early pregnancy complication by um
DESCRIPTION
TRANSCRIPT
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!!