Ectopic pregnancy and miscarriage - medical detective

Ectopic Pregnancy and Miscarriage

Overview

• Speaker: Dr. Pauli van Heerden, Maternal Fetal Medicine Fellow.

• Focus: Ectopic pregnancy and miscarriage.

• Source: 2020-2022 Saving Mothers Report indicates rising incidence and maternal mortality.

Ectopic Pregnancy

Definition

• Occurs when a developing blastocyst implants outside the uterine cavity.

Incidence

• Increasing trend: Affects 2-3% of all pregnancies.

• Significant cause of maternal mortality.

Risk Factors

• Previous ectopic pregnancy: Odds ratio of 3.04.

• Pelvic inflammatory disease: Linked to infections in the pelvis.

• Infertility-related factors:

  • General infertility.

  • In vitro fertilization (IVF) or assisted reproduction techniques.

  • Tubal reconstruction surgery.

• Contraceptive methods:

  • Sterilization: 19-fold increased risk.

  • Intrauterine contraceptive devices (IUDs): 16-fold increased risk.

  • Combined and progestin-only contraceptives: Risk factor but less defined.

• Smoking: Known to increase risk.

• Vaginal douching: Associated with increased risk.

• Endometriosis: Linked to higher incidence of ectopic pregnancy.

Clinical Signs and Symptoms

• Typical Symptoms:

  • Abdominal pain (may be diffuse or one-sided).

  • Vaginal bleeding.

  • Amenorrhea (missed menstrual period).

• Pelvic examination findings:

  • Severe tenderness if tubal rupture occurs.

  • Cervical motion tenderness and adnexal tenderness on bimanual examination.

• Vaginal bleeding:

  • No specific bleeding pattern; cervical os usually closed.

  • May have significant intraperitoneal bleeding without vaginal bleeding.

• Timeline: 6-8 weeks of amenorrhea usually observed.

Natural History of Ectopic Pregnancy

• Possible Outcomes:

  • Tubal Rupture: Can lead to intra-abdominal hemorrhage and requires urgent surgery.

  • Tubal Abortion: Pregnancy may be expelled from the trophoblastic end of the tube.

  • Resolution: Pregnancies may undergo resorption with negative pregnancy tests.

  • Chronic Ectopic: Possible inflammatory mass may form after pregnancy expulsion.

Differential Diagnosis

• Conditions to consider:

  • Physiological early pregnancy symptoms.

  • Miscarriage: Various stages and presentations.

  • Subchorionic hematoma: Common in early pregnancy.

  • Gestational trophoblastic disease: Symptoms may overlap with ectopic pregnancy.

Diagnostic Evaluation Steps

1. Confirm Pregnancy: Assess HCG levels and urine pregnancy tests.

2. Haemodynamic Stability:

   • Signs of hypovolemia or shock should be recognized.

3. Transvaginal Ultrasound:

   • Primary modality for diagnosing ectopic pregnancies.

Normal HCG Levels and Pregnancy

• HCG Patterns: Typically rises curvilinearly; inadequate rise may suggest complications.

• For normal pregnancies, HCG should rise 66% within 48 hours.

• Ectopic pregnancies typically show irregular HCG patterns.

Ultrasound Findings

• Transabdominal ultrasound: Useful after specific HCG thresholds.

• Transvaginal ultrasound: Most effective for visualizing ectopic pregnancies.

  • Signs include: gestational sac outside uterus, adnexal mass, free fluid in the pelvic cavity.

Summary of Ultrasound Features

• Normal vs. ectopic pregnancies:

  • Empty uterus indicates potential ectopic location or miscarriage.

  • An adnexal mass or free fluid are significant findings for ectopic.

Conclusion - Ectopic Pregnancy

• Key Points:

  • 95% of ectopic pregnancies are tubal; awareness of other locations is important.

  • Main risk factors include previous ectopic pregnancies and pelvic infections.

  • Critical to assess symptoms: abdominal pain, vaginal bleeding, amenorrhea.

  • Importance of evaluating haemodynamic stability in diagnosis.

Miscarriage/Spontaneous Abortion

Definition

• Clinically recognized pregnancy ending before viability.

• Overall conception loss rate is about 50%; miscarriage risk before 20 weeks is 8-20%.

Risk Factors

• Maternal age: Lowest risk between ages 24-29; significant increase post-35.

• Prior pregnancy loss: Raises baseline risk.

• Maternal medical conditions: Infection, obesity, diabetes, thyroid disorders.

• Environmental factors: Teratogenic medications, smoking, and illicit substances.

Aetiology of Miscarriages

• Early Spontaneous Miscarriages (1st Trimester):

  • Chromosomal abnormalities are the most common cause.

  • Environmental factors and uterine anomalies also play significant roles.

• Late Spontaneous Miscarriages (2nd Trimester):

  • Poor placentation, cervix insufficiency, and fetal anomalies.

Classification of Miscarriages

• Types:

  • Threatened, inevitable, incomplete, complete, and retained miscarriage.

• Clinical signs vary with each type based on examination and ultrasound findings.

Conclusion - Miscarriage

• Miscarriage is a common outcome; must consider risk factors.

• Different aetiologies in 1st and 2nd trimester miscarriages.

• A comprehensive approach including speculum and ultrasound for diagnosis is essential.

• Consider the possibility of a pregnancy of unknown location if the uterus appears empty.