Early Pregnancy Loss
Definition
• Nonviable intrauterine pregnancy
charactized by empty gestational sac or
embryo/fetus <13 weeks with no fetal
heart activity
• 10% of all pregnancies
• 50% are generally chromosomal
abnormalities
Signs and Symptoms
• First trimester cramping/bleeding
• DDx: early pregnancy loss, viable
intrauterine pregnancy, ectopic pregnancy
• A pelvic exam is important before testing
Testing
• Ultrasound is the prefered method to
determine viabilty
• HCG levels are important in interpreting
ultrasound findings and for serial follow
up
Beta HCG
• Discriminatory zone 1500-2000 mIU/ml is
associated with a gestational sac in
singleton pregnancies
• A rise of < 50% in 48 hours is associate
with an abnormal pregnancy with a
sensitivity of 99%
Treatment Options
• Expectant
• Medical treatment
• Surgical treatment
Expectant
• May take up to 8 weeks
• 80% success
• What is success
– HCG < 5 mIU/ml
– Endometrial stripe of < 3 cm
– Return of normal menstrual function
• Patient needs to be prepared for moderate
to heavy bleeding with cramps and may
need a suction currettage
Medical Treatment
• Goal is to shorten the time to complete
explusion as compared to expectant
• 85% success with complete expulsion with
in 3 days for 70% of patients
• Patient should expect moderate to heavy
bleeding and cramping issues as well as
possible suction currettage
Surgical
• Suction curettage has replaced sharp
curetting
• It is immediate and 99% successful
• Clinically important intrauterine
adhesions are a rare complication
Complications of all treatments
• Incomplete requiring curettage
• Infection 2%
• Transfusion 1%
Rh Negative Mother
• Give 50-300 micrograms rhogam within 72
hrs of diagnosis of early pregnancy loss
Subsequent Pregnancy
• No evidenced based data on when it is safe
to get pregnant again
• BCP or IUD can be started as soon as you are
sure the process is complete
• Consider workup for recurrent EPL after the
2nd consecutive EPL
• No proven treatment for threatened abortion
• Progesterone in first trimester after at least 3
EPL may be beneficial
Case Studies
Am I ready to do office gyn?
Sally is a 23 y/o GoPo complaining of irregular
bleeding
Gyn Hx: sexually active uses condoms most times
PE: 105 lb
Abdomen soft nontender
Pelvic exam: no vaginal bleeding, Cervix is closed
nontender, uterus normal, adenexa neg
Test Results
• Quantative Beta HCG < 1
• Ultrasound normal uterus, endometrium,
and ovaries
What if Ultrasound Shows
• uterus 11x9x8 cm with multiple
leiomyoma about 2-3 cm in diameter,
endometrial thickness 6 mm, normal
ovaries
Sally returns after 3 months on her new birth control
pill still having breakthrough bleeding
Pelvic exam is normal
Test: STD negative
pregnancy test negative
Judy is a 30 y/o G2P2 for annual exam on Ortho
Tricyclen Lo
Social hx: married, monogamous
She is complaining that she had regular periods for a
while but now having breakthrough bleeding for 6
months
Exam: Normal
Differential diagnosis?
Mary is a 45 y/o G3P3 status post tubal ligation
Menstral formula:
2 weeks/3 days heavy on day 1
PMH: negative
Pelvic exam: Cervix normal, pap done
Uterus 6 weeks size, irregular, firm,
nontender
Ovaries not enlarged, nontender
Guidelines for Endometrial Biopsy
• All women with history of AUB of 2-3 yrs
duration
• All women > 45 yrs old with AUB
• All women who do not respond to
treatment
Endometrial Biopsy Results
• Complex hyperplasia with atypia
• Complex hyperplasia
• Simple hyperplasia
• Proliferative endometrium
• Secretory endometrium
Vicki is a 60 y/o complaining of 3 days of light bleeding 3 weeks
ago
PMH: Illnesses:
diabetes controlled on diet
mild hypertension
Meds: Atenolol
Continuous hormone replacement therapy
Exam: 5’4”, 175 lb
Pelvic:vagina slightly atrophic
cervix stenotic, pap done
uterus NS/NS
adenexa negative
Endometrial thickness
• < 4 mm generally atrophic endometrium
• > 4 mm you can’t rule out cancer
60 yr old menopausal female complaining of
incontinence
PI: leaking urine for several months now worse
PMH: TAH/BSO for benign disease age 45
Lumbar disk fusion 1 years ago
PE: Pelvic – 1st degree cystocoele and 1st degree
rectocoele
• Complaining of urgency, frequency,
nocturia, sudden loss of large amounts of
urine
• Residual urine 10 ml
• Urine culture positive > 100,000 e-coli
• Loss of urine with coughing, sneezing,
laughing, squatting, jumping
• Residual 50 ml and culture negative
• Residual > 200 ml
22 yr old female complaining of amenorrhea for 1 yr
PI: LMP 1 yr ago prior menstral formula 28d/5d
BC: none
Gyn Hx delivered a baby 2 yrs ago
PMH: Schizophrenic on anti-psychotic med
Soc Hx: Occasionally sexually active without condoms
PE: Thin female, no distress
Breasts bilateral milky discharge
Pelvic exam normal
• Prolactin 100 ng/ml., TSH 5.5 uU/ml.,
• Prolactin, TSH normal