Complications of Early

Pregnancy
Dr TC Pun
Dept of Obs & Gyn
24/9/2011

Complications of Early Pregnancy

Common presenting complaints
Outline of management strategy
Outline of emotional impact on the couple
with early pregnancy losses
Summary

Common presenting complaints

Nausea and vomiting

Vaginal bleeding
Abdominal pain
Others

Nausea and vomiting

Aetiology and mechanism remain unclear

Higher level of hCG
Other hormones
Gastrointestinal tract disorder
Psychological causes
(Verberg 2005 Hum Reprod Update 527-39)

Relative levels of maternal hormones and incidence of hyperemesis gravidarum (HG) according
to the duration of human pregnancy

Verberg, M.F.G. et al. Hum Reprod Update 2005 11:527-539;

doi:10.1093/humupd/dmi021

hCG
Mechanism unclear
?stimulating effect on the secretory
processes in the upper gastrointestinal
tract
?stimulation of thyroid function because of
its structure similarity to TSH
(Verberg 2005 Hum Reprod Update 527-39)

Conclusion
We are concerned as far the inadequacies
in the design, analysis, and reporting of
case-control studies examining the
etiology of HG. It is mandatory to follow
adequate clinical research methodology in
executing and reporting such studies
(Sandven 2010 Arch Gynecol Obstet)

Vaginal bleeding in ectopic

pregnancy
In an ectopic gestation, the endometrium usually
responds to the hormonal changes of pregnancy
and undergoes decidual change
May be mistaken as a pseudosac in ultrasound
examination
If the ectopically sited fetus dies, the uterine
decidua may slough off as a cast or irregularly
shed
(Fox 1997 in Problems in Early Pregnancy RCOG Press)

http://www.erpocketbooks.com/er-ultrasounds/pelvic-ultrasound-for-the-ed/

Abdominal pain
Uterine contraction
Distension of uterine cervix
In ectopic pregnancy
Distension of the fallopian tube
Haemoperitoneum

Others
Shock
Hypovolaemia as a result of bleeding
Vasovagal as a result of distension of
cervix

Others
Shoulder pain
Blood irritates
the diaphragm
stimulation
of phrenic
nerve
referred pain
to shoulder

http://www.healcentral.org/content/collections/RCSI/ILLab449.JPG

Complications of Early Pregnancy

Common presenting complaints
Outline of management strategy
Outline of emotional impact on the couple
with early pregnancy losses
Summary

Outline of management strategy

Miscarriage
Ectopic pregnancy
Gestational trophoblastic disease
Hyperemesis gravidarum
anxiety state

Miscarriage
Expulsion or extraction of a fetus weighing less
than 500 g(WHO)
spontaneous abortion should be replaced with
the term miscarriage(RCOG 2000)
incomplete abortion

incomplete miscarriage

missed abortion,
silent miscarriage,
anembryonic pregnancy delayed miscarriage,
early fetal demise

Definition
Threatened Bleeding from the uterus prior to 24 weeks with
the cervix not dilated and the fetus alive
Inevitable

Bleeding from the uterus prior to 24 weeks with

pain and dilatation of the cervix

Incomplete

Part of the conceptus has been expelled but

there is continuing bleeding due to tissues
retained

Complete

The whole conceptus has been expelled

Recurrent

3 or more consecutive miscarriages

Silent

Pregnancy failure is identified before expulsion

of fetal/placental tissues

Miscarriage
History
LMP and menstrual history
pregnancy test
vaginal bleeding
abdominal pain
passage of tissue mass
?planned ?wanted

Miscarriage
Physical examination
general condition
haemodynamic status
?pallor
abdominal tenderness

Miscarriage
Vaginal examination
introitus ?blood stained
vagina ?blood ?tissue mass
cervix ?tissue mass ?vulsellum mark ?os
open/closed
uterus - size
fornix

abdominal
pain
threatened
silent
incomplete
inevitable
complete

cervical os

uterine size

abdominal
pain
threatened nil
silent

nil

incomplete +/inevitable

yes

complete

nil

cervical os

uterine size

abdominal
pain

cervical os

threatened nil

closed

silent

closed

nil

incomplete +/-

open

inevitable

yes

open

complete

nil

closed

uterine size

abdominal
pain

cervical os

uterine size

threatened nil

closed

corresponding

silent

closed

small

incomplete +/-

open

small

inevitable

yes

open

corresponding

complete

nil

closed

small

nil

Miscarriage
Investigations
Hb - also note MCV
Rh factor
pelvic sonogram
tissue mass for histology - ?decidua ?
chorionic villi ?fetal parts

Miscarriage
Guidelines for First Trimester Ultrasound
Examination: Part 1 March 2004
http://hkcog.obg.cuhk.edu.hk/docs/college_guidelines/Guidelines_for_F
irst_Trimester_Ultrasound_Exam_Part1_2004.pdf

Dr J Woos homepage
http://www.ob-ultrasound.net/

http://www.ob-ultrasound.net/

Miscarriage
Pelvic sonogram
transvaginal versus transabdominal
gestational sac versus pseudosac
silent miscarriage if mean sac diameter
>20 mm with no evidence of embryo or
yolk sac; CRL >5 mm with no evidence of
cardiac pulsation

Miscarriage
Pelvic sonogram
incomplete miscarriage - thick irregular
echoes in the midline of the uterine cavity

Miscarriage
Pelvic sonogram
incomplete miscarriage - thick irregular
echoes in the midline of the uterine cavity
complete miscarriage - well defined
regular endometrial line
beware of ectopic pregnancy

Miscarriage
Role of pregnancy test
Level of hCG in urine are very similar to
the level in blood(Chard 1992)
if negative, can rule out pregnancy
complication e.g. Surestep pregnancy test
sensitivity - 20 miu/ml
cannot differentiate complete and
incomplete miscarriage

Miscarriage
Management
threatened conservative
silent suction evacuation or medical
treatment
incomplete suction evacuation or
expectant management
inevitable suction evacuation
complete beware of ectopic pregnancy

Miscarriage
The management of early pregnancy
loss
RCOG Green Top Guideline 25
http://www.rcog.org.uk/files/rcog-corp/uploadedfiles/GT25ManagementofEarlyPregnancyLoss2006.pdf

Miscarriage
A prospective randomized study to compare
the use of repeated doses of vaginal with
sublingual misoprostol in the management
of first trimester silent miscarriges
Tang et al 2003 Hum Reprod 18:176-81

Management of early pregnancy loss

Graziosi 2004 Int J Gynecol Obstet 86:337-46

Miscarriage
Recurrent miscarriage
The investigation and treatment of couples
with recurrent miscarriage
RCOG Green Top Guideline 17
http://www.rcog.org.uk/files/rcogcorp/GTG17recurrentmiscarriage.pdf

Miscarriage
Recurrent miscarriage
peripheral blood karyotyping of both
partners
karyotyping of placental tissue
pelvic ultrasound to assess ovarian
morphology and uterine cavity
screening tests for antiphospholipid
antibodies

Outline of management strategy

Miscarriage
Ectopic pregnancy
Gestational trophoblastic disease
Hyperemesis gravidarum
anxiety state

Ectopic pregnancy
Presentation
Triad of missed period, vaginal bleeding
and abdominal pain
in shock
syncopy, shoulder pain
abdominal tenderness with varying degree
of peritonism; cervical excitation
clinical diagnosis can only be made in half
of the patients

Ectopic pregnancy
Risk factors
previous ectopic pregnancy
tubal damage from infection/surgery
history of infertility
assisted reproduction techniques
increased age
smoking

Ectopic pregnancy
Investigations
Hb, Rh, type and screen
a negative pregnancy test effectively rule
out ectopic pregnancy
pelvic ultrasound examination
HCG assay
diagnostic laparoscopy
others

Ectopic pregnancy
Immediate management
fast
intravenous line of wide gauge
close observation

Ectopic pregnancy
Pelvic ultrasound
Inhomogeneous adnexal mass
Empty extra-uterine sac with a hyperechoic ring
A yolk sac and/or fetal pole with or without
cardiac activity in an extra-uterine sac
(Kirk 2009 Best Pract Res Clin OG)

Ectopic pregnancy
Pelvic ultrasound
rule out ectopic pregnancy if intrauterine
sac seen (with exception)
may be normal in up to a quarter
live embryo within a gestational sac in
adnexa is diagnostic

http://www.advancedfertility.com/ectopic.htm

http://www.advancedfertility.com/ectopic.htm

Ectopic pregnancy
hCG
concept of discriminatory zone
repeat assay in 48 hours
cannot differentiate between abnormal
pregnancy outcomes

Positive pregnancy test

USG

Intrauterine
pregnancy

antenatal care

Extrauterine
pregnancy,
noncystic
adnexal mass

laparoscopy

Standby USG - no ectopic

pregnancy, no noncystic
adnexal mass

>=1500 iu/l

Consider
laparoscopy

<1500 iu/l

Repeat
in 2 days

HCG

decreasing

Repeat HCG
in 2 days

>=53% rise

<53% rise

Repeat
weekly till
undetectable
Repeat HCG
every 2 days;
repeat USG in
1 week
Repeat HCG every
2 days; keep
patient in ward

Ectopic pregnancy
The management of tubal pregnancies
RCOG Green Top Guideline No 21
http://www.rcog.org.uk/files/rcog-corp/uploadedfiles/GT21ManagementTubalPregnancy2004.pdf

Ectopic pregnancy
laparoscopic approach is preferable to an
open approach
In the presence of haemodynamic
instability, should be managed by the most
expedient method. In most cases this will
be laparotomy
In the presence of a healthy contralateral
tube, there is no clear evidence that
salpingotomy should be used

Ectopic pregnancy
Medical therapy should be offered to
suitable women
expectant management is an option for
clinical stable women with minimal
symptoms and a pregnancy of unknown
location
non-sensitised Rh negative women should
receive anti-D immunoglobulin

Ectopic pregnancy
Heterotopic pregnancy
coexistence of an intrauterine and
extrauterine gestation
classical incidence 1 in 30000
1-3% following assisted reproduction
technique

Early Pregnancy Assessment

Service
streamline the management of women
with early pregnancy bleeding or pain
reduce the need for admission
need appointment system, appropriate
settings, transvaginal ultrasound
examination, access to laboratory facilities
(for Rh antibody and HCG)

Outline of management strategy

Miscarriage
Ectopic pregnancy
Gestational trophoblastic disease
Hyperemesis gravidarum
anxiety state

Gestational trophoblastic disease

Complete hydatidiform mole, partial mole,
invasive mole, metastatic mole
Choriocarcinoma
Gestational trophoblastic neoplasia
persistently elevated hCG in the absence
of a normal pregnancy and with a history
or antecedent normal or abnormal
pregnancy

Gestational trophoblastic disease

Presentation of hydatidiform mole
similar to that of threatened miscarriage
size of uterus may be larger than date
exaggerated pregnancy symptoms
early onset preeclampsia

Gestational trophoblastic disease

Diagnosis of hydatidiform mole
ultrasound examination - snowstorm
appearance; lutein cysts of ovary

http://www.obgyn.net/us/present/9812/fougner.htm

Gestational trophoblastic disease

Management of hydatidiform mole
hCG
CBP, type and screen
chest X-ray
suction evacuation
monitoring of hCG level after evacuation
Exclude recurrence after any further
pregnancies

Outline of management strategy

Miscarriage
Ectopic pregnancy
Gestational trophoblastic disease
Hyperemesis gravidarum
anxiety state

Hyperemesis gravidarum
Patients with intractable vomiting and
disturbed nutrition such as alteration of
electrolyte balance, loss of weight of 5%
or more, ketosis, and acetonuria, with
ultimate neurological disturbances, liver
damage, retinal haemorrhage, and retinal
damage
Am Council on Pharmacy and Chemistry 1956
Jarvis 2011 BMJ

Hyperemesis gravidarum
patients with excessive vomiting
resulting in admission to hospital
other causes of vomiting

multiple pregnancy
gestational trophoblastic disease
hyperthyroidism
upper gastrointestinal tract disorder
hepatitis
other infection

Hyperemesis gravidarum
Investigations
CBP, RFT, LFT, (thyroid function)
hCG NOT useful
msu for routine, microscopy and culture
pelvic ultrasound
others

Hyperemesis gravidarum
hyperemesis gravidarum is associated with
biochemical hyperthyroidism but rarely with
clinical hyperthyroidism and is largely transitory
women who required treatment throughout the
remainder of their pregnancies had other
symptoms
there is no need to measure TFTs routinely in
women with hyperemesis(Level C)
ACOG Practice Bulletin No 37(2002)

Hyperemesis gravidarum
Complications
Mallory-Weiss oesophageal tear
Mendelson syndrome
neurological disturbances e.g. Wernickes
encephalopathy, peripheral neuropathy

Hyperemesis gravidarum
Management
fast
intravenous fluid and electrolyte
replacement
multivitamins replacement
intake and output chart, daily body weight
monitoring

Hyperemesis gravidarum
Subsequent management
dry diet
small frequent meals
fairly dry and high in easily digested
carbohydrates
liquids are taken between the meals

antiemetics

Hyperemesis gravidarum
Dietary advice(1)
initially oral fluid intake
followed by small carbohydrate meals
total avoidance of fatty foods
Eliakim et al Am J Perinatal 2000;17:207-18

Hyperemesis gravidarum
Dietary advice(2)
avoiding offensive foods and odour
eating frequent small meals
low protein, low fat, high carbohydrate
avoid iron supplements
encouraged to take whichever foods
appeal when hungry
Chin J Paed Obstet Gynaecol 2001;25(2):37-40

 No studies of dietary or other lifestyle

interventions
Evidence regarding the effectiveness of P6
acupressure, auricular acupressure and
acustimulation of the P6 point was limited
The use of ginger products may be helpful but
the evidence was limited and not consistent
Only limited evidence to support the use of
pharmacological agents including vitamin B6,
and anti-emetic drugs

Hyperemesis gravidarum
Dimenhydrinate (Gravol)
FDA category B either animal-reproduction studies
have not demonstrated a fetal risk but there are no
controlled studies in pregnant women or animalreproduction studies have shown an adverse effect that
was not confirmed in controlled studies in women in the
first trimester
Oral or rectal
Drugs in pregnancy and lactation : a reference guide to
fetal and neonatal risk
G. Briggs, Roger K.
Freeman, Sumner J. Yaffe
MR 618.32071 B8

Outline of management strategy

Miscarriage
Ectopic pregnancy
Gestational trophoblastic disease
Hyperemesis gravidarum
anxiety state

Abortion Law
the continuation of the pregnancy would
involve risk to the life of the pregnant
woman or of injury to the physical or
mental health of the pregnant woman,
greater than if the pregnancy were
terminated

Complications of Early Pregnancy

Common presenting complaints
Outline of management strategy
Outline of emotional impact on the couple
with early pregnancy losses
Summary

Psychiatric morbidity following miscarriages:

a prevalence study of Chinese women in
Hong Kong
48-51% of women in western countries
developed depressive disorder
150 subjects interviewed
12% has major depression and 1.3% had
anxiety disorder 6 weeks after the
miscarriage
(Lee 1997 J Affect Disord 43:63-8)

Psychaitric morbidity following miscarriage in Hong

Kong
3 months after miscarriage, 10% of subjects
suffered depressive disorder, 1.2% were
diagnosed with anxiety disorder not otherwise
specified, 0.6% suffered from obsessive
compulsive disorder and 0.6% suffered from
posttraumatic stress disorder
Risk factors of depression included younger age,
history of infertility and depression
(Sham 2010 Gen Hosp Psychiatry 32:284-9)

A comparison of the psychologic impact and client

satisfaction of surgical treatment with medical
treatment of spontaneous abortion: a
randomized controlled trial
218 women who suffered from spontaneous
abortion randomized to routine suction
evacuation or medical evacuation
No difference in psychological outcomes
More participants with successful medical
treatment would choose the same mode of
treatment
Less satisfied in those patients with failed
medical treatment
(Lee 2001 Am J Obstet Gynecol 185:953-8)

 About 65% of subjects believed

spontaneous abortion adversely affected
their health
>90% expressed plans to take tonics to
revitalize their health
47% of the surgical and 33% of the
medical group felt that surgical
evacuation weakened their body
More women in the surgical group felt that
the intervention damaged the devitalized
body(39% vs 21%)
(Lee 2001 Am J Obstet Gynecol 185:953-8)

Summary
miscarriage is the preferred term as
compared to spontaneous abortion
clinical differentiation for the different types
of miscarriage
importance of pelvic sonography in the
diagnosis
best treatment is still evolving

Summary
ectopic pregnancy is an important
differential diagnosis
use of algorithm in early diagnosis
laparoscopic salpingectomy is the gold
standard of treatment
role of Early Pregnancy Assessment
Service

Summary
gestational trophoblastic disease is an
important differential diagnosis of
threatened miscarriage
hyperemesis gravidarum can be life
threatening and it is important to exclude
other specific diagnoses

Summary
Miscarriages is associated with significant
psychiatric morbidity although the
prevalence may be lower in our population
Choice of mode of treatments is affected
by ethnomedical beliefs, success rate and
should be individualised

Thank you
Dr TC Pun
Dept of Obs & Gyn
24/9/2011