The document discusses various causes of bleeding in early pregnancy including abortion, ectopic pregnancy, and hydatidiform mole. Abortion is described as spontaneous or induced expulsion of products of conception before viability. Ectopic pregnancy is implantation outside the uterus, most commonly in the fallopian tubes. Hydatidiform mole is an abnormal placenta with cyst formation due to genetic abnormalities preventing embryo development. Signs of these conditions include vaginal bleeding, abdominal pain, and elevated beta-hCG levels. Diagnosis involves ultrasound and beta-hCG testing. Treatment depends on factors like severity but may include medication, surgery, or monitoring.

1. BLEEDING IN EARLY PREGNANCY:
ABORTION, ECTOPIC PREGNANCY,
HYDATIDIFORM MOLE
SHARON TREESA ANTONY
Second Year M.sc Nursing

2.  Abortion
 Ectopic Pregnancy
 Hydatidiform mole

3. ABORTION
 Definition
 Types

4. PATHOLOGY
 Hemorrhage into the decidua basalis
 Necrotic changes in the tissues
 Ovum detaches and stimulates uterine contractions

5. ETIOLOGIES AND RISK FACTORS
 Most in first 12 weeks
 Chromosomal anomalies
 Parity
 Maternal and paternal age
 Conception with < 3months gap

6. FETAL FACTORS
 Abnormal zygote development
 Aneuploid abortion
 Euploid abortion

7. MATERNAL FACTORS
 Infections
 Chronic debilitating disease
 Endocrine abnormalities
 Drug use and environmental factors
 Immunological factors
 Aging gamates
 Physical trauma
 Uterine defects

8. PATERNAL FACTORS

9. THREATENED ABORTION
 Definition
 Diagnosis
 USG
 S. Progesterone
 TVS
 Beta hcg
o Treatment

10. LEVEL OF BETA HCG
DAYS FROM LMP BETA HCG
(mIU/ml)
TVS
34.8+/- 2.2 914+/-106 FETAL SAC
40.3+/- 3.4 3783+/- 683 FETAL POLE
46.9+/- 6.0 13,178+/-2898 FETAL HEART
ACTIVITY

11. INEVITABLE MISCARRIAGE
 Definition
 Signs and symptoms
 Management

12. COMPLETE ABORTION
 Definition
 Clinical features
 Management

13. INCOMPLETE ABORTION
 Definition
 Clinical features
 Management
 Complications

14. MISSED MISCARRIAGE
 Definition
 Pathology
 Clinical features
 Diagnosis
 Management
 Compllications

15. SEPTIC ABORTION
 Definition
 Mode of infection
 Pathologgy
 Clinical features
 Clinical grading
 Investigations
 Management

16. GRADE 1
 Antibiotics
• Gram positive
• Penicillin G 5 million units Q6H
• Ampicillin 0.5-1g IV Q6h
• Gram negative
• Genta 15mg/kg IV Q8H
• Ceftriaxone 1g IV Q12H

17. • Anaerobes
• Metronidazole 500mg IV Q8H
• Clindamycin 600mg IV Q8H
• AGS 8000 units IM
• ATS 3000 units IM
• Analgesics and sedatives
• blood transfusion
• evacuation

18. GRADE 2
 antibiotics+
 Analgesics
 AGS
 ATS
 Surgery
 Evacuation of uterus

19. GRADE 3
 Antibiotics
 Supportive therapy
 Monitoring
 Active surgery

20. RECURRENT ABORTION
 Definition
 Etiology
 Investigations
 Treatment
 Interconceptional period
 During pregnancy

21. ETIOLOGY
FIRST TRIMESTER
 Genetic factors
 Endocrine and metabolic factors
 Infection
 Inherited thrombophilia
 Immunological causes
SECOND TRIMESTER
 Chronic maternal illness
 Infection
 Unexplained

22. NURSING CARE
 Physiologic stabilization
 Preparation for manual or surgical evacuation
 Oxytocin
 Management of bleeding
 Antibiotics
 Analgesics
 Transfusion therapy
 Anti D
 Psychosocial care
 Home care
 Discharge teaching

23. ECTOPIC PREGNANCY
An ectopic pregnancy is one in which
the zygote is implanted and develops
outside the normal endometrial cavity.

24. SITES
Extrauterine Intrauterine
tubal
abdominal
Ovarian
Ampulla Isthmus Infundibulum
Interstitial
Primary secondary
Cervical Cornual Angular caesarean
Intraperito
neal
Extraperit
oneal

26. ETIOLOGY
 MECHANICAL FACTORS
 Salpingitis
 Peritubal adhesions
 Developmental abnormalities
 Previous ectopic pregnancy
 Previous operations on the tube
 Multiple previous induced aabortions
 Tumors that distort the tube
 Previous caesarean section
 Previous pelvic surgery

27.  FUNCTIONAL FACTORS
 External migration of the ovum
 Menstrual reflux
 Altered tubal motility
 Cigarette smoking

28.  Increased receptivity of tubal mucosa to fertilized
ovum
 Assisted reproduction
 Failed contraception

29. TUBAL PREGNANCY
 Anatomical considerations
Ampulla is the most frequent site
 Zygote implantation
 Burrows through the epithelium
 Lies in the muscular wall
 Maternal blood vessels open into the space
between trophoblast
 embryo or foetus is usually absent

30. UTERINE CHANGES
 Under the influence of corpus luteum
 Softening of cervix
 Increase in size
 Increased vascularity
 Decidua develops but no villi
 Decidual cast

31. CHANGES IN THE TUBE
 Implant in inter columnar fashion
 Stretching of muscles
 Engorged blood vessels
 May burrow through the mucous membrane
 Intra muscular implantation
 Blood in between blastocyst and serous coat
 Distended tube
 Blood spillage from fimbrial end
 Stretching of peritoneum
 Hemoperitoneum

32. NATURAL HISTORY OF TUBAL PREGNANCY
 Tubal abortion: ampulla
 Hemorrhage
 Disrupt connection between the placenta and
membranes and tubal wall
 May expel through fimbrial end forming
hematosalpinx
 Incomplete abortion placental polyp

33. TUBAL RUPTURE
 Isthmic : early rupture
 Interstitial : late rupture
 Signs of collapse
 If expelled into peritoneal cavity may survive or
absorbed
 May become lithopedion in cul-de-sac
Abdominal pregnancy
Broad ligament pregnancy

34. ABDOMINAL PREGNANCY
 Placenta remains attached to tube

35. BROAD LIGAMENT PREGNANCY
 When implantation is towards mesosalpinx, rupture
may occur at a site not immediately covered by
peritoneum
 Extrusion of gestational sac into a space between
the folds of broad ligament

36. INTERSTITIAL PREGNANCY
 Variable symmetry of uterus
 Rupture later 8th-16th week
 Fatal hemorrhage

37. TUBAL MOLE
 Multiple small hemorrhage in chorio-capsular space
 Villi separate from attachment
 Complete absorption
 Tubal abortion
 Pelvic hematocele

38. ARIAS STELLA REACTION
 Benign change in the endometrium associated with
presence of chorionic tissue
 May be misdiagnosed as malignancy

39. CLINICAL AND LABORATORY FEATURES OF
TUBAL PREGNANCY
 Spotting
 Severe lower abdominal pain
 Vertigo to syncope
 Amenorrhea/ delayed menstruation
 ABDOMINAL PALPATION
 Tenderness
 VAGINAL EXAMINATION
 Cervix excitation positive
 Bulged posterior fornix

40.  SYMPTOMS OF DIAPHRAGMATIC IRRITATION
 Pain in neck or shoulder especially on inspiration

41. SIGNS AND SYMPTOMS
Pain
Spotting/
bleeding
Amenorrhea

42. UTERINE CHANGES
 Uterus grows during 3 months
 Consistency
 Pushed to one side

43.  Slight rise in BP/ vasovagal response
 Shock
 Upto 38 celsius in ruptured cases
 Pelvic mass
 Pelvic hematocele

44. LAB TESTS
 Hemoglobin and hematocrit
 TC
 UPT
 Serum beta HCG
 Serum progesterone
 Sonography
 Abdominal USG
 Vaginal colour and pulsed Doppler ultrasound
 Laparoscopy
 D&C
 Laparotomy
 Culdocentesis

45. COMBINATION OF BETA HCG AND USG
 TVS : 1500 IU/L
 TAS: 6000IU/L
 <1500+ empty uterus
 failure in doubling of hcg

46. MANAGEMENT
 Salpingostomy: <2cm
 Salpingotomy: > 2 cm+ unruptured
 Salpingectomy: both ruptured and unruptured
cases
 Segmental resection and anastamosis: isthmic
unruptured

47. MEDICAL MANAGEMENT
 Methotrexate
 Kcl
 PG F 2 alpha
 Hyperosmolar glucose

48. CRITERIA
 Hemodynamically stable
 Serum HCg < 3000 IU / L
 Sac < 4cm without cardiac activity
 No intra abdominal hemorrhage

49. DOSAGE
 50mg/ m2 IM
 MONITORING
 S. Beta HCG on D4 and D7
 Weekly follow up until <10 mIU/ ml
 If the decline is< 15%, a second dose of Mtx is
given on D7

50. VARIABLE DOSE OF METHOTREXATE
 Methotrexate 1 mg/ kg IM on D 1,3,5,7
 Folinic acid 0.1 mg/ kg IM on D 2,4,6,8

51. FOR ACUTE CASES
 Resuscitation with preparation for laparotomy
 RL IV
 Blood transfusion after clamping
 Colloids
 Anti D

52. ABDOMINAL PREGNANCY
 Implantation in peritoneal cavity
 Caused by Tubal rupture
Primary
Secondary

53. SYMPTOMS
 History suggestive of disturbed tubal pregnancy
 Exaggerated minor ailments
SIGNS
 Absent Braxtonhick’s contraction
 Ill defined uterine contour
 Fetal parts felt easily
 Persistent abnormal attitude and position

54.  Internal examination
Difficult to separate uterus from abdominal mass
 USG
 Absent uterine wall around fetus
 Abnormally high position with abnormal atttitude
 Fetal parts in close approximation to abdominal wall
 Separate visualisation of uterus
Intraperitoneal
Intra ligamentary

55.  MRI
 X ray
 Abnormally high position of fetus with absence of
outline of uterine shadow
 Superimposition of gas shadow on the fetal
skeleton
 Lateral X ray on standing position shows
superimposition of fetal skeleton shadow with the
maternal spine shadow

56. MANAGEMENT
 Emergency laparotomy

57. OVARIAN PREGNANCY
 Criteria for diagnosis
 Intact tube on affected side
 Gestational sac must be in the position of ovary
 The gestation sac is connected to the uterus by the
ovarian ligament
 The ovarian tissue must be present on its wall on
histological examination

58. SIGNS AND SYMPTOMS
 Similar to tubal pregnancy or bleeding corpus
luteum
 MANAGEMENT
 Ovarian wedge resection/ cystectomy
 Ovariectomy
 Unruptured: methotrexate

59. CERVICAL PREGNANCY
 Implantation at or below the internal os
 Diagnostic criteria
 soft, enlarged cervix equal to or larger than the
fundus
 Uterine bleeding following amenorrhea without
cramping pain
 Products of conception entirely confined within and
firmly attached to endocervix
 A closed cervical internal os and a partially opened
external os

60. SIGNS AND SYMPTOMS
 Painless bleeding appearing shortly after
implantation
 Distended thin walled cervix with the external os
partially dialated

61. DIAGNOSIS
 USG
 Histological evidence of villi in cervical stroma

62. MANAGEMENT
 Hysterectomy may be needed to control bleeding
 Cervical plugging
 Cerclage
 Foley catheter
 Uterine artery embolization

63. MEDICAL MANAGEMENT
 Methotrexate

64. CORNUAL PREGNANCY
 In rudimentary horn of a bicornuate uterus
 Rupture by 12-20 weeks with massive
intraperitoneal hemorrhage

65. NURSING MANAGEMENT
 Monitor for active bleeding
 Single PV examination
 Preop preparation
 V/s Q15 min before surgery
 Preop lab tests
 Blood replacement
 Support
 Monitor beta hcg in Mtx therapy

66. DURING MTX THERAPY
 Avoid tampons and intercourse
 No alcohol and folic acid containing tablets
 Avoid sun exposure

67. HYDATIDIFORM MOLE

68.  Gestational trophoblastic disease refers to a
spectrum of pregnancy related trophoblastic
proliferative abnormalities

69. CLASSIFICATION (WHO)
 Hydatidiform mole
 Invasive mole
 Placental site trophoblastic tumor
 Chorio carcinoma
 Non metastatic disease
 Metastatic disease
COMPLETE
PARTIAL

70. HYDATIDIFORM MOLE
 It is an abnormal condition of the placenta where
there are partly degenerative and partly proliferative
changes in the young chorionic villi.these result in
formation of clusters of small cysts of varying sizes.

71. ETIOLOGY
 Teenage pregnancy
 Age> 35 years
 Inadequate intake of protein, animal fat
 low intake of carotene
 Disturbed maternal immune system
 Cytogenetic abnormality
 prior hydatidiform mole

73. PATHOLOGY
 Death of ovum/ failure of embryo growth is needed
for Complete mole
 Secretion from cells
 Substances from maternal blood
 Edema
 Liquefaction of stroma
Distension of
vesicles with hcg
rich fluid

75. OVARIAN CHANGES
 Bilateral lutein cysts
 Due to excessive production of chorionic
gonadotropin
 Regress within 2 months of expulsion

76. TYPES
 Complete mole
 Partial mole

77. COMPLETE MOLE
 Chorionic villi are converted into a mass of clear
vesicles
 No fetus or amnion

78. PARTIAL MOLE
 Changes are focal and less advanced
 There may be a fetus or at least an amniotic sac

79. CLINICAL FEATURES
 Amenorrhea of 8-12 weeks
 Vaginal bleeding
WHITE CURRANT IN RED CURRANT JUICE
 Lower abdominal pain
 Hyperemesis
 Breathlessness
 Thyrotoxic features
 Grape like vesicles PV
 No quickening

80. SIGNS
 Features suggestive of early pregnancy
 Ill looking
 pallor

81. CLASSICAL CLINICAL FEATURES OF COMPLETE
MOLE
 Abnormal vaginal bleeding
 Lower abdominal pain
 Hyperemesis gravidarum
 Features of early onset pre- eclampsia<20 weeks
 Uterus> 20 weeks
 Absent fetal pulse and FHS
 Expulsion of vesicular tissue
 Theca lutein cyst of ovaries
 Hyperthyroidism
 Serum hcg>100,000mIU/ml
 USG: snow storm appearance

82. PER ABDOMEN
 Size more than gestational age
 Doughy feel of uterus
 No fetal parts and movements
 No external ballotment
 No FHS

83. VAGINAL EXAMINATION
 No internal ballottment
 Unilateral or bilateral enlargement of ovary
 Finding of vesicles in vaginal discharge
 If cervical is open, blood clots or vesicles may be
felt

84. INVESTIGATIONS
 CBC, ABO and Rh grouping
 LFT, RFT and TFT
 USG
 Snow storm appearance

85. QUANTITATIVE ESTIMATION OF CHORIONIC
GONADOTROPIN
 High hcg titre in urine
 Rapidly increasing serum hcg (> 100,000 mIU/ml)
 Hcg value > 2 MoM for corresponding gestational
age

86. PLAIN X RAY ABDOMEN
 If uterine size> 16 weeks, absent fetal shadow
 CXR : for pulmonary embolization
 Histological examination

87. MANAGEMENT
 Group A: mole in process of expulsion
 Group B: inert uterus
 Supportive therapy for anemia and infection

88. DEFINITIVE MANAGEMENT
 SUCTION EVACUATION

89. GROUP A
 Cervix is favourable
 Sution evacuation(200-250 mmHg)
 D&C
 Digital exploration followed by removal of mole by
ovum forceps
 Post procedure
 Inj. Methergin 0.2 mg IM

90. GROUP B
 Cervix tubular and closed
 Laminaria tent/
 misoprostol PG E1 400 microgram, 3 hours before
surgery
 Hysterotomy
 Anti D
 Vaginal curettage 5-7 days after evacuation in
persistent bleeding

91. FOLLOW UP
 For at least 1 year
 Hcg should regress to normal level within 3 months
 INTERVAL
 Weekly till hcg becomes negative ( within 56 days)
 Then every one month for 6 months
 Those undergone chemotherapy, followed up for 1
year

92. FOLLOW UP PROTOCOLS
 History and clinical examination
 hcg assay

93. METHODS EMPLOYED IN EACH VISIT
 Symptoms
 Abdomino vaginal examination
 Detection of hcg in urine or serum
 CXR

94. PROPHYLATIC CHEMOTHERAPY
 High hcg after 10-12 weeks / re elevation
 hemorrhage
 Inadequate follow up
 Evidences of metastasis
 Risk for malignancy

95. REGIMES
 Methotrexate 1mg/kg on D1,3,5,7 IM/IV
 Folinic acid 0.1mg/kg on D2,4,6,8 IM
 Repeated every 7 days
 MONITOR HCG
 Contraceptive advise
 For 1 year

96. COMPLICATIONS
 Immediate
 Hemorrhage, shock
 Sepsis
 Perforation of uterus
 Pre eclampsia
 Acute pulmonary insufficiency
 Coagulation failure
 Late
 Chorio carcinoma

97. RISK FACTORS OF MALIGNANT CHANGE
 Age> 40or <20
 Parity>3
 S. Hcg100,000 mIU/ml
 Uterine size> 20 weeks
 Previous history of molar pregnancy
 Theca lutein cyst> 6 cm

98. NURSING MANAGEMENT
 Monitor for signs in 1st 24 weeks
 Anti D
 Help to cope with pregnancy loss
 Follow up
 Advise contraception
 V/S
 Fowl smelling discharge