I EARLY PREGNANCY COMPLICATIONS

The management of early pregnancy complications is within the purview of obstetrician-gynecologists and other providers of women’s health care. Clinicians should be aware of local hospital rules and regulations and requirements of their professional liability insurance carrier as to whether this is viewed as obstetric or gynecologic care.

Early Pregnancy Loss

Early pregnancy loss is defined as a nonviable intrauterine pregnancy at less than 13 weeks of gestation. It is the most common complication of the first trimester of pregnancy. Early pregnancy loss is unrelated to induced abor­tion procedures. In the first trimester, the terms miscarriage, spontaneous abortion, and early pregnancy loss are all used interchangeably, and there is no consensus on terminology in the literature. Later in pregnancy, losses are categorized as either early fetal death (20-27 weeks of gestation) or late fetal death (28 weeks of gestation and later). The term stillbirth also is used to describe fetal deaths at 20 weeks of gestation or more. These types of losses are not addressed in this section.

Etiology, Risk Factors, and Complications

The most frequent cause of early pregnancy loss is fetal genetic abnor­malities. Other rare but possible causes for early pregnancy loss include infection, maternal hormonal factors, immune responses, and serious medical disease of the mother. Among clinically established pregnan­cies, the rate of early pregnancy loss is approximately 10-20%; it usually occurs between the 7th week and 12th week of pregnancy.

The risk of early pregnancy loss is higher in women older than 35 years, in women with systemic diseases, in women undergoing fertility treat­ment, and in women with a history of repeated early pregnancy losses. Complications of early pregnancy loss are rare but include excessive blood loss, retained fetal tissue, and infection.

Diagnosis and Management

Possible symptoms of early pregnancy loss include lower back or abdomi­nal pain, vaginal bleeding, abdominal cramps, or tissue that passes from the vagina. In addition to evaluation of the patient’s medical history and signs and symptoms, an evaluation to diagnose early pregnancy loss may include the following:

• Interpretation of serum human chorionic gonadotropin (hCG) measurements

• Interpretation of endovaginal ultrasonography

• Interpretation of serum progesterone concentrations

• Physical examination

If an early pregnancy loss occurs, it is important to determine whether any fetal or placental tissue remains in the uterus. Management options for early pregnancy loss may include the following:

• Expectant management and observation

• Uterine curettage

• Medical treatment with misoprostol

• Review of histopathology

• Evaluation to determine causes of recurrent pregnancy loss (see also the “Recurrent Pregnancy Loss” section later in Part 4)

• Grief counseling, as indicated

If any remaining tissue is not passed in a reasonable amount of time, uterine curettage or medical treatment with misoprostol can be used to complete the abortion. Clinicians should be familiar with any state requirements regarding the reporting of fetal death and the disposal of fetal remains.

Ectopic Pregnancy-

More than 100,000 ectopic pregnancies occur in the United States every year.

Risk Factors

Because ectopic pregnancy can be life-threatening, women with known risk factors for ectopic pregnancy should seek care early in the gestation to ensure that it is a normal intrauterine gestation. Risk factors for ectopic pregnancy include the following:

• Advanced maternal age

• Prior treatment for infertility

• Pelvic infection

• Previous tubal surgery, including tubal occlusion

• Previous ectopic pregnancy

Most women who have an ectopic pregnancy are unaware of any risk fac­tors and seek care when they experience pain or bleeding.

Diagnosis and Management

In addition to obtaining a medical history and evaluating signs and symp­toms, the evaluation to diagnose an ectopic pregnancy may include the following:

• Interpretation of serum hCG measurements

• Interpretation of transvaginal ultrasonography

• Interpretation of serum progesterone concentrations

• Surgical procedures such as endometrial biopsy, dilation and curettage

• Culdocentesis, laparoscopy, or laparotomy

Ectopic pregnancy is suspected in the presence of the following:

• Hemoperitoneum in the first trimester

• Abnormally low hCG levels or low hCG levels with incremental increases that do not rise appropriately

• Ultrasonography that reveals an empty uterus when the hCG value is above the discriminatory zone, or a gestational sac outside the endometrial cavity

An ectopic pregnancy is confirmed when it can be visualized either laparo­scopically or by ultrasonography.

The goal of early diagnosis is to treat the patient before the ectopic preg­nancy ruptures and the patient presents as a surgical emergency.

• Expectant management and observation

• Chemotherapy

• Surgery

The choice of therapy must take into consideration the skill of the clinician and his or her experience with the treatment modalities. One must consider the reproductive desires of the patient and use good clinical judgment in determining whether expectant management is appropriate for select ectopic pregnancies that show signs of possible spontaneous resolution. Intramuscular methotrexate is appropriate for the treatment of selected patients with small, unruptured tubal pregnancies who can be expected to present reliably for posttreatment follow-up. Patients need to be carefully monitored, and successful treatment may require more than one dose of methotrexate. Although expectant management of an ectopic pregnancy is not ideal in most circumstances, there may be a role for it when hCG levels are low and falling.

Molar Pregnancy

A molar pregnancy, also called a hydatidiform mole, is an abnormal preg­nancy characterized by the presence of an abnormal growth of cells origi­nating from the placenta. Molar pregnancy is a form of gestational tropho­blastic disease that often is diagnosed in the first trimester or early second trimester of pregnancy. The incidence of molar pregnancy is approximately 1 in 1,000 pregnancies, and it is more common in women of Southeast Asian origin. The clinical presentation of a molar pregnancy is similar to other forms of failed pregnancies and can include abnormal bleeding, uter­ine enlargement greater than expected for gestational age, and absent fetal heart tones. See the “Cancer Diagnosis and Management” section earlier in Part 4 for a description of the management of molar pregnancy.

Bibliography

American Academy of Pediatrics, American College of Obstetricians and Gyne­cologists. Standard terminology for reporting of reproductive health statistics in the United States: appendix F. Guidelines for perinatal care.

American Cancer Society. What are the key statistics about gestational trophoblastic disease? Available at: http://www.cancer.org/cancer/gestationaltrophoblasticdis ease/detailedguide/gestational-trophoblastic-disease-key-statistics. Retrieved August 9, 2013.

Bianco K, Caughey AB, Shaffer BL, Davis R, Norton ME. History of miscarriage and increased incidence of fetal aneuploidy in subsequent pregnancy. Obstet Gynecol 2006;107:1098-102. [PubMed] [Obstetrics & Gynecology]

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Medical treatment of ectopic pregnancy. Practice Committee of American Society for Reproductive Medicine. Fertil Steril 2008;90:S206-12. [PubMed] [Full Text]

Murphy SL, Xu J, Kochanek KD. Deaths: final data for 2010. Natl Vital Stat Rep 2013;61 (4): 1—168. Available at: http://www.cdc.gov/nchs/data/nvsr/nvsr61/nvsr 61_04.pdf September 20, 2013.

National Institute for Health and Care Excellence. Ectopic pregnancy and miscar­riage: diagnosis and initial management in early pregnancy of ectopic pregnancy and miscarriage. NICE Clinical Guideline 154. Manchester (UK): NICE; 2012. Available at: http://www.nice.org.uk/guidance/CG154. Retrieved July 14, 2014.

Professional liability and gynecology-only practice. Committee Opinion No. 567. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013;122:186. [PubMed] [Obstetrics & Gynecology]

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Resources

American College of Obstetricians and Gynecologists. Early pregnancy loss: miscar­riage and molar pregnancy. Patient Education Pamphlet AP090. Washington, DC: American College of Obstetricians and Gynecologists; 2013.

American College of Obstetricians and Gynecologists. Ectopic pregnancy. ACOG Patient Education Pamphlet AP155. Washington, DC: ACOG; 2009.

Misoprostol for postabortion care. ACOG Committee Opinion No. 427. American College of Obstetricians and Gynecologists. Obstet Gynecol 2009;113:465-8. [PubMed] [Obstetrics & Gynecology]

Resolve Through Sharing: Bereavement Services. Gundersen Health System. Available at: http://www.bereavementservices.org/resolve-through-sharing. Retrieved August 9, 2013.

RESOLVE: The National Infertility Association. Available at: http://www.resolve.org. Retrieved August 9, 2013.