Early Pregnancy

Complications
By Harvir Singh
Supervised by Dr Ranjit and Dr Syafiqah
3 main categories of early
pregnancy disorders are:

Abortion

Ectopic Pregnancy

Molar Pregnancy
Abortion
Definition
 Expulsion of product of conception (POC) before 22nd week of
period of gestation (POG), which mean before period of fetal
viability

Aetiology factors
 Maternal’s age >35 years old
 Trauma
 Infections (TORCHES, malaria)
 Endocrine disorders (diabetes, hypothyroidism, PCOS)
 Immunological disorders (SLE, antiphospholipid syndrome)
 Abnormalities in uterus (uterine fibroid)
 Psychological disorder (stress)
 Chromosomal abnormalities (Down syndrome)
 Exposure to chemical agents (benzene, tobacco, arsenic,
pesticides
Types of Abortion
 THREATENED ABORTION
 Painless vaginal bleeding, that occur at anytime between implantation and 24 weeks of
gestation.
 POC has threatened to abort but has not done so yet.

Clinical Presentation
 Bleeding (minimal, painless)
 Associated with dull aching lower abdominal pain

Examination
 Size of uterus is correspond to period of amenorrhea (POA)
 Closed cervical os
 U/S : well-formed, rounded gestational sac
with fetus within it

Management
 Bed rest
 Folic acid supplements
 Progesterone supplements
 Avoid coitus
 INEVITABLE ABORTION
 Painful vaginal bleeding from retro-placental site
 POC is about to be aborted but not yet
 It can progress to complete/ incomplete abortion depending on whether or
not all fetal & placental tissues have been expelled from uterus

Clinical Presentation
 Vaginal bleeding (painful)
 Associated with cramping pain at lower abdomen

Examination
 Size of uterus is correspond to/less than POA
 Dilated cervical os

Management
 Hospitalization
 Analgesics for control of pain
 Evacuation of uterine cavity with suction
evacuation, or ovum forceps (manually)
 INCOMPLETE ABORTION
 POC has aborted but not completely

Clinical Presentation
 Vaginal bleeding (heavy, passed out POC as fleshy masses)
 Associated with colicky pain at lower abdomen
 +/- signs of shock

Examination
 Size of uterus is smaller than POA
 Open cervical os
 U/S : reveal retained POC in uterine cavity

Management
 Resuscitate if bleeding is severe, do blood group and
cross match
 Give analgesia for pain
 Ergometrine (i.m) to contract the uterus and control bleeding
 Evacuation of the uterus of its product of conception once patient’s
condition is stable.
 COMPLETE ABORTION
 All the POC has completely aborted

Clinical Presentation
 History of pain and passage of product
 Followed by absent of pain, minimal bleeding

Examination
 Size of uterus is smaller than POA
 Closed cervical os
 U/S : empty uterine cavity

Management
 Do U/S to look for empty of uterine cavity and to rule out any possibility of
extra uterine pregnancy
 MISSED ABORTION
 When the embryo/fetus is already died, but still remain in the uterine cavity for a
period of time
 without symptoms of miscarriage
Clinical Presentation
 Decreased in pregnancy symptoms
 Vaginal bleeding (absent, minimal)

Examination
 Size of uterus is smaller than POA
 Closed cervical os
 U/S : crumpled gestational sac
: revealed fetal pole but no signs of activity (no heart activity)

Management
 Wait for spontaneous expulsion (disadvantage: involve further maternal anxiety, pain of
expulsion, DIVC)
 Evacuation of uterus of its POC
surgically : dilatation & currettage
medically : mifepristone + misoprostol
 COMPLICATIONS OF
EVACUATION

Perforation of Uterus Cervical Incompetence Asherman’s Syndrome

• Can occur as uterus is soft in • Excessive dilation of cervix • Overzealous D&C also cause
pregnancy and dilators are (>12mm) may rupture the removal of decidua of
hard and sharp fibers of cervix endometrial lining
• Thus, can easily perforate the • In long term, it may cause • Endometrium unable to
uterus cervical incompetence that regenerate and wall of uterus
lead to recurrent abortion and will fuse together
preterm labour • Patient present with
secondary amenorrhea and
infertility
RECURRENT ABORTION
 3 or more consecutive spontaneous abortion
Can be divided to:

• Uterine abnormality (uterine fibroid)

• Endocrine (DM, thyrotoxicosis, PCOS)
1st Trimester • Autoimmune (SLE)
Abortion ( <12 • Infection (TORCHES)
• Chromosomal abnormalities in parents
weeks)

• Cervical incompetence (hx of

termination of pregnancy, vigorous
2nd Trimester dilatation of cervix, hx of cone
abortion ( >12 biopsy)
weeks) • Uterine abnormalities (septate of
subseptate uterus)
Ectopic Pregnancy
ECTOPIC PREGNANCY
 Pregnancy outside uterine cavity

Sites of implantation:
 In fallopian tube (fimbrial,
ampullary, isthmic, interstitial)
 In the ovary
 In the abdominal cavity
 In the cervical site
Risk Factors
 Previous ectopic pregnancy
 History of PID
 Induction of ovulation
 Previous procedure on fallopian tube
 Previous pelvic surgery
 Structural :
 Uterine fibroid
 Abnormal uterine anatomy
Clinical Features
(diagnose between 5th & 12th week of gestation)

 Vaginal Bleeding (scanty, dark and intermittent)

 Lower abd pain, back or pelvic pain (usu. unilateral)
 Shoulder pain
 Syncopal attacks (hemoperitoneum)
 Symptom of hypovolemic shock
 Upset menstrual pattern
 Vague abdominal pain
Examination
General examination
 shoulder pain 2° to free blood in the peritoneal cavity
 irritating the diaphragm
 vascular instability - low BP, fainting, dizzy, rapid heart rate
 abdominal palpation : mild tenderness, guarding, decreased
bowel sounds may be present (ectopic pregnancy rupture may
cause intra-abdominal bleeding)

Gynecological examination
 Speculum : cervical os is closed
 BE : uterus will be smaller than the
expected date
Investigations
UPT
 positive

Beta hCG
 If a patient has a beta subunit of human chorionic gonadotropin level of
1,500 mIU per mL or greater, but the transvaginal ultrasonography does
not show an intrauterine gestational sac, ectopic pregnancy should be
suspected

Transvaginal ultrasound
 Empty uterus
 Presence of free fluid especially in Pouch of Douglas

Diagnostic laparoscopic
Management
 Surgical : salpingectomy/salpingotomy either by
 laparotomy/laparoscopy
 Medical
 Methotrexate ; i.m/direct into tubal pregnancy
 Expectant
 Strict criteria in selected pt.
 Ultrasound & hCG assessments are prerequisites
Salpingectomy
Molar Pregnancy
Molar Pregnancy
 Also known as ‘hydatidiform mole’
 ‘Gestational throphoblastic disease’.
 Abnormal pregnancy in which the developing fetus and placenta
are replaced by proliferation of throphoblastic tissue.
Classification
Complete hydatiform mole
 no normal fetal tissue forms

Partial hydatiform mole

 incomplete fetal tissues develop alongside molar tissue

Choriocarcinoma (invasive mole)

 contains many villi, but these may grow into or through the
muscle layer of the uterus wall
 can spread to tissues outside of the uterus
Epidemiology
 Complete : 1 per 1000-2000 pregnancies.
 Partial : 1 per 700 pregnancies.
 Choriocarcinoma : varies ( 3-10%)

Risk factors
 Increase with maternal age.
 Previous history of molar pregnancy.
 Dietary habits of some ethnic group (remains controversial).
 A diet low in carotene (a form of vitamin A)
Complete mole Incomplete mole
Most common type of hydatidiform
mole
Diffuse thropoblastic hyperplasia, Hydropic villi and focal focal
hydropic swelling of chorionic villi, trophoblastic hyperplasia are
no fetal tissue or membrane associated with fetus or fetal parts
present
46XX or 46XY Often triploid (XXY,XYY,XXX)
with chromosome complement
from both parents
2 sperm fertilize 1 empty egg or 1 Single ovum fertilized with
sperms with reduplication 2 sperms
15-20 % risk of progression to
malignant sequale
Clinical features

Clinical features
complete Incomplete
Vaginal bleeding -97% Presentation similar to
Uterine larger than date threatened/
-51% spontaneous/ missed abortion
Hyperemesis gravidarum
– 26%
B-hcg > 100,000
No fetal heart beat
Investigations
 UPT
 B-hcg level
 U/S
o Complete – no fetus, classic snow storm
o Incomplete – molar degeneration of placenta +/- fetal anomalies,
multiple echogenic regions corresponding to hydropic villi and focal
intrauterine haemorrhage
 CXR – may show metastatic lesions
 Features of high risk of neoplasm
 Local uterine invasion
 B-hcg >100,000
 Excessive uterine size
 Prominent theca- lutein cyst
Treatment
 Suction and curettage
 Rhogam in rhesus –ve
 Consider hysterectomy if pt no longer desire fertility
 Chemo for carcinoma

Follow up
 TCA 2/52 till upt –ve
 B-hcg 2/52 till normal
 Follow up monthly until 1 year
 Follow up 3monthly until 1 year
Thank you