Early Pregnancy Loss

Definition

• Nonviable intrauterine pregnancy charactized by empty gestational sac or embryo/fetus <13 weeks with no fetal heart activity

• 10% of all pregnancies• 50% are generally chromosomal

abnormalities

Signs and Symptoms

• First trimester cramping/bleeding• DDx: early pregnancy loss, viable

intrauterine pregnancy, ectopic pregnancy

• A pelvic exam is important before testing

Testing

• Ultrasound is the prefered method to determine viabilty

• HCG levels are important in interpreting ultrasound findings and for serial follow up

Beta HCG

• Discriminatory zone 1500-2000 mIU/ml is associated with a gestational sac in singleton pregnancies

• A rise of < 50% in 48 hours is associate with an abnormal pregnancy with a sensitivity of 99%

Treatment Options

• Expectant• Medical treatment• Surgical treatment

Expectant

• May take up to 8 weeks• 80% success• What is success

– HCG < 5 mIU/ml– Endometrial stripe of < 3 cm– Return of normal menstrual function

• Patient needs to be prepared for moderate to heavy bleeding with cramps and may need a suction currettage

Medical Treatment

• Goal is to shorten the time to complete explusion as compared to expectant

• 85% success with complete expulsion with in 3 days for 70% of patients

• Patient should expect moderate to heavy bleeding and cramping issues as well as possible suction currettage

Surgical

• Suction curettage has replaced sharp curetting

• It is immediate and 99% successful• Clinically important intrauterine

adhesions are a rare complication

Complications of all treatments

• Incomplete requiring curettage• Infection 2%• Transfusion 1%

Rh Negative Mother

• Give 50-300 micrograms rhogam within 72 hrs of diagnosis of early pregnancy loss

Subsequent Pregnancy

• No evidenced based data on when it is safe to get pregnant again

• BCP or IUD can be started as soon as you are sure the process is complete

• Consider workup for recurrent EPL after the 2nd consecutive EPL

• No proven treatment for threatened abortion

• Progesterone in first trimester after at least 3 EPL may be beneficial

Case Studies

Am I ready to do office gyn?

Sally is a 23 y/o GoPo complaining of irregular bleeding

Gyn Hx: sexually active uses condoms most times

PE: 105 lb

Abdomen soft nontender

Pelvic exam: no vaginal bleeding, Cervix is closed nontender, uterus normal, adenexa neg

Test Results

• Quantative Beta HCG < 1

• Ultrasound normal uterus, endometrium, and ovaries

What if Ultrasound Shows

• uterus 11x9x8 cm with multiple leiomyoma about 2-3 cm in diameter, endometrial thickness 6 mm, normal ovaries

Sally returns after 3 months on her new birth control pill still having breakthrough bleeding

Pelvic exam is normal

Test: STD negative pregnancy test negative

Judy is a 30 y/o G2P2 for annual exam on Ortho Tricyclen Lo

Social hx: married, monogamous

She is complaining that she had regular periods for a while but now having breakthrough bleeding for 6 months

Exam: Normal

Differential diagnosis?

Mary is a 45 y/o G3P3 status post tubal ligation

Menstral formula: 2 weeks/3 days heavy on day 1

PMH: negative

Pelvic exam: Cervix normal, pap doneUterus 6 weeks size, irregular, firm,

nontenderOvaries not enlarged, nontender

Guidelines for Endometrial Biopsy

• All women with history of AUB of 2-3 yrs duration

• All women > 45 yrs old with AUB• All women who do not respond to

treatment

Endometrial Biopsy Results

• Complex hyperplasia with atypia• Complex hyperplasia• Simple hyperplasia• Proliferative endometrium• Secretory endometrium

Vicki is a 60 y/o complaining of 3 days of light bleeding 3 weeks ago

PMH: Illnesses: diabetes controlled on diet

mild hypertension

Meds: Atenolol

Continuous hormone replacement therapy

Exam: 5’4”, 175 lb

Pelvic:vagina slightly atrophic

cervix stenotic, pap done

uterus NS/NS

adenexa negative

Endometrial thickness

• < 4 mm generally atrophic endometrium

• > 4 mm you can’t rule out cancer

60 yr old menopausal female complaining of incontinence

PI: leaking urine for several months now worse

PMH: TAH/BSO for benign disease age 45

Lumbar disk fusion 1 years ago

PE: Pelvic – 1st degree cystocoele and 1st degree rectocoele

• Complaining of urgency, frequency, nocturia, sudden loss of large amounts of urine

• Residual urine 10 ml

• Urine culture positive > 100,000 e-coli

• Loss of urine with coughing, sneezing, laughing, squatting, jumping

• Residual 50 ml and culture negative

• Residual > 200 ml

22 yr old female complaining of amenorrhea for 1 yr

PI: LMP 1 yr ago prior menstral formula 28d/5d

BC: noneGyn Hx delivered a baby 2 yrs ago

PMH: Schizophrenic on anti-psychotic med

Soc Hx: Occasionally sexually active without condoms

PE: Thin female, no distressBreasts bilateral milky dischargePelvic exam normal

• Prolactin 100 ng/ml., TSH 5.5 uU/ml.,

• Prolactin, TSH normal