Early pregnancy abnormalities

Posted by e-Medical PPT Tuesday, July 17, 2012
Objectives of this lecture
Differential diagnosis/work up for first trimester bleeding
Different types of first trimester pregnancy loss
Ectopic pregnancies: diagnosis and management
Miscellaneous other oddities of the first trimester

First trimester bleeding
Occurs in 20-40% women
Etiology often unknown, goal = exclusion
Prognosis: association b/w FTB and adverse outcome (SAB, PTD, PPROM, IUGR)
Worse prognosis with heavier bleeding or extending into second trimester
PTD frequency with no, light, or heavy FTB was 6, 9.1, and 13.8% respectively
Spontaneous loss frequency prior to 24 WG was 0.4, 1.0, and 2.0 % respectively
Vaginal bleeding in >1 trimester associated with 7 fold increased in PPROM

Differential diagnosis
Abortion (threatened, inevitable, complete, incomplete, missed)
Ectopic pregnancy
Vanishing twin
Trauma, wounds, vaginitis, vaginal/cervical neoplasia, warts, polyps, fibroids, ectropion
Physiologic/implantation (diagnosis of exclusion)

Miscarriage
SAB = most COMMON complication of early pregnancy
8-20% of clinically recognized pregnancies under 20 wks undergo SAB, 80% of these will be <12 wks Low risk of loss after 15 wks (0.6%) if fetus chromosomally normal Loss of unrecognized/subclinical pregnancies occurs in 13-26% of all pregs Unlikely to be recognized without daily UPTs
Types of miscarriage 
Threatened: closed cervix, uterus appropriately sized, FCA present if gestational age sufficiently advanced Inevitable: cervix dilated, increased bleeding with cramps/ctx, POC can be at os Complete/incomplete Complete (1/3): small contracted uterus, open cervix, scant bleeding/cramping Incomplete: (2/3): placental tissue remaining, cervix open, POC can be at os, uterus smaller than expected for gestational but not well contracted, variable bleeding/cramping Missed: in utero death of embryo prior to 20th wk with retention of pregnancy for prolonged period of time. Cervix closed, +/- bleeding Septic abortion: rare with SABs, foreign bodies ie IUDs, invasive procedures, legal EABs; common complication of illegal EABs.
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