Pregnant and Bleeding in the I have no disclosures. First Trimester - PDF document

7/3/18 Disclosures- July 3, 2018 Pregnant and Bleeding in the I have no disclosures. First Trimester Jody Steinauer, MD, MAS D e p t . O b / G y n & R e p r o d u c t iv e S c ie n c e s ! ! Objectives Patient Case: Presentation 1. Review the workup of bleeding in the first trimester • Maya is a 26 yo G1P0 presenting to the emergency room 2. Apply evidence-based principles to ectopic pregnancy (EP) “I’m 2 months pregnant and I’m bleeding and and early pregnancy loss (EPL) diagnoses cramping. Am I going to lose the baby?” 3. Apply evidence-based counseling and treatment for EPL and EP • How do we care for Maya? ! ! 1

7/3/18 Patient Case: H&P • Sure LMP was 9 weeks ago • Positive UPT 2 weeks ago • Desired pregnancy Symptomatic Early Pregnancy • First prenatal care visit scheduled for next week • Bleeding is like a “light period” for the past 3 days Evaluation • No risk factors for ectopic pregnancy • On exam closed cervical os • Rh-negative What can we tell Maya right now? ! ! Symptomatic Early Pregnancy: Symptomatic Early Pregnancy Presentation • Ectopic pregnancy must be ruled out, but we must not • Urgent or emergency care visit diagnose a desired IUP as abnormal – Vaginal bleeding – There are new guidelines for the hCG discriminatory zone – Abdominal or pelvic pain or cramping • Management is a preference-sensitive decision – Passage of pregnancy tissue from the vagina – Loss of pregnancy-related symptoms – Hemodynamic instability • Incidental clinical finding – Bimanual exam inconsistent with LMP – Ultrasound suggestive of abnormal pregnancy ! ! 2

7/3/18 Bleeding in Early Pregnancy Evaluation • Keep the patient informed. • History – Risk factors for ectopic pregnancy – Provide reassurance that not all vaginal bleeding & • Physical exam cramping = an abnormality, but avoid guarantees that Is the pregnancy desired? – Vital signs “everything will be all right” – Abdominal and pelvic exam – Assure that you are available • Ultrasound • What does the bleeding mean? – Transvaginal often necessary – Up to 20% chance of ectopic pregnancy • Lab – 50% ongoing pregnancy with closed cervical os – Rh factor – Hemoglobin or Hematocrit – 85% ongoing pregnancy with viable IUP on sono – β-hCG when indicated – 30% of normal pregnancies have vaginal bleeding ! ! Ectopic Pregnancy Early Pregnancy Loss (EPL) • 1-2% of all pregnancies • 15-20% of clinically • Up to 20% of symptomatic pregnancies recognized pregnancies • ½ of ectopic patients have no risk factors • 1 in 4 women will • Mortality has dramatically declined: 0.5/100,000 experience EPL – 6% of pregnancy-related deaths • Includes all non-viable – 21 deaths per year in US pregnancies in first • Early diagnosis important trimester = miscarriage • Concern about management errors ! ! 3

7/3/18 Positive pregnancy test, vaginal Pregnancy of Unknown Location bleeding and/or abdominal pain 61% Ongoing IUP • When the pregnancy test is positive, but no signs of 28% Spontaneous Abortion intrauterine or extrauterine pregnancy on u/s 9% Ectopic Pregnancy – We try to follow these women until a diagnosis is made – We have to weigh risk of ectopic pregnancy (EP) Dxupon presentation (80% ) Dxw ith additional testing (20% ) – Sometimes there is never a final diagnosis as both EPL and 77% O ngoing IU P 11% O ngoing IU P EP may resolve spontaneously 16% Spontaneous Abortion 77% Spontaneous Abortion • More commonly encountered in symptomatic early 6% Ectopic Pregnancy 17% Ectopic Pregnancy pregnancy, but can also be encountered in 49% of all w om en w ith Ectopic 51% of all w om en w ith Ectopic asymptomatic women, especially when u/s early Dxat presentation Dxafter outpatient follow -up Barnhart 2004 Obstet Gynecol ! ! β-hCG Utility in Symptomatic Early Simplified Workup of Bleeding &/or Pain Pregnancy Diagnosis • β-hCG m edian serum concentration: 1. Where is the pregnancy? à U/S (same day, if possible) 2. If the pregnancy undesired? à uterine aspiration – 4 weeks: 100 mIU/ml (5-450) 3. If desired and we can’t tell where it is: Is it normal or – 10 weeks: 60,000 (5,000 – 150,000) abnormal? à quantitative (serial) Beta-HCG – If Bhcgabove threshold and no IUP = Abnorm al Discriminatory Level – Serial beta HCGs: • If Bhcgdrops > 50% in 48 hours = Abnorm al • Serum β-hCG at which a norm al intrauterine • If Bhcgrises > 50% in 48 hours = M ost likely norm al (can be EP) – Continue to follow and repeat u/s pregnancy should be visualized on ultrasound • If betw een = M ost likely abnorm al (still can be norm al) – – If >2000 nl IUP unlikely but possible à new values Continue to follow and repeat u/s • Once above, lim ited role for “following betas” 4. Once pregnancy clearly abnormal, if undesired or if patient desires definitive dx à uterine aspiration IU P=Intrauterine pregnancy ! ! 4

7/3/18 Society of Radiologists in Ultrasound: Discriminatory & Threshold level No Gestational Sac • 366 ♀ with VB/pain à nl IUP • HCG 2000 - 3000 – Non-viable pregnancy most likely, 2X ectopic 99% Predicted Probability of Detection – Ectopic is 19 x more likely than viable pregnancy Discriminatory Threshold – For each viable pregnancy: In women with desired • 19 ectopic pregnancies Gestational sac 3510 390 pregnancy consider beta • 38 nonviable pregnancies Yolk sac 17,716 1094 – 2% chance of viable pregnancy hcg cut-off of >= 3000. Fetal pole 47,685 1394 • HCG > 3000 – Ectopic 70 x more likely Highest seen in the study with no sac: 2,300 than viable pregnancy Old value of 2000= 91% prob. 0.5% chance viable IUP of seeing GS in viable IUP Connolly, Obstet Gynecol, 2013. ! ! Balance of Diagnostic Tests Simplified Workup of Bleeding &/or Pain • Maximize sensitivity at the cost of diagnosing some 1. Where is the pregnancy? à U/S (same day) IUPs as Ectopic Pregnancies 2. If the pregnancy undesired? à uterine aspiration – Error – interrupting desired IUP 3. If desired and we can’t tell where it is: Is it normal or abnormal? à quantitative (serial) Beta-HCG • Maximize specificity at the cost of diagnosing some – If Bhcgabove threshold and no IUP = Abnorm al EPs as IUPs – Serial beta HCGs: • If Bhcgdrops > 50% in 48 hours = Abnorm al – Error – delay diagnosis resulting in rupture • If Bhcgrises > 50% in 48 hours = M ost likely norm al (can be EP) – • Use cut-off of 3,000 v. repeat beta hcg or u/s Continue to follow and repeat u/s • If betw een = M ost likely abnorm al (still can be norm al) – Continue to follow and repeat u/s 4. Once pregnancy clearly abnormal, if undesired or if patient desires definitive dx à uterine aspiration IU P=Intrauterine pregnancy ! ! 5

7/3/18 β HCG trends in normal IUP β HCG trends : Other Key Points • Two hcgvalues may not be enough • If close to the thresholds –check another 9 9 % o f n l IU P s M e d ia n ris e : 1 d a y r is e ≥ 2 4 % 1 d a y = 5 0 % 2 d a y r is e ≥ 5 3 % 2 d a y = 1 2 4 % Slowest expected 48-hour increase for normal pregnancy = 53% (20% of ectopics increase) Barnhart 2004 Barnhart 2002 ! ! Simplified Workup of Bleeding &/or Pain If Diagnose as Abnormal… • Presumed ectopic pregnancy –uterine 1. Where is the pregnancy? à U/S (same day) 2. If the pregnancy undesired? à uterine aspiration aspiration before MTX 3. If desired and we can’t tell where it is: Is it normal or – High HCG & nothing in the uterus (50% SAB) abnormal? à quantitative (serial) Beta-HCG – If Bhcgabove threshold and no IUP = Abnorm al – Very low HCG with abnormal rise or definite fall – Serial beta HCGs: • If Bhcgdrops > 50% in 48 hours = Abnorm al (25% SAB) • If Bhcgrises > 50% in 48 hours = M ost likely norm al (can be EP) – Continue to follow and repeat u/s • If betw een = M ost likely abnorm al (still can be norm al) – Continue to follow and repeat u/s 4. Once pregnancy clearly abnormal, if undesired or if patient desires definitive dx à uterine aspiration IU P=Intrauterine pregnancy ! ! 6