In early pregnancy, common issues range from bleeding to ectopic attachment to miscarriage, and patients need accurate information and gentle guidance. Here’s help with delivering news and sharing decisions, including how to answer questions on specific management choices and whether a problem now signifies future pregnancy difficulties.
mm Thanks. I'm happy to be here and talk to you about uh erosion, counseling for early pregnancy issues. I think it was originally built as vaginal bleeding, which of course is the most common symptom that leads us here to talk about pregnancy loss and pregnancy of unknown location and other concerns. Um with diagnosis of miscarriage options for management. Not that you would necessarily be doing those, but it's really helpful to have counseling at the initial stages. Uh someone recurrent miscarriages, Rh immunoglobulin spacing after miscarriage and then second half more about just bleeding in the first trimester pregnancy of unknown location, a topic and what we want to do for keeping people safe. And since we're talking about pregnancy options, I wanted to start with or not options, pregnancy issues. I wanted to start with a positive pregnancy test, which I know that you all get a lot of. Um and one thing that I think probably most everybody knows that almost half of pregnancies are not planned. There's a wide range of what planned really means, but desired later or desired at different times. So, our goal with any pregnancy issue is to establish an environment that's free of stigma around pregnancy issues and where patients feel they can ask questions and obtain accurate information. So, any time you give information about a pregnancy or concerned about a pregnancy or anything. And I would say this public goes beyond pregnancy, but it's just a good reminder for us that the next step is silence and to give people a moment for things to settle in. And then open ended questions of how are you doing with that information or something similar to that. And this is this can be not just with pregnancy tests, but I think it's something that is helpful to remember, remind ourselves about. And then sometimes from that first moment people are very clear with their reaction, but not always and pretty much if someone is interested in or happy about the pregnancy at that moment and giving them some resources where they can get information when they're ready. Um if they're unsure, this is the pregnancy options website that we use at UCSF Women's options. It's a pregnancy options. Workbook that we usually tell people. Um you know, there's lots of things that won't pertain to you, but if there's any components that do that hopes that would be helpful and then whether someone has any idea what they want to do, eventually getting to just to check in about prenatal vitamins or folic acid, vitamin D. And then uh one thing I would suggest is asking about nausea and vomiting often in that the moment people don't think to ask and I can't tell you how many people I've seen who think that they have to have an abortion because they can't tolerate nausea, vomiting and they haven't really even started with getting what they can get to support them. Um I included in the pregnancy websites that ACOG uh UCSF has a wonderful video program called zooming through pregnancy. I did the one on miscarriage, although it's very high literacy, a lot of graphs and things, but there's a lot of information on zooming through pregnancy and then uh you may already know about the UCSF uh perinatal care for black families, but there's this website for UCSF actually has a lot of information about midwifery in case someone is interested in that. And I don't think it's a surprise to anyone that one of the reasons we talk about avoiding stigma with early pregnancy is because a fair number of people current evidences are close to 20% of pregnancies. people choose excluding miscarriages will choose abortion and abortion is really shrouded in many, many layers of stigma in our culture. That being kind of one of the definitions from answer, which is at UCSF Davis and see changed out program, which is also a really good website based in Berkeley about the worst and stigma is a shared understanding that abortion is morally wrong or socially unacceptable. And there's many, many layers where we see this manifest and this really contributes to kind of the ah paradox of how often or prevalence see paradox and that people don't think abortion and this is also true of miscarriage is not, it's not common because people hide it because of the stigma and then when they hide it. People think it's less common and less normal and it uh contributes to the stigma. So at UCSF with all our learners, we take a moment and try to do professionalism counseling, to really try to avoid creating atmospheres of stigma around pregnancy, around anything, but particularly around pregnancy and by taking doing workshops about our own values, because even those of us who feel like people should be able to make decisions about their own body. We do harbor um feelings about what is more deserving and more appropriate. And so just taking a moment to think through something like this, where how would I feel about these specific interests instances? And um are there any surprises for me or is it worth me thinking about before I counsel a patient? So I'm not um in a position of, you know, dropping my jaw or looking concerning or judgmental when I'm talking to a patient. And then a lot of us noticed that when we get another layer of information, like their partner just died or their partners abusive, they other child has cancer or some other reason it can actually change or modify the level of empathy you have for someone, even if you'd like to think that you have empathy for everyone. I think we all have some situations that engender more empathy than others. And any time you find your empathy kind of wavering, it's one I find and many people find that this is one way to remind yourself that you can't know the many layers that are going behind patients feelings or thoughts or decisions and miscarriage of course is something that we also see a fair amount of stigma for people are concerned that it means that they didn't take care of themselves or they did something to deserve it or they aren't healthy. So there's still quite a bit of stigma around miscarriage. And one way we can kind of avoid this is thinking carefully about our language and there's a lot of other language that I'm not really going to take time with today could be could be its own our but their studies have shown that patients prefer the term pregnancy loss or miscarriage in red. And then we often in medicine also use non viable pregnancy, which can get confusing with incompatible with life because it can still be viable but incompatible with life. And then we designed early pregnancy loss as gestational e up to 12.12 weeks and six days. So under 13 weeks by gestation, not and also by size, but also by jazz station. You'll also hear a spontaneous abortion fetal demise or an embryonic, but we really are trying to avoid some of the old terminology and this is not universal. A lot of people. And certainly all of our epic building still says missed abortion. Um but to use terminology that adds more negativity or something. Okay, that patients find distasteful or it's uh more bothersome. I think it's worth trying to avoid and missed abortion is also confusing, like no one missed it. Blighted sounds like some disease threatening and failure are certainly not words that people like to be labeled labeled with an early pregnancy loss is very common. Um Clinically recognized pregnancies are those that's generally defined as seen on an ultrasound these days. Um and if it's clinically or seen by tissue to tissue or ultrasound like clearly seen, it's about 15% of clinically recognized pregnancies. But if you actually test people's serum pregnancy hormone, it goes very early and regularly it goes way up 32. Even 50% of of just of pregnancies end in miscarriage. But most people are not doing um serum pregnancy tests every three days or anything like that. Um This goes way down once you get past the early first trimester and I'm sorry. And of people who have at least one delivery. Uh just another example of how common it is. About 43% have experienced at least one early pregnancy loss. And it goes up with increasing age, prior pregnancy loss, Certain maternal conditions. Fibroids have not been associated enlargement analysis. We of course know that inter cavity terry or something. Coastal fibroids can lead to miscarriage. Um And there's some other studies that do associate certain fibroids with miscarriage but in general most fibroids and in large studies have not found that some change with medication and substance use exposures and then trauma. Um CVS Grant bill is sampling an amnio. Each have a risk of about one and 200 or 1 to 300 for loss. This is a group of studies that look at natural uh populations just what age people are no longer having term pregnancies or successful pregnancies. And you can see in multiple populations around the world, age is a significant factor as we all know, that leads to a decrease in the ability to have successful pregnancy. And a big part of that is miscarriage. So miscarriage is gradually increases over age. And Even though that clinically recognized the term, or the number we often talk about is 15%. That's really for the 20 to 30 year old range, which is where the most common age to have pregnancies. But as we get toward 40 and beyond it goes up very quickly. So if we do know that prior pregnancy loss, when it's multiple does increase the chance of it happening again. Whether one early pregnancy loss does makes any difference or not, there aren't definitive studies that show it does. And all of the studies put the range of what the risk is for another pregnancy loss right in the middle of the population risk. So that's usually how I counsel. Um And then as you'll notice for two prior early pregnancy losses and three, There's still 70, of couples that are going on to have successful pregnancies. So it is not uh determined that after two or even three losses, that there's not a chance for successful pregnancy. Most common cause of early pregnancy loss is genetics and it's up to 70% on the most common time that we see miscarriage. There's 6 to 10 weeks, It's a little, it's less with an embryonic pregnancies and over 10 weeks and continues to go less. And Most of these are trisomy, trisomy 21 like we have here or trisomy of most any chromosome can occur. Monos omi is another common and then polyp lady. Yeah, maternal health conditions can also be associated but not very strongly even diabetes if it's very well, if it's well controlled, there is no difference from baseline risk. But uncontrolled diabetes certainly is associated with early loss, significant infections and early pregnancy can be hard to determine. Um Sometimes the symptoms do not always correlate when people find out and lots of people get sick in pregnancy and have no trouble. Um but having a fever in the calendar month of conception is somewhat associated chronic stress. A certain inherited from Amelia's and then we know that certain medicines substances or environmental exposures can increase the risk, but it is very hard to tell people to control their exposure to environmental and there are certain things that we are in our routine pregnancy counseling, like avoid changing the cat litter and um trying not to get exposed to radiation, but air pollution and other things, especially people in lower socioeconomic communities or um bipac folks also tend to be exposed to more of the environmental risks for for loss, smoking alcohol and caffeine and ibuprofen. They have been slightly associated only only an epidemiologic studies. So when someone says, well, how do I prevent miscarriage? We really don't have any clear interventions that prevent early pregnancy loss, especially primary early pregnancy loss by prenatal vitamins. Really, the overall evidence is not suggesting does not suggest that it makes much of a difference. There's some suggestion that iron and folic acid maybe have slightly less stillbirth, that's different category. Um, lots of debate about progesterone in early pregnancy, although most organizations and experts agree that there is no clear evidence that giving progesterone benefits or prevents early pregnancy loss. There is question about people who've had three prior early pregnancy loss. Even then it's questionable about whether there could be benefits. Um some people talk about metformin and people with PCOS. Pcos, which is common common condition, but that's also not been proven to make a difference. And then, as I said before, lifestyle modification is only associated in epidemiologic studies, not an interventional studies and it can be really challenging, especially to talk about obesity or exposure to environmental or lifestyle issues because it can move into blame. And that's certainly a common issue that people are looking for a reason to blame themselves or to think that they could have caused this or preventative um, definitely should never be suggesting bedrest or avoiding intercourse in very specific late pregnancy issues. like listen to previous maybe but or even vigorous activity. And we certainly recommend that people avoid activity that lead could lead to injury and pregnancy. But if someone is used to be vigorous activity short of really intense, that leads to anaerobic metabolism, there's actually no evidence that it causes problems. Um I just put this up as an example. I keep this uh smart phase of these kind of counseling issues so that I can for whatever I talked to about patients, it's easy for me to just swipe on the ones that I spent time talking about with somebody And then recurrent pregnancy loss is much much less common. But 43% of people who've had a term pregnant or a Successful pregnancy having had a loss. The chance of recurrent pregnancy loss is only about 2%. So it is really uncommon. Of course there's no absolute definition of relief of the current pregnancy loss. The most organizations recommend something around two consecutive clinical losses. There's some debate about whether it has to be a clinical loss or if it could just be by HCG um uh european society of human reproduction and embryology recommended that we include HCG either by serum or urine. Um but a cog and our UCSF department really pays attention to more clinically confirmed inter union pregnancy confirmed. Yeah. And then what they recommend for people who meet that criteria is discussing possible evaluation. So those are the people who we talk about potentially sending genetics for for the and the pregnancy that they have at the moment, it's not required. But it has been shown to be cost effective after two early pregnancy losses. Because it keeps people from doing all these other expensive tests. And it it is very commonly uh finds random causes. There are other labs that may have a chance of making a difference for people. So endocrine and anti fossil lipid labs and then moving on to the possibility of carry a type of both parents and a cavity evaluation. And we usually start with the products of conception that carry a type on that pregnancy. And if that gives an answer most of the time, do not move on to these unless there's been significant other numbers of losses. And for diagnosis of early. So we finally get to the bleeding part. When someone comes in with early pregnancy bleeding, that is a really common occurrence. It's 20-30% of pregnancies and people often wonder, well, there's nausea. If I have nausea, does that mean that I'm going to have a successful pregnancy or? Well, I doesn't mean that I I'm going to have a miscarriage because I don't have nausea. And there is some evidence to support at least in people with bleeding, that having nausea with the bleeding decreases the chance of ultimately having a loss compared to having no nausea plus vaginal bleeding. And then ultrasound findings such as seeing a sub chorionic hematoma or a few other borderline that we'll talk about in a moment. Um But when someone's bleeding, we know that there's possible causes and a topic pregnancy or other abnormal pregnancy non viable and then there's the non pregnancy causes like cervical pathology, the cervix gets very vascular and pregnancy, vulvar lesion or trauma, and gi cause they still remain in the differential implantation, bleeding is something that is common and it happens right about the time when people would miss their period. So often people are even up to a month off on their estimation of their last menstrual period, the three days that it takes the embryo to implant in the endometrium can often lead to a little disruption and bleeding. Okay, so when someone has bleeding, the diagnosis that we uses ultrasound and so early pregnancy bleeding, if they we generally recommend that people get an ultrasound fairly quickly if it was bleeding that they reported that happened a while ago and has not continued, that doesn't necessarily have to be the issue. Most recent, a very recent evaluation of that evidence suggested that if it hasn't been in the last week, the chance of it needing urgent evaluation is much smaller. So clearly diagnosis diagnostic of early pregnancy loss. This is the society of radiologists. Early first trimester guidelines. And these are very conservative. They're more conservative than the studies they use to create the guidelines and they significantly changed the prior guidelines, which are now moved into suspicious but not diagnostic, but if so there's three options No cardiac motion. If the embryo is large enough 7 mm an enlarged sack without a Um an embryonic pole with cardiac motion. And they changed that from it was 17cm. And then it was too. And know this. They moved it to 2.5 cm. And even though the evidence was not quite that far, but they just wanted to make it very, very unlikely to have anyone get a diagnostic diagnosis without it being correct. And then there's lack of growth. It used to be is seven days with no growth and have now changed it to 11 days. If there's no uh if there is a yolk sac or 14 days with a yolk sac, that doesn't mean that you can never have a discussion about the possible diagnosis if you don't reach these levels. Um The suspicious findings are very concerning and very likely. So if this act is not quite 2.5 centimeters, but it's on the larger side, the an expanded annual into something that you can often see that is uh not on the list because it's hard to see sometimes. Um and then a large yolk sac or an embryo that's almost as big as the gestational sac. And um slow heart rate after, there's after six weeks. So there's several other things that can be used for counseling. But we really Are generally using the Red three options for full diagnosis. ACOG also made a point of saying that These guidelines are aimed to achieve 100% certainty of pregnancy lost. And that may not be the individual pregnant persons priority if someone doesn't desire pregnancy or they don't desire uh are they kind of don't desire to wait and try to figure it out? The one thing to be cautious about is that some people think that if they're having one of these issues early that it means that if everything is okay that they will still have a risk of pregnancy problems or anomalies in the future. So that's an important thing to make sure people don't realize that even though we see these borderline issues, it's not going to necessarily lead to a problem. Um And then there's other things that can help with shared decision making and obviously if there's a cardiac motion but there is extremely heavy bleeding, that's something that we would all consider uh inevitable and non viable. But that is an issue for religious care centers which don't consider it the same. Always minimum menstrual age. I find really helpful if someone knows exactly when their first pregnancy tests are the only time they had intercourse, you can count with the sperm being viable for five days or days with ultrasound error and have a minimum menstrual age, which will often help with diagnosis. And then we don't use HCG after we see an embryonic pole generally. But if you happen to have HCG that is plateau door dropped and there's no pole with cardiac motion. That is when it can be helpful. It's by itself, it is not diagnostic and that's because there's a huge variation in HCG in pregnancy. So high court, it'll lower quartile. Very I think that's portal. And and the that that is a really variable finding in pregnancy. We do know that if it rises less than 35% or so in two days, the chance of viable I enter enter in pregnancy is really small and for the discriminatory levels for when we expect to see these have gone up since uh we usually see things at much lower levels of HCG. But this being discriminatory at one point at which point the chance of it being a viable pregnancy is very low. This is a long list. But I just wanted to let you know that people have really studied counseling with early pregnancy failure because um some studies have found that patients rate their care around miscarriage primarily on being able to give given space and people listening to what it means to them being space to given space to tell the story of what the miscarriage means in their life. And so how people respond to it and the counseling around miscarriage can be really critical to quality care. And and this study by uh people who many of them have connections are at UCSF or used to be at UCSF uh gives a nice list of ways to think about proceeding with counseling after miscarriage, their remaining silent that we talked about finding out whether it was desired because even if it was undesired, sometimes people feel guilt in a way that they wished the pregnancy to be non viable or something like that and normalizing their emotions of waiting. Um feelings that they are, comments about what they should do or what's normal other than what they're. All emotions are normal and a range of emotional emotions are normal. And then whenever possible, trying to really validate that they ask good questions and that you're there to hear what their concerns are. I'm not going to go through this, but they actually made it into a list of that patients can fill out to see what their priorities are and that can help guide management. So having a conversation of what someone's priorities that can help guide management and it's helpful. You don't want to jump right into this one minute after you give someone the diagnosis, but often people do want to know what their options are from someone before they get referred. Um And the three options, I always get frustrated when I hear expectant management means doing nothing because it's really not. We still follow people check in and recommend evaluation. Um even though we're not doing an intervention and then medical management with kristen and music hostel, same doses that we use for medication, abortion and aspiration in the office in the operating room or sometimes in the emergency room. And the main thing to know is that people have very strong preferences about this and we find higher satisfaction when they're treated according to their preferences, but you don't want to leave them out of important information. So we want to do share decision making and there's personal and emotional factors that can make a difference. Sometimes people really care about what's more natural or more private or what their friend told them. There is also physical factors that they really care about pain or really being out of the hospital or wanting to avoid a procedure or avoiding additional carriage or being done as quickly as possible. And it's important to let them know that all options are safe. We're talking about up until 12 weeks, six days by just station and we'll talk a little bit about when we might lean toward aspiration. But there's really no difference in hemorrhage infection, future, live birth or people who would choose that option again or recommend it. Mhm. Just want to mention the mistrial because it's one of the most famous miscarriage treatment comparisons that did give us the information that if someone's goal is to avoid an aspiration or avoid a surgical procedure. We know that recommending medical management is much better at doing that than recommending expectant management. So, um for expectant management as we said, people often just want the most natural letting their body take the court their course with medical management. We find that In about a week we get close to 90% success. Uh And this is certainly faster and more plan able than expectant management. And the best way to avoid a DNC or uterine aspiration and then aspiration being the most predictable. The chance they'll need any further treatment is the lowest and they have pain control options and then in the operating room has the same issues. But sometimes people really feel like they uh want to be asleep or they might have a medical condition where we would recommend that U. C. S. S. Guidelines for expectant management or medical management actually also talk about nine weeks size as being something to consider. That certainly does not mean we can't offer it to someone who's 10 week size and 12.5 by dates. But the chance of having heavier bleeding or having an incomplete does start to go up a bit. And one thing I add on here to think about when you're counseling someone is our primary tool in keeping people comfortable is instead. So if someone can't and they would likely have a higher chance of needing narcotics and it's something to take into consideration. Um And always I would say when you can't offer you can offer one option but the others are reasonable options. You want to make sure people realize that. And certainly they may choose an option. That means they don't have to change providers or they don't have to do something different. But to make sure that they know that all of the options are available. So success uh also for expectant management, people say, well, how long will I have to wait if I wait? It's we don't have great data, but in because most of it looks at a very long time, like going more like two months out. So we're talking 70, Uh if there's an embryo or incomplete, incomplete, they've already passed the sack, it's much higher. But if there's a retained non viable, it's more like 75% in two months and it's a little bit uh even less if it's in an embryonic. So I often will tell people that sometimes it's about 50% in the next few weeks. But we really don't have great data to predict to predict that. But what I mean by it's not nothing is we want to make sure they have expectation counseling on expectations. They have medicines to use. If they start to bleed, they know what the precautions are and they have a follow up plan. And then medical management is uh mifepristone and miSOPROStol. The main difference between from medication abortion is the research is primarily vaginal for them. It's a presto. And then the success rate being in a week of close to 90%, about 88%. And they need for aspiration in a month goes down to under 10%. It's not quite as low as with medication, abortion. And then aspiration is something that is very simple and very safe. And often we can control pain very well. But it is also something that some people prefer to avoid. Um there is not any evidence that this increases the chance of uterine adhesions or Ash Shermans compared to other options. And that's probably primarily because the time when we actually know that that's a risk is when there's retained tissue because aspiration has such a lower chance of having retained tissue and with the other modalities, the chance of a little bit of retained tissue is higher. And that is when we see the risk of uterine adhesions, having a DNC for a small amount of routine tissue that's been there for a while. Um this is probably more than I want to go through in detail, but just to say, uh Rh immunoglobulin or rhodium is clearly known to be effective for preventing or each auto uh immunization. But everyone agrees that there is no known harm before eight weeks of sides of pregnancy. What varies is the recommendations? So ACOG still recommends that if you have an aspiration that you get it and that you consider it for later, first trimester for medical management And National Abortion Federation says it's not needed prior to eight weeks. And for either aspiration or and or medical management but that consider it if Over 10 weeks it would be needed for everyone. There's a range, but under eight weeks it is reasonable to talk to people about for going it, especially if they otherwise wouldn't have to come in or have their blood type check. And then after early pregnancy loss, there's the way I usually describe it as we used to recommend that people wait when normal cycle before they try start trying for pregnancy again. Based on some older studies that showed a slightly higher risk of miscarriage. However, those studies have really been repeated and not shown any benefit to delay. So we feel like overall the evidence is really not strong enough for us to tell anyone that they should do something they don't want to do. So we still recommend the one week which is not evidence based either. Um, but really not recommending any significant or any delay other than that one week for if someone desires to get pregnant again. And then Menzies are often a little bit delayed and remind people that they would not expect to see a negative pregnancy test until 3-4 weeks. I would add grease counseling. Sorry, I want to make sure I touch on that because it is often a really significant loss and that people experience with early even know early pregnancy loss is very common for some people. It is not for others. It's really intense especially recurrent pregnancy loss and checking in with someone and offering options is really important. Here are some resources. I will send you these with the slides just that they'll be there. And this is also a really kind of busy slide that I don't expect you to follow. But so we've taken we've kind of done this side of non viable pregnancy and viable pregnancy. And we're going to move on to this side. And I will send this to you as well um with the slides or holes in the slides but I can send it separately in case itself all. So another thing that we worry about when someone's bleeding in early pregnancy is a topic. It's a small percent of total pregnancies and it's even smaller in people who are presenting for abortion. But in someone who's symptomatic, so bleeding or pain or both. Um it's Up to 18% of those people at least when they present for an emergency room can end up having an ectopic pregnancy. And the topic pregnancy that ruptures is still a significant component of pregnancy tests. So risk factors are primarily priority topic or tubal surgery and and pregnant like you'd present when you get pregnant. Two will damage from public infection. The odds ratio for that is really not clearly elevated. But if someone knows they have had significant P. I. D. Or two bolivarian abscess or were admitted and it wasn't just a clinical diagnosis. I would generally include that. Um it was not included in the recent medication abortion protocol for when people don't need an ultrasound mainly because of the poor correlation and research. And then so there's risk factors and then their symptoms and the symptoms are just vaginal bleeding or pain. Many people have cramp e. Midline pain so we don't usually include that. But remembering the symptomatic is the ones that we are also particularly worried about and would recommend ultrasound. So when to do ultrasound in a normal pregnancy we often don't recommend any ultrasound before eight weeks because it puts people on this treadmill of pregnancy about no location when they otherwise don't have any concerns. It also at least at UCSF it's hard to fit that in other obstetric wait period is unfortunately kind of long having any risk factor. Risk factor. Uh You would want you can either follow HCG or ultrasound but once someone has symptoms you really want to move to ultrasound. And I certainly see people go to HCG first because it's more convenient but those people need an ultrasound so we usually start with that and then only do the HCG if needed. And the ultrasound doesn't show a clear interview during pregnancy this. Um I'll skip over quickly but just as a reminder. So even though this almost certainly is an interview during pregnancy. It's e centric it's hyper quick ring it's round it's bundle compared to this inter cava torrey fluid or pseudo sac we still don't officially definitively define pregnancy. An interview and pregnancy without a you expect or an embryo. Um I'm gonna I know we're getting a little close on time so I'm gonna skip that being like very early ultrasound. If they're supposed to be early and everything is fine we don't have to worry where we worry is when someone has risk factors concerning ultrasound finding or concerning symptoms. Um And if they have any of these, our goal at UCSF is to get someone in ultrasound within 24 hours. Obviously if they're having symptoms that are suggested or suggesting or concerning for a ruptured ectopic that's immediate emergency room but someone was spotting or some pain that is not central cramping. We would, or an ultrasound in the clinic might see something that is concerning. We aim to get a formal ultrasound within 24 hours and then at what point of HcG should we expect to see an interview during pregnancy? ACOG says to use 3500. That's very definitive for everyone interested in pregnancy. There's 78 topics and 140 non viable. So really small chance that being normal 2000 has been a traditional cut off for a very long time because the chance of a normal U. P. is very small but it's not zero. It's still possible and then if you have even a lower HcG but there's also a concerning ultrasound finding that is also quite predictive for a topic. And Oh sorry we already I thought anything I'm going the wrong direction there. So minimal rise when we're following CG. We generally follow it in 48 hours. And that's when we have the most data of comparison to prior rise. And as I mentioned before, 35 Rise, less than 35% rise in 48 hours is puts it at .1 chance of viable pregnancy. But there's also new data that makes it clear that in very early times the chance It should be rising even faster. So if with a very early HDG if you don't have a 49% rise in 48 hours. That puts you at an extremely low chance of continuing pregnancy. All right, successful pregnancy. Yeah. And management of an undesired or a non viable pregnancy of unknown location is really the same as as long as you're not concerned. A clinical suspicion for a topic in general, we recommend aspiration if someone has no preference because we get the fastest answer, we can get an HCG in the next day. Or sometimes we'll see tissue at that moment. But medical management or medication, abortion, if they just have an undesired pregnancy is also acceptable. And National abortion federation explicitly made it clear that people should be offered that if that is their preference. And pregnancy of unknown location. Workups should be continued in parallel. Oh that one thing to think about though is if someone wants medical management and it's a very, very early pregnancy, it has a lower chance of being successful. This is five. This is abortion data, but it's just a reminder that when there's no sack, maybe it's because it doesn't have anything to squeeze on. But if there's no sack, the chance of medical management working on the lower side compared to the data that I showed earlier. This is the handout that we use to counsel people about pregnancy of unknown location. So that we talked to people about what we're worried about, what we're not worried about and what symptoms they should think about. And luckily the risk of rupture is very very low. So during pregnancy of unknown location evaluation, the chance of rupture is Generally less than half of 1%. And specifically in the population ended up having an ectopic. The chance of rupture during the evaluation was less than 2%. And the last couple of slides I get this question all the time. Well if it's a pl why can't I just give methotrexate whether they they don't want it? If they don't want to be pregnant, we can just do that. And this is a debate within our specialty and and UCSF comes down on the size of that. We don't recommend this when it doesn't work as well as mifepristone and two, you don't end up with the diagnosis and it is fine to do the medical management with Mr. Preston needs a possible while you're doing the work up but other people disagree. And that is something that is done elsewhere. And another really common question I get is uh about anything that we're doing in pregnancy is subsequent fertility. It's almost the most common question. I think I would get about any early pregnancy intervention and to know that at least for those who do end up having any topic, methotrexate is a safe option and that it doesn't have difference compared to surgery in trouble, potency or repeated topic or future pregnancies. Where there could be some issue is self and costumey versus self inject to me some of our patients really do not have IVF as an option. So that's something to consider on the other side. So again we've kind of gone through this side as well and I'll send this and hopefully still have some time for questions
