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Early Pregnancy in General Practice: Miscarriage and Ectopic Pregnancy Dr Georgina Elliot-Smith Obstetrics and Gynaecology Trainee, ST4 North West LondonWhat we will be covering • Background and epidemiology • Referral guidelines • PUL and PUV • Miscarriage • Ectopic pregnancy • Management, complications and counsellingPoll How confident do you feel on a scale of 1-10 managing and counselling a woman with a suspected miscarriage or ectopic pregnancy?Background and Epidemiology • Miscarriage is common • 1 in 5 pregnancies in the UK end in miscarriage (possibly up to 1 in 6) • Risk 1 in 5 at 30 years and 1 in 2 at 40 years • Recurrent miscarriage (3 or more miscarriages) has an incidence of ~1% • Chromosomal abnormalities are the cause of ~50% of miscarriages • Risk of ectopic pregnancy is ~1% • Risk factors for ectopic pregnancy: Previous ectopic, PID, abdominal/ pelvic surgery, black ethnicity, IVF, smoking, advancing maternal age, intrauterine contraception, sterilisationReferral from primary care • Women with bleeding in early pregnancy • ≥6 weeks by the first day of their last menstrual period (or if gestation is unclear) should be referred to EPAU or out of hours gynaecology • <6 weeks they should be advised to take a pregnancy test 7-10 days after the cessation of bleeding* • If haemodynamically unstable or bleeding heavily → A&E • Women with pain and bleeding at any gestation (with a positive pregnancy test) • Refer all women to EPAU/ out of hours gynae to exclude ectopic pregnancy • 1/3 - 1/2 of women will have no known risk factors • If haemodynamically unstable or severe pain → A&EEmergency Assessment and Care • There is nothing we can do to stop a miscarriage from happening • Examination and full assessment of haemodynamic stability • Speculum examination and removal of pregnancy tissue if visible in external cervical os • Bloods including a venous gas to review blood loss • Arrange a TVUSS- This will very rarely happen out of hours • If haemodynamically stable, not bleeding heavily, pain controlled with simple analgesia, discharge home to await scan • Haemodynamic instability may require urgent surgical or medical management +/- blood transfusion • Laparoscopy out of hours for a suspected ectopic if haemodynamic instability or strong suspicion with severe painWhat do we diagnose in EPAU/ EPU/ AEPU • Viable intrauterine pregnancy (VIUP)- most of the time! • Pregnancy of uncertain viability (PUV) • Pregnancy of unknown location (PUL) • Miscarriage – complete, incomplete, missed, spontaneous • Ectopic pregnancy • Molar pregnancyUltrasound Diagnosis of Miscarriage • A viable intrauterine pregnancy is diagnosed when there is a visible intrauterine gestational sac (IUGS) with a visible fetal pole and a visible fetal heartbeat • The diagnostic parameters of miscarriage are the same in every UK unit and dictated by NICE to avoid inadvertent termination of a viable pregnancy • A miscarriage is diagnosed in the following circumstances: • An IUGS containing a fetal pole at least 7mm in size with no fetal heartbeat confirmed by at least 2 operators • The presence of an empty IUGS >25mm in size confirmed by at least 2 operatorsA quick note on PUV/PUL... • Pregnancy of uncertain viability (PUV) – where there is a visible intrauterine pregnancy but there is no visible fetal heart pulsations and it doesn’t meet criteria for miscarriage • IUGS with a fetal pole <7mm with no FH or an empty GS <25mm • Re-scan in 7-14 days • Pregnancy of unknown location – where there is no definitive pregnancy within the intrauterine cavity and no clear ectopic pregnancy • Otherwise known as an inconclusive scan • Early IUGS not visible, complete miscarriage or ectopic pregnancy • HCG +/- progesterone level and repeat in 48 hoursWhat are we actually looking at? Measuring the CRL Measuring the GS Mean sac diameter (MSD)Management of Miscarriage • Expectant – 50% success • Should be offered first line for an uncomplicated miscarriage • Follow-up is generally offered after 2-3 weeks • Medical (usually outpatient unless large pregnancy or later gestation) – 85% success • 200mg mifepristone and 800mcg misoprostol 48 hours later • Expect a heavy bleed within 12 hours after misoprostol • Period-like bleeding or less can occur for up to 2 weeks • UPT 3 weeks after bleeding has stopped • Surgical – 95% success • Outpatient (MVA) or inpatient (SMM) using suction curettage +/- misoprostol https://www.rcog.org.uk/media/ps1l2keo/pi-early-miscarriage.pdfMiscarriage: Complications of Management Expectant Medical Surgical Infection Infection (less than expectant) Infection Unmanaged bleeding/ prolonged Heavy bleeding and pain at home Heavy bleeding in the operating bleeding theatre Failure (50%) Failure (15%) Failure (5%) Incomplete management/ RPOC Incomplete management/ RPOC Uterine perforation and associated (less than expectant) damage 1-15 in 1,000 Uterine adhesions/ Asherman Syndrome Image source: https://pie.med.utoronto.ca/TVASurg/pe/hysteroscopy/risks.htmlRetained Products of Conception (RPOC) • Occurs usually after miscarriage or termination– less likely with intervention (medical, surgical) but still possible. Can also occur after birth – more common with vaginal birth than caesarean • Causes bleeding at the site of the tissue • Persistent and light • Heavy • Infected • Causes a prolonged raised HCG level and prevents the menstrual cycle from re-starting • In cases of heavy bleeding, clots can form within the uterus which prevents the muscle from contracting down and tamponading effectively • Management: Conservative, medical or surgical management +/- antibioticsMiscarriage: Cases Case 1 A 28 year-old woman presents to your surgery after being diagnosed with a miscarriage at 6 weeks’ gestation. She was given tablets, which she took a week ago. She had a heavy bleed after the tablets and now has some ongoing spotting. Case 2 A 34 year-old woman presents to your surgery after being diagnosed with a miscarriage 1 week ago. She opted for expectant management and has been bleeding for 3 weeks now. She reports not feeling well, the bleeding now smells strange and she has constant lower abdominal pain. When you take her temperature, it is 38.6 degrees.Miscarriage: Cases Case 1 A 28 year-old woman presents to your surgery after being diagnosed with a miscarriage at 6 weeks’ gestation. She was given tablets, which she took a week ago. She had a heavy bleed after the tablets and now has some ongoing spotting. Answer: This is normal after medical management of miscarriage. Period-like bleeding (or less) is normal for up to 2 weeks Case 2 A 34 year-old woman presents to your surgery after being diagnosed with a miscarriage 1 week ago. She opted for expectant management and has been bleeding for 3 weeks now. She reports not feeling well, the bleeding now smells strange and she has constant lower abdominal pain. When you take her temperature, it is 38.6 degrees. Answer: This is most likely a septic miscarriage/ septic retained pregnancy tissue.The correct response is to send the patient to A&E for assessment, IV antibiotics and likely surgical managementMiscarriage: Cases Case 3 A 24 year-old woman presents to your surgery with persistent bleeding following a termination of pregnancy at 5 weeks gestation, 4 weeks ago. She reports ongoing bleeding since she took the tablets, changing 2 pads per day. She feels generally well and her observations are normal. Case 4 A 38 year-old woman presents to your surgery 3 days after a surgical management of miscarriage was carried th out for a miscarriage at 10 weeks gestation in her 5 pregnancy. She has ongoing lower abdominal pain which is getting worse rather than better and reports some vomiting and diarrhoea. She has light vaginal bleeding but feels dizzy and unwell.Miscarriage: Cases Case 3 A 24 year-old woman presents to your surgery with persistent bleeding following a termination of pregnancy at 5 weeks gestation, 4 weeks ago. She reports ongoing bleeding since she took the tablets, changing 2 pads per day. She feels generally well and her observations are normal. Answer: This is most likely an incomplete termination of pregnancy (this could also be an ectopic pregnancy, but less likely).The patient should be referred to the Early Pregnancy Unit for a scan and further assessment. Case 4 A 38 year-old woman presents to your surgery 3 days after a surgical management of miscarriage was carried out for a miscarriage at 10 weeks gestation in her 5 pregnancy. She has ongoing lower abdominal pain which is getting worse rather than better and reports some vomiting and diarrhoea. She has light vaginal bleeding but feels dizzy and unwell. Answer: This is suspicious for a uterine perforation and possible bowel injury.The correct response is to send the patient to A&E/ED as soon as possible for assessment (for stabilization, CT scan and possibly surgical repair).Ectopic Pregnancy • A pregnancy which is not appropriately placed within the uterine cavity • Presents with pain +/- bleeding (most of the time), shoulder tip pain,haemodynamic instability with a positive pregnancy test (urine or serum) • >90% are tubal (interstitial, CS scar, cervical, abdominal, ovarian) • On TVUSS: A heterogenous/ inhomogenous adnexal mass OR a visible extra-uterine gestational sac with or without yolk sac/ fetal pole Image source: https://www.journalmc.org/tables/jmc2484wt.htm • Free fluid in the POD – bleeding due to rupture/ fluid leaking from the fimbrial end of the tubeManagement of Ectopic Pregnancy Expectant management Monitoring only HCG <1,500 (preferably <1,000), asymptomatic or minimal symptoms Serum HCG on days 0, 2, 4, 7 and then weekly Success rate of 57 – 100% The patient must be contactable, able to come in for follow-up and understand the follow-up plan and safety netting adviceManagement of Ectopic Pregnancy Expectant management Medical Management Monitoring only Methotrexate 50mg/m2 IM (may be HCG <1,500 (preferably <1,000), repeated depending on HCG) with asymptomatic or minimal serial HCG follow-up symptoms Ideally HCG <1,500 but can be up to 5,000 Serum HCG on days 0, 2, 4, 7 and Serum HCG on days 0, 2, 4, 7 and then weekly then weekly Success rate of 57 – 100% Success rate 65 – 95% The patient must be contactable, Alcohol and folic acid need to be able to come in for follow-up and avoided and not to conceive for at understand the follow-up plan and least 3 months safety netting adviceManagement of Ectopic Pregnancy Expectant management Medical Management Surgical Management Monitoring only Methotrexate 50mg/m2 IM (may be Salpingectomy if both tubes are HCG <1,500 (preferably <1,000), repeated depending on HCG) with healthy asymptomatic or minimal serial HCG follow-up Salpingotomy if diseased symptoms Ideally HCG <1,500 but can be up contralateral tube to 5,000 Serum HCG on days 0, 2, 4, 7 and Serum HCG on days 0, 2, 4, 7 and Definitive management if then weekly then weekly salpingectomy Success rate of 57 – 100% Success rate 65 – 95% Success rate ~100% The patient must be contactable, Alcohol and folic acid need to be Indications for surgery: able to come in for follow-up and avoided and not to conceive for at HCG >5,000 understand the follow-up plan and least 3 months Pregnancy >35mm safety netting advice Live ectopic Possible or impending rupture Patient preferenceComplications of Management of Ectopics • Expectant management • Rupture (peritonitis,haemoperitoneum) • Failure of treatment (i.e. need for medical/ surgical management) Rupture is still • Recurrent ectopic in the same tube possible! Even a small ectopic • Medical management (methotrexate) with a very low HCG can • Side effects: Excessive flatulance and bloating, transient mild rupture at any elevation in liver enzymes and stomatitis point • Adverse effects: marrow suppression, pulmonary fibrosis, non- specific pneumonitis, liver cirrhosis, renal failure gastric ulceration • Rupture, failure, bleeding, recurrence • Surgical management • Laparoscopic injury – vascular, visceral, ureteric etc. • Bleeding, infection, increased VTE risk • Loss of a fallopian tube/ ovary if ovarian or adherent to ovaryCounselling • Early pregnancy loss is common and we are particularly bad at talking about it • Remember that those with ectopic pregnancies have lost a pregnancy as well • Almost everyone will know someone who has been through pregnancy loss • It is highly unlikely to have been caused by the patient herself • Smoking, alcohol etc. can increase the risk of miscarriage, but is unlikely to have caused it • Miscarriage/ ectopic pregnancy isn’t caused by stress, working too much, heavy lifting etc. • The next pregnancy is highly likely to be straightforwardFAQs – And any questions?? • Loss of pregnancy symptoms • A loss of pregnancy symptoms can sometimes preclude pain/ bleeding, however it isn’t an indication for further investigation in isolation – often people’s symptoms can change significantly throughout the first trimester, and sometimes people don’t have any symptoms at all • Vaginal discharge • An increase in white physiological discharge is normal in pregnancy, however passing clear fluid isn’t. Candidiasis is also common. • Does a previous termination affect your fertility/ risk of miscarriage? • No. Some studies suggest it increases the risk of preterm birth depending on gestation • You can start trying again after a miscarriage as soon as you feel ready (waiting for a normal period is helpful for dating)Resources • NICE guideline on Miscarriage and Ectopic Pregnancy https://www.nice.org.uk/guidance/ng126 • RCOG Green-Top Guideline on Recurrent Miscarriage https://obgyn.onlinelibrary.wiley.com/doi/pdf/10.1111/1471-0528.17515 • Miscarriage Association PILs (including in other languages) https://www.miscarriageassociation.org.uk/information/leaflets/ • RCOG Early Miscarriage leaflet https://www.rcog.org.uk/media/ps1l2keo/pi-early- miscarriage.pdf • SANDS Pregnancy Loss Charity https://www.sands.org.uk/ • Tommy’s miscarriage support https://www.tommys.org/baby-loss-support/miscarriage- information-and-support/support-after-miscarriage