patients are pregnant until proven otherwise • ?9-50yrs, sexual hx reliability, contraceptive failure • Assume all pregnant patients are ectopic until proven otherwise • danger of preexisting diagnosis of SAB

  28. Risk factors • Tubal damage • Prior ectopic • PID 1:24 pregs • pelvic surg- appi, cystectomy, section, TL • Failed contraception • IUD, progesterone only methods, TL, emergency? • Misc. • extrinsic mass, infert, smoking at conception • Absence of risk factors does not rule out ectopic

  29. Clinical Presentation-an evolution- • Pregnancy • amenorrhea, N, V, frequency, rising HCG • Failing pregnancy • vag bleeding, ?tissue, flat/ falling HCG • Growing/ rupturing ectopic • pain (colic, peritoneal irritation, referred), mass, hemodynamic instability, fluid in belly

  30. HCG • >99% ectopics positive • absolute values correlate poorly w/ EGA • relative rise helpful early in gestation • abnormal rise signifies abnormal gestation • note 20-30% of ectopics have normal rise

  31. Lower normal limits HCG rise

  32. Sonography • Primary-Verify or rule out IUP-?heterotopic • Also ectopic cardiac, complex mass, free fluid • “Discriminatory zone” • Endovaginal vs. transabdominal • Availability • Indication-low thresholds symptoms-All?

  33. Sonographycontinued • Gestational sac (vs pseudo sac) • EGA~5wks, singleton 1000-1800 • Fetal pole • EGA~5.5wks, by mean sac diam of 16-20mm • Cardiac activity • EGA~6wks, by 7 wks “minimum EGA” or fetal pole >5mm

  34. DDX • SAB • Molar preg • IUP complicated by: • ovarian cyst complication • fibroid degeneration, torsion • appendicitis • etc.

  35. DIAGNOSTIC ALGORITHM

  36. DIAGNOSTIC ALGORITHM

  37. DIAGNOSTIC ALGORITHM

  38. DIAGNOSTIC ALGORITHM

  39. Treatment options • Expectant • Methotrexate • Surgery

  40. Expectant • Selection criteria • asymptomatic, small ectopic, low falling HCG • Rationale • ?incidence tubal SAB, no therapeutic M&M • Concerns • risk of rupture awaiting resolution

  41. Methotrexate • Inclusion criteria • <3-4cm, unruptured, no liver, renal, heme dis ?no cardiac activity, ?HCG <5000-15,000 • Education/ consent • Workup • CBC/d, AST, BUN/Cr,Type/Rh • Sono • D&C

  42. Methotrexateinformed consent • Alternatives • nature of treatment & follow-up • failure rate, risk of rupture • Side-effect profile • pain, stomatitis, liver, marrow, renal tox • things to avoid • NSAID’s, ETOH, folic acid, intercourse

  43. Methotrexate • Dose • 50mg/m2 • Follow-up • quant HCG 3&6 days after injection • Success • >15% drop on HCG between day 3&6 • follow weekly till negative

  44. ALT METHOTREXATE • 1mg/kg IM every other day to 4 doses • Quant HCG with leucovorin rescue on alternate days • Stop when 15% drop in HCG • ?higher efficacy, less lost sleep

  45. Surgery • Laparoscopy vs laparotomy • Conservative- maximize fertility • salpingostomy • Extirpative- prevent future ectopics • salpingiectomy

More Related