Early Pregnancy Complications

• Ectopic pregnancy


  A pregnancy that implants outside the uterine cavity, most commonly in the fallopian tube
• Ectopic pregnancy


  • Incidence has been increasing over the past 10 years, currently more than 1:100 of all pregnancies are ectopic
  • Can result in rapid hemorrhage, leading to shock and eventually death
• Risk factors for ectopic pregnancy

  • Prior ectopic pregnancy
  • Assisted reproductive technology
  • Use of intrauterine device (IUD)
  • Sexually transmitted infections (STIs)
  • Pelvic inflammatory disease (PID)
  • Tubal scarring
  • Decreased tubal peristalsis
• Diagnosis of ectopic pregnancy

  1. History taking

  2. Physical examination

  3. Laboratory tests (beta human chorionic gonadotropin, hematocrit)

  4. Ultrasound
• Beta human chorionic gonadotropin (β-hCG)

  In ectopic pregnancy, levels are low for gestational age and do not increase at the expected rate
• Heterotopic pregnancy


  A multiple gestation with at least one intrauterine pregnancy and at least one ectopic pregnancy
• Treatment of ruptured ectopic pregnancy

  1. Stabilize patient with intravenous fluids, blood products, and vasopressors

  2. Exploratory laparotomy or laparoscopy to stop bleeding and remove ectopic pregnancy
• Treatment of unruptured ectopic pregnancy

  1. Surgical (salpingostomy or salpingectomy)

  2. Medical (methotrexate)
• Spontaneous abortion (SAB)


  A pregnancy that ends before 20 weeks' gestation
• Types of spontaneous abortion

  • Abortus (fetus lost before 20 weeks or less than 500g)
  • Complete abortion
  • Incomplete abortion
  • Inevitable abortion
  • Threatened abortion
  • Missed abortion
• First-trimester spontaneous abortions


  • 60-80% associated with abnormal chromosomes, most commonly autosomal trisomy
  • Other factors include infections, maternal anatomic defects, immunologic factors, environmental exposures, and endocrine factors
• Diagnosis of first-trimester spontaneous abortion

  1. Vaginal bleeding

  2. Cramping, abdominal pain

  3. Decreased pregnancy symptoms

  4. Pelvic examination

  5. Laboratory tests (beta-hCG, CBC, blood type, antibody screen)

  6. Ultrasound
• Treatment of first-trimester spontaneous abortion

  1. Expectant management

  2. Surgical management (dilation and curettage)

  3. Medical management (prostaglandins, mifepristone)
• Second-trimester spontaneous abortions


  • Multiple etiologies including infection, maternal anatomic defects, maternal systemic disease, exposure to fetotoxic agents, and trauma
  • Abnormal chromosomes are not a frequent cause
• Treatment of second-trimester spontaneous abortion

  1. Expectant management

  2. Dilation and evacuation (D&E)

  3. Labor induction with oxytocin or prostaglandins
• Late abortions (12 to 20 weeks' gestational age)


  • Have multiple etiologies
  • Infection
  • Maternal uterine or cervical anatomic defects
  • Maternal systemic disease
  • Exposure to fetotoxic agents
  • Trauma
• Abnormal chromosomes are not a frequent cause of late abortions
• Late second-trimester abortions and periviable deliveries


  Are also seen with PTL and incompetent cervix
• Treatment plan for abortions


  Based on the specific clinical scenario
• Incomplete and missed abortions

  Can be allowed to finish on their own, but are often taken to completion with a D&E (dilation and evacuation)
• Distinction between a D&C and D&E

  Depends on gestational age at the time of procedure (i.e., first or second trimester)
• Second trimester abortion procedures

  Between 16 and 24 weeks, either a D&E may be performed or labor may be induced with high doses of oxytocin or prostaglandins
• Advantages of a D&E

  • The procedure is self-limited and performed faster than an induction of labor
  • However, aggressive dilation is necessary prior to the procedure with laminaria and there is a significant risk of uterine perforation and cervical lacerations
• Advantages of induction of labor

  • Can take longer, but allows completion of the abortion without the inherent risks of instrumentation
  • Allows for the possibility of an external genetics examination or autopsy of the POC
• Patient preference and capabilities of the facility


  Should be considered when choosing medical or surgical options
• With either method, great care should be taken to ensure the complete evacuation of all POC
• In the second trimester, the diagnoses of PTL and incompetent cervix


  Need to be ruled out
• PTL


  Begins with contractions leading to cervical change
• Incompetent cervix


  Characterized by painless dilation of the cervix
• In the case of an incompetent cervix


  An emergent cerclage may be offered
• PTL


  Can potentially be managed with tocolysis
• Incompetent cervix or cervical insufficiency

  Patients present with painless dilation and effacement of the cervix, often in the second trimester of pregnancy
• As the cervix dilates, the fetal membranes are exposed to vaginal flora and risk of increased trauma
• Infection, vaginal discharge, and rupture of the membranes are common findings in the setting of incompetent cervix
• Patients with incompetent cervix


  May also present with short-term cramping or contracting, leading to advancing cervical dilation or pressure in the vagina with the chorionic and amniotic sacs bulging through the cervix
• Cervical incompetence is estimated to cause approximately 15% of all second-trimester losses
• Risk factors for cervical incompetence

  • Surgery or other cervical trauma
  • Dilation and curettage
  • Loop electrocautery excisional procedure (LEEP)
  • Cervical conization
  • Congenital abnormality of the cervix that can sometimes be attributed to diethylstilbestrol (DES) exposure in utero
• Many patients who present with cervical incompetence have no known risk factors
• Diagnosis of incompetent cervix

  Patients often present with a dilated cervix noted on routine examination, ultrasound, or in the setting of bleeding, vaginal discharge, or rupture of membranes
• Differentiating incompetent cervix from PTL


  Patients who present with mild cramping and have advancing cervical dilation on serial examinations and/or an amniotic sac bulging through the cervix are more likely to have an incompetent cervix, with the cramping being instigated by the dilated cervix and exposed membranes rather than the contractions/cramping leading to cervical change as in the case of PTL