Is my baby okay? 1. Review the workup of bleeding in the first - PDF document

Objectives “Is my baby okay?” 1. Review the workup of bleeding in the first trimester Evaluation of First ‐ trimester Bleeding 2. Apply evidence‐based principles to ectopic pregnancy Ectopic, Early Pregnancy Loss, or Normal Pregnancy (EP) and early pregnancy loss (EPL) diagnoses 3. Apply evidence‐based counseling and treatment for EPL and EP Jody Steinauer, MD, MAS Dept. Ob/Gyn & Reproductive Sciences Patient Case: Presentation Patient Case: H&P • Maya is a 26 yo G1P0 presenting to the emergency room • Sure LMP was 9 weeks ago • Positive UPT 2 weeks ago “I’m 2 months pregnant and I’m bleeding and • Desired pregnancy cramping. Am I going to lose the baby?” • First prenatal care visit scheduled for next week • Bleeding is like a “light period” for the past 3 days • No risk factors for ectopic pregnancy • How do we care for Maya? • On exam closed cervical os • Rh‐negative What can we tell Maya right now?

Symptomatic Early Pregnancy • Ectopic pregnancy must be ruled out, but we must not diagnose a desired IUP as abnormal – There are new guidelines for the hCG discriminatory zone Symptomatic Early Pregnancy • Management is a preference‐sensitive decision Evaluation Symptomatic Early Pregnancy: Presentation Bleeding in Early Pregnancy • Urgent or emergency care visit • Keep the patient informed. – Vaginal bleeding – Provide reassurance that not all vaginal bleeding & cramping = an abnormality, but avoid guarantees that – Abdominal or pelvic pain or cramping “everything will be all right” – Passage of pregnancy tissue from the vagina – Assure that you are available – Loss of pregnancy‐related symptoms • What does the bleeding mean? – Hemodynamic instability – Up to 20% chance of ectopic pregnancy • Incidental clinical finding – 50% ongoing pregnancy with closed cervical os – Bimanual exam inconsistent with LMP – 85% ongoing pregnancy with viable IUP on sono – Ultrasound suggestive of abnormal pregnancy – 30% of normal pregnancies have vaginal bleeding

Evaluation Ectopic Pregnancy • History • 1‐2% of all pregnancies – Risk factors for ectopic pregnancy • Up to 20% of symptomatic pregnancies • Physical exam Is the pregnancy desired? • ½ of ectopic patients have no risk factors – Vital signs – Abdominal and pelvic exam • Mortality has dramatically declined: 0.5/100,000 • Ultrasound – 6% of pregnancy‐related deaths – Transvaginal often necessary – 21 deaths per year in US • Lab • Early diagnosis important – Rh factor – Hemoglobin or Hematocrit • Concern about management errors – β‐hCG when indicated Early Pregnancy Loss (EPL) Pregnancy of Unknown Location • When the pregnancy test is positive, but no signs • 15‐20% of clinically of intrauterine or extrauterine pregnancy on u/s recognized pregnancies – We try to follow these women until a diagnosis is made • 1 in 4 women will – We have to weigh risk of ectopic pregnancy (EP) experience EPL – Sometimes there is never a final diagnosis as both EPL • Includes all non‐viable and EP may resolve spontaneously pregnancies in first • More commonly encountered in symptomatic trimester = miscarriage early pregnancy, but can also be encountered in asymptomatic women, especially when u/s early

Positive pregnancy test, vaginal Simplified Workup of Bleeding &/or Pain bleeding and/or abdominal pain 61% Ongoing IUP 1. Where is the pregnancy?  U/S (same day) 28% Spontaneous Abortion 2. If the pregnancy undesired?  uterine aspiration 9% Ectopic Pregnancy 3. If desired and we can’t tell where it is: Is it normal or abnormal?  quantitative (serial) Beta‐HCG Dx upon presentation (80%) Dx with additional testing (20%) – If Bhcg above threshold and no IUP = Abnormal – Serial beta HCGs: • If Bhcg drops > 50% in 48 hours = Abnormal 77% Ongoing IUP 11% Ongoing IUP • If Bhcg rises > 50% in 48 hours = Most likely normal (can be 16% Spontaneous Abortion 77% Spontaneous Abortion EP) – Continue to follow and repeat u/s 6% Ectopic Pregnancy 17% Ectopic Pregnancy • If between = Most likely abnormal (still can be normal) – Continue to follow and repeat u/s 49% of all women with Ectopic 51% of all women with Ectopic 4. Once pregnancy clearly abnormal, if undesired or if Dx at presentation Dx after outpatient follow‐up patient desires definitive dx  uterine aspiration IUP=Intrauterine pregnancy β‐ hCG Utility in Symptomatic Early Pregnancy Diagnosis Discriminatory & Threshold level • β‐hCG median serum concentration: • 366 ♀ with VB/pain  nl IUP – 4 weeks: 100 mIU/ml (5‐450) 99% Predicted Probability of Detection – 10 weeks: 60,000 (5,000 – 150,000) Discriminatory Threshold Gestational sac 3510 390 Discriminatory Level Yolk sac 17,716 1094 • Serum β‐hCG at which a normal intrauterine Fetal pole 47,685 1394 pregnancy should be visualized on ultrasound – If >2000 nl IUP unlikely but possible  new values Highest seen in the study with no sac: 2,300 • Once above, limited role for “following betas” Old value of 2000= 91% prob. of seeing GS in viable IUP Connolly, Obstet Gynecol, 2013. Connolly 2013 Obstet Gynecol

Society of Radiologists in Ultrasound: Balance of Diagnostic Tests No Gestational Sac • HCG 2000 ‐ 3000 • Maximize sensitivity at the cost of diagnosing – Non‐viable pregnancy most likely, 2X ectopic some IUPs as Ectopic Pregnancies – Ectopic is 19 x more likely than viable pregnancy – Error – interrupting desired IUP – For each viable pregnancy: • Maximize specificity at the cost of diagnosing In women with desired • 19 ectopic pregnancies pregnancy consider beta some EPs as IUPs • 38 nonviable pregnancies hcg cut‐off of >= 3000. – 2% chance of viable pregnancy – Error – delay diagnosis resulting in rupture • HCG > 3000 • Use cut‐off of 3,000 v. repeat beta hcg or u/s – Ectopic 70 x more likely than viable pregnancy 0.5% chance viable IUP Simplified Workup of Bleeding &/or Pain β HCG trends in normal IUP 1. Where is the pregnancy?  U/S (same day) 2. If the pregnancy undesired?  uterine aspiration 3. If desired and we can’t tell where it is: Is it normal or abnormal?  quantitative (serial) Beta‐HCG – If Bhcg above threshold and no IUP = Abnormal 99% of nl IUPs Median rise: 1 day rise ≥ 24% 1 day= 50% – Serial beta HCGs: 2 day rise ≥ 53% 2 day =124% • If Bhcg drops > 50% in 48 hours = Abnormal • If Bhcg rises > 50% in 48 hours = Most likely normal (can be EP) – Continue to follow and repeat u/s • If between = Most likely abnormal (still can be normal) – Continue to follow and repeat u/s Slowest expected 48‐hour increase for normal 4. Once pregnancy clearly abnormal, if undesired or if pregnancy = 53% (20% of ectopics increase) patient desires definitive dx  uterine aspiration IUP=Intrauterine pregnancy Barnhart 2004 Obstet Gynecol

β HCG trends : Other Key Points Simplified Workup of Bleeding &/or Pain • Two hcg values may not be enough 1. Where is the pregnancy?  U/S (same day) 2. If the pregnancy undesired?  uterine aspiration • If close to the thresholds – check another 3. If desired and we can’t tell where it is: Is it normal or abnormal?  quantitative (serial) Beta‐HCG – If Bhcg above threshold and no IUP = Abnormal – Serial beta HCGs: • If Bhcg drops > 50% in 48 hours = Abnormal • If Bhcg rises > 50% in 48 hours = Most likely normal (can be EP) – Continue to follow and repeat u/s • If between = Most likely abnormal (still can be normal) – Continue to follow and repeat u/s 4. Once pregnancy clearly abnormal, if undesired or if patient desires definitive dx  uterine aspiration Barnhart, Ob Gyn, 2002 IUP=Intrauterine pregnancy Role of Ultrasound in Ectopic If Diagnose as Abnormal… Diagnosis • Only 2% of u/s are diagnostic for EP • Presumed ectopic pregnancy – uterine – “Diagnostic” = Gestational Sac with yolk sac or fetal pole aspiration before MTX visualized outside uterus – High HCG nothing in the uterus (50% SAB) • Normal adnexal exam does not exclude ectopic – Very low HCG with abnormal rise or definite • Suggestive of ectopic fall (25% SAB) • Empty uterus + hCG above discriminatory zone • Complex mass + fluid in cul‐de‐sac (94% are EP) • Should still follow them if desired pregnancy Main role of U/S is to rule in IUP