Hydatidiform Molar Pregnancy

Defined as proliferation and degeneration of the chorion A benign neoplasm of the chorion The embryo fails to develop in most cases Occurs in 1 of 2000 pregnancies More often in low socioeconomic groups with low protein diets More often is the younger or older mother

Symptoms of a Molar Pregnancy Uterus expands faster and reaches landmarks earlier More morning sickness Earlier signs of PIH Vaginal bleeding in the 4th month Discharge with grape-like vesicles

Treatment and nursing care with Molar Pregnancy A d & c is done to evacuate the mole Follow-up care is very important Tends to be carcinogenic—choriocarcinoma Recommend no future pregnancies for at least a year Evaluate HCG levels closely Chest x-rays at interverals

Incompetent Cervix Cervix dilates prematurely, painlessly, when the fetus is of sufficient weight to put pressure on the cervix. Signs/symptoms: mucousy, pink discharge ROM Onset of contractions Birth of the fetus

Treatment/Care --Incompetent Cervix Cervical circlage done between 4-6 months Earliest time maybe 14 weeks Success rate as good as 80 % Must be removed prior to the onset of labor

Abortion Loss of a pregnancy during the first 20 weeks of pregnancy, at a time that the fetus cannot survive. Such a loss may be involuntary (a "spontaneous" abortion), or it may be voluntary ("induced" or "elective" abortion). Miscarriage is the term used for spontaneous abortion, an unexpected 1st trimester pregnancy loss.

Categories of Abortions These include: Threatened Inevitable Incomplete Complete Septic

Facts about abortion Such losses are common, occurring in about one out of every 6 pregnancies. These losses are unpredictable and unpreventable. About 2/3 are caused by chromosome abnormalities. About 30% are caused by placental malformations and are similarly not treatable. The remaining miscarriages are caused by miscellaneous factors but are not usually associated with: Minor trauma Intercourse Medication Too much activity

Following a miscarriage, the chance of having another miscarriage with the next pregnancy is about 1 in 6.

Habitual abortion Habitual abortion, recurrent miscarriage or recurrent pregnancy loss (RPL) is the occurrence of three or more pregnancies that end in miscarriage of the fetus, usually before 20 weeks of gestation. RPL affects about 0.34% of women who conceive.

Causes Anatomical conditions: Uterine conditions Cervical conditions Chromosomal disorders Endocrine disorders Immune factors Lifestyle factors Infection

Spontaneous Spontaneous abortion (also known as miscarriage) is the expulsion of an embryo or fetus due to accidental trauma or natural causes before approximately the 22nd week of gestation; the definition by gestational age varies by country.[ Most miscarriages are due to incorrect replication of chromosomes; they can also be caused by environmental factors

Induced A pregnancy can be intentionally aborted in many ways. The manner selected depends chiefly upon the gestational age of the embryo or fetus, which increases in size as the pregnancy progresses. Specific procedures may also be selected due to legality, regional availability, and doctor-patient preference. Reasons for procuring induced abortions are typically characterized as either therapeutic or elective.

Induced abortion Therapeutic abortion when it is performed to: save the life of the pregnant woman preserve the woman's physical or mental health terminate pregnancy that would result in a child born with a congenital disorder that would be fatal or associated with significant morbidity or selectively reduce the number of fetuses to lessen health risks associated with multiple pregnancy.

Induced abortion An elective abortion: When it is performed at the request of the woman "for reasons other than maternal health or fetal disease.

Threatened Abortion A threatened abortion means the woman has experienced symptoms of bleeding or cramping. At least one-third of all pregnant women will experience these symptoms. Half will abort spontaneously. The other half , bleeding and crampingwill disappear and the remainder of the pregnancy will be normal. These women who go on to deliver their babies at full term can be reassured that the bleeding in the first trimester will have no effect on the baby and that you expect a full-term, normal, healthy baby.

Threatened abortion (Features)  History  Mild vaginal bleeding.  No abdominal pain or mild abdominal pain  Examination  Good general condition.  The cervix is closed  The uterus is usually the correct size for date U/S which is essential for the diagnosis Showed the presence of fetal heart activity

Threatened abortion (Management) Reassurance If fetal heart activity is present, > 90% of cases will be progressed satisfactorily Advice: Decrease physical activity (bed rest is of no therapeutic value) avoid intercourse Hormones i.e. Progesterone & hCG Which are used in the first trimester to support pregnancy, (but they are of no proven value) Anti- D: An adequate dose of anti-D should be given to all Rh –ve,non-immunised patients, whose husbands are Rh +ve ANC as high risk patients Because those patients are liable to late pregnancy complications such as APH and preterm labour .

Inevitable abortion A condition in which: Vaginal bleeding has been profuse The cervix has become dilated Abortion will invetably occur.

Inevitable and incomplete abortions (Features) History Heavy vaginal bleeding. with no passage of products conception (inevitable) with the passage of products of conception (incomplete abortion) Severe lower abdominal pain which follows the bleeding

Inevitable and incomplete abortions (Features) Examinations Poor general condition. The cervix is dilating and products of conception may be passing trough the os The uterus may be the correct size for date (inevitable abortion) or small for date (incomplete abortion) U/S  Fetal heart activity may or may not present in inevitable abortion or retained products of conception ( RPOC ) in incomplete abortion

Inevitable and incomplete abortions (management) CBC , blood grouping , XM 2 units of blood Resuscitation  large IV line, fluids & blood transfusion Oxytoxic drugs  Ergometrine 0.5 mg IM + Oxytocin infusion (20-40 units in 500 cc saline) Evacuation & curettage. Post-abortion management.

Complete Abortion

Complete abortion (Features) History Heavy vaginal bleeding which has been stopped. lower abdominal pain which follows the bleeding which has been stopped. Examination The cervix is closed U/S showed empty uterine cavity or PROP

Complete abortion (Management) - Evacuation & curettage in the presence of RPOC. Post-abortion management.

Missed abortion Retention of products for several weeks No increase in fundal height Absence of FHT Regressions of signs of pregnancy Loss of wight

Missed abortion (Features) Most of missed abortions are diagnosed accidentally during routine U/S in early pregnancy . In some cases there may be a history of : Episodes of mild vaginal bleeding Regression of early symptoms of pregnancy . Stop of fetal movements after 20 weeks gestation. Examination The uterus may be small for date

Missed abortion (Features) U/S (which is essential for diagnosis ) diagnosed if two ultrasound ( T/V or T/A) at least 7days apart showed an embryo of > 7 weeks gestation ( CRL > 6mm in diameter and gestational sac > 20 mm in diameter ) with no evidence of heart activity .

Missed abortion (Management) CBC , blood grouping Platelets count, to exclude the risk of DIC NB : DIC does not occur before 5 weeks of missed abortion or IUFD and if occurred will be of mild grade

Missed abortion (Management) Options of treatment Conservative treatment:  if left alone spontaneous expulsion will occur Surgical evacuation of the uterus; by D & C: Indicated in 1st trimester missed abortion Medical termination of pregnancy: by Misoprostol (PGE1) Cytotec: Indicated in 1st & 2nd trimesters missed abortions. Cytotec vaginal ( is the best) or oral tab. 200 μg, 2 tab/ 3 hrs/ up to 5 doses daily, which can be repeated next day if there is no response in the first day Subsequent surgical evacuation is needed in cases of RPOC The main side effects of cytotec are nausea, vomiting and fever.  Post-abortion management.

Anembryonic pregnancy (Blighted ovum) It is due to an early death and resorption of the embryo with the persistence of the placental tissue It is diagnosed if two ultrasound ( T/V or T/A) at least 7 days apart showed after 7 weeks of gestation i.e. gestational sac > 20mm , an empty gestational sac with no fetal echoes seen . It is treated in a similar way to missed abortion .

Septic abortion Spontaneous or induced termination of a pregnancy in which the mother's life may be threatened because of the invasion of germs into the endometrium, myometrium, and beyond. The woman requires immediate and intensive care Massive antibiotic therapy Evacuation of the uterus Emergency hysterectomy to prevent death from overwhelming infection and septic shock.

Complications of abortion Haemorrhage . Complication related to surgical evacuation ie E&C and D&C. Uterine perforation- which may lead to rupture uterus in the subsequent pregnancy. Cervical tear & excessive cervical dilatation – which may lead to cervical incompetence. Infection – which may lead to infertility & Asherman's syndrome. Excessive curettage – which may lead to Adenomyosis  Rh- iso immunisation  if the anti –D is not given or if the dose is inadequate . Psychological trauma .

Post - abortion management In cases of incomplete, inevitable, complete, missed & septic abortions Support: from the husband, family& obstetric staff Anti D – to all Rh –ve, nonimmunised patients, whose husbands are Rh+ve Counseling & explanation: Contraception (Hormonal, IUCD, Barrier) Should start immediately after abortion if the patient choose to wait , because ovulation can occur 14 days after abortion and so pregnancy can occur before the expected next period .

Post - abortion management Counseling & explanation: When can try again : Best to wait for 3 months before trying again . This time allow to regulate cycles and to know the LMP, to give folic acid, and to allow the patient to be in the best shape (physically and emotionally) for the next pregnancy Why has it happened In the fiIn the majority of cases there is no obvious cause In the first trimester abortion , the most common cause is fetal chromosomal abnormality

Post - abortion management Counseling & explanation: Can it happen again As the commonest cause is the fetal chromosomal abnormality which is not a recurrent cause , so the chance of successful pregnancy next time in the absence of obvious cause is very high even after 2 or 3 abortions Not to feel guilty  as it is extremely unlikely that anything the patient did can cause abortion No evidence that intercourse in early pregnancy is harmful No evidence that bed rest will prevent it ..

Recurrent abortion Definition : Types : Incidence : Is defined as 3 or more consecutive spontaneous abortions It may presented clinically as any of other types of abortions .  Types : Primary : All pregnancies have ended in loss Secondary : One pregnancy or more has proceeded to viability(>24 weeks gestation) with all others ending in loss Incidence : occurs in about 1% of women of reproductive age .

Recurrent abortion Causes Anatomical disorders: Chromosomal disorders: Idiopathic recurrent abortion, in about 50%, in which no cause can be found . The known causes include the followings : Chromosomal disorders: Fetal chromosomal abnormalities & structural abnormalities Parental balanced translocation  Anatomical disorders: Cervical incompetence: →congenital and aquired Uterine causes: → submucous fibroids, uterine anomalies & Asherman’s syndrome  

Recurrent abortion Causes Medical disorders: Endocrine disorders : diabetes , thyroid disorders , PCOS & corpus luteum insufficiency . Immunological disorders : Anticardiolipin syndrome & SLE. Thrombophilia: congenital deficiency of Protein C&S and antithrombin III, & presence of factor V leiden. Infections ToRCH - CMV may be a cause of recurrent abortion, but ToRH are not causes of recurrent abortion. Genital tract infection e.g Bacterial vaginosis Rh – isoimmunization

Recurrent abortion Diagnosis : History : Previous abortions : gestational age and place of abortions & fetal abnormalities. Medical history : DM , thyroid disorders, PCOS, autoimmune diseases & thrombophilia. Examination : General : weight , thyroid & hair distribution Pelvic: cervix ( length & dilatation ) and uterine size.

Recurrent abortion Diagnosis : investigations : Investigations for medical disorders: Blood grouping & indirect Coomb’s test in Rh –ve women Endocrinal screening: Blood sugar , TFT & LH /FSH ratio Immunological screening: Anti anticardiolipine antibodies & lupus inhibitor. Thrombophilia screening: Protein C & S, antithrombin III levels, factor V leiden, APTT and PT. Infection screening High vaginal & cervical swabs ToRCH profile ( which scientifically is not necessary )

Recurrent abortion Diagnosis : investigations : Investigations for anatomical disorders: TV/US: fibroids, cervical incompetence & PCOS. Hystroscopy or HSG, fibroids, cervical incompetence, uterine anomalies & Asherman's syndrome Investigations for chromosomal disorders: Parental karyotyping: Parental balanced translocation. Fetal karyotyping: Fetal chromosomal anomalies.

Recurrent abortion Management: in idiopathic recurrent abortion. With support and good antenatal care , the chance of successful spontaneous pregnancy is about 60-70% Support : from husband, family & obstetric staff. Advice : stop smoking & alcohol intake, decrease physical activity Tender loving care Drug therapy Progesterone & hCG: start from the luteal phase & up to 12 weeks. Low dose aspirin ( 75 mg/day ) start from the diagnosis of pregnancy & up to 37 weeks LMWH (20-40 mg/day) start from the diagnosis of fetal heart activity & up to 37 ws

Recurrent abortion Management: In the presence of a cause treatment is directed to control the cause Endocrine disorders Control DM and thyroid disorders before pregnancy Ovulation induction drugs , ovarian drilling or IVF in PCOS. Progesterone or hCG in corpus luteum insufficiency . :In anti-cardiolipin syndrome: Low dose aspirin ( 75 mg/day ) & prednisilone ( 20-30 mg / day), starting when pregnancy is diagnosed till 37 weeks. These drugs are not teratogenic.

Recurrent abortion Management: In thrombophilia: Low dose aspirin ( 75 mg/day) starting when pregnancy is diagnosed and low molecular weight heparin ie LMWH ( 20-40 mg/day) starting when fetal heart activity diagnosed & to continue both till 37 weeks . In uterine disorders Cervical cerclage in cervical incompetence, best time at the 14 weeks of pregnancy. Myomectomy in submucus fibroid, excision of uterine septum in septate & subseptate uterus & adhesolysis in Asherman's syndrome.

Recurrent abortion Management: In infection:: treatment of the genital tract infection. In Rh isoimmunization: Repeated intrauterine transfusion In parental balanced translocation Explain the risk of fetal chromosomal disorders ( about 30% ) Encourage to try again or adoption.