Expectant Management
Because complications of abdominal surgery are increased in pregnancy, the surgical management of ovarian cysts in pregnancy has been reconsidered.10 Historically, pregnant women with persistent adnexal masses underwent elective removal of the masses in the second trimester.11 This is no longer acceptable practice in asymptomatic women, as surgical intervention, either as an emergency or after 24 weeks' gestation is associated with a poorer obstetric outcome.12 Complications include spontaneous...
Practical Points
Arrangements to provide information, follow-up, counselling and support by dedicated personnel for women with first trimester miscarriages should be made in all departments of obstetrics and gynaecology. These departments should formulate guidelines for the management of first trimester miscarriage and provide access to specialized personnel familiar with the use of transvaginal ultrasound in early pregnancy. 2. Expectant management should be considered for all women presenting with symptoms of...
Outpatient medical management
Outpatient use of misoprostol compared to surgical management has been evaluated in An efficacy of 60 after 72 hours following the vaginal administration of 800 mg of misoprostol (repeated after 24 hours and 48 hours) has been reported in the management of early fetal demise.13 The mean time to the expulsion of products was 12.6 hours. Using smaller doses of misoprostol (400 mg then 200 mg 2 hours later), but allowing a longer time period (8 days) for the miscarriage to complete increases the...
Polyploid PHM
Vaginal bleeding in the first or second trimester with a total incidence of 47 is the most common maternal symptom reported in both types of triploidies (Table 14.1). The phenotypic expression of both diandric and digynic triploi-dies includes growth restriction and disturbance of organogenesis that becomes obvious in fetuses surviving into the second trimester. From 16 weeks, almost all triploid fetuses have a least one measurement below the normal range and more than 70 present with severe...
Conclusion Of Ectopic Pregnancies
Expectant management should be the accepted standard of clinical practice for the management of ovarian cysts diagnosed in the first trimester. The majority of ovarian cysts detected in the first trimester resolve sponta neously. As only 1.3 1000 women with an ovarian cyst in early pregnancy require acute intervention throughout their pregnancy, surgical intervention should be the exception rather than the rule. It is rarely indicated and should be reserved for those women with an acute abdomen...
Treatment Of Miscarriage A historical perspective
In an analysis of 2287 cases of miscarriage including an unknown number of illegal abortions registered in Baltimore from 1896 to 1934, the average pregnancy length was 14 weeks measured from the LMP.42 Only women who were bleeding excessively or had infections were admitted to the hospital. Over 50 of those women had a gestation of above 16 weeks. The mortality was 1.7 in this cohort of women and the majority of deaths were attributed to infections, and in no instance was haemorrhage the...
Introduction Prevalence
The prevalence of adnexal pathology in the first trimester has been reported as varying from 0.2 to 5.4 .1-4 In a recent cross-sectional study, the prevalence of ovarian cysts at various stages of pregnancy was assessed, i.e. in the first, second and third trimesters. Only 1.2 (79 6636) of the total number of women in this study had an ovarian cyst with a maximum diameter of greater than 30 mm.3 This figure was significantly lower than in a more recent longitudinal study in which the prevalence...
An 8 Week Old On A Fallopian Tube Alive
The increased incidence of ectopic pregnancy seen over recent decades has occurred simultaneously with an increased incidence of pelvic inflammatory disease. This suggests a causal relationship (Figure 11.1). Improvements in the treatment of pelvic inflammatory diseases may now preserve tubal function in women who previously would have suffered from tubal factor infertility. However, more recently in Norway a fall in the incidence of ectopic pregnancy has been reported.1 It has been suggested...
Identification Of Fetal Structural Anomalies In The First Trimester
A detailed discussion of screening for fetal abnormalities and aneuploidy is outside the scope of this chapter and is generally not within the remit of the EPU or first trimester scan. An awareness of major developmental landmarks is important however, as many anomalies can be identified in the first trimester allowing early referral and management. The ability to recognize abnormalities and be able to discuss them with the parents will become more important as patient awareness and demand for...
Natural History Of Caesarean Scar Pregnancy
The natural history of caesarean scar pregnancy is not fully known. Unlike a cervical pregnancy, a caesarean scar pregnancy may potentially be carried to term, though this is likely to be associated with significant morbidity and possibly mortality. The known association between multiple caesarean sections and an increased risk of abnormally implanted placentae (praevia, accreta and percreta) suggests that if a caesarean scar pregnancy were to continue to term, then it would be associated with...
Manual vacuum aspiration
Despite the superior success rate, up to 75 of women will choose expectant as an alternative to surgical management.33 This decision, in some women is in order to avoid an 'operation' with its inherent risks.34 It is usual practice in the UK to manage miscarriage by performing electric suction curettage under general anaes-thetic.27 In the developing world, however, manual vacuum aspiration (MVA) performed under local anaesthetic is widely used. In the UK, there is increasing experience using...
Risk of ovarian malignancy in pregnancy
The incidence of ovarian malignancy in pregnancy is extremely rare - it is reported to be between 1 in 15 000 and 1 in 32 000 pregnancies.9 Women with ovarian cysts that have ultrasound features suggestive of malignancy diagnosed in the first trimester should be referred for a gynaecological oncology opinion with a view to considering intervention after 14 weeks' gestation. In a cross-sectional study of 2245 women, there were no cases of malignancy.1 In another study of 55 278 women undergoing...
What Are The Reason Of Overy Size 110x90
A 35-year-old Para 2+0 woman presented at 13+3 weeks' gestation with severe lower abdominal pain. A TVS and transabdominal scan confirmed a viable 13-week fetus and she was noted to have a tender right ovarian simple cyst measuring 110 x 90 x 70 mm the left ovary was normal in size and appearance. A diagnosis of subacute torsion was made and she underwent transabdominal ultrasound-guided drainage of this ovarian cyst. This was done in an attempt to alleviate her symptoms and also to potentially...
Linear Salpingotomy Versus Salpingectomy
In women who wish to preserve their fertility, conservative surgery by linear salpingotomy is considered the gold standard for the management of ectopic pregnancy (Figure 11.3). In practice, any haemoperitoneum if present is evacuated, the ectopic pregnancy is identified and the tube is immobilized. A 1.5-2.5 cm longitudinal incision is made on the maximally distended ante-mesosalpinx wall of the tube, with a unipolar needle. The products of conception are then flushed out using a suction...
References
Effect of transvaginal sonography on the use of invasive procedures for evaluating patients with a clinical diagnosis of ectopic pregnancy. J Clin Ultrasound 2003 31 1-8. 2. Hajenius PJ, Engelsbel S, Mol BW, et al. Randomised trial of systemic methotrexate versus laparoscopic salpingostomy. Lancet 1997 350 774-9. 3. Korhonen J, Stenman UH, Ylostalo P. Serum human chorionic gonadotropin dynamics during spontaneous resolution of ectopic pregnancy. Fertil Steril...
Natural history of ovarian cysts diagnosed in early pregnancy
In the largest prospective observational longitudinal study to date, 3000 women underwent TVS in the first trimester. This study differed from previous cross sectional studies in that the prevalence of ovarian pathology was established in an early pregnancy population and then the natural history of the ovarian cysts in these women was observed. Although 6.1 of women were found to have an ovarian cyst of > 25 mm, complete follow-up data were available on 5.4 .4 The mean gestational age at the...
Expectant Management Of Miscarriage
For many years there was a consensus that prevailed in the Western world concerning the approach to miscarriages and custom has dictated that inevitable and incomplete miscar riages must be completed, usually by curettage. Many physicians considered curettage mandatory to prove that a miscarriage is complete. Expectant management of first-trimester miscarriages had not been evaluated since Peckham stated in 1936 that women without profuse bleeding or signs of infection could avoid...
Ovarian Cysts In Early Pregnancy
Women who present with lower abdominal pain or unilateral iliac fossa pain need to have a TVS in order to exclude an ectopic pregnancy. In the situation where an intrauterine pregnancy is confirmed, an ovarian cyst may be the cause of the abdominal pain. In a recent study in our unit, we reported that the prevalence of ovarian cysts of > 25 mm in the firsttrimester population studied was 5.4 the vast majority of these were incidental findings.25 The Figure 3.6 Flow diagram to illustrate a...
Future Pregnancies
Although a case of a repeat caesarean scar pregnancy has been reported, many authors have reported normally implanted intrauterine pregnancies after successful treatment of a caesarean scar pregnancy.3,4,53 However, the risk remains of severe complications. In Seow's series of eight cases, one maternal and fetal death occurred due to uterine rupture at 38 weeks in a subsequent pregnancy after prior treatment of a caesarean scar pregnancy with suction curettage and Foley catheter tamponade. He...
Diagnosis
In 1911, Rubin proposed pathological criteria for the diagnosis of cervical ectopic pregnancy after hysterectomy 1 cervical glands must be present opposite the placental attachment, 2 the attachment of the placenta to the cervix must be intimate 3 the whole or a portion of the placenta must be situated below the entrance of the uterine vessels, or below the peritoneal reflection of the anterior and posterior surface of the uterus and 4 no fetal elements are present in the corpus uteri.23 The...
Ultrasonography
Wild and Reid described transvaginal ultrasonography with a rigid transducer in 1957. This type of transducer was, however, never used in clinical practice. With the development of high-frequency transvaginal transducers in 1983, ultrasound became an important tool in the diagnosis of early pregnancy.26-27 The gestation sac can be visualized from around 36 days from the last menstrual period LMP , when it reaches a size of 2-4 mm, corresponding to a level of hCG of 800 to 3200 IU L.28 The yolk...
Embryonic Losses
The embryonic period is a 5-week window from 21 days' post conception 5 weeks from the last menstrual period LMP when the endothelial heart tube folds on itself and begins to beat. It is a time of organogenesis and thus concerns about teratogens are real. It concludes at 70 days LMP 10 weeks when organ system development is complete and the embryo now becomes a fetus the word itself from the Latin meaning 'having a human-like appearance' . Numerous authors have looked at the role of chromosomal...
Transvaginal Ultrasound Bagel Sign
It used to be standard teaching that an 'empty uterus with a positive pregnancy test is an ectopic pregnancy until proved otherwise'. This was based on transabdominal ultrasound findings and usually led to the patient being admitted for laparoscopy. We have seen in Chapter 2 that an intrauterine pregnancy can be visualized at a very early stage. However today if a pregnancy cannot be seen on transvaginal ultrasonography the situation is described as a pregnancy of unknown location PUL and the...
Bagel Sign In Ectopic Pregnancy
A 33-year-old woman presented to the EPU for a dating scan, as she was unsure of her last menstrual period. She had had some light vaginal spotting over the previous 3 days but no associated pain. A TVS was performed. The uterine cavity appeared empty but there was a 16 x 17 x 16 mm right adnexal mass with a visible gestational sac 'bagel sign' see Figure 10.2 . She was given the diagnosis of a right tubal ectopic pregnancy. Blood was taken. The initial hCG was 208 IU L and progesterone 6 nmol...
Laparoscopy Versus Transvaginal Ultrasound
Laparoscopy has always been considered the gold standard for the diagnosis of ectopic pregnancy.5 Laparoscopy, however, does not confer 100 sensitivity, and false-negative laparoscopies do occur. These may occur when early ongoing ectopic pregnancies are too small to be seen or when some ectopic pregnancies resolve spontaneously and are never seen. There are even rarer instances where a fallopian tube is removed at the time of laparoscopy for possible ectopic pregnancy, only to show no...
Psychological Effects Of Medical Versus Surgical Management
In randomized controlled trials to compare the psychological impact of surgical with medical management, no difference has been observed in psychological outcomes.10,40 In measuring client satisfaction overall, significantly more women would choose to undergo surgical management, rather than medical management if they suffered a further miscarriage.10 However, significantly more women who experience successful evacuation of the uterus with misoprostol would choose the same mode of treatment if...
Singledose methotrexate
Methotrexate is most commonly given systemically according to a single-dose regimen Table 10.1 .5 In most units this involves giving a dose of 50 mg m2 on the day of presentation or Table 10.1. Protocol for the use of single dose methotrexate in unruptured ectopic Serum hCG, FBC, U amp Es, LFTs, G amp S 2nd dose of methotrexate if hCG decrease If hCG decrease gt 15 repeat hCG weekly Table 10.2. Success rates for single dose methotrexate - a review of the literature. Reproduced from2 Table 10.2....
Definitions
Threatened miscarriage Clinically if women present in the first trimester with vaginal bleeding with or without lower abdominal pain cervical os is closed they are labelled as a 'threatened miscarriage'. This very common problem requires an ultrasound scan to establish the viability of the pregnancy. Complete miscarriage Clinically the products of conception have totally passed the cervix is likely to be closed on examination bleeding and cramping should have diminished. A transvaginal...
Success Rates
Reported success rates for expectant management vary from 48 to 100 .1-8 Table 9.1 summarizes studies published between 1992 and 2004.9 The largest study to date is on 118 ectopic pregnancies. In this particular study, the overall success rate for expectant management was 65.3 77 118 .2 Transvaginal ultrasound scans TVS and serum hCG determinations were performed every 1-3 days until the hCG was less than 10 IU L. The mean time to resolution was 20 days range 4-67 days . The initial serum hCG...
Laparoscopy Versus Laparotomy
The first laparoscopic treatment of this condition was reported in 1973 by Shapiro.11 Although several series have since been published,12 the technique took some time to gain general acceptance. There were predictable surgical complications and significant problems with training. There were initial concerns about tubal patency and adhesion formation after laparo-scopic treatment versus traditional laparotomy for ectopic pregnancy. However more recently these concerns have been resolved....
Heterotopic Pregnancy
Spontaneous heterotopic pregnancy is rare and is reported to occur in between 1 10 000 and 1 50 000 pregnancies Figure 8.5 .11 They are Figure 8.5 Heterotopic pregnancy - spontaneous conception. Reproduced with permission from Condous et al. Best Pract Res Clin Obstet Gynaecol, 2004 18 37-57. Figure 8.5 Heterotopic pregnancy - spontaneous conception. Reproduced with permission from Condous et al. Best Pract Res Clin Obstet Gynaecol, 2004 18 37-57. often missed as once an intrauterine pregnancy...
Clinical Symptoms And Risk Factors For Ectopic Pregnancy
When evaluating pregnant women in the first trimester, it is very important to take into account the history and symptomatology. The Figure 3.4 Blood in the pouch of Douglas seen as ground glass fluid on transvaginal scan. Reproduced from Condous et al. Ultrasound Obstet Gynecol 2003 2 420-30. Figure 3.4 Blood in the pouch of Douglas seen as ground glass fluid on transvaginal scan. Reproduced from Condous et al. Ultrasound Obstet Gynecol 2003 2 420-30. end of the fallopian tube. It is very...
Threatened Miscarriage
Women who present in the first trimester with vaginal bleeding with or without lower abdominal pain are given the label of a threatened miscarriage. This is a common first trimester problem occurring in up to one-third of pregnancies.19 This condition requires an ultrasound scan to establish the viability of the pregnancy. If the uterus contains an embryopositive cardiac activity, then the woman can be reassured that she has a viable intrauterine pregnancy. If the crown-rump length CRL is at...
Last menstrual period LMP and cycle length
Knowledge of the first day of the LMP and the cycle length in any individual can alter the Table 2.1. Correction of dates for cycle expected gestation and therefore the ultrasound findings considerably and may make the difference between seeing an early pregnancy and having a non-diagnostic scan that necessitates follow-up. Correction for cycle length is therefore important if the length deviates by 7 or more days from a 28-day cycle Table 2.1 . It should be remembered, however, that recall of...
When should you see a yolk sac
The discriminatory level for a yolk sac with transabdominal ultrasound was a mean gestation sac diameter MSD of 20 mm.9 Early TVS described a discriminatory level for the yolk sac of 8 mm.10 More recently Rowling et al.11 found that with 5 MHz transducers the yolk sac is definitively seen by a MSD of 13 mm but with newer 5-9 MHz transducers a yolk sac was definitively seen by the time the MSD was 5 mm. The presence of a larger sac with no evidence of yolk sac formation contained within it is a...
The ultrasound scan
Before embarking on an ultrasound it helps to ask yourself a few questions 1. What am I trying to find out by performing 2. Does the scan need to be performed now or can it wait 3. Will the scan change my management 4. What type of scan do I need to perform i.e. transvaginal or transabdominal In the emergency setting, your decision to perform an ultrasound may not always be correct and we have all been in the situation when we wish that we had not Always be sure that you are competent to...
Complete Miscarriage
This should not be based on an ultrasound diagnosis. Women who present with heavy vaginal bleeding with clots and undergo an ultrasound scan which suggests a complete miscarriage i.e. an empty uterus with an endometrial thickness less than 15 mm , should be followed up with serum hCG levels until the diagnosis is established.24 We have described Figure 3.5 Haemorrhagic corpus luteum classic internal 'spider web'-like appearance on transvaginal scan. Figure 3.5 Haemorrhagic corpus luteum classic...
Normal Human Development Table 22 Week
Ultrasound scanning at this very early gestation can be difficult because of the reasons stated above. Often the only ultrasound feature visible is a thickening of the endometrium and the presence of a corpus luteum cyst. The deciduo-placental interface and the exocoelomic cavity ECC are the first sonographic evidence of a pregnancy that can be visualized with TVS from around 4 4-4 6 menstrual weeks 32-34 days when they reach together a size of 2 to 4 mm visible at approximately 5 weeks or 10...
When Are Serial Hcg Determinations Appropriate
Serial hCG determinations are appropriate to exclude ectopic pregnancy in a woman with a serum hCG level below the discriminatory zone in whom there is a concern about the possibility of extrauterine pregnancy. This concept is discussed in detail elsewhere in this book. However once an ectopic pregnancy has been excluded, any assessment of embryonic wellbe-ing depends on serial ultrasound examinations and not serial hCG determinations. These are unnecessary. Although average serum hCG levels...
Transvaginal Versus Transabdominal Approach
If the urinary pregnancy test is positive, TVS should be performed, preferably in a dedicated Early Pregnancy Unit EPU by an ultrasonographer or gynaecologist trained in the management of early pregnancy complications. Not only does TVS confirm viability and gestation, but most importantly it confirms the location of the pregnancy.5,6 In a recent study of 6621 consecutive women, 91.2 had their pregnancy location confirmed at the initial TVS.7 In approximately...
What about cardiac activity
The endothelial heart tube folds on itself and begins to beat 21 days post conception. Thus any pregnancy whose outcome is ultimately normal has cardiac activity present in the early embryo prior to our ability to image it. The question is therefore not how early we can see cardiac activity the threshold level but at what point if cardiac activity is not seen with TVS is Figure 4.7 A transvaginal scan at 58 days' gestation. A routine scan 9 days previously had revealed an embryo of 7 mm with...
When should you see a gestational sac
Usually by 5 weeks LMP 3 weeks post conception a gestational sac will be visualized. However, virtually all clinicians know that menstrual dating is notoriously unreliable. Therefore the concept of a discriminatory level of hCG was developed. The discriminatory level of hCG was originally described in 1981.6 The initial report was with transabdominal ultrasound and equalled 6500IU L. This was updated in 1985 by Nyberg et al.7 to 3600 IU L. Transvaginal ultrasonography led to the level being...
Ectopic Pregnancy 8 Weeks
For years the management of early pregnancy complications was very much the poor relation when training in gynaecology. In general the most junior doctor available was delegated to see the patient and perform any surgery, if indicated. Yet they are among the most common conditions seen by gynaecologists and cause a huge amount of anxiety and distress for patients. The introduction of transvaginal ultrasono-graphy, laparoscopic surgery and the rapid measurement of serum hCG levels has radically...
Setting up and running an Early Pregnancy Unit space staffing and equipment
Introduction Logistical requirements Record keeping Laboratory services Emergency operating theatres Information and protocols Additional services Conclusion Practical points Early pregnancy complications represent a significant number of attendances both to primary care and hospital emergency A amp E departments. Considering at least one in four pregnant women will have a miscarriage in the first trimester, and up to one in 50 will have an ectopic pregnancy, the rapid identification,...
