The document provides notes on abnormal pregnancies including ectopic pregnancy, miscarriage, recurrent miscarriage, termination of pregnancy, eclampsia, multiple pregnancies, breech presentation, rhesus iso-immunization, and uterine fetal pregnancy. It discusses risk factors, diagnostic criteria, management options, and complications for each condition. The notes were created by Mariechen Puchert for her second year studies using textbooks and lecture materials from her university in South Africa.

1. Mariechen Puchert 2010
NOTE/Disclaimer: These are notes I made for myself during my second year. I cannot
guarantee that there aren’t mistakes. I do know that studying them were great help to me. I
used notes and powerpoints given to my class by lecturers (University of Stellenbosch,
Tygerberg Campus, South Africa) as well as the following textbooks:
Clinical Gynaecology : TF Kruger, MH Botha
Ostetrics in South Africa: Cronje
Feel free to contact me with any queries or complaints.
Abnormal Pregnancy
Ectopic Pregnancy
Ectopic Pregnancy Implantation of developing blastocyst anywhere else but the
endometrial lining of the uterine cavity
♪ Most common: Ampulla of Fallopian Tube
♪ Other sites: Broad ligament, cervix, abdomen, ovary
Risk factors
• Previous miscarriage
• Previous induced abortion
• Previous PID or genital infection
• Previous tubal surgery
• IUD use, current or previous (>2 years)
• Smoking
• Age >40 years
• Infertility
• Sterilisation
• Previous ectopic pregnancy
• Diethylstilboestrol exposure
• Sexual promiscuity
Diagnostic Triad
1. Abdomino-pelvic pain
2. Amenorrhoea
3. Vaginal bleeding
o + ᵝHCG
o peritonitis, pelvic mass, CET
o empty uterus on ultrasound
Differential Diagnosis
• PID
• Ovarian cyst complications (rupture, torsion)
• Miscarriage
• Appendicitis
• Pylenephritis

2. Mariechen Puchert 2010
Medical Management
Methotrexate 1mg/kg
No evidence of rupture
ᵝHCG ≤ 3 000 IU/ℓ
Absence of foetal cardiac activity
No sex or pelvic examination until resolved
No pregnancy for three months
Surgical Management
Signs of rupture
ᵝHCG ≥ 3 000 IU/ℓ
Salpingostomy vs salpingectomy vs laparotomy
Management Options
A. Expectant
B. Medical
C. Surgical
Expectant management
No evidence of rupture
ᵝHCG < 1 000 IU/ℓ
Haemoperitonium < 50mℓ, tubal mass < 2cm, no recognisable foetal parts on sonar
Patient remains close to medical facilities
Weekly ᵝHCG-testing until not detected
No sexual intercourse or pelvic examination until resolved
Salpingostomy
• Fertility conservation
• Absent or damaged contra-lateral tube
• Haemodynamically stable
• Unruptured
• < 5cm diameter
♪ Salpingectomy preferred when contra-lateral tube is healthy.
Laparotomy
• Signs of rupture
• Unstable patient, acute abdomen
• Free fluid in pouch of Douglas
Advantages
Blood loss less
Analgesic less
Hospital stay shorter
Cost savings

3. Mariechen Puchert 2010
Miscarriage
Miscarriage end of intrauterine pregnancy before 28 weeks i.e. viability
1. Spontaneous
o Sporadic
o Recurrent
2. Induced
o Therapeutic
o Iatrogenic
o Criminal
Aetiology
• Chance
• Corpus luteum defect
• Weak placentation
• Anatomical defect
• Trophoblast infiltration
Types
i. Threatened miscarriage
ii. Inevitable miscarriage
iii. Incomplete miscarriage
iv. Complete miscarriage
v. Missed miscarriage
vi. Septic miscarriage
Management
1. Rhesus and other evaluations
2. Evacuate uterus
3. Emotional support
4. Discuss contraception
Complications
o Infection
o Bleeding
o Kidney failure
o Haemolytic anaemia
o Trauma
o Infertility
o Psychiatric problems
Signs of septic abortion
• Weak pulse > 100 BPM
• Respiratory rate > 20 RPM
• Temperature < 36,5°C or >37,8°C
• Tender abdomen or uterus
• Offensive vaginal discharge
♫MUST stabilise, give antibiotics and fluids.

4. Mariechen Puchert 2010
Recurrent Miscarriage
1. Inability of ovary to maintain: Corpus Luteum defect; Rx Progesterone
2. Cervical incompetence: Cervical cerclage
3. Congenital uterine abnormality: Cerclage, Hysteroscopy, Metroplasty
4. Leiomyomata
5. Poor placentation
6. Genetics
7. Maternal disease: e.g. syphilis causes 2nd
trimester abortion
Termination of Pregnancy
Legal indications
I. Pregnancy
II. Woman’s life/health
Severe foetal risk
Rape/incest
Socio-economic circumstance
III. Mother’s life
Malformation
Foetal injury risk
Methods
A. Surgical
B. Medical: Misoprostol or Mifepristone
C. Combination
Eclampsia
Eclampsia Patient with pre-eclampsia has a generalised convulsion
Symptoms Signs
Headache Tenderness over liver
Visual disturbances Increased tendon reflexes
Upper abdominal pain
Management
1. Position: prevents aspiration of stomach content
2. Arrest convulsion: Magnesium Sulphate
3. Blood pressure control: Dihydralizine if diastolic > 110mm/Hg
4. Monitor urine output: Foley’s catheter
5. Transfer: to adequate health care facility
♪ Magnesium Sulphate prevents eclampsie and controls and prevents further
convulsions. If convulsions recur twice, give Diazepam.

5. Mariechen Puchert 2010
Multiple Pregnancies
Dizygotic two ova and two sperm hence fraternal, different genetics
Monozygotic one ovum and one sperm that divide after fertilisation
Chorionicity and amnionicity according to zygotic division
[dizygotic dichorionic and diamniotic]
Early dichorionic and diamniotic
Late dichorionic and monoamniotic
Later monochorionic and monoamniotic
Latest monochorionic, monoamniotic, conjoint twins
Dizygotic determinants
o Family history
o Race
o Maternal age
o Maternal obesity
o Assisted reproductive techniques
o Contraptive history
Signs of twinning
• Large symphesis-fundus height
• Wide abdomen
• Polyhydramnios
• More foetal poles
• Small head for GA
Clinical confirmation
1. two heads
2. three foetal poles
3. two foetal heart rates
Maternal complications
o extensive physiological changes
o exaggerated minor complaints
o anaemia
o increased hypertensive conditions
o APH
o PPH
o Risk of caesarean section
Foetal Complications
• Abortion risk
• Aneuploidy risk
• IUGR
• Malpresentation
• Cord prolapse and foetal distress

6. Mariechen Puchert 2010
• IUD
• Twin-twin transfusion syndrome
Breech Presentation
Breech Foetal buttock are presenting part at maternal pelvis
Side-effects of vaginal delivery
o Asphyxia
o Cord prolapse
o Brachial plexus trauma
ECV External manual pressure to life presenting part out of pelvis
and turn foetus into cephalic presentation
Contraindications to External Cephalic Version
• Antepartum haemorrhage
• Rupture of membranes
• Multiple pregnancies
• Pregnancy < 37 weeks
• Caesarean section indicated
• Hypertensive disorder
Complications of ECV
o ROM
o Placenta Abruptio
o Haemorrhage
o Uterine rupture
Rhesus Iso-immunisation
Rhesus-negative mother gives birth to Rhesus-positive baby.
Progression
1. Anaemia and haemolysis
2. Hypoxia and metabolic acidosis
3. Congestive heart failure
♫ Prophylaxis with Anti-D-globulin is very effective and prevents allo-immunisation.
Uterine Foetal Pregnancy
Uterine tumour Neuromotor abnormality Placenta praevia
Pelvic tumour Hydrocephalus Multiple pregnancy
Congenital abnormality Short umbilical cord Poly/Oligohydramnios
Foetal death Advanced ectopic

7. Mariechen Puchert 2010
Failure of prophylaxis
i. Not given
ii. Low dosage
iii. Too late
iv. Poor quality
v. Already immunised