Gestörte Frühgravidität

Die ersten Schwangerschaftswochen sind entscheidend für eine gesunde Entwicklung des Kindes. Jedoch führen zahlreiche Ursachen in der Phase der Frühgravidität zu Fehlgeburten vor der 20. Schwangerschaftswoche, die differenzialdiagnostisch abgeklärt werden sollten. In diesem Artikel werden zunächst die Diagnostik einer regulären Schwangerschaft und in weiterer Folge die verschiedenen Krankheitsbilder der gestörten Frühgravidität dargestellt.

Kernaussagen

• Insbesondere die vaginale Blutung mit oder ohne abdominale Schmerzen in der Frühgravidität erfordert die differenzialdiagnostische Abklärung.

• Die Bestimmung von β-hCG aus dem Serum sowie die transvaginale Sonografie zählen zu den wichtigen diagnostischen Mitteln.

• Die häufigste Form der gestörten Frühgravidität stellt der Abort mit seinen verschiedenen Subtypen wie z. B. der Missed Abortion oder dem Abortus (in)completus dar.

• Etablierte Therapieoptionen bei gestörter intrauteriner Frühgravidität sind die kontraktile Therapie mit Misoprostol im Off-Label-Use oder die Saugkürettage nach Zervix-Priming.

• Ektope Graviditäten können medikamentös mit Methotrexat im Off-Label-Use oder operativ behandelt werden. Die Entscheidung ist abhängig vom Beschwerdebild der Patientin, dem sonografischen Befund und der Höhe des β-hCG.

• Eine Sonderform der ektopen Gravidität stellen Zervix- und Narbenschwangerschaften dar, da diese unter engmaschiger Kontrolle nach Aufklärung der Patientin über die assoziierten Morbiditäten ausgetragen werden können.

• Bei Blasenmole oder Partialmole sollte eine Saugkürettage unter sonografischer Kontrolle durchgeführt werden. Wichtig im Anschluss ist die Kontrolle des β-hCG bis unter die Nachweisgrenze.

Schlüsselwörter

Frühgravidität - gestört - ektope Gravidität - Throphoblasterkrankung - Abort

Publication History

Article published online:
14 December 2023

• Literatur

• 1 Gemeinsamer Bundesausschuss. Richtlinien des Gemeinsamen Bundesausschusses über die ärztliche Betreuung während der Schwangerschaft und nach der Entbindung („Mutterschafts-Richtlinien“). Accessed September 12, 2023 at: https://www.g-ba.de/downloads/62–492–3144/Mu-RL_2023–02–16_iK-2023–05–13.pdf
• 2 Regan L, Braude PR, Trembath PL. Influence of past reproductive performance on risk of spontaneous abortion. BMJ 1989; 299: 541-545 DOI: 10.1136/bmj.299.6698.541. (PMID: 2507063)
• 3 Centers for Disease Control and Prevention (CDC). Ectopic pregnancy – United States, 1990–1992. MMWR Morb Mortal Wkly Rep 1995; 44: 46-48 (PMID: 7823895)
• 4 Bottomley C, Bourne T. Dating and growth in the first trimester. Best Pract Res Clin Obstet Gynaecol 2009; 23: 439-452 DOI: 10.1016/j.bpobgyn.2009.01.011. (PMID: 19282247)
• 5 Goldstein SR, Snyder JR, Watson C. et al. Very early pregnancy detection with endovaginal ultrasound. Obstet Gynecol 1988; 72: 200-204
• 6 Lee IT, Rubin ES, Wu J. et al. The incidence and importance of the pseudogestational sac revisited. Am J Obstet Gynecol 2022; 226: 537.e1-537.e7 DOI: 10.1016/j.ajog.2021.10.033. (PMID: 34736913)
• 7 Brezinka C. Das Corpus luteum im gynäkologischen Ultraschall. J Gynäkol Endokrinol 2020; AT30: 75-78 DOI: 10.1007/s41974-020-00139-7.
• 8 Yeh HC, Rabinowitz JG. Amniotic sac development: ultrasound features of early pregnancy – the double bleb sign. Radiology 1988; 166: 97-103 DOI: 10.1148/radiology.166.1.3275972. (PMID: 3275972)
• 9 Dooley WM, De Braud L, Thanatsis N. et al. Predictive value of presence of amniotic sac without visible embryonic heartbeat in diagnosis of early embryonic demise. Ultrasound Obstet Gynecol 2021; 57: 149-154 DOI: 10.1002/uog.23533. (PMID: 33147646)
• 10 Tong S, Kaur A, Walker SP. et al. Miscarriage risk for asymptomatic women after a normal first-trimester prenatal visit. Obstet Gynecol 2008; 111: 710-714 DOI: 10.1097/AOG.0b013e318163747c. (PMID: 18310375)
• 11 Doubilet PM, Benson CB, Bourne T. et al. Diagnostic criteria for nonviable pregnancy early in the first trimester. N Engl J Med 2013; 369: 1443-1451 DOI: 10.1056/NEJMra1302417. (PMID: 24106937)
• 12 Barnhart KT, Sammel MD, Rinaudo PF. et al. Symptomatic patients with an early viable intrauterine pregnancy: HCG curves redefined. Obstet Gynecol 2004; 104: 50-55 DOI: 10.1097/01.AOG.0000128174.48843.12. (PMID: 15229000)
• 13 Taran FA, Kagan KO, Hübner M. et al. The diagnosis and treatment of ectopic pregnancy. Dtsch Arztebl Int 2015; 112: 693-704 DOI: 10.3238/arztebl.2015.0693. (PMID: 26554319)
• 14 Connolly A, Ryan DH, Stuebe AM. et al. Reevaluation of discriminatory and threshold levels for serum β-hCG in early pregnancy. Obstet Gynecol 2013; 121: 65-70 DOI: 10.1097/aog.0b013e318278f421. (PMID: 23262929)
• 15 Passuello V, Lindner C, Steiner E. et al. Vergleich der Normvariablen beim Ersttrimester-Screening bei Zwillings- und Einlingsschwangerschaften. Geburtshilfe Frauenheilkd 2006; 66: PO_G_04_24 DOI: 10.1055/s-2006-952883.
• 16 Verhaegen J, Gallos ID, van Mello NM. et al. Accuracy of single progesterone test to predict early pregnancy outcome in women with pain or bleeding: meta-analysis of cohort studies. BMJ 2012; 345: e6077 DOI: 10.1136/bmj.e6077. (PMID: 23045257)
• 17 World Health Organization. Recommended definitions, terminology and format for statistical tables related to the perinatal period and use of a new certificate for cause of perinatal deaths. Modifications recommended by FIGO as amended October 14, 1976. Acta Obstet Gynecol Scand 1977; 56: 247-253
• 18 American College of Obstetricians and Gynecologists, Society for Maternal-Fetal Medicine. Obstetric Care consensus No. 6: Periviable Birth. Obstet Gynecol 2017; 130: e187-e199 DOI: 10.1097/AOG.0000000000002352. (PMID: 28937572)
• 19 van den Berg MM, Van Maarle MC, van Wely M. et al. Genetics of early miscarriage. Biochim Biophys Acta 2012; 1822: 1951-1959 DOI: 10.1016/j.bbadis.2012.07.001. (PMID: 22796359)
• 20 Luise C, Jermy K, May C. et al. Outcome of expectant management of spontaneous first trimester miscarriage: observational study. BMJ 2002; 324: 873-875 DOI: 10.1136/bmj.324.7342.873. (PMID: 11950733)
• 21 Hosang B. Fehlgeburt. Abort – Verlaufsformen. Geburtshilfe Frauenheilkd 2013; 73: 213-217 DOI: 10.1055/s-0032-1328329.
• 22 Abdallah Y, Daemen A, Kirk E. et al. Limitations of current definitions of miscarriage using mean gestational sac diameter and crown-rump length measurements: a multicenter observational study. Ultrasound Obstet Gynecol 2011; 38: 497-502 DOI: 10.1002/uog.10109. (PMID: 21997898)
• 23 Panelli DM, Phillips CH, Brady PC. Incidence, diagnosis and management of tubal and nontubal ectopic pregnancies: a review. Fertil Res Pract 2015; 1: 15 DOI: 10.1186/s40738-015-0008-z. (PMID: 28620520)
• 24 Bouyer J, Coste J, Fernandez H. et al. Sites of ectopic pregnancy: a 10 year population-based study of 1800 cases. Hum Reprod 2002; 17: 3224-3230 DOI: 10.1093/humrep/17.12.3224. (PMID: 12456628)
• 25 Cacciatore B, Stenman UH, Ylöstalo P. Diagnosis of ectopic pregnancy by vaginal ultrasonography in combination with a discriminatory serum hCG level of 1000 IU/l (IRP). Br J Obstet Gynaecol 1990; 97: 904-908 DOI: 10.1111/j.1471-0528.1990.tb02445.x. (PMID: 2223681)
• 26 Kirk E, Bottomley C, Bourne T. Diagnosing ectopic pregnancy and current concepts in the management of pregnancy of unknown location. Hum Reprod Update 2014; 20: 250-261 DOI: 10.1093/humupd/dmt047. (PMID: 24101604)
• 27 Moawad NS, Mahajan ST, Moniz MH. et al. Current diagnosis and treatment of interstitial pregnancy. Am J Obstet Gynecol 2010; 202: 15-29 DOI: 10.1016/j.ajog.2009.07.054. (PMID: 20096253)
• 28 Lau S, Tulandi T. Conservative medical and surgical management of interstitial ectopic pregnancy. Fertil Steril 1999; 72: 207-215 DOI: 10.1016/s0015-0282(99)00242-3. (PMID: 10438980)
• 29 Jurkovic D, Mavrelos D. Catch me if you scan: ultrasound diagnosis of ectopic pregnancy. Ultrasound Obstet Gynecol 2007; 30: 1-7 DOI: 10.1002/uog.4077. (PMID: 17587215)
• 30 Chen X, Gao L, Yu H. et al. Intramural Ectopic Pregnancy: Clinical Characteristics, Risk Factors for Uterine Rupture and Hysterectomy. Front Med (Lausanne) 2021; 8: 769627 DOI: 10.3389/fmed.2021.769627. (PMID: 34778327)
• 31 Kampioni M, Chmaj-Wierzchowska K, Wszołek K. et al. Interstitial Ectopic Pregnancy – Case Reports and Medical Management. Medicina 2023; 59: 233 DOI: 10.3390/medicina59020233. (PMID: 36837435)
• 32 Barrenetxea G, Barinaga-Rementeria L, Lopez de Larruzea A. et al. Heterotopic pregnancy: two cases and a comparative review. Fertil Steril 2007; 87: 417.e9-417.15 DOI: 10.1016/j.fertnstert.2006.05.085. (PMID: 17074353)
• 33 Liu M, Zhang X, Geng L. et al. Risk Factors and Early Predictors for Heterotopic Pregnancy after In Vitro Fertilization. PLoS One 2015; 10: e0139146 DOI: 10.1371/journal.pone.0139146. (PMID: 26510008)
• 34 Andrea K, Cali G, Monteagudo A. et al. The clinical outcome of cesarean scar pregnancies implanted “on the scar” versus “in the niche”. Am J Obstet Gynecol 2017; 16: 510.e1-510.e6 DOI: 10.1016/j.ajog.2017.01.019. (PMID: 28115056)
• 35 Calì G, Timor-Tritsch IE, Palacios-Jaraquemada J. et al. Outcome of Cesarean scar pregnancy managed expectantly: systematic review and meta-analysis. Ultrasound Obstet Gynecol 2018; 51: 169-175 DOI: 10.1002/uog.17568. (PMID: 28661021)
• 36 Köninger A, Rusch P, Kimmig R. Successful myometrial closure over protruding Cesarean scar pregnancy. Ultrasound Obstet Gynecol 2021; 57: 1010-1011 DOI: 10.1002/uog.22135. (PMID: 32602973)
• 37 Timor-Tritsch IE, Monteagudo A, Santos R. et al. The diagnosis, treatment, and follow-up of cesarean scar pregnancy. Am J Obstet Gynecol 2012; 207: 44.e1-44.13 DOI: 10.1016/j.ajog.2012.04.018.
• 38 Köninger A, Nguyen BP, Schwenk U. et al. Cervical ectopic pregnancy – the first case of live birth and uterus-conserving management. BMC Pregnancy Childbirth 2023; 23: 664
• 39 Köninger A, Schwenk U, Iannaccone A. et al. Uterine Artery Embolization in the Twentieth Week of Pregnancy in Abnormally Invasive Placenta with Live Birth. J Vasc Interv Radiol 2021; 32: 339-342 DOI: 10.1016/j.jvir.2020.12.002.
• 40 Avery DM, Wells MA, Harper DM. Cervico-isthmic corporeal pregnancy with delivery at term: a review of the literature with a case report. Obstet Gynecol Surv 2009; 64: 335-344 DOI: 10.1097/OGX.0b013e31819f95ff. (PMID: 19386140)
• 41 Kirk E, Bourne T. Diagnosis of ectopic pregnancy with ultrasound. Best Pract Res Clin Obstet Gynaecol 2009; 23: 501-508 DOI: 10.1016/j.bpobgyn.2008.12.010. (PMID: 19356985)
• 42 Delke I, Veridiano NP, Tancer ML. Abdominal pregnancy: review of current management and addition of 10 cases. Obstet Gynecol 1982; 60: 200-204 (PMID: 7155482)
• 43 Cetin MT, Aridogan N, Coskun A. Abdominal pregnancy. Six personal cases. Rev Fr Gynecol Obstet 1992; 87: 76-78 (PMID: 1570458)
• 44 Huang K, Song L, Wang L. et al. Advanced abdominal pregnancy: an increasingly challenging clinical concern for obstetricians. Int J Clin Exp Pathol 2014; 7: 5461-5472 (PMID: 25337188)
• 45 Hui P, Martel M, Parkash V. Gestational trophoblastic diseases: recent advances in histopathologic diagnosis and related genetic aspects. Adv Anat Pathol 2005; 12: 116-125 DOI: 10.1097/01.pap.0000163960.11107.73. (PMID: 15900112)
• 46 Soper JT. Gestational Trophoblastic Disease: Current Evaluation and Management. Obstet Gynecol 2021; 137: 355-360 DOI: 10.1097/AOG.00000000000042. (PMID: 33416290)
• 47 Griebel CP, Halvorsen J, Golemon TB. et al. Management of spontaneous abortion. Am Fam Physician 2005; 72: 1243-1250 (PMID: 16225027)
• 48 Lemmers M, Verschoor MA, Kim BV. et al. Medical treatment for early fetal death (less than 24 weeks). Cochrane Database Syst Rev 2019; (06) CD002253 DOI: 10.1002/14651858.CD002253.pub4.
• 49 Ghosh J, Papadopoulou A, Devall AJ. et al. Methods for managing miscarriage: a network meta-analysis. Cochrane Database Syst Rev 2021; (06) CD012602 DOI: 10.1002/14651858.CD012602.pub2.
• 50 Meirik O, My Huong NT, Piaggio G. WHO Research Group on Postovulatory Methods of Fertility Regulation. et al. Complications of first-trimester abortion by vacuum aspiration after cervical preparation with and without misoprostol: a multicentre randomised trial. Lancet 2012; 379: 1817-1824 DOI: 10.1016/S0140-6736(11)61937-5. (PMID: 22405255)
• 51 Tunçalp O, Gülmezoglu AM, Souza JP. Surgical procedures for evacuating incomplete miscarriage. Cochrane Database Syst Rev 2010; (09) CD001993 DOI: 10.1002/14651858.CD001993.pub2. (PMID: 20824830)
• 52 Committee on Practice Bulletins – Gynecology. ACOG Practice Bulletin No. 191: Tubal Ectopic Pregnancy. Obstet Gynecol 2018; 131: e65-e77 DOI: 10.1097/AOG.0000000000002464. (PMID: 29232273)
• 53 Jurkovic D, Memtsa M, Sawyer E. et al. Single-Dose Systemic Methotrexate vs Expectant Management for Treatment of Tubal Ectopic Pregnancy: A Placebo-Controlled Randomized Trial. Ultrasound Obstet Gynecol 2017; 49: 171-176 DOI: 10.1002/uog.17329. (PMID: 27731538)
• 54 van Mello NM, Mol F, Verhoeve HR. et al. Methotrexate or expectant management in women with an ectopic pregnancy or pregnancy of unknown location and low serum hCG concentrations? A randomized comparison. Hum Reprod 2013; 28: 60-67 DOI: 10.1093/humrep/des373. (PMID: 30702252)
• 55 Barnhart KT, Hansen KR, Stephenson MD. et al. Reproductive Medicine Network. Effect of an Active vs Expectant Management Strategy on Successful Resolution of Pregnancy Among Patients With a Persisting Pregnancy of Unknown Location: The ACT or NOT Randomized Clinical Trial. JAMA 2021; 326: 390-400 DOI: 10.1001/jama.2021.10767. (PMID: 35015037)
• 56 Camuzcuoglu A, Vural M, Hilali NG. et al. Surgical management of 58 patients with placenta praevia percreta. Wien Klin Wochenschr 2016; 128: 360-366 DOI: 10.1007/s00508-016-0962-4. (PMID: 26913862)
• 57 Palacios-Jaraquemada JM, Basanta N, Labrousse C. et al. Pregnancy outcome in women with prior placenta accreta spectrum disorders treated with conservative-reconstructive surgery: analysis of 202 cases. J Matern Fetal Neonatal Med 2022; 35: 6297-6301 DOI: 10.1080/14767058.2021.1910671. (PMID: 33843411)
• 58 Miller R, Timor-Tritsch IE, Gyamfi-Bannerman C. Cesarean scar pregnancy. Am J Obstet Gynecol 2020; 222: B2-B14 DOI: 10.1016/j.ajog.2020.01.030. (PMID: 31972162)
• 59 Robinson JK, Dayal MB, Gindoff P. et al. A novel surgical treatment for cesarean scar pregnancy: laparoscopically assisted operative hysteroscopy. Fertil Steril 2009; 92: 1497.e13-1497.e16 DOI: 10.1016/j.fertnstert.2009.07.996.
• 60 Zhang X, Pang Y, Ma Y. et al. A comparison between laparoscopy and hysteroscopy approach in treatment of cesarean scar pregnancy. Medicine (Baltimore) 2020; 99: e22845 DOI: 10.1097/MD.0000000000022845.
• 61 Monteagudo A, Calì G, Rebarber A. et al. Minimally Invasive Treatment of Cesarean Scar and Cervical Pregnancies Using a Cervical Ripening Double Balloon Catheter: Expanding the Clinical Series. J Ultrasound Med 2019; 38: 785-793 DOI: 10.1002/jum.14736. (PMID: 30099757)
• 62 Zhuang Y, Huang L. Uterine artery embolization compared with methotrexate for the management of pregnancy implanted within a cesarean scar. Am J Obstet Gynecol 2009; 201: 152.e1-152.e3 DOI: 10.1016/j.ajog.2009.04.038. (PMID: 19527897)
• 63 Weibel HS, Alserri A, Reinhold C. et al. Multidose methotrexate treatment of cervical pregnancy. J Obstet Gynaecol Can 2012; 34: 359-362 DOI: 10.1016/S1701-2163(16)35217-3. (PMID: 22472336)
• 64 Fowler ML, Wang D, Chia V. et al. Management of Cervical Ectopic Pregnancies: A Scoping Review. Obstet Gynecol 2021; 138: 33-41 DOI: 10.1097/AOG.0000000000004423. (PMID: 34259461)
• 65 Zhou Q, Young D, Vingan H. Uterine artery embolization for cervical ectopic pregnancy. Radiol Case Rep 2015; 10: 72-75 DOI: 10.1016/j.radcr.2015.08.004. (PMID: 26649125)
• 66 Verma U, Maggiorotto F. Conservative management of second-trimester cervical ectopic pregnancy with placenta percreta. Fertil Steril 2007; 87: 697.e13-697.e16 DOI: 10.1016/j.fertnstert.2006.05.088. (PMID: 17140571)
• 67 Munoz JL, Kalan A, Singh K. Second Trimester Cervical Ectopic Pregnancy and Hemorrhage: A Case Report and Review of the Literature. Case Rep Obstet Gynecol 2018; 2018: 3860274 DOI: 10.1155/2018/3860274. (PMID: 30225155)
• 68 Pezeshki M, Hancock B, Silcocks P. et al. The role of repeat uterine evacuation in the management of persistent gestational trophoblastic disease. Gynecol Oncol 2004; 95: 423-429 DOI: 10.1016/j.ygyno.2004.08.045. (PMID: 15581942)
• 69 Descargues P, Hajri T, Massardier J. et al. Gestational trophoblastic neoplasia after human chorionic gonadotropin normalization in a retrospective cohort of 7761 patients in France. Am J Obstet Gynecol 2021; 225: 401.e1-401.e9 DOI: 10.1016/j.ajog.2021.05.006.