Abortion, ectopic pregnancy and gestational trophoblastic diseases

1. ABORTION, ECTOPIC
PREGNANCY AND
GESTATIONAL
TROPHOBLASTIC DISEASES
Abhishek Prakash (5)
Akhilesh Kumar (6)
Aleena Rehman (7)
Aman Rahul (8)
Presented By-

2. ABORTION
Abortion is the expulsion or extraction from its mother of an embryo
or fetus weighing 500g or less when it is not capable of independent
survival (WHO).
This 500g of fetal development is attained approximately at 22 weeks
of gestation. The expelled embryo or fetus is called abortus.

3. ABORTION
Spontaneous
(miscarriage)
Induced
(deliberate)
Isolated
(sporadic)
Recurrent
Threatened Inevitable Complete Incomplete Missed Septic(rare)
Legal
(MTP)
Illegal
(unsafe)
Septic(common)

4. Etiology
The important factors are:-
• Genetics
• Anatomical
• Immunological
• Environmental
• Endocrine and metabolic
• Infection
• Thrombophilias
• Unexplained
• others

5. Common causes of miscarriage:
First trimester
1) Genetic factors (50%)
2) Endocrine disorders (LPD, diabetes)
3) Autoimmune and alloimmune disorders
4) Infections
5) Unexplained
Second trimester
1) Anatomic abnormalities
• Cervical incompetence
• Mullerian fusion defect
• Uterine synechiae
• Uterine fibroid
2) Maternal Medical Illness
3) Unexplained

6. Threatened miscarriage:
It is a clinical entity where the process of miscarriage has started but has not progressed
to a state from which recovery is impossible.
Clinical features:
• Bleeding per vaginum- usually slight brownish or brick red, usually stops spontaneously.
• Pain- appears usually following haemorrhage.
Pelvic examination reveals bleeding, if any escape through external os.
Investigation:
Routine investigation includes:
• Blood- for Hb, haemtocrit, ABO and Rh grouping.
• Urine for immunological test of pregnancy is not helpful.

7. Cont..
Ultrasonography :
• A well formed gestation ring with central echoes from embryo indicating
healthy fetus.
• Observation of fetal cardiac motions.
• Blighted ovum.
Treatment:
• Rest- the patient should be in bed for few days until bleeding stops.
• Drugs- relief of pain can be ensured by diazepam 5mg twice daily.

8. Inevitable miscarriage:
It is the clinical type of abortion where the changes have progressed to a state from
where continuation of pregnancy is impossible.
Clinical features:
• Increased vaginal bleeding.
• Aggravation of pain in lower abdomen which may be colicky in nature.
Internal examination reveals dilated interal os of the cervix through which the product of
conception are felt.
Management:
Excessive bleeding is controlled by administering Methergine 0.2mg if the cervix is dilated
and the size of uterus is less than 12 weeks.
Blood loss is corrected by IV fluid therapy and blood transfusion.

9. Complete miscarriage:
When the product of conception is expelled, it is called complete miscarriage.
Clinical features:
• Subsidence of abdominal pain.
• Vaginal bleeding becomes absent.
Internal examination reveals: Uterus is smaller than the period of amenorrhea and
a little firmer, cervical os is closed and bleeding is absent.
Ultrasonography reveals empty uterine cavity.
Management:
If the uterine cavity is not empty then evacuation of uterine curettage can be done.

10. Incomplete miscarriage:
When the entire product of conception is not expelled, instead a part of it is left
inside the uterine cavity, it is called incomplete miscarriage.
Clinical features:
• Continuation of pain in the lower abdomen.
• Persistence of bleeding.
Internal examination reveals uterus smaller and expelled mass is found incomplete.
Complication: the retained product may cause sepsis or placental polyp.
Management:
Evacuation of retained product of conception is done.

11. Missed miscarriage:
When the fetus is dead and retained inside the uterus for a variable period, it is
called missed miscarriage or early fetal demise.
Pathology: The exact cause is not clear. Beyond 12 weeks, the retained fetus
becomes macerated or mummified. The liquor amnii gets absorbed and the
placenta becomes pale, thin and adherent.
Clinical features:
• Persistence of brownish vaginal discharge.
• Subsidence of pregnancy symptoms.
• Retrogression of breast changes.
• Cessation of uterine growth.
• Nonaudibility of fetal heart sound.
• Cervix feels firm.
• Immunological test for pregnancy becomes negative.

12. Management:
Uterus is less than 12 weeks:
Expectant management—Many women expel the conceptus spontaneously
Medical management: Prostaglandin E1 (misoprostol) 800 ug vaginally in the
posterior fornix is given and repeated after 24 hours if needed. Expulsion usually
occurs within 48 hours.
Surgical management: suction evacuation or dilation and evacuation is done either
as a definitive treatment or it can be done when the medical method fails.
Uterus more than 12 weeks:
Prostaglandin E1 analogue 200ug tab. every 4 hours for 5 times.
Oxytocin 10-20 units in 500ml of NS.
Surgical evacuation could be done.

13. Septic Abortion:
Any abortion associated with clinical evidences of infection of the uterus and its
content is called septic abortion.
Clinically it is considered septic when:
• Rise of temp. of at least 100.4˚F for 24 hr or more.
• Offensive or purulent vaginal discharge.
• Other evidence of pelvic infection such as lower abdominal pain and tenderness.
Mode of infection:
Many organism such as Streptococci, Clostridium welchii, tetanus bacilli, Klebsiella,
Pseudomonas, etc could cause septic abortion when:
• Proper antiseptic and asepsis is not taken,
• Incomplete evacuation,
• Injury to the genitals and adjacent structure.

14. Clinical features:
• The women looks sick and anxious,
• Temperature: >36˚C
• Chills and rigor,
• Persistent tachycardia,
• Abdominal or chest pain,
• Impaired mental state,
• Diarrhoea or vomiting,
• Renal angle tenderness.
Pelvic examination:
Offensive, purulent vaginal discharge, uterine tenderness, boggy feel in the
POD(pelvic abscess)

15. Clinical Grading:
Grade I: the infection is localised in the uterus.
Grade II: the infection spreads beyond the uterus to the parametrium, tubes and
ovaries or pelvic peritoneum.
Grade III: Generalised peritonitis and endotoxic shock or jaundice or acute renal
failure.
Management:
Antibiotics such as piperacillin-tazobactam or carbapenem with clindamycin gives
broadest range of microbial coverage.
Analgesics and sedatives as required
Blood transfusion is given to control anemia and body resistance

16. Grade 1:
• Antibiotics
• Prophylactic antigas gangrene serum and antitetanus serum
intramuscularly
• Analgesics and sedatives
Blood transfusion is given to improve anemia and body
resistance

17. Grade 2:
• Antimicrobial therapy along with Grade 1 treatment.
Piperacillin-tazobactam and carbapenems
Vancomycin or teicoplanin
Clindamycin
Gentamycin
Metronidazole
• Surgery
Evacuation of the uterus
Posterior colpotomy

18. Grade 3:
Antibiotics are used as discussed above.
Clinical monitoring should be done.
Supportive therapy is directed to treat generalized peritonitis by gastric
suction and intravenous crystalloids infusion.

19. ECTOPIC PREGNANCY
An ectopic pregnancy is the one in which the fertilized ovum is implanted and develops
outside the normal endometrial cavity.
Site of implantation could be uterine and extrauterine.
Extrauterine includes:
• Tubal (most common)- ampulla, isthmus, infundibulum or interstitium
• Ovarian
• Abdominal
Uterine includes:
• Cervical
• Angular
• Cornual
• Cesarean scar

20. Tubal pregnancy:
Etiology:
I) Salpingitis and pelvic inflammatory disease.
II) Iatrogenic:
• Contraception failure
• IUD there is relative increase in tubal pregnancy should pregnancy occur with IUD
in situ.
• Sterilization- the risk in highest following laproscopic tubal motility.
• Use of progestin only pills.
III) Tubal surgeries
IV) Intrapelvic adhesion following pelvic surgery
V) Prior induced abortion
VI) Developmental defects of the tube
VII)Transperitoneal migration of the ovum

21. Acute Ectopic Pregnancy
Acute ectopic pregnancy is fortunately less common and it is associated with case
of tubal rupture or tubal abortion with massive intraperitoneal haemorrhage.
Symptoms: the classical triad of AEP are:
• Abdominal pain
• Amenorrhea
• appearance of vaginal bleeding
Signs:
• The patient is quiet and conscious
• Pallor could be seen in case of anaemia
• Features of shock could be seen
• Pelvic examination shows whitish vaginal mucosa, extreme tender cervix and
floating uterus

22. Unruptured tubal ectopic pregnancy
Symptoms:
• Presence of delayed period or spotting with features suggestive of pregnancy.
• Uneasiness on one side of flank which is continuous or at times colicky in nature.
Signs:
• Uterus is usually soft showing signs of early pregnancy.
• A pulsatile small, well circumscribed tender mass may be felt through one fornix
separated from the uterus.

23. Chronic or Old ectopic pregnancy
The onset is insidious. The patient had previous attacks of acute pain from which she had
recovered or she had chronic features from beginning.
Symptoms:
• Amenorrhea of short periods.
• Lower Abdominal pain of varying degree.
• Vaginal bleeding appears sooner or later following the pain.
Signs:
• The patient looks ill
• Pallor of varying degree is present
• Feature of shock are absent
• Temperature may be slightly elevated
• Tenderness on lower abdomen
• Cullen’s sign: dark bluish discoloration around the umbilicus if found, suggest intraperitoneal
haemorrhage.
• Bimanual examination is painful, ill defined, boggy and extreme tender mass is felt through the
posterolateral fornix extending to the pouch of Douglas.

24. Management of ectopic pregnancy
Acute: The principle of management of acute ectopic is resuscitaton and
laparotomy.
Antishock treatment-
• Ringer solution is started, if necessary with venesection.
• Arrangement for blood transfusion.
Laprotomy-
• Abdomen is opened by longitudinal incision.
• To grasp the uterus and draw it up undervision.
• The tubes and ovary of both the sides are inspected to fin out the side of rupture.
• The ipsilateral ovary and its vascular supply is preserved. Oophorectomy is done
only if the ovary is damaged beyond pathology.
Subtotal hysterectomy could be done.

25. Chronic:
• The patient is kept under observation, investigations are done and the patient is
put for laparotomy at earliest time.
• Usually a pelvic hematocele is found.
• The tube is identified and salpingectomy(surgical removal of fallopian tube/s) is
done.

26. GESTATIONAL TROPHOBLASTIC DISEASE
Gestational Trophoblastic Disease (GTD) is a spectrum of abnormal growth
and proliferation of the trophoblasts of the placenta that continue even
beyond the end of pregnancy of the placenta.
Persistent GTN
Is evidenced of molar pregnancy. This is diagnosed clinically when the
patient presents with-
Irregular vaginal bleeding
Subinvolution of the uterus
Level of hCG either elevate or fall after initial fall.
GTN after non molar pregnancy is always choriocarcinoma.

27. Placental Site Trophoblastic Tumor
The tumor arise from trophoblast of the placental bed.
B-hCG secretion is low but human placental lactogen (hPL) is secreted.
The entity is not responsible to chemotherapy.
Hysterectomy is the preferred treatment.
Serial serum hPL is reliable marker and useful for immunohistochemical staining.
Invasive Mole (Chorioadenoma Destruens)
Comprise 15% of all GTN and has massive invasive and destructive potentialities.
The uterine wall may be perforated at multiple areas showing purple fungating
growth.
The neoplasm may invade the pelvic blood vessels and metastasize to vagina or
distant.

28. Choriocarcinoma
Highly malignant tumor arising from chorionic epithelium.
Trophoblastic disease following a normal pregnancy is either choriocarcinoma or
PSTT and not a benign or invasive mole.
The primary site is anywhere in the uterus, rarely starts in tube or ovary.
The lesion is usually localized nodular, red, hemorrhagic and necrotic.

29. Clinical features of GTN:
Symptoms:
• Persistent ill health
• Irregular vaginal bleeding at time brisk
• Continued amenorrhea
Signs:
• Patient look ill
• Pallor of varying degree
• Bimanual examination reveals subinvolution of uterus. This may be purplish red
nodule in lower third of anterior vaginal wall.
• Unilateral or bilateral enlarged ovaries may be palpable.

30. PARAMETER SCORE
0 1 2 4
Age(years) <40 >40 - -
Antecedent
Pregnancy
Mole Abortion Term -
Interval(months) <4 4-6 7-12 >=13
Pretreatment hCG <10^3 10^3 - 10^4 10^4 – 10^5 >=10^5
Largest tumor(cm) <3 3-4 >5 -
Site of metastasis Lung
Pelvis
Spleen
Kidney
GI Tract
Liver
Brain
No. of metastasis - 1-4 5-8 >8
WHO Prognostic Scoring System of GTN as modified by FIGO (2000)
Total score: <6 is low and total score of >=7 is high risk.

31. Stage I The lesion is confined to uterus
Stage II The lesion spread outside the uterus but is confined to genital organs
Stage III The lesion metastasize to the lungs
Stage IV The lesion metastasizes to sites such as brain, liver or GIT
FIGO Anatomic staging for Gestational trophoblastic tumors:

32. Management of GTN
Preventive
Prophylactic chemotherapy in ‘at risk’ women following evacuation of molar
pregnancy may be considered.
‘at risk’ women are:
• Age of patient >35 years.
• Initial levels of serum hCG > 100,000 IU/ml
• Previous history of molar pregnancy.
Selective hysterectomy.
Diagnostic uterine curettage.
Curative
1) Chemotherapy:
Patient with non metastatic and good prognosis disease are treated effectively with
single agent therapy(methotrexate or actinomycin).
The patient with poor prognosis metastatic disease should be treated with
combination drug regimen (EMA-CO regimen)

33. 2) Surgical:
Indication of Hysterectomy:
• Lesion confined to uterus in women aged >35 years.
• Placental site trophoblastic tumor.
• Intractable vaginal bleeding.
• Localized uterine lesion resistant to chemotherapy.
• Accidental uterine perforation during curettage.
Types of surgeries:
• Total Hysterectomy is enough. The ovaries if involved can be effectively cured with postoperative chemotherapy.
• Lung resection in pulmonary metastasis.
• Craniotomy for control of bleeding.
3) Radiation:
Patients with brain metastasis require whole brain radiation therapy (3000 cGy over 10 days).
Intrathecal high dose methotrexate may be given to prevent haemorrhage and tumor shrinkage.