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.