3. Last Normal Menstrual
Period
Patients do not always remember LRMP (especially when
presenting late for care) - Reliability
May be mistaken for implantation bleeding
Irregular periods
May be difficult to determine for Depo - provera and
implant users
Delayed Period
Recent pregnancy
4. What should you ask regarding
LRMP
Can You remember ?
Was it similar to your previous periods ?
Are the periods regular ?
Are you on hormonal contraception ?
Have you had a recent pregnancy ?
6. Positive Pregnancy Tests
Both urine and serum will become positive within 7-10
days of conception
Urine pregnancy test
Early morning sample
Sensitivity of the test
Serum ß HCG level doubles every 48 hours when the
pregnancy is intrauterine
7.
8. hCG
Oestrogen
Blood levels of hormones during gestation, 40 weeks
0 10 20 weeks 30 40
Bloodconcentration
End of period Parturition
Progesterone
hPL
Next slide
9.
10. Ultrasound features of a viable pregnancy
Regular Sac Fetal Echo
Yolk Sac Fetal Heart
A pregnancy sac that is seen in-utero on ultrasound scan
when the HCG is
> 1000 IU/L Transvaginal
> 1800 IU/L Transabdominal
11. Characteristics of a viable
intrauterine pregnancy
A yolk sac will be seen transvaginally when the
gestational sac is > 8mm (5.3 weeks)
A fetal pole should be seen transvaginally when
the gestation sac > 20mm (5.5 weeks)
A fetal heart will be seen with the CRL > 4mm
The normal fetal heart rate at 6 weeks is 70-100
beats/min.
17. Features of Miscarriages
conceptus Vaginal abdominal Cervix os Uterine
Subgroups expulsion bleeding pain dilation enlargement
Threatened no + -+ Closed compatible
miscarriage
Inevitable no + + + + Open compatible or
miscarriage smaller
Incomplete part + + + + Open smaller
miscarriage
Complete all + - - Closed normal
Miscarriage
19. Missed Miscarriage
Expulsion of the conceptus does not
occur despite a prolonged period
after embryonic death.
Symptoms of pregnancy regress
Pregnancy test becomes negative
No fetal heart motion is detected
Uterine enlargement ceases
Clinical Features
•Mild bleeding
or brown
discharge
•Uterus smaller
•Cervix closed
21. Septic miscarriage
Any type of spontaneous miscarriage is
complicated by infection
Endometritis, parametritis, peritonitis
Fever, abdominal tenderness, uterine
pain
Septicemia, septic shock
22. Recurrent miscarriage
Three or more consecutive spontaneous
losses of pregnancy
First-trimester: hypothyroidism, chromosomal
abnormalities, immunologic factors
Second-trimester: uterine malformations,
cervical incompetence, myomas
23. Options for the management of early
pregnancy failure
Surgical evacuation of the uterus
Medical evacuation of the uterus
Wait and see
24. Surgical management is recommended
when...
The patient is febrile (>37.50 C)
After appropriate antimicrobial management
If there is significant bleeding
Failed medical induction
25. Medical management is recommended
when
There are fetal parts >14 weeks in size
Missed Miscarriage
Incomplete Miscarriage
26.
27. Medical management of early pregnancy failure
or incomplete miscarriage
2 x 200 mcg Misoprostol into the posterior
fornix
Repeat in 4-6 hrs if required
Must scan or evaluate clinically to confirm
that evacuation is complete
In general echogenic material >16 mm in AP diameter is required for the
US diagnosis of retained products of conception
28. Conservative management of early pregnancy
failure or incomplete miscarriage
Repeat clinical and USS evaluation after 3
days
Then 7 days and weekly
Must come in at any hour if pain or
bleeding is unacceptable or fever occurs
29. Other aspects of management
Anti-D is required for EP bleeding if Rh Neg
Send all tissue for histology
Provide or arrange psychological support
Patients want an explanation for the loss
And advice about the future
Or contraceptive advice
Offer referral to GP, counsellor or a Support Group
31. Definition:
An ectopic pregnancy occurs when the
conceptus implants either outside the uterus
(Fallopian tube, ovary or abdominal cavity)
or in an abnormal position within the uterus
(cornua, cervix).
Combined tubal and uterine
(heterotopic) pregnancies are
uncommon.
32. Epidemiology and risk
factors
The incidence of ectopic
pregnancy is about 1 %.
Between 95 and 98 percent of
ectopic pregnancies occur in
the Fallopian tube.
33. Ectopic pregnancy
Pregnancy outside the uterine corpus
Ampulla
Cornu
Ovary
Abdominal
High index of suspicion if
previous ectopic
IUD
infertility
34. Site of ectopic pregnancy:
Site of tubal ectopic pregnancy are:
1.More than 50 % of tubal pregnancies are
situated in the ampulla.
2. approximately 20 % occur in the isthmus.
3. around 12 % are fimbrial .
4.approximately 10 % are interstitial
35. Pathogenesis
Sites of Implantation
Fallopian tube – most common site (ampulla) – 95%
Ovary
Uterine cornu
Cervix
Broad ligament
Spleen 5%
Liver
Retroperitoneum
Diaphragm
Cesarean scar
36. Risk factor for ectopic pregnancyRisk Factors for an Ectopic
Tual Sterilization
Previous Ectopic Pregnancy
Assisted reproduction & infertility
Intrauterine Device
Documented Tubal Pathology
Infertility
Previous Genital Infection
Multiple Partners
Previous Pelvic/Abdominal Surgery
Smoking
Caesarean section
Tubal Corrective Surgery
37. Clinical features
Compared to the other forms of early pregnancy disorders,
there is no pathognomonic pain or findings on clinical
examination that are diagnostic of a developing extrauterine
pregnancy.
Vaginal bleeding (usually old blood in small amounts) and
chronic pelvic pain (iliac fossa, sometimes bilateral) are the
most commonly reported symptoms.
38. General examination
This must include a record of pulse rate and blood
pressure.
Shoulder pain, which may occur secondary to blood
irritating the diaphragm .
vascular instability characterized by low blood pressure,
fainting, dizziness and rapid heart rate may be noted.
These symptoms are present in more than 50 % of patients
and are most typical of patients whose ectopic pregnancy
has ruptured (intra-abdominal bleeding).
39. Signs & Symptoms
Often subtle, or even absent
1.Pain :Pelvic and abdominal pain – sharp, stabbing or tearing in
character, rectal pain.
Pleuritic chest pain – from diaphragmatic irritation caused by the
hemorrhage
2.Abnormal Menstruation
Amenorrhea
Vaginal bleeding – may be scanty, dark brown, intermittent or
continuous
3.Abdominal and pelvic Tenderness
Tenderness on abdominal and vaginal
examination especially on motion of the cervix
– ruptured or rupturing tubal pregnancies
40. Signs & Symptoms
4. Uterine changes
In 25% of women, the uterus enlarges due to hormonal stimulation of
pregnancy.
5. Blood pressure and pulse
Before rupture vital signs are generally normal. Hypotension and
tachycardia – if bleeding continues and hypovolemia becomes
significant
6. Pelvic Mass
Almost always either posterior or lateral to the uterus, and typically
soft and elastic
The mass may be firm with extensive infiltration of blood into the
tubal wall.
41. Tubal Ectopic Pregnancy
Ultrasound Features of
Ectopic Pregnancy
•Empty uterus
•Adnexal mass
+/- FHR
Ring of blood flow
on doppler
Free fluid especially
POD
42.
43. Gynaecological examination:
Speculum or bimanual examination must be performed in
an environment where facilities for resuscitation are
available,
as this examination may provoke the rupture of the tube.
44. Laparoscopy
Laparoscopy should be considered in
women with hCG above the discriminatory
level and absence of an intrauterine
gestational sac on ultrasound
45. Management
Ectopic pregnancy can be treated :
1. conservative (expectant ).
2. medical.
3. surgical .
According to:
1. Clinical presentation.
2. Ultrasound finding.
3. B-HCG titer.
46. Expectant Management
Criteria:
1.Decreasing serial β-hCG levels.
2.Tubal pregnancies only .
3.No evidence of intra-abdominal
bleeding or rupture as assessed by
vaginal sonography
4.Diameter of the ectopic mass not
greater than 3.5 cm
47. Medical Management:
METHOTREXATE
An anti-neoplastic drug that acts as a folic
acid antagonist, and is highly effective
against rapidly proliferating trophoblasts.
Success is greatest if
The gestation is <6 weeks
The tubal mass should be <3.5 cm in diameter
The fetus is dead
Β-hCG is <5,000 mIU/mL
49. Surgical Management:
CONSERVATIVE
Salpingostomy
Used to remove a small pregnancy
usually <2 cm in length.
A 10-15 mm linear incision is made on
the antimesenteric border immediately
over the ectopic pregnancy, and is left
unsutured to heal by secondary intention
Readily performed through a laparoscope
Gold standard surgical method used for
unruptured ectopic pregnancy
52. Gestational Trophoblastic disease
Abnormal placental development
Usually no recognizable fetus
Exaggerated symptoms of pregnancy
Hyperemesis
Thyroid hormone abnormality
Large theca-lutein cysts
Can recur and rarely in malignant form
55. 46xx
23x
Proliferation of
monospermic
androgenetic
complete HM
Duplication
of haploid
sperm
Maternal DNA
lost from
ovum
46xy
23x
Proliferation of
dispermic
androgenetic
complete HM
Two paternal
genetic
contributions
Maternal DNA
lost from
ovum
69xxx
23x
Proliferation of
triploid
partial HM
Maternal and two
paternal genetic
contribution
69xxy