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By: Dr Ismah Haron
O&G Department
8/6/2014 1
Miscarriage
Ectopic pregnancy
Molar pregnancy
3 main categories of early pregnancy
complications are:
8/6/2014 2
8/6/2014 3
Miscarriage
Definition :Expulsion of product of conception (POC) before 22nd week of
period of gestation (POG), which mean...
Threatened
abortion
Inevitable
abortion
Incomplete
abortion
Missed
abortion
Complete
abortion
Recurrent
abortion
TYPES OF ...
THREATENED ABORTION
Definition : Painless vaginal bleeding, that occur at anytime between
implantation and 24 weeks of ges...
INEVITABLE ABORTION
Definition : Painful vaginal bleeding from retro-placental site
: POC is about to be aborted but not y...
INCOMPLETE ABORTION
Definition : POC has aborted but not completely
Clinical features:
• Vaginal bleeding (heavy, passed o...
COMPLETE ABORTION
Definition : All the POC has completely aborted.
Clinical features:
• History of pain and passage of pro...
MISSED ABORTION
Definition : When the embryo/fetus is already died
: but still remain in the uterine cavity for a period o...
RECURRENT ABORTION
Definition : 3 or more consecutive spontaneous abortion
Can be divided into:
• Uterine abnormality (ute...
8/6/2014 12
ECTOPIC PREGNANCY
Definition : Pregnancy outside uterine cavity
1. In fallopian tube (fimbriae,
ampullary, isthmus,
inters...
◦ Previous ectopic pregnancy
◦ History of PID
◦ Induction of ovulation
◦ Previous procedure on fallopian tube
◦ Previous p...
Vaginal Bleeding
Lower abdominal pain, back or pelvic pain
Shoulder pain
Syncopal attacks (hemoperitoneum)
Symptoms o...
Vital signs – hypotension, tachycardia, fever
 Generally – pale, CRT
 Abdominal palpation : uterus not palpable, tender...
UPT
 positive
Beta hCG
 If a patient has a beta subunit of human chorionic gonadotropin level of
1,500 mIU per mL or gre...
Stabilize patient
Surgical : salpingectomy/salpingotomy either by
laparotomy/laparoscopy
Medical
 Methotrexate ; i.m/d...
8/6/2014 19
Can be classified as
Complete hydatiform mole
- no normal fetal tissue forms
Partial hydatiform mole
- incomplete fetal ...
Complete mole Incomplete mole
Most common type of hydatidiform
mole
Diffuse thropoblastic hyperplasia,
hydropic swelling o...
8/6/2014 22
Clinical features
complete Incomplete
Vaginal bleeding -97%
Uterine larger than date -51%
Hyperemesis gravidarum – 26%
B-h...
Investigation
◦ UPT
◦ B-hcg level
◦ U/S
Complete – no fetus, classic snow storm
Incomplete – molar degeneration of place...
8/6/2014 25
Treatment
◦ Suction and curettage
◦ Rhogam in rhesus –ve
◦ Consider hysterectomy if pt no longer desire fertility
◦ Chemo ...
8/6/2014 27
8/6/2014 28
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early pregnancy complications

  1. 1. By: Dr Ismah Haron O&G Department 8/6/2014 1
  2. 2. Miscarriage Ectopic pregnancy Molar pregnancy 3 main categories of early pregnancy complications are: 8/6/2014 2
  3. 3. 8/6/2014 3
  4. 4. Miscarriage 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 (tobacco, arsenic, pesticides) 8/6/2014 4
  5. 5. Threatened abortion Inevitable abortion Incomplete abortion Missed abortion Complete abortion Recurrent abortion TYPES OF ABORTION: 8/6/2014 5
  6. 6. THREATENED ABORTION Definition : 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 features: • 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 • Avoid coitus 8/6/2014 6
  7. 7. INEVITABLE ABORTION Definition : 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 features: • 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 8/6/2014 7
  8. 8. INCOMPLETE ABORTION Definition : POC has aborted but not completely Clinical features: • 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 • Evacuation retained product of conception 8/6/2014 8
  9. 9. COMPLETE ABORTION Definition : All the POC has completely aborted. Clinical features: • 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 8/6/2014 9
  10. 10. MISSED ABORTION Definition : When the embryo/fetus is already died : but still remain in the uterine cavity for a period of time : without symptoms of miscarriage Clinical features: • 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 • ERPOC 8/6/2014 10
  11. 11. RECURRENT ABORTION Definition : 3 or more consecutive spontaneous abortion Can be divided into: • Uterine abnormality (uterine fibroid) • Endocrine (DM, thyrotoxicosis, PCOS) • Autoimmune (SLE) • Infection (TORCHES) 1st trimester abortion (<12 weeks) • Cervical incompetence (hx of termination of pregnancy, vigorous dilatation of cervix, hx of cone biopsy) • Uterine abnormalities (septate or subseptate uterus) 2nd trimester abortion (>12 weeks) 8/6/2014 11
  12. 12. 8/6/2014 12
  13. 13. ECTOPIC PREGNANCY Definition : Pregnancy outside uterine cavity 1. In fallopian tube (fimbriae, ampullary, isthmus, interstitial) 2. In the ovary 3. In the abdominal cavity 4. In the cervical site Sites of implantation: 8/6/2014 13
  14. 14. ◦ Previous ectopic pregnancy ◦ History of PID ◦ Induction of ovulation ◦ Previous procedure on fallopian tube ◦ Previous pelvic surgery ◦ Structural : Uterine fibroid Abnormal uterine anatomy 8/6/2014 14
  15. 15. Vaginal Bleeding Lower abdominal pain, back or pelvic pain Shoulder pain Syncopal attacks (hemoperitoneum) Symptoms of hypovolemic shock 8/6/2014 15
  16. 16. Vital signs – hypotension, tachycardia, fever  Generally – pale, CRT  Abdominal palpation : uterus not palpable, tenderness, guarding  Per speculum & VE – os closed, cervical excitation, adnexa mass, bimanual examination of uterus 8/6/2014 16
  17. 17. 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 8/6/2014 17
  18. 18. Stabilize patient Surgical : salpingectomy/salpingotomy either by laparotomy/laparoscopy Medical  Methotrexate ; i.m/direct into tubal pregnancy 8/6/2014 18
  19. 19. 8/6/2014 19
  20. 20. Can be classified as 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. 8/6/2014 20
  21. 21. Complete mole Incomplete mole Most common type of hydatidiform mole Diffuse thropoblastic hyperplasia, hydropic swelling of chorionic villi, no fetal tissue or membrane present Hydropic villi and focal focal trophoblastic hyperplasia are associated with fetus or fetal parts 46XX or 46XY Often triploid (XXY,XYY,XXX) with chromosome complement from both parents 2 sperm fertilize 1 empty egg or 1 sperms with reduplication Single ovum fertilized with 2 sperms 15-20 % risk of progression to malignant sequale 8/6/2014 21
  22. 22. 8/6/2014 22
  23. 23. Clinical features complete Incomplete Vaginal bleeding -97% Uterine larger than date -51% Hyperemesis gravidarum – 26% B-hcg > 100,000 No fetal heart beat Presentation similar to threatened/ spontaneous/ missed abortion 8/6/2014 23
  24. 24. Investigation ◦ UPT ◦ B-hcg level ◦ U/S Complete – no fetus, classic snow storm 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 8/6/2014 24
  25. 25. 8/6/2014 25
  26. 26. 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 8/6/2014 26
  27. 27. 8/6/2014 27
  28. 28. 8/6/2014 28
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