The First 8 Weeks, The New OB Visit and Early Pregnancy Complications

Podcast Transcript

Erica Newlin, MD:

Welcome to Ob/Gyn Time, a Cleveland Clinic podcast covering all things obstetrics and gynecology. These podcast episodes are intended to help you better understand your health, leaving you feeling empowered to live your best. We hope you enjoy today's episode.

Erica Newlin, MD:

Hi, everyone. I'm your host, Dr. Erica Newlin. Welcome to Ob/Gyn Time.

During this season, we are focusing on topics related to pregnancy and obstetric concerns. On this episode, I'd like to welcome Dr. Emily Freeman, who will be talking to us about the first trimester.

Dr. Freeman, thanks so much for joining me on the podcast.

Emily Freeman, DO:

Thanks so much for having me, Dr. Newlin. It's really a pleasure to be here today.

Erica Newlin, MD:

Can you tell us a little about your role in the Cleveland Clinic and about your background?

Emily Freeman, DO:

Sure. So I am an OB-GYN and also a complex women planning specialist. So I specialize in contraception, particularly contraception for medically-complex patients, management of unintended, or medically-complex pregnancies, in the first and second trimester, as well as the management of early pregnancy loss and pregnancy complications in early pregnancy.

Erica Newlin, MD:

Let's start talking about how we date pregnancies. So what are "trimesters" when people talk about trimesters?

Emily Freeman, DO:

Sure. So when we're thinking about trimesters, we break pregnancies down into typically three trimesters.

So the first trimester is from when somebody has a positive pregnancy test through about 12 to 13 weeks, the second trimester is dated as essentially like 13 weeks to 28 weeks, and then the third trimester, the last part of pregnancy, is dated usually 28 weeks to 41 weeks.

Erica Newlin, MD:

I don't know about you, but I get really confused when someone tells me they're seven months pregnant. I'm like, "Are you 28 weeks? Are you 30 weeks?"

Emily Freeman, DO:

Yeah, no it's a...

Erica Newlin, MD:

As an OB, the weeks are the way I go.

Emily Freeman, DO:

Exactly.

Erica Newlin, MD:

So months really mess me up.

Emily Freeman, DO:

Weeks are really important for us, especially because, you know, things can be really different in that seventh months, right? The weeks really matter. So we tend to use weeks and date things by the first, second, and third trimester.

Erica Newlin, MD:

Sure.

And then how do we determine due dates and how would someone begin to figure out how far along they are?

Emily Freeman, DO:

Yeah.

So most of the time we start things off by asking a patient, "What was the first day of your last menstrual period?" So we start things out by figuring out how far along we think they might be based off that assessment, from their last menstrual period, or their LMP. And then oftentimes we're using an ultrasound to sort of correspond what we think they should be based off their last menstrual period, comparatively to their ultrasound.

Erica Newlin, MD:

And then how accurate are home pregnancy tests? How do those work?

Emily Freeman, DO:

Yeah, that's a great question.

So home pregnancy tests are actually quite accurate. Modern home pregnancy tests are fairly accurate at predicting HCG or Human Chorionic Gonadotropin. And so it's just gonna tell you, is there HCG there, yes or no? But they're going to pick up anything from 25 to 50 milli-international units, which is a really low level of HCG.

Erica Newlin, MD:

So when is the best time for someone to take a home pregnancy test?

Emily Freeman, DO:

That's a great question. So I think most people are going to take their home pregnancy test once they miss their period. Some patients may be planning for pregnancy, or be anticipating, or anxious that they might be pregnant and may take it sooner, but that can cause a lot of anxiety, and so I tend to try to ask patients to wait until they've missed a period to test for a pregnancy.

Erica Newlin, MD:

So say somebody has that positive home pregnancy test, what's the next best step? You know, we get a lot of calls of, "My test is positive, do I get a blood test now?"

Emily Freeman, DO:

Yeah.

So most patients, when they have a home pregnancy test that's positive, we would encourage them just to call their care provider, their OB-GYN, to set up a first OB visit. Some patients may be having complications, such as bleeding or cramping, that we may do other testing, but for most patients, we don't need any other tests, any other lab values, they can just set up that first OB visit.

Erica Newlin, MD:

Sure.

Can you explain kind of the role of the blood HCG levels, how we follow those, and what we'd be looking for in those?

Emily Freeman, DO:

Yeah.

So the blood HCG level, so comparatively to the urine, or the qualitative HCG test, a blood HCG test is going to give us a level, or an actual value, of what the number of HCG is.

So we typically are going to se that if maybe we're trying to figure out should we expect to see something on a ultrasound based off a certain HCG value. Sometimes we're going to use it to trend HCGs to see if they're increasing or decreasing.

Erica Newlin, MD:

So to summarize, the urine pregnancy test will tell us HCG, yes or no, and then that in itself can just be valuable, and... If someone isn't having any symptoms.

Emily Freeman, DO:

Exactly.

Erica Newlin, MD:

Any symptoms at all, we can follow that quantitative HCG in the blood.

Emily Freeman, DO:

Exactly, exactly. But from patients that are not having any symptoms, they don't necessarily have to get a blood draw HCG test.

Erica Newlin, MD:

Sure.

And it can be a really long time to wait from that positive pregnancy test to that new OB visit, which may be eight weeks, some cases 12 weeks, what kind of things should people look out for in that time in between? What would tell you that something might be wrong?

Emily Freeman, DO:

Sure.

Yeah, it definitely can be an anxiety-provoking time, especially if it's someone's first pregnancy, or if they have had experiences with complications in previous pregnancies. So we always advise patients to call us for certain things: bleeding in pregnancy.

So sometimes people can have spotting or some light vaginal bleeding in pregnancy and things may end up being okay, but that's definitely something we want to know about. We'd also want to know about things like lightheadedness, dizziness, pelvic pain, anything that was concerning there might be something going on that's not normal in pregnancy.

Erica Newlin, MD:

We hear a lot about implantation bleeding, and someone might think that their bleeding is just implantation bleeding. When would you worry that something is something more?

Emily Freeman, DO:

Yeah.

Implantation bleeding isn't an uncommon experience for a lot of people in early pregnancy, so I would definitely encourage patients that if they have more than just a little bit of spotting to definitely call their healthcare provider. So...

And especially if it's ongoing. And then certainly if somebody's having heavier bleeding, especially if they're saturating, typically like a maxi pad an hour for multiple hours in a row, that's definitely something you want to contact a healthcare provider for, and for some patients, even seek emergency treatment and evaluation.

Erica Newlin, MD:

And then what kind of pelvic pain is normal in early pregnancy?

Emily Freeman, DO:

Yeah.

That's a great question. Pelvic pain or cramping is sometimes, you know, normal in pregnancy. Some people have cramping as a pregnancy's implanting, as the uterus is growing, but we definitely want to know if somebody's having pain that they're feeling like they need to take something like Tylenol or pain if they are having severe pain, especially like if they're like doubled over in pain. Anything that's concerning to them, we wanna know about it and we can help triage what might be normal or not normal. And we'd rather see somebody and tell them that, "yeah, everything seems okay" than miss something that might be going on.

Erica Newlin, MD:

Let's go down the road of someone who is having a little more bleeding than expected. We order that HCG level. Can you explain kind of how we follow that? What we're looking for is one value any value?

Emily Freeman, DO:

Yeah.

Erica Newlin, MD:

Or should we follow it over over time?

Emily Freeman, DO:

Yeah.

So typically what we're going to do if we are thinking about trending, or following HCGs, we're going to have a patient come back to get the lab draw every 48 hours. And what we're looking for is what is that HCG level doing compared to the last value?

In normal pregnancy, we're typically going to expect to see a certain trend of increasing HCG, and that trend is different based off what that initial lab value was. We're also going to be looking to see if the HCG is decreasing, which could make us think that this could be a miscarriage, but could also be concerning for something like an ectopic pregnancy.

Erica Newlin, MD:

When would an ultrasound be valuable? Can you get an ultrasound too early? How does that ultrasound relate to the HCG level?

Emily Freeman, DO:

Yeah, that's a great question.

So ultrasound is very valuable in early pregnancy for a lot of patients, especially if they're having symptoms like bleeding or pain, or we're trying to correspond what we would expect to see based off an HCG value.

Sometimes, though, we can get an ultrasound and we might not see anything yet, and that can be a really frustrating situation for both the healthcare provider and the patient, but what we're really using it to do is to try to rule out the location of the pregnancy. Is the pregnancy located inside the uterus or could it be something concerning for an ectopic pregnancy?

Erica Newlin, MD:

Can you how we would diagnose a miscarriage or pregnancy loss on an ultrasound?

Emily Freeman, DO:

Yeah.

So we diagnose miscarriage in a couple different ways. Most patients we're going to diagnose it off an ultrasound. So some patients, when they get that ultrasound, we may meet enough criteria to diagnose the miscarriage based off one ultrasound. But for a lot of patients, we actually need to get multiple ultrasounds.

And sometimes the length between those two ultrasounds are as long as two weeks in between, and what we're looking for is really specific diagnostic criteria to diagnose the miscarriage.

Erica Newlin, MD:

Yeah, I think it can be very frustrating for patients for sure to have to wait that long.

Emily Freeman, DO:

Yeah.

Erica Newlin, MD:

What we're trying to do is really just not erroneously diagnose a miscarriage in an intended, or highly-desired, pregnancy.

Emily Freeman, DO:

Exactly.

And you know, I always try to validate patients concerns and frustrations that this can be a really anxiety-provoking time, but what we're really doing is trying to be as certain as we can be that this is a miscarriage. There's times where we do an ultrasound, and I might be suspicious that there's an early pregnancy loss or a miscarriage, but we just might not have enough criteria to diagnose that, and so we may have them come back anywhere from, you know, seven days to as long as 14 days in between ultrasounds in order to be as accurate as possible for diagnosing that miscarriage.

Erica Newlin, MD:

For sure. And it really depends on what we see, whether it's that seven days, whether that's 14 days.

Emily Freeman, DO:

Exactly.

Erica Newlin, MD:

So really trying to follow those criteria.

Emily Freeman, DO:

Yeah.

And these are really individualized, right? And there's not, you know, a blueprint or you know, each patient is totally different. And so it can be really frustrating, especially if patients are talking to their friends or family members that might have experienced. They may find that there's differences between each person's experience. So yeah, definitely sympathize with patient's. Frustrations of how anxiety-provoking it can be.

Erica Newlin, MD:

And let's say we do diagnose an early pregnancy loss or miscarriage for someone. What treatment options are available?

Emily Freeman, DO:

Yeah.

So treatment options depend on, in some ways, what's going on with the miscarriage, and in other ways it also depends on what feels right for the patient. So most patients actually get to choose between three options for management of their early pregnancy loss, or their miscarriage.

The first option we call "expectant management" or sometimes you'll hear us referred to it as "watchful waiting." And so that's us giving time for the patient to spontaneously pass their pregnancy on their own. But that can take some time. For some patients that's within a week of the diagnosis of a miscarriage, but for some patients that actually can take up to eight weeks or two months of time for them to pass their pregnancy.

There's other options for management, including medical management, as well as procedural management, sometimes referred to as a DNC, or sometimes referred to as a manual vacuum aspiration.

Erica Newlin, MD:

People who are undergoing the watchful waiting, is there harm in waiting that long?

Emily Freeman, DO:

Yeah, that's a great question.

So for most patients, as long as they are medically or clinically stable, they're not having significant bleeding that's worrisome, they're not showing any signs of infection, it is okay to wait. But certainly if anything changes clinically, we encourage patients to follow up with their healthcare providers to see if the watchful waiting options still seems like the best fit for that patient.

Erica Newlin, MD:

Sure.

And for people who opt for a medication management, what medications are out there? What are the treatment options?

Emily Freeman, DO:

Yeah.

So there's definitely different regimens, and some of that depends on what's available from your healthcare provider, what's available in your healthcare system.

One regimen that's available is the use of a medication called Mifopristone, followed by a medication called Misoprostol. So Mifopristone is a medication that blocks one of the hormones that's important in early pregnancy called progesterone. So patients are gonna take that in the office, and that's given by a healthcare provider, they swallow that pill orally, and then we send patients home with the medications Misoprostol for them to finish the medical management of that miscarriage at home.

Erica Newlin, MD:

Can you briefly discuss why someone might not have Mifopristone available and the restrictions on Mifopristone?

Emily Freeman, DO:

Yeah.

So there are some restrictions on Mifopristone. Mifopristone requires a special license to be able to dispense that, and there is a requirement right now to continue to dispense that from the office. So patients do need to come in, it's not able to be prescribed right now, so they can't pick it up at the pharmacy they have to come in and see a healthcare provider.

Currently, they sign a special patient agreement form as well, and then they're able to take the Mifopristone in the office and then, like I said, go home with the other medications.

Erica Newlin, MD:

So in areas where Mifopristone might not be available, are there other treatment options?

Emily Freeman, DO:

Yeah, absolutely.

So their medical management of early pregnancy loss can also be accomplished with just a medication called Misoprostol alone. And so there are places where there might not be access to Mifopristone, and so early pregnancy loss can also be managed with Misoprostol.

Erica Newlin, MD:

What is the experience like for someone who takes the medication and experiences their miscarriage at home?

Emily Freeman, DO:

Yeah.

So most patients are going to start having bleeding and cramping within typically about one to four hours after they take the medication. Most patients have, you know, bleeding experience anywhere from a menstrual cycle, to sometimes a little bit heavier. They can experience cramping or uterine contraction-like pain, but typically it's pretty well controlled with over-the-counter pain medications such as ibuprofen or acetaminophen, and other things that you would do to help with menstrual-like cramps, heating pack, shower, and to help kind of those symptomatic, you know, uterine contractions.

Erica Newlin, MD:

And then people who opt for the surgical or procedural option, you mentioned that can be done in the office or in the or.

Emily Freeman, DO:

Yeah. And that's sort of, in many ways, patient dependent, again, on whatever clinical or medical situation they have going on. As long as they're not having, you know... Some patients may be having too much bleeding where we feel like we can't manage that procedurally in the office, and the better place for them to get care might be in the operating room.

And some of it comes down to patient preference. There is some limitations on what type of anesthesia we can offer, or pain management we can offer in the office where we can perform a manual vacuum aspiration, compared to what's available in the operating room where patients may have higher levels of sedation options to help with pain.

Erica Newlin, MD:

I often tell patients when I counsel about options that there's no good option.

Emily Freeman, DO:

Yeah, right.

Erica Newlin, MD:

It's only what's best for for the person in that moment.

Emily Freeman, DO:

Exactly.

And a lot of times I tell patients, "You know, you're picking in many ways when they're experiencing an early pregnancy loss, you know, the best, worst option, right?"

Erica Newlin, MD:

Mm-hmm.

Emily Freeman, DO:

And it's really individualized and you know what's right for one patient might not be right for the next. And really it's just important to make sure patients feel very well-informed, and we give them the tools to make the decision that they know that's best for them.

Erica Newlin, MD:

And one thing I always tell patients who are experiencing a miscarriage is it's nothing that they did that made it happen, and nothing they could have done could have prevented it from happening.

Emily Freeman, DO:

Absolutely.

Erica Newlin, MD:

So I think it's very common for people to blame themselves or to think about things that they did.

On that topic are there any resources that you recommend or anything you recommend for patients who are experiencing early pregnancy loss?

Emily Freeman, DO:

We want to empower patients to know how to manage the clinical aspects of their miscarriage and early pregnancy loss, but also the emotional aspects.

So there's definitely lots of resources, support groups, online groups, counseling, and behavioral health support. And it's really important for patients to know that they're not alone when they're navigating this. So I definitely encourage patients to reach out to their healthcare provider if they feel like not only do they need help physically, right, but also emotionally and mentally.

Erica Newlin, MD:

Let's pivot to ectopic pregnancy.

What kind of symptoms might make you concerned that someone has an ectopic pregnancy, and how would we diagnose that?

Emily Freeman, DO:

Yeah.

So ectopic pregnancies can present with a wide variety of symptoms. One symptom that's pretty common in ectopic pregnancy is bleeding. That can range from anywhere from spotting to light bleeding. Some patients may also present with pelvic pain or cramping. Some patients may even present with lightheadedness, or dizziness, or sometimes even nausea. And some patients actually have no symptoms at all.

And the tricky thing about ectopic pregnancies is a lot of those symptoms I just listed are common symptoms that happen in early pregnancy.

Erica Newlin, MD:

And I should back up and mention an ectopic pregnancy is a pregnancy that's outside of the uterus.

Emily Freeman, DO:

Exactly. Yeah.

So an ectopic pregnancy is a term that really just encompasses a pregnancy that is not located within the uterus. Most commonly those are gonna be in things like the fallopian tubes, but it really can be anywhere. It can be in your abdomen, it could be in the cervix, which is the bottom part of the uterus. And then it could be even located in a previous caesarian section scar. So a pregnancy that's called a cesarean scar ectopic pregnancy.

Erica Newlin, MD:

And when we always see it on ultrasound, or are there other ways that we can diagnose it?

Emily Freeman, DO:

Yeah, that's a great question.

So, oftentimes an ectopic pregnancy may not show up on an ultrasound, and we may diagnose it with a variety of things. Sometimes following or trending those HCGs to see if they are increasing or decreasing in a way that we would expect, and sometimes also using an ultrasound to try to diagnose that.

Erica Newlin, MD:

What kind of treatment options are available after you diagnose the ectopic pregnancy?

Emily Freeman, DO:

Yeah.

So treatment options are similar to what we talked about with miscarriages, sort of dependent on each individual patient. There are medical treatment for an ectopic pregnancy, and that is typically with a medication called methotrexate, which stops rapidly dividing cells, and so it's given to candidates for it. So they have to not have signs of a ruptured ectopic pregnancy, where the pregnancy ruptures or comes out of the tissue where it's growing.

And then there's also surgical management, which is done typically through a laparoscopic procedure where we might have to remove, let's say, like the fallopian tubes, or we may be able to remove just the ectopic pregnancy.

And then very rarely, but sometimes, especially in the setting of emergency, may require a bigger abdominal incision in an open or a laparotomy type surgery.

Erica Newlin, MD:

And similar to how we discussed that it may take a while to diagnose a pregnancy loss, it may take a little time to definitively diagnose an ectopic pregnancy, too.

Emily Freeman, DO:

Yeah, oftentimes ectopic pregnancies are not going to be diagnosed with one HCG lab test, or one ultrasound, and it's really about getting enough information, and piecing the picture together to accurately diagnose the ectopic pregnancy.

Erica Newlin, MD:

Are there any ectopic pregnancies that can continue to viability?

Emily Freeman, DO:

That's a great question.

Unfortunately, the answer is no. An ectopic pregnancy is not a normal pregnancy, and should not be continued to viability because of the high risk for maternal health. And even, unfortunately, it's the leading cause of maternal death in the first trimester.

Erica Newlin, MD:

Are there any cases where ectopic pregnancies could be moved to the uterus or where they could be viable?

Emily Freeman, DO:

Unfortunately, no.

We don't have that technology and capabilities, and quite honestly, I don't think we ever will. But unfortunately, an ectopic pregnancy should be medically or surgically treated.

Erica Newlin, MD:

Going back to just normal first trimester concerns, what kind of symptoms might someone experience in their first trimester? What's... What's normal?

Emily Freeman, DO:

Yeah.

There's a variety of symptoms that patients can experience in the first trimester when they find out that they are pregnant, a common symptom is fatigue.

Some patients just notice that they are just really tired in the first trimester. They're sleeping more, are just not able to keep up with their normal routine like they did prior to pregnancy. Nausea and vomiting are very common symptoms in the first trimester. Sometimes people will call it morning sickness, a lot of patients have all-day sickness.

Erica Newlin, MD:

Mm-hmm.

Emily Freeman, DO:

And, you know, their nausea and vomiting might not just be associated in the morning and it... It might show up in the evening, or it might unfortunately persist all day.

Other common symptoms are things like breast tenderness, or food aversions, or food cravings. So there is a wide variety of symptoms that can happen. Some patients experience all of those, some patients experience none of those, or just a few of those. So it's a very individualized experience.

Erica Newlin, MD:

Yeah. I really don't know who coined the term morning sickness.

Emily Freeman, DO:

I think anybody that's had nausea throughout their day sort of rolls their eyes when somebody says, "Oh, you have morning sickness."

Erica Newlin, MD:

Mm-hmm.

Emily Freeman, DO:

As they're, you know, struggling throughout the whole day with nausea.

Erica Newlin, MD:

How do we differentiate just normal pregnancy "morning sickness"...

Emily Freeman, DO:

Mm-hmm.

Erica Newlin, MD:

Versus what might be more serious, what might need treatment?

Emily Freeman, DO:

Yeah.

So there's some patients that can have pretty severe nausea, vomiting, and I think it's important to know that even if somebody says it's, you know, "oh, you're just having morning sickness" if it's, it's really affecting the quality of your life, right? That really matters. And I definitely encourage patients to, you know, if they feel like they are not doing well and it's affecting the quality of their life to reach out to their healthcare providers because there are some things that we can do to intervene to help with nausea and vomiting.

Certainly if a patient is unable to keep any liquids down, or is unable to eat for long periods of time, lightheadedness, dizziness, those are symptoms that we would want more urgently or even emergently, in some situations, evaluated.

Erica Newlin, MD:

Yeah.

I often tell people that the baby will still grow if you're not eating, but if you're not drinking, if you're not feeling well, we need to get you feeling better.

Emily Freeman, DO:

Yes. You have to stay hydrated still, even if you just feel like you cannot take any liquids down. So that is a more worrisome sign, when people are not able to keep anything down at all.

Erica Newlin, MD:

Well, great.

Well thanks so much for joining us. Anything you'd like to add?

Emily Freeman, DO:

No, thanks so much for having me.

Erica Newlin, MD:

Alright, great. Thank you so much.

Erica Newlin, MD:

Thank you for listening to this episode of Ob/Gyn Time. We hope you enjoyed the podcast. To make sure you never miss an episode, subscribe wherever you get your podcasts, or visit clevelandclinic.org/OB-GYN-Time.