Noor Asyikin Bt AbdullahAriana Bt Syamsidi

3 main categories of early pregnancy disorders are:

ABORTIONDefinition :Expulsion of product of conception (POC) before 22nd week of period of gestation (POG), which mean before period of fetal viability.

Aetiology factors:

• Maternal’s age >35 years old• Trauma• Infections (TORCHES, malaria)• Endocrine disorders (diabetes, hypothyroidism, PCOS)• Immunological disorders (SLE, antiphospholipid syndrome)• Abnormalities in uterus (uterine fibroid)• Psychological disorder (stress)• Chromosomal abnormalities (Down syndrome)• Exposure to chemical agents (benzene, tobacco, arsenic, pesticides)

TYPES OF ABORTION:

THREATENED ABORTIONDefinition : Painless vaginal bleeding, that occur at anytime between

implantation and 24 weeks of gestation.: POC has threatened to abort but has not done so yet.

Clinical features:• Bleeding (minimal, painless)• Associated with dull aching lower abdominal pain

Examination:• Size of uterus is correspond to period of amenorrhea (POA)• Closed cervical os• U/S : well-formed, rounded gestational sac with fetus within itManagement:• Bed rest• Folic acid supplements• Progesterone supplements • Avoid coitus

INEVITABLE ABORTIONDefinition : Painful vaginal bleeding from retro-placental site

: POC is about to be aborted but not yet

It can progress to complete/ incomplete abortion depending on whether or not all fetal & placental tissues have been expelled from uterus.

Clinical features:• Vaginal bleeding (painful)• Associated with cramping pain at lower abdomen

Examination:• Size of uterus is correspond to/less than POA• Dilated cervical os

Management•Hospitalization•Analgesics for control of pain•Evacuation of uterine cavity with suction evacuation, or ovum forceps (manually)

INCOMPLETE ABORTIONDefinition : POC has aborted but not completely

Clinical features:• Vaginal bleeding (heavy, passed out POC as fleshy masses)• Associated with colicky pain at lower abdomen• +/- signs of shock

Examination:• Size of uterus is smaller than POA• Open cervical os• U/S : reveal retained POC in uterine cavity

Management:• Resuscitate if bleeding is severe, do blood group and cross match• Give analgesia for pain• Ergometrine (i.m) to contract the uterus and control bleeding• Evacuation of the uterus of its product of conception once patient’s condition is stable.

COMPLETE ABORTIONDefinition : All the POC has completely aborted.

Clinical features:• History of pain and passage of product• Followed by absent of pain, minimal bleeding

Examination:• Size of uterus is smaller than POA• Closed cervical os• U/S : empty uterine cavity

Management:• Do U/S to look for empty of uterine cavity and to rule out any possibility of extra uterine pregnancy

MISSED ABORTIONDefinition : When the embryo/fetus is already died

: but still remain in the uterine cavity for a period of time

: without symptoms of miscarriage

Clinical features:• Decreased in pregnancy symptoms• Vaginal bleeding (absent, minimal)

Examination:• Size of uterus is smaller than POA• Closed cervical os• U/S : crumpled gestational sac

: revealed fetal pole but no signs of activity (no heart activity)

Management:• Wait for spontaneous expulsion (disadvantage: involve further maternal anxiety, pain of expulsion, DIVC)• Evacuation of uterus of its POC - surgically : dilatation & currettage - medically : mifepristone + misoprostol

COMPLICATIONS OF EVACUATION

RECURRENT ABORTIONDefinition : 3 or more consecutive spontaneous abortion

Can be divided into:

ECTOPIC PREGNANCYDefinition : Pregnancy outside uterine cavity

1. In fallopian tube (fimbrial, ampullary, isthmic, interstitial)

2. In the ovary3. In the abdominal cavity4. In the cervical site

Sites of implantation:

•Trophoblast invade epithelium of the tube, proliferating into the deeper muscular wall . It will cause hematoma & tubal dilatation . Thus, the patient will present with pain.

• As the trophoblast proliferates further , it will cause rupture of serosa and hemoperitoneum.

•The trophoblast does not differ histologically from a normal intrauterine pregnancy, but the embryo in an ectopic pregnancy is usually stunted or frequently absent.

PATHOPHYSIOLOGY•Any mechanical or functional factors that interfere the passage of the fertilized ovum to the uterine cavity.

•Important factors involved in its transport: tubal contractility, ovarian hormones & cilial action within the tubes

Vaginal Bleeding (scanty, dark and intermittent)

Lower abd pain, back or pelvic pain (usu.

unilateral)

Shoulder pain

Syncopal attacks (hemoperitoneum)

Symp of hypovolemic shock

- Upset menstrual pattern

- Vague abdominal pain

General examination

shoulder pain 2° to free blood in the peritoneal cavity

irritating the diaphragm

vascular instability - low BP, fainting, dizzy, rapid

heart rate

abdominal palpation : mild tenderness, guarding,

decreased bowel sounds may be present (ectopic

pregnancy rupture may cause intra-abdominal

bleeding)

Gynecological examination

speculum : cervical os is closed

BE : uterus will be smaller than

the expected date

Positive cervical excitation

gentle motion of the cervix to both sides of

the lateral fornix

tender if stretching of the involved site

Human chorionic gonadotrophin (hCG)

normal/low hCG

Transvaginal ultrasound

+/- gestational sac(intrauterine/tubal)

Extrauterine sac with an embryo/embryonic remnants

Any fluid in the pelvis esp. in Pouch of Douglas

Empty ectopic sac/heterogenous adnexal mass

Pseudogestational sac(small, centrally located endometrial

fluid collection surrounded by a single echogenic rim of

endometrial tissue undergoing decidual reaction)

Culdocentesis

to exclude hemoperitoneum (late ectopic pregnancy-

emergency cases)

Laparoscopy

All but the very early ectopic pregnancies can be

diagnosed by this technique

Dilatation and Curettage

Not useful as a primary investigation.

On the contrary, many ectopic pregnancies are missed

even after dilatation and curettage is done for termination

of pregnancy

CuldocentesisTransvaginal puncture of the Douglas’ cul-de-sac

for aspiration of fluid

Surgical : salpingectomy/salpingotomy either by

laparotomy/laparoscopy

Medical

Methotrexate ; i.m/direct into tubal pregnancy

Expectant

Strict criteria in selected pt.

Ultrasound & hCG assessments are

prerequisites

Also known as ‘hydatidiform mole’

‘Gestational throphoblastic disease’.

Abnormal pregnancy in which the developing

fetus and placenta are replaced by proliferation

of throphoblastic tissue.

Can be classified as

Complete hydatiform mole

- no normal fetal tissue forms

Partial hydatiform mole

- incomplete fetal tissues develop alongside

molar tissue

Choriocarcinoma (invasive mole)

- contains many villi, but these may grow into or

through the muscle layer of the uterus wall

- can spread to tissues outside of the uterus.

Epidemiology

Complete : 1 per 1000-2000 pregnancies.

Partial : 1 per 700 pregnancies.

Choriocarcinoma : varies ( 3-10%)

Risk factors

Increase with maternal age.

Previous history of molar pregnancy.

Dietary habits of some ethnic group (remains

controversial).

A diet low in carotene (a form of vitamin A)

Complete hydatidiform mole

Partial hydatidiform mole

Generalized swelling of the villous tissue.

Focal swelling of the villous tissue.

Diffuse throphoblastic hyperplasia.

Focal throphoblastic hyperplasia.

No embryonic or fetal tissue.

Embryonic or fetal tissue present.

clusters of tissue swollen with fluid, giving it the appearance of a cluster of grapes

Bleeding in early pregnancy

Passing out “grape-like structure”

Hyperemesis gravidarum

Thyrotoxicosis

Other findings :-

Uterus larger than dates

No fetal heart ( doptone examination )

Beta HCG measurements – High level

Ultrasound :-

- ‘snow storm’ appearance

- no fetal parts seen

- bilateral theca lutein cysts in ovaries

(as a result of excessive hormonal stimulation)

Histological examination -large edematous villi are

avascular and show evidence of throphoblastic

proliferation.

Chest X-ray – exclude invasive mole in lung

Suction evacuation of the molar tissue

Weekly hCG level monitoring until

undetectable

Monthly monitoring for 6-24 months

Highly malignant tumour that arises from

throphoblastic epithelium.

Can metastasizes to lung, liver and brain.

50% follow molar pregnancy, 30% after

miscarriage, 20% after normal pregnancy.

Also can occur after extrauterine pregnancy →

signs and symptom of ectopic pregnancy

High maternal age

Prev hx of molar pregnancy

ABO blood gp (parents) – chorioCA women with

blood

gp A have higher risk than gp O

History of miscarriage.

Genital manifestations Amenorrhea Vaginal bleeding Intraperitoneal hemorrhage Vaginal metastasis

Extravaginal manifestations Lungs-’cannon ball’ lesion Brain-stroke Liver GIT

Vaginal bleeding (passing out grape like struc.) Uterine enlargement greater than dates Abnormally high hCG secrete by the proliferating

trophoblast

Complications hypertension, hyperthyroidism, hyperemesis gravidarum, anaemia, ovarian lutein cyst

Dx U/s : ‘snow storm’ app, no fetal pole Doptone : no fetal heart beat VE : theca lutein cyst

Other Ix histological examination : confirming the

trophoblastic hyperplasia CXR : to exclude the presence of lung

metastasis

Suction evacuation of the molar tissue

Follow-up closely :

- Seen weekly : beta-chain specific hCG is taken.

- 2 weekly for the next 2 months, followed monthly for the

next 2 years.

- Pregnancy is discouraged until at least 6 months after

beta-chain specific hCG level have returned to normal.

- Each visit : serum hCG, assessment of menstrual period,

look for signs and symptoms of choriocarcinoma.

Indication for starting chemotheraphy :

A rising trend in the serum level of beta-chain

specific hCG.

Any evidence of ‘invasive’ mole.

Any evidence of choroicarcinoma

Chemotherapy :

Methotrexate

Combination of methotrexate and Actinomycin D

Thank you!!