Early pregnancy dilemmas. DR. Sharda Jain , Dr. Jyoti Bhaskar
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Transcript of Early pregnancy dilemmas. DR. Sharda Jain , Dr. Jyoti Bhaskar
EARLY PREGNANCY
LOSSDILEMMAS
Dr. JYOTI BHASKARDR. SHARDA JAIN
Director of Lifecare IVF
LOGO
Content
ULTRASOUND 2
HCG INTERPRETATION3
PREGNANCY OF UNKNOWN LOCATION
4
ANTI D PROPHYLAXIS5
DEFINITIONS1
MANAGEMENT6
SOURCES Diagnosis and initial management in early pregnancy of ectopic pregnancy and miscarriage NICE clinical guideline 154, Dec 2012
AEPU Guidelines 2007
Management of Early Pregnancy Loss Green Top Guideline No. 25 , 2006
Rhesus D Prophylaxis, The Use of Anti-D Immunoglobulin for (Green-top 22,2011)
Lifecare Centre Experience
DEFINITIONS Change in terminology to MISCARRIAGE
Spontaneous/Threatened/Missed/Inevitable/ Complete/Incomplete/Recurrent Miscarriage
Anembryonic / Blighted Ovum
Delayed / Silent Miscarriage
Pregnancy of Unknown Location( PUL) ( 8-31% at first visit) No signs of either Intrauterine or extrauterine
pregnancy or RPOC on TVS in a women with positive pregnancy test.
Pregnancy of Uncertain Viability ( PUV) ( 10% at first visit) Intrauterine GS < 20 mm with No YS or FP or Fetal echo < 7mm with No CA
ULTRASOUND TVS is the method of choice
If unacceptable, do TAS and explain the limitations of this method of scanning
Diagnosis of miscarriage using 1 ultrasound scan cannot be guaranteed to be 100% accurate
Diagnosis and initial management in early pregnancy of ectopic pregnancy and miscarriageNICE clinical guideline 154, December 2012
What to expect in USG
4 weeks 5 weeks
6 weeks
GS
GS < 20mm No YS
GS < 25 mmNo Fetal Pole
GS >25mmNo embryo
Rescan after 1 weekMISSED MISCARRIAGE
Rescan after 1 weekSecond opinion
CRL
CRL < 7MM NO CA
PUV
CRL > 7MMNO CA
EARLY FETAL LOSS
Rescan after 1 weekMISSED MISCARRIAGE
Rescan after 1 weekSecond opinion
ET
< 15MM > 15MM
HOMOGENOUS MASSIN CAVITY
COMPLETE MISCARRIAGE
INCOMPLETE MISCARRIAGE
EXCLUDE PREGNANCY OF UNKNOWN LOCATION/ ECTOPIC
H.MOLESERUM B HCG
UNDERSTANDIING HCG MEASUREMENTS
USEFUL IN Screening in women at high risk of ectopic
pregnancy
Monitoring during expectant management or medical management of women with pregnancy of unknown location and ectopic pregnancy
Evaluation of conservative surgical treatment of ectopic pregnancy
HCG DOUBLING TIMEIt refers to the time taken for the hCG
level to double its original value
Serum hCG levels double approximately every two days in early (<8 weeks)
a lesser increase (<66% over 48 hours) is associated with ectopic pregnancy and miscarriage.
CAUTION15% of normal pregnancies will have
abnormal doubling time and 13% of ectopic pregnancies will have a normal doubling time
In multiple pregnancies and heterotropic pregnancies the level of hCG on D2 would be a little higher
DISCRIMINATORY HCG ZONE Level of hCG above which the gestational sac
of an intrauterine pregnancy should be visible on ultrasound.
It usually lies between 1000 – 2400IU/L.
Depends on three factors: i) hCG assay ii) quality of ultrasound iii) the experience of the person Performing
USG
BETA HCG INTERPRETATION
Serum B HCG at 0 and 48 hrs
> 66% increase > 66% increase or < 21-35% decrease
>21-35% decrease
IUP ? Ectopic Pregnancy
? Failing PULMiscarriage
Pregnancy test positive + TVS
Inconclusive result (No evidence of IUP or EP)
Serum HCG measurements every 2-3 days
Falling Complete miscarriage No further scans are necessaryFollow up until hCG <20 IU/L
Rising (doubling)
Repeat TVS when hCG >1000 IU/L
IUPNo further hCG assays
Rescan in one week
Suboptimal rise/plateauing/falling slowly after 2-3 measurements
EP PUL Non-viable IUP
TVS
Role of serum progesterone
Serum progesterone
< 20 nmol/L >60 nmol/L
PPV > 95% to predictPregnancy failure
(Banerjee et al., 2001)
‘Strongly’associated with
viable pregnancies
Viable IUPs reported withlevels < 16nmol/L
Discriminative capacity insufficient to diagnose ectopic pregnancy withcertainty (Mol et al., 1998)
Good at predicting viability but not location
RHESUS ANTI D PROPHYLAXIS THREATENED MISCARRIAGE - all > 12 weeks - if bleeding persists , given at 6 weekly interval ( RCOG recommendation )
Prudent to administer anti-D as gestation approaches 12 weeks
1. where bleeding is heavy or repeated 2. where there is associated abdominal pain
(RCOG Grade C recommendation)
Spontaneous Miscarriage Given to all non-sensitised RhD negative-
With spontaneous complete or incomplete miscarriage after 12 weeks of pregnancy
(RCOG Grade B recommendation)
Before 12 weeks not recommended as risk of immunisation is negligible. (RCOG Grade C recommendation).
SPECIAL SITUATIONS -- GIVEN
ERPC OR TOP Therapeutic termination of pregnancy,
whether by surgical or medical methods, regardless of gestational age (RCOG Grade B recommendation).
ECTOPIC PREGNANCY confirmed or suspected ectopic
pregnancy (RCOG Grade B recommendation).
DO NOT GIVE
Threatened Spontaneous
<12 weeks
NO ANTI D
PROPHYLAXIS
Complete H. MOLE
DOSAGE OF ANTI D
• UPTO 20 WEEKS -- 250 IU ( 50 ug)
• MORE THAN 20 WEEKS – 500 IU ( 100 ug)
Available in India
1. 50 ug – Microhogam UF2. 100 ug - Vinobulin
3. 300 ug -- Predominantly
MEDICAL MANAGEMENT – Method of Choice
Missed miscarriage Incomplete miscarriage
NO MIFEPRISTONE
VAGINAL MISOPROSTOL
800 MG 600 MG
Surgical Management
Only in
• Persistent excessive bleeding• Haemodynamically unstable• Infected retained tissue• Suspected Gestational trophoblastic tissue
Surgical ManagementVaccum Aspiration – Method of choice
Prior Prostaglandin administration
If infection suspected – delay intervention for 12 hrs for I/V antibiotic
TAKE HOME MESSAGE Understand changing management trends Moved Towards
• Treatment on Outpatient basis• Refined and Indicated Diagnostic techniques• Patient centred Therapeutic Interventions
Interpret USG and HCG results wisely and reach a diagnosis
Always be on look out for ectopic pregnancy and PUL
Follow the latest protocols for Anti D prophylaxis in early pregnancy
Medical management is the treatment of choice
The approach has to be patient centred.
Pregnancy of Unknown LocationExpectant management suitable for majority of women
No consensus on appropriate intervention but no routine role for curettage
Serum hCG and progesterone levels useful, but no role for single hCG measurement
ADDRESS 35 , Defence Enclave, Opp. Preet
Vihar Petrol Pump, Metro pillar no. 88, Vikas Marg , Delhi – 110092
CONTACT US 011-22414049, 42401339
WEBSITE : www.lifecarecentre.in
www.drshardajain.com www.lifecareivf.com
E-MAIL [email protected]
[email protected]@lifecareivf.com
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