Early Pregnancy Complications

Early Pregnancy Bleeding

• Ectopic Pregnancy: Vaginal bleeding and abdominal pain should be considered ectopic until ruled out.
• Initial Assessment: Hemodynamic stability and signs of infection should be assessed first. Referral is necessary if these are present.
• Bleeding Quantity: Bleeding exceeding 2 pads per hour for 2 consecutive hours is concerning.
• Genitalia Exam: Important components of the exam include pelvic exam, and assessment of the quantity and source of bleeding.

Types of Early Pregnancy Loss

• Subchorionic Hemorrhage: Blood collection between the uterine lining and the chorionic membrane. Presentation is painless spotting/bleeding; Hypoechoic area adjacent to the gestational sac will be noted. Often resolves by 20 weeks by reabsorption but the risk of loss is greater when > 50% of the sac is affected.
• Chemical Pregnancy: Blastocyst implants, HCG levels rise, but the pregnancy spontaneously aborts before ultrasound detection.
• Embryonic Demise: Death of an embryo before 10 weeks gestation, before reaching viability; an ultrasound may reveal no heartbeat.
• Complete Abortion: All products of conception (POC) are expelled; cervix closed, small uterus, heavy cramping and bleeding, followed by decreased symptoms.
• Inevitable Abortion: Cervical dilation and/or rupture of membranes, vaginal bleeding, low abdominal or back pain occurring after 20 weeks but no tissue passage. Embryo will be 5mm or absent of cardiac activity.
• Incomplete Abortion: Some POC are passed (< 20 weeks); remaining tissue left in the uterus; absence of evidence of viability.
• Missed Abortion: Cervix closed with retained POC in the uterus, absent fetal heart tones (FHTs)
• Threatened Abortion: Painless bleeding without cervical dilation or effacement (no dilation or thinning of the cervix).

Types of Pregnancy Failure

• Anembryonic pregnancy (blighted ovum): Gestational sac forms but no embryo develops.
• Septic Abortion: Loss accompanied by infection and sepsis.

Recurrent Pregnancy Loss

• Criteria: 2 or more clinical pregnancy losses.
• Referral: If recurrent pregnancy loss is diagnosed, referral to endocrinology is necessary.
• Potential Pathogenesis: Abnormal karyotype (50%), infection, anatomic defects, endocrine factors, exposure to toxic substances, or unknown.

Spontaneous Abortion Management

• Hemorrhage/Stabilization: Primary goal is preventing/assessing for life-threatening blood loss.
• Expectant Management: High risk of retained POC.
• Medical Management: Misoprostol (800mcg vaginally) or mifepristone (200mg 24 hours prior) and misoprostol (800mcg following mifepristone). Ultrasound follow-up is recommended within 7-14 days.
• Surgical Management: Lowest risk of retained POC; necessary for hemorrhage, hemodynamic instability, or infection. Doxycycline (200mg) one hour pre-procedure.
• Management by EGA: Manual Vacuum Aspiration (MVA) or Manual Uterine Aspiration (MUA) for < 10 weeks; Dilation and Evacuation (D&E) for > 14 weeks.

Post-Management Considerations

• Retained POC/Pain: Severe pain post-management warrants re-evaluation; if retained POC suspected. Patient may resume normal activity and return to previous state after a spontaneous abortion once menses starts (4-6 weeks/ hormone levels measured if not returned at this point); may try to conceive again w/o limit.
• Pregnancy failure diagnostics: various ultrasound findings diagnose pregnancy failure.
• Recurrent Pregnancy Loss Lab Eval: Tests for endocrine, coagulation, and autoimmune disorders. Recurrent pregnancy loss often associated with aneuploidy (50%). Anticoagulation will only be used if antiphospholipid antibodies present.
• Factors increasing hemorrhage risk: Expectant/medical management.
• Factors increasing infection risk: Retained POC or genital tract infection.
• Post-spontaneous abortion complications: retained POC requiring surgical treatment; endometritis (infection of the uterine lining) may result from sepsis.

Ectopic Pregnancy

• Site: The most common site for ectopic pregnancy is the ampulla.
• Risk Factors: Pelvic inflammatory disease (PID), smoking, previous tubal or pelvic surgery, contraceptive failure, Assisted Reproductive Technology (ART), or unknown.
• Symptoms: Minimal initial pregnancy symptoms; pain preceding any bleeding, bleeding continues if pain stops, abdominal pain/tenderness, delayed menses, absence of common pregnancy signs, palpable mass, hemodynamic instability in later stages.
• Lab Tests: Complete Blood Count (CBC) to assess hemodynamic status. Monitoring hCG levels; absence of doubling every 48 hours is concerning.
• Pharmacologic Management: Methotrexate, which causes cellular death of trophoblastic tissue to decrease ectopic size without surgery.
• Surgical Management: Laparotomy or salpingotomy, depending on EGA.
• Monitoring after Methotrexate: HCG levels are monitored until they reach non-pregnancy levels.
• Avoidance: Sexual intercourse, exercise, and excessive pelvic exams should be avoided.
• Follow-up after Treatment: Delay pregnancy for 1-3 months after methotrexate treatment.

Hydatidiform Mole

• Types: Complete mole (all paternal origin, 46XX), or partial mole (mosaicism, 69XXY or 69XXX).
• Symptoms: First-trimester bleeding, variable uterine size (small or large), ovarian enlargement (multiple theca lutein cysts). Pregnancy symptoms are often exaggerated.
• Physical Findings: Grape-like structures passed from the vagina, also known as vesicular mole.
• Diagnosis: Ultrasound (snowstorm appearance, grape-like lesions).
• Monitoring: hCG monitored weekly until undetectable, than monthly.
• Post-Treatment: Pregnancy avoided until hCG is undetectable; IUD avoidance.

Explore the critical aspects of early pregnancy complications, including ectopic pregnancy and types of early pregnancy loss. This quiz covers assessments, bleeding types, and signs to watch for in early pregnancy. Test your knowledge and understanding of these important concepts.