Complications in Early Pregnancy Part One. The two commonest complaints in early pregnancy are bleeding and vomiting in pregnancy. In part one of this series of presentations, we will focus on bleeding in early pregnancy and, in particular, the approach to spontaneous abortions in pregnancy.
The learning objectives are to learn to diagnose and assess the severity of common complications in early pregnancy, to provide a list of differential diagnoses for common complaints in early pregnancy, and to learn to manage these complications in early pregnancy.
The commonest causes of bleeding in early pregnancy include spontaneous abortions, also known as miscarriages, ectopic pregnancies, gestational trophoblastic disease, and certain local causes, such as endocervical lesions. History taking. It is important to take a basic menstrual history.
The last menstrual period and the regularity of the patient’s menstrual cycle may give a clue to the gestation of the pregnancy. Next, the details of the per vaginal bleeding is important. The amount of bleeding, the onset, as well as symptoms of anemia, such as postural giddiness, palpitations, syncope, exertional dyspnea, are important if excessive bleeding resulting in anemia is suspected.
Commonly associated symptoms, such as lower abdominal cramps, passage of products of conception, foul-smelling per vaginal discharge, fever, or pronounced symptoms of early pregnancy, such as excessive nausea and vomiting, should be elucidated.
Following this, a thorough physical examination should be performed. Vital parameters should be charted, looking out specifically for signs of hemodynamic instability. The abdomen should be palpated, especially if the patient complains of abdominal pain, assessing for evidence of acute abdomen– involuntary guarding and rebound tenderness.
A [INAUDIBLE] examination is performed to assess the amount of perivaginal bleeding, whether the cervical os is open or closed, presence of products of conception or foul-smelling discharge. Vaginal examination may detect adnexal tenderness or masses or cervical excitation.
Next, certain specific investigations should be performed to elucidate the etiologies of the bleeding. Serum beta-hCG. Serum beta-hCG classically doubles every 48 hours in a normal pregnancy. If the serum beta-hCG level is falling instead of rising, this likely indicates a spontaneous abortion or miscarriage.
Conversely, if the increase in serum beta-hCG is less than 66% within 48 hours, suspicion of ectopic pregnancy should be entertained. If the serum beta-hCG is in much higher levels than that expected in a normal pregnancy, gestational trophoblastic disease should now be suspected. Sonographic features.
Features to look out for include a gestational sac. This may be intrauterine, within the uterus, or extrauterine, outside the uterus. This can be seen as early as five weeks gestation and, usually, when the serum beta-hCG is above 1,500, via a transvaginal ultrasound of the pelvis. A double decidual indicates an intrauterine pregnancy.
In general, the rate of increase of the gestational sac size is 1.2 millimeters per day. Yolk sac. The yolk sac is usually visualized within five to six weeks gestation and disappears by 10 weeks gestation. A blighted ovum is diagnosed when the gestational sac is more than 25 millimeters but there is no yolk sac.
A miscarriage is diagnosed when the crown rump length is more than 7 millimeters without fetal cardiac activity. If a miscarriage is diagnosed, identification of remnant products of conception and thickness of endometrium are necessary. If an ectopic pregnancy is suspected, efforts should be made to look for adnexal masses or free fluid within the pouch of Douglas.
If a gestational trophoblastic disease is suspected, the classical image of a cystic snowstorm appearance should be evident. Now we shall discuss the different types of spontaneous abortions and the appropriate approach. A threatened miscarriage is diagnosed when the patient presents with per vaginal staining, usually without abdominal pain.
But on examination of the cervix, it is closed and the scan shows fetal cardiac activity. An incomplete miscarriage is when the patient has per vaginal bleeding associated with lower abdominal cramps and sometimes even passage of products of conception. On examination, the cervical os is open with products of conception seen, and the scan shows no fetal cardiac activity with an irregular gestational sac or remnants of products of conception.
A complete miscarriage may present similar to that of an incomplete miscarriage. But on examination, the cervical os is closed and the scan shows an empty uterus. An inevitable miscarriage is diagnosed when the fetal heart is still present on performing a scan, but the cervix is open. Patients with missed miscarriage usually present with per vaginal staining, rarely, lower abdominal cramps, but no passage of products of conception.
On examination, the cervix is closed. And on scanning, there are products of conception but no evident fetal cardiac activity. Lastly, a septic miscarriage is suspected when the patient complains of fever, foul-smelling discharge. And in addition to the above symptoms, physical examination findings reflect a septic state. Management of a spontaneous abortion. Expectant treatment with reassurance should be offered in a threatened miscarriage.
If fetal cardiac activity is present, 97% of patients will have normal outcomes. There is no evidence to support restriction of physical activity or progestogenic support. If there are no further episodes of per vaginal bleeding, a repeat scan may be performed in a week’s time for a reassessment of fetal viability.
In a complete miscarriage, an ultrasound should be performed to identify if there are remnant products of conception and the endometrial thickness measured. If the endometrial thickness is less than 15 millimeters, the option for conservative management may be offered.
If the patient is septic, broad-spectrum antimicrobial agents should be commenced and cultures obtained, with subsequent conversion to specific antimicrobial agents. The patient should be stabilized. And a surgical evacuation of the uterus should be performed to eradicate the nidus of infection.
In a diagnosed incomplete miscarriage, we need to ensure that the patient is hemodynamically stable and subsequently proceed with an evacuation of the uterus. In an inevitable miscarriage or a missed miscarriage, options of expectant or surgical management may be considered.
In an inevitable miscarriage, both expectant management via spontaneous expulsion of the remnant products of conception or surgical evacuation of the uterus are acceptable options. In a missed miscarriage, expectant management via spontaneous expulsion of products of conception, medical treatment with oral or vaginal misoprostol, as well as surgical evacuation of the uterus are acceptable options.
