These topics comes under OBG for the first year PbBSc & 4th yr BSc nursing students. it helps the students to learn, understand each of the condition & will be able to provide nursing care accordingly.

1. VESICULAR MOLE/
HYDATIDIFORM MOLE

2. VESICULAR
MOLE
It is a benign neoplasm of
the chorionic villi.

3. PATHOLOGY
● The uterus is distended by
thin walled, translucent,
grape-like vesicles of different
sizes. These are degenerated
chorionic villi filled with fluid.
● There is no vasculature in the
chorionic villi leads to early
death and absorption of the
embryo.

4. ● There is trophoblastic
proliferation, with mitotic activity
affecting both syncytial and
cytotrophoblastic layers. This
causes excessive secretion of
hCG, chorionic thyrotropin and
progesterone. On the other hand,
oestrogen production is low due
to absence of the foetal supply of
precursors.
● High hCG causes multiple theca
lutein cysts in the ovaries in about
50% of cases. It also results in
exaggeration of the normal early
pregnancy symptoms and signs

5. TYPES :-
● COMPLETE
● PARTIAL
● Complete mole:
○ The whole conceptus is
transformed into a mass
of vesicles.
○ No embryo is present.
○ It is the result of
fertilisation of
enucleated ovum (has no
chromosomes) with a
sperm which will
duplicate giving rise to
46 chromosomes of
paternal origin only.

6. Partial mole:
● A part of trophoblastic
tissue only shows molar
changes.
● There is a foetus or at
least an amniotic sac.
● It is the result of
fertilisation of an ovum
by 2 sperms so the
chromosomal number is
69 chromosomes.

7. SYMPTOMS
● Amenorrhoea: usually of short
period (2-3 months).
● Exaggerated symptoms of
pregnancy especially vomiting.
● Vaginal bleeding which is usually
dark brown and may be associated
with passage of vesicles.
● Abdominal pain: may be,
○ dull-aching due to rapid
distension of the uterus,
○ colicky due to starting
expulsion,
○ sudden and severe due to
perforating mole.

8. SIGNS
● General examination:
○ Pre-eclampsia develops in 20% of
cases, usually before 20 weeks’
gestation.
○ Hyperthyroidism develops in 10% of
cases manifested by enlarged thyroid
gland, tachycardia and elevated
plasma thyroxine level.
○ Breast signs of pregnancy.
● Abdominal examination:
○ The uterus is larger than the period of
amenorrhoea in 50% of cases,
corresponds to it in 25% and smaller
in 25% with inactive or dead mole.
○ The uterus is doughy in consistency
○ Foetal parts and heart sound cannot
be detected except in partial mole.

9. ● Local examination:
○ Passage of vesicles
(sure sign).
○ Bilateral ovarian cysts
(5-20 cm) in 50% of
cases.

10. INVESTIGATIONS
● Positive urine pregnancy test
● Highly elevated serum hCG
level
● Ultrasonography reveals:
○ The characteristic
intrauterine "snow storm"
appearance,
○ no identifiable foetus,
○ bilateral ovarian cysts may
be detected.
● X-ray: shows no foetal
skeleton.

11. COMPLICATIONS
● Haemorrhage.
● Infection due to absence
of the amniotic sac.
● Perforation of the uterus.
● Pregnancy induced
hypertension
● Hyperthyroidism.
● Subsequent development
of choriocarcinoma

12. TREATMENT
1. Suction evacuation
2. Hysterotomy
3. Hysterectomy
4. Medical induction

13. ECTOPIC
PREGNANCY

14. ECTOPIC
PREGNANCY
The term ectopic pregnancy
refers to any pregnancy
occuring outside the uterine
cavity.

15. ● The commonest site of extra uterine implantation is
the uterine tube, usually in the ampullary region.
● Ectopic implantation may also occur on the ovary,
abdominal cavity or in the cervical canal.
● Abdominal pregnancy may result from direct
implantation of the conceptus or it may result from
extrusion of a tubal pregnancy with secondary
implantation in the peritoneal cavity.

16. ● Here to the conceptus produces hCG , which
maintains the corpus luteum & the production of
oestrogen & progesterone.
● This causes the uterus to enlarge & the endometrium
to undergo decidual changes.
● Trophoblastic cells invade the wall of the tube &
erode into blood vessels of the mesosalpinx.

17. ● This process will continue until the pregnancy
ruptures into the abdominal cavity or the broad
ligament, or the embryo dies, thus resulting in a
tubal mole. Thus absorption or tubal miscarriage
may occur.
● Expulsion of the embryo into the peritoneal cavity or
partial miscarriage may also occur with continuing
episodes of bleeding from the tube.

18. ● Vaginal bleeding occurs as a result of shedding
of the decidual lining of the endometrium &
progesterone levels fall with the failing
pregnancy.

19. PREDISPOSING
FACTORS
● Previous history of
ectopic pregnancy
● Failed Sterilisation
● Pelvic inflammatory
disease
● Subfertility
● Failed IUCD
● Previous tubal surgeries

20. CLINICAL PRESENTATION

21. ACUTE PRESENTATION
● The classical pattern of symptoms include
AMENORRHEA, LOWER ABDOMINAL PAIN &
VAGINAL BLEEDING.
● Typical sudden onset of abdominal pain starting on
one side of the lower abdomen, but rapidly becomes
generalized as blood loss extends into the peritoneal
cavity.

22. ● Sub - diaphragmatic irritation by blood produces
referred shoulder tip pain & discomfort on
breathing.
● There may be episodes of syncope.
● Clinical examination reveals - hypotension,
tachycardia, signs of peritonism including
abdominal distension, guarding & rebound
tenderness.
● On pelvic examination the cervix is closed & acutely
tender when moved because of irritation of the
pelvic peritoneum caused by the bleeding.

23. SUB ACUTE PRESENTATION
● Some or all of the classic symptoms like pain,
bleeding & amenorrhea may be absent.
● It may be possible to feel a mass in one fornix on
vaginal examination.

24. DIAGNOSIS
● Threatened or
incomplete miscarriage
● Transvaginal ultrasound
● Laparoscopy

25. SURGICAL
MANAGEMENT
● Laparotomy is indicated in
the hemodynamically
compromised patient & in
obese patients or those
with extensive pelvic
adhesions or
haemoperitoneum.
● Advantages: lower blood
loss & reduced need for
postoperative pain relief

26. Two main
options for
surgical removal
of the ectopic:-
1. Partial Salpingectomy (
removal of part of the
tube)
2. Salpingectomy ( leaving
the tube in place &
removing the ectopic
through an incision in
the wall of the tube).

27. MEDICAL
MANAGEMENT
● Inj. METHOTREXATE 1
mg/Kg body weight or 50
mg/ M2.
● A single dose of this
drug given IM , is an
antimetabolite that
interferes with the
synthesis of DNA.

28. ABORTION / TERMINATION

29. INDUCED ABORTION /
PREGNANCY TERMINATION

30. ● According to the Abortion Act of 1967 :-
It requires that two doctors agree that continuation
of the pregnancy would either involve greater the
risk to the physical or mental health of the mother or
her other children than termination, or that the
fetus is at risk of an abnormality, likely to result it
being seriously handicapped.

32. METHODS OF
TERMINATION OF
PREGNANCY
● All women should be
screened for STDs or
offered antibiotic
prophylaxis.
● Administration of Anti- D
immunoglobulin to all
rhesus negative mothers.

33. SURGICAL
TERMINATION OF
PREGNANCY
1. Dilatation & curettage in
the first trimester
2. Dilatation & evacuation
in the 2nd trimester.

34. MEDICAL
TERMINATION OF
PREGNANCY
For the first trimester use
the regimes of:-
● Progesterone antagonist
Mifepristone (RU 486)
given orally followed 36-
48 hrs later by
prostaglandins
administered vaginal
pessary or orally.

35. Second trimester
terminations can be
performed using:-
● Vaginal prostaglandins
given 3 hourly or as an
extra amniotic infusion
through a balloon
catheter passed through
the cervix.

36. COMPLICATIONS
OF TERMINATION
OF PREGNANCY
● Bleeding
● Uterine perforation
● Cervical laceration
● Retained products
● Sepsis