Management of Early Pregnancy Loss I have no disclosures. & - PowerPoint PPT Presentation

10/16/2019 Disclosures- October, 2019 Management of Early Pregnancy Loss I have no disclosures. & Pregnancy of Unknown Location Jody Steinauer, MD, PhD Dept. Ob/Gyn & Reproductive Sciences 1 2 Objectives Patient Case: H&P 1. Review the workup of bleeding in the first trimester • Maya is a 26 yo G1P0 at 9 weeks’ gestation by LMP 2. Apply evidence-based principles to management of presenting with bleeding. Pregnancy of Unknown Location 3. Apply evidence-based counseling and treatment for EPL – focus on ultrasound dx, evidence for mifepristone as medical management 3 4 1

10/16/2019 Evaluation Patient Case: H&P • History • Maya is a 26 yo G1P0 presenting with bleeding. – Risk factors for ectopic pregnancy – Desired pregnancy – Symptoms, pregnancy course – Positive UPT 2 weeks ago, confirmed today in ER • Physical exam Is the pregnancy desired? – Bleeding like a “light period” for the past 3 days – Vital signs – No risk factors for ectopic pregnancy – Abdominal and pelvic exam – On exam, VSS, nontender abdomen, closed cervical os, • Ultrasound small uterus – Transvaginal may be necessary – Rh positive • Lab – Rh factor – Hemoglobin or hematocrit may be helpful – β-hCG when indicated 5 6 Bleeding in Early Pregnancy • Ectopic pregnancy must be ruled out, and we must be careful to not diagnose a desired, normal IUP as abnormal Symptomatic Early Pregnancy • Management includes preference-sensitive decisions Evaluation 7 8 2

10/16/2019 Bleeding in Early Pregnancy Ectopic Pregnancy • Keep the patient informed • 1-2% of all pregnancies – Provide reassurance but avoid guaranteeing that • ½ of ectopic patients have no risk factors “everything will be all right” • Mortality has dramatically declined: 0.5/100,000 – Assure that you are available – 6% of pregnancy-related deaths • What does the bleeding mean? – 21 deaths per year in US – Up to 20% chance of ectopic pregnancy • Early diagnosis important – Up to 20% chance of early pregnancy loss (EPL) – 30% of normal pregnancies have vaginal bleeding 9 10 Early Pregnancy Loss (EPL) Pregnancy of Unknown Location • Pregnancy test + , but no pregnancy on u/s • Generally defined as up to – Try to follow until a diagnosis is made 12 6/7 weeks’ gestation – Be aware of risk of ectopic pregnancy (EP) • 15-20% of clinically – Sometimes never have diagnosis as both EPL and EP may recognized pregnancies resolve spontaneously • 1 in 4 will experience EPL • More commonly encountered in symptomatic early pregnancy, but can also be encountered when asymptomatic, especially when u/s early 11 12 3

10/16/2019 Positive pregnancy test, vaginal Simplified Workup of Bleeding bleeding and/or abdominal pain 61% Ongoing IUP 61% Ongoing IUP Where is the pregnancy?  U/S 1. 28% Spontaneous Abortion If the pregnancy undesired?  uterine aspiration 2. 9% Ectopic Pregnancy 3. If desired and we can’t tell where it is: Is it normal or abnormal?  quantitative Beta-HCG(s) Dx upon presentation (80%) Dx upon presentation (80%) Dx with additional testing (20%) Dx with additional testing (20%) 4. Once pregnancy clearly abnormal, if undesired or if 77% Ongoing IUP 77% Ongoing IUP 11% Ongoing IUP 11% Ongoing IUP patient desires definitive dx  uterine aspiration 16% Spontaneous Abortion 77% Spontaneous Abortion 6% Ectopic Pregnancy 17% Ectopic Pregnancy 49% of all with Ectopic 51% of all with Ectopic Dx at presentation Dx after outpatient follow-up IUP=Intrauterine pregnancy Barnhart 2004 Obstet Gynecol 13 14 Simplified Workup of Bleeding Simplified Workup of Bleeding Where is the pregnancy?  U/S 1. 3. If desired and we can’t tell where it is: Is it normal or abnormal?  quantitative Beta-HCG(s) If the pregnancy undesired?  uterine aspiration 2. – If Bhcg above threshold and no IUP = Abnormal 3. If desired and we can’t tell where it is: Is it normal – If Bhcg below threshold - serial beta HCGs or abnormal?  quantitative Beta-HCG(s) • If Bhcg drops > 50% in 48 hours = Abnormal 4. Once pregnancy clearly abnormal, if undesired or if • If Bhcg rises > 50% in 48 hours = Most likely normal – patient desires definitive dx  uterine aspiration Follow & repeat u/s • If between = Most likely abnormal – Follow & repeat u/s IUP=Intrauterine pregnancy IUP=Intrauterine pregnancy 15 16 4

10/16/2019 Simplified Workup of Bleeding Simplified Workup of Bleeding Where is the pregnancy?  U/S Where is the pregnancy?  U/S 1. 1. If the pregnancy undesired?  uterine aspiration If the pregnancy undesired?  uterine aspiration 2. 2. 3. If desired and we can’t tell where it is: Is it normal 3. If desired and we can’t tell where it is: Is it normal or abnormal?  quantitative Beta-HCG(s) or abnormal?  quantitative Beta-HCG(s) – – Above threshold - abnormal Above threshold - abnormal – – Below threshold - serial Below threshold - serial 4. Once pregnancy clearly abnormal, if undesired or if 4. Once pregnancy clearly abnormal, if undesired or if patient desires definitive dx  uterine aspiration patient desires definitive dx  uterine aspiration IUP=Intrauterine pregnancy IUP=Intrauterine pregnancy 17 18 β-hCG Utility in Symptomatic Early Pregnancy Diagnosis Discriminatory & Threshold level • N=366 with VB/pain  nl IUP Wide ranges of values • β-hCG median serum concentration: 99% Predicted Probability of Detection – 4 weeks: 100 mIU/ml (5-450) Discriminatory Threshold – 10 weeks: 60,000 (5,000 – 150,000) Gestational sac 3510 390 Yolk sac 17,716 1094 Discriminatory Level Fetal pole 47,685 1394 • Serum β-hCG at which a normal intrauterine pregnancy should be visualized on ultrasound 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. 19 20 5

10/16/2019 Society of Radiologists in Ultrasound: No Gestational Sac Balance of Diagnostic Tests • HCG 2000 - 3000 • Maximize sensitivity at the cost of diagnosing some – 2% chance of viable pregnancy IUPs as Ectopic Pregnancies – Non-viable intrauterine pregnancy most likely, 2X ectopic – Decrease false negatives – try to never miss an ectopic – Ectopic is 19 x more likely than viable pregnancy – Error – interrupt desired IUP – For each viable pregnancy: • 19 ectopic pregnancies • Maximize specificity at the cost of diagnosing some • 38 nonviable pregnancies Ectopic Pregnancies as IUPs • HCG > 3000 – Decrease false positives – try to never misdiagnose IUP – 0.5% chance viable IUP – Error – delay diagnosis resulting in rupture – Non-viable IUP still most common – Ectopic 70 x more likely • Use cut-off of 3,000 v. repeat beta hcg or u/s than viable pregnancy Doubilet, NEJM, 2013. 21 22 Simplified Workup of Bleeding β HCG trends in normal IUP Where is the pregnancy?  U/S 1. If the pregnancy undesired?  uterine aspiration 2. 3. If desired and we can’t tell where it is: Is it normal or abnormal?  quantitative Beta-HCG(s) 99% of nl IUPs Median rise: Median rise: 1 day rise ≥ 24% 1 day= 50% 1 day= 50% – Above threshold - abnormal 2 day rise ≥ 53% 2 day =124% 2 day =124% – Below threshold - serial 4. Once pregnancy clearly abnormal, if undesired or if patient desires definitive dx  uterine aspiration Slowest expected 48-hour increase for normal pregnancy = 53% (20% of ectopics increase) IUP=Intrauterine pregnancy Barnhart 2004 23 24 6

10/16/2019 β HCG trends : Other Key Points Simplified Workup of Bleeding • Two hcg values may not be enough Where is the pregnancy?  U/S 1. • If close to the thresholds – check another If the pregnancy undesired?  uterine aspiration 2. 3. If desired and we can’t tell where it is: Is it normal or • Repeat ultrasound abnormal?  quantitative Beta-HCG(s) – If Bhcg above threshold and no IUP = Abnormal – If Bhcg below threshold - serial beta HCGs Discriminatory Threshold • If drops > 50% in 48 hours = Abnormal Gestational sac 3510 390 • If rises > 50% in 48 hrs = Most likely NL – Follow & rpt u/s • If between = Most likely abnormal – Follow & repeat u/s Yolk sac 17,716 1094 4. Once pregnancy clearly abnormal, if undesired or if Fetal pole 47,685 1394 patient desires definitive dx  uterine aspiration IUP=Intrauterine pregnancy Barnhart 2002 25 26 Role of Ultrasound in Ectopic If Diagnose as Abnormal… Diagnosis • Only 2% of u/s are diagnostic for EP • Do not presume an 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% failed IUP) • Normal adnexal exam does not exclude ectopic – Very low HCG with decrease or abnormal rise (25% failed IUP) • Suggestive of ectopic • 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 27 28 7