Early Pregnancy Complication by UM

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Early Pregnancy Complication by UM

  1. 1. Noor Asyikin Bt Abdullah Ariana Bt Syamsidi
  2. 2. 3 main categories of early pregnancy disorders are:
  3. 4. <ul><li>ABORTION </li></ul><ul><li>Definition :Expulsion of product of conception (POC) before 22 nd week of period of gestation (POG), which mean before period of fetal viability. </li></ul><ul><li>Aetiology factors: </li></ul><ul><li>Maternal’s age >35 years old </li></ul><ul><li>Trauma </li></ul><ul><li>Infections (TORCHES, malaria) </li></ul><ul><li>Endocrine disorders (diabetes, hypothyroidism, PCOS) </li></ul><ul><li>Immunological disorders (SLE, antiphospholipid syndrome) </li></ul><ul><li>Abnormalities in uterus (uterine fibroid) </li></ul><ul><li>Psychological disorder (stress) </li></ul><ul><li>Chromosomal abnormalities (Down syndrome) </li></ul><ul><li>Exposure to chemical agents (benzene, tobacco, arsenic, pesticides) </li></ul>
  4. 5. TYPES OF ABORTION:
  5. 6. <ul><li>THREATENED ABORTION </li></ul><ul><li>Definition : Painless vaginal bleeding, that occur at anytime between </li></ul><ul><li> implantation and 24 weeks of gestation. </li></ul><ul><li>: POC has threatened to abort but has not done so yet. </li></ul><ul><li>Clinical features: </li></ul><ul><li>Bleeding (minimal, painless) </li></ul><ul><li>Associated with dull aching lower abdominal pain </li></ul><ul><li>Examination: </li></ul><ul><li>Size of uterus is correspond to period of amenorrhea (POA) </li></ul><ul><li>Closed cervical os </li></ul><ul><li>U/S : well-formed, rounded gestational sac </li></ul><ul><li>with fetus within it </li></ul><ul><li>Management: </li></ul><ul><li>Bed rest </li></ul><ul><li>Folic acid supplements </li></ul><ul><li>Progesterone supplements </li></ul><ul><li>Avoid coitus </li></ul>
  6. 7. <ul><li>INEVITABLE ABORTION </li></ul><ul><li>Definition : Painful vaginal bleeding from retro-placental site </li></ul><ul><li>: POC is about to be aborted but not yet </li></ul><ul><li>It can progress to complete/ incomplete abortion depending on whether or not all fetal & placental tissues have been expelled from uterus. </li></ul><ul><li>Clinical features: </li></ul><ul><li>Vaginal bleeding (painful) </li></ul><ul><li>Associated with cramping pain at lower abdomen </li></ul><ul><li>Examination: </li></ul><ul><li>Size of uterus is correspond to/less than POA </li></ul><ul><li>Dilated cervical os </li></ul><ul><li>Management </li></ul><ul><li>Hospitalization </li></ul><ul><li>Analgesics for control of pain </li></ul><ul><li>Evacuation of uterine cavity with suction evacuation, or ovum forceps (manually) </li></ul>
  7. 8. <ul><li>INCOMPLETE ABORTION </li></ul><ul><li>Definition : POC has aborted but not completely </li></ul><ul><li>Clinical features: </li></ul><ul><li>Vaginal bleeding (heavy, passed out POC as fleshy masses) </li></ul><ul><li>Associated with colicky pain at lower abdomen </li></ul><ul><li>+/- signs of shock </li></ul><ul><li>Examination: </li></ul><ul><li>Size of uterus is smaller than POA </li></ul><ul><li>Open cervical os </li></ul><ul><li>U/S : reveal retained POC in uterine cavity </li></ul><ul><li>Management: </li></ul><ul><li>Resuscitate if bleeding is severe, do blood group and cross match </li></ul><ul><li>Give analgesia for pain </li></ul><ul><li>Ergometrine (i.m) to contract the uterus and control bleeding </li></ul><ul><li>Evacuation of the uterus of its product of conception once patient’s condition is </li></ul><ul><li>stable. </li></ul>
  8. 9. <ul><li>COMPLETE ABORTION </li></ul><ul><li>Definition : All the POC has completely aborted. </li></ul><ul><li>Clinical features: </li></ul><ul><li>History of pain and passage of product </li></ul><ul><li>Followed by absent of pain, minimal bleeding </li></ul><ul><li>Examination: </li></ul><ul><li>Size of uterus is smaller than POA </li></ul><ul><li>Closed cervical os </li></ul><ul><li>U/S : empty uterine cavity </li></ul><ul><li>Management: </li></ul><ul><li>Do U/S to look for empty of uterine cavity and to rule out any possibility of extra </li></ul><ul><li>uterine pregnancy </li></ul>
  9. 10. <ul><li>MISSED ABORTION </li></ul><ul><li>Definition : When the embryo/fetus is already died </li></ul><ul><li>: but still remain in the uterine cavity for a period of time </li></ul><ul><li>: without symptoms of miscarriage </li></ul><ul><li>Clinical features: </li></ul><ul><li>Decreased in pregnancy symptoms </li></ul><ul><li>Vaginal bleeding (absent, minimal) </li></ul><ul><li>Examination: </li></ul><ul><li>Size of uterus is smaller than POA </li></ul><ul><li>Closed cervical os </li></ul><ul><li>U/S : crumpled gestational sac </li></ul><ul><li>: revealed fetal pole but no signs of activity (no heart activity) </li></ul><ul><li>Management: </li></ul><ul><li>Wait for spontaneous expulsion (disadvantage: involve further maternal anxiety, </li></ul><ul><li>pain of expulsion, DIVC) </li></ul><ul><li>Evacuation of uterus of its POC </li></ul><ul><li>- surgically : dilatation & currettage </li></ul><ul><li>- medically : mifepristone + misoprostol </li></ul>
  10. 11. COMPLICATIONS OF EVACUATION
  11. 12. RECURRENT ABORTION Definition : 3 or more consecutive spontaneous abortion Can be divided into:
  12. 14. ECTOPIC PREGNANCY Definition : Pregnancy outside uterine cavity <ul><li>In fallopian tube (fimbrial, ampullary, isthmic, interstitial) </li></ul><ul><li>In the ovary </li></ul><ul><li>In the abdominal cavity </li></ul><ul><li>In the cervical site </li></ul>Sites of implantation:
  13. 15. <ul><li>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. </li></ul><ul><li>As the trophoblast proliferates further , it will cause rupture of serosa and hemoperitoneum. </li></ul><ul><li>The trophoblast does not differ histologically from a normal intrauterine pregnancy, but the embryo in an ectopic pregnancy is usually stunted or frequently absent. </li></ul>
  14. 16. <ul><li>PATHOPHYSIOLOGY </li></ul><ul><li>Any mechanical or functional factors that interfere the passage of the fertilized ovum to the uterine cavity. </li></ul><ul><li>Important factors involved in its transport: tubal contractility, ovarian hormones & cilial action within the tubes </li></ul>
  15. 17. <ul><ul><li>Vaginal Bleeding (scanty, dark and intermittent) </li></ul></ul><ul><ul><li>Lower abd pain, back or pelvic pain (usu. unilateral) </li></ul></ul><ul><ul><li>Shoulder pain </li></ul></ul><ul><ul><li>Syncopal attacks (hemoperitoneum) </li></ul></ul><ul><ul><li>Symp of hypovolemic shock </li></ul></ul><ul><li>- Upset menstrual pattern </li></ul><ul><li>- Vague abdominal pain </li></ul>
  16. 18. <ul><ul><li>General examination </li></ul></ul><ul><ul><li>shoulder pain 2° to free blood in the peritoneal cavity irritating the diaphragm </li></ul></ul><ul><ul><li>vascular instability - low BP, fainting, dizzy, rapid heart rate </li></ul></ul><ul><ul><li>abdominal palpation : mild tenderness, guarding, decreased bowel sounds may be present (ectopic pregnancy rupture may cause intra-abdominal bleeding) </li></ul></ul>
  17. 19. <ul><ul><li>Gynecological examination </li></ul></ul><ul><ul><li>speculum : cervical os is closed </li></ul></ul><ul><ul><li>BE : uterus will be smaller than </li></ul></ul><ul><ul><li>the expected date </li></ul></ul><ul><ul><li>Positive cervical excitation </li></ul></ul><ul><ul><li>gentle motion of the cervix to both sides of the lateral fornix </li></ul></ul><ul><ul><li>tender if stretching of the involved site </li></ul></ul>
  18. 20. <ul><li>Human chorionic gonadotrophin (hCG) </li></ul><ul><ul><li>normal/low hCG </li></ul></ul><ul><li>Transvaginal ultrasound </li></ul><ul><ul><li>+/- gestational sac(intrauterine/tubal) </li></ul></ul><ul><ul><li>Extrauterine sac with an embryo/embryonic remnants </li></ul></ul><ul><ul><li>Any fluid in the pelvis esp. in Pouch of Douglas </li></ul></ul><ul><ul><li>Empty ectopic sac/heterogenous adnexal mass </li></ul></ul><ul><ul><li>Pseudogestational sac(small, centrally located endometrial fluid collection surrounded by a single echogenic rim of endometrial tissue undergoing decidual reaction) </li></ul></ul>
  19. 21. <ul><ul><li>Culdocentesis </li></ul></ul><ul><ul><li>to exclude hemoperitoneum (late ectopic pregnancy-emergency cases) </li></ul></ul><ul><ul><li>Laparoscopy </li></ul></ul><ul><ul><li>All but the very early ectopic pregnancies can be diagnosed by this techniqu e </li></ul></ul><ul><ul><li>Dilatation and Curettage </li></ul></ul><ul><ul><li>Not useful as a primary investigation. </li></ul></ul><ul><ul><li>On the contrary, many ectopic pregnancies are missed even after dilatation and curettage is done for termination of pregnancy </li></ul></ul>
  20. 22. Culdocentesis Transvaginal puncture of the Douglas’ cul-de-sac for aspiration of fluid
  21. 24. <ul><ul><li>Surgical : salpingectomy/salpingotomy either by laparotomy/laparoscopy </li></ul></ul><ul><ul><li>Medical </li></ul></ul><ul><ul><ul><li>Methotrexate ; i.m/direct into tubal pregnancy </li></ul></ul></ul><ul><ul><li>Expectant </li></ul></ul><ul><ul><ul><li>Strict criteria in selected pt. </li></ul></ul></ul><ul><ul><ul><li>Ultrasound & hCG assessments are prerequisites </li></ul></ul></ul>
  22. 28. <ul><li>Also known as ‘hydatidiform mole’ </li></ul><ul><li>‘ Gestational throphoblastic disease’. </li></ul><ul><li>Abnormal pregnancy in which the developing fetus and placenta are replaced by proliferation of throphoblastic tissue. </li></ul>
  23. 29. <ul><li>Can be classified as </li></ul><ul><ul><li>Complete hydatiform mole </li></ul></ul><ul><ul><ul><li>- no normal fetal tissue forms </li></ul></ul></ul><ul><ul><li>Partial hydatiform mole </li></ul></ul><ul><ul><ul><li>- incomplete fetal tissues develop alongside molar tissue </li></ul></ul></ul><ul><ul><li>Choriocarcinoma (invasive mole) </li></ul></ul><ul><ul><ul><li>- contains many villi, but these may grow into or through the muscle layer of the uterus wall </li></ul></ul></ul><ul><ul><ul><li>- can spread to tissues outside of the uterus. </li></ul></ul></ul>
  24. 30. <ul><li>Epidemiology </li></ul><ul><li>Complete : 1 per 1000-2000 pregnancies. </li></ul><ul><li>Partial : 1 per 700 pregnancies. </li></ul><ul><li>Choriocarcinoma : varies ( 3-10%) </li></ul><ul><li>Risk factors </li></ul><ul><li>Increase with maternal age. </li></ul><ul><li>Previous history of molar pregnancy. </li></ul><ul><li>Dietary habits of some ethnic group (remains controversial). </li></ul><ul><li>A diet low in carotene (a form of vitamin A) </li></ul>
  25. 31. <ul><li>Genetic karyotype: </li></ul><ul><li>Complete mole </li></ul><ul><ul><li>- Homozygous XX – both Xs derived from paternal side ( haploid sperm 23X fertilizes “empty egg”  replicates itself) </li></ul></ul><ul><ul><li>- Heterozygous 46XY (occasionally) </li></ul></ul><ul><li>Partial mole </li></ul><ul><li> - triploid with extra sets of chromosomes paternally </li></ul><ul><li>derived(69XXX/69XXY) </li></ul>
  26. 32. 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.
  27. 33. clusters of tissue swollen with fluid, giving it the appearance of a cluster of grapes
  28. 34. <ul><li>Bleeding in early pregnancy </li></ul><ul><li>Passing out “ grape-like structure ” </li></ul><ul><li>Hyperemesis gravidarum </li></ul><ul><li>Thyrotoxicosis </li></ul><ul><li>Other findings :- </li></ul><ul><li>Uterus larger than dates </li></ul><ul><li>No fetal heart ( doptone examination ) </li></ul>
  29. 35. <ul><li>Beta HCG measurements – High level </li></ul><ul><li>Ultrasound :- </li></ul><ul><li>- ‘ snow storm ’ appearance </li></ul><ul><li>- no fetal parts seen </li></ul><ul><li>- bilateral theca lutein cysts in ovaries </li></ul><ul><li>(as a result of excessive hormonal stimulation) </li></ul><ul><li>Histological examination -large edematous villi are avascular and show evidence of throphoblastic proliferation. </li></ul><ul><li>Chest X-ray – exclude invasive mole in lung </li></ul>
  30. 36. <ul><li>Suction evacuation of the molar tissue </li></ul><ul><li>Weekly hCG level monitoring until undetectable </li></ul><ul><li>Monthly monitoring for 6-24 months </li></ul>
  31. 37. <ul><li>Highly malignant tumour that arises from throphoblastic epithelium. </li></ul><ul><li>Can metastasizes to lung, liver and brain. </li></ul><ul><li>50% follow molar pregnancy, 30% after miscarriage, 20% after normal pregnancy. </li></ul><ul><li>Also can occur after extrauterine pregnancy -> signs and symptom of ectopic pregnancy </li></ul>
  32. 39. <ul><ul><li>High maternal age </li></ul></ul><ul><ul><li>Prev hx of molar pregnancy </li></ul></ul><ul><ul><li>ABO blood gp (parents) – chorioCA women with blood </li></ul></ul><ul><ul><li>gp A have higher risk than gp O </li></ul></ul><ul><ul><li>History of miscarriage. </li></ul></ul>
  33. 40. <ul><li>Genital manifestations </li></ul><ul><ul><li>Amenorrhea </li></ul></ul><ul><ul><li>Vaginal bleeding </li></ul></ul><ul><ul><li>Intraperitoneal hemorrhage </li></ul></ul><ul><ul><li>Vaginal metastasis </li></ul></ul><ul><li>Extravaginal manifestations </li></ul><ul><ul><li>Lungs-’cannon ball’ lesion </li></ul></ul><ul><ul><li>Brain-stroke </li></ul></ul><ul><ul><li>Liver </li></ul></ul><ul><ul><li>GIT </li></ul></ul><ul><li>Vaginal bleeding (passing out grape like struc.) </li></ul><ul><ul><li>Uterine enlargement greater than dates </li></ul></ul><ul><ul><li>Abnormally high hCG  secrete by the proliferating trophoblast </li></ul></ul>
  34. 41. <ul><ul><li>Complication s  hypertension, hyperthyroidism, hyperemesis gravidarum, anaemia, ovarian lutein cyst </li></ul></ul><ul><li> Dx </li></ul><ul><ul><li>U/s : ‘snow storm’ app, no fetal pole </li></ul></ul><ul><ul><li>Doptone : no fetal heart beat </li></ul></ul><ul><ul><li>VE : theca lutein cyst </li></ul></ul><ul><li>Other Ix </li></ul><ul><ul><li>histological examination : confirming the trophoblastic hyperplasia </li></ul></ul><ul><ul><li>CXR : to exclude the presence of lung metastasis </li></ul></ul>
  35. 42. <ul><li>Suction evacuation of the molar tissue </li></ul><ul><li>Follow-up closely : </li></ul><ul><li>- Seen weekly : beta-chain specific hCG is taken. </li></ul><ul><li>- 2 weekly for the next 2 months, followed monthly for the next 2 years. </li></ul><ul><li>- Pregnancy is discouraged until at least 6 months after beta-chain specific hCG level have returned to normal. </li></ul><ul><li>- Each visit : serum hCG, assessment of menstrual period, look for signs and symptoms of choriocarcinoma. </li></ul>
  36. 43. <ul><li>Indication for starting chemotheraphy : </li></ul><ul><ul><li>A rising trend in the serum level of beta-chain specific hCG. </li></ul></ul><ul><ul><li>Any evidence of ‘invasive’ mole. </li></ul></ul><ul><ul><li>Any evidence of choroicarcinoma </li></ul></ul><ul><li>Chemotherapy : </li></ul><ul><ul><li>Methotrexate </li></ul></ul><ul><ul><li>Combination of methotrexate and Actinomycin D </li></ul></ul>
  37. 44. Thank you!!

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