hemorrhagic complication in first trimester

1. Hemorrhagic complications of the first

period of pregnancyLesson/Package 5

TBILISI STATE MEDICAL UNIVERSITY - UNICEF GEORGIA

2. At the end of this presentation students will be able to understand what

hemorrhagic complications of the first period of pregnancy

are


3. Most common complications are:


•Abortion •Gestational Trophoblastic Disease

4. Abortion

• Abortion is the expulsion of fetus before it reaches viability (until 22 weeks of gestation. WHO)


5. Causes of abortion:

• Ovofetal factors• Maternal factors


6.Varieties of abortion:

• Induced (therapeutic) abortion• Spontaneous abortion


7. Varieties of spontaneous abortion:

• threatened• inevitable• complete or incomplete• missed • and recurrent abortion


8. Threatened abortion Threatened abortion is bleeding of

intrauterine origin occurring before the 20th completed week, with or without uterine contractions, without dilatation of the cervix, and without expulsion of the products of conception.


9.Threatened abortion


10.Threatened abortion

The clinical diagnosis of threatened abortion is presumed when a bloody vaginal discharge or bleeding appears through a closed cervical os during the first half of pregnancy.


11.Treatment of threatened abortion

There are no effective therapies for threatened abortion. Bed rest, although often prescribed, does not alter the course of threatened abortion. Acetaminophen-based analgesia may be given to help/relieve the pain.


12. Inevitable abortion

Abortion becomes inevitable if uterine bleeding is associated with strong uterine contractions which caused dilatation of the cervix.


13.Complete and incomplete abortion

Complete abortion is the expulsion of all of the products of conception before the 20th completed week of gestation, whereas incomplete abortion is the expulsion of some, but not all, of the products of conception.


14.Missed abortion

In a few cases of abortion the dead embryo or fetus and placenta are not expelled spontaneously and are retained in utero.


15.Clinical aspects of missed abortion

• The patients complain of a dirty brown discharge which persists.

• The uterus fails in grow and symptoms indicating early pregnancy disappear


16.Treatment of missed abortion

• There is no need to treat missed abortion urgently

• If spontaneous abortion has not occurred within 28 days, the pregnancy should be terminated, as coagulation defects may result

• If the uterus is <12 weeks gestational size, the uterus can be evacuated by sponge forceps and curette after cervical dilatation


17.Treatment of missed abortion

• If the uterus is >12 weeks gestational size, either mifepristone 600mg RU 486followed 36 hours later by misoprostol (300mg repeated in 2 hours) or prostaglandine E2 vaginal pessaries(20mg) every 3 or 6 hours are effective


18.Recurrent (habitual) abortion

Recurrent abortion in its broadest definition is defined as 2 or more consecutive pregnancy losses before 20 weeks of gestation, each with a fetus weighing less than 500 g. Approximately 1% of women are habitual aborters.


19. Investigation

• A careful medical and obstetrical history may reveal systemic disease or suggest cervical incompetence

• A vaginal examination may show uterine myomata or cervical incompetence


20. Investigation

• Diagnosis can be clarified if a transvaginal ultrasound image is made. Ultrasound will also detect uterine malformations

• Although it is usual to investigate both parents for chromosome abnormalities


21.Treatment of recurrent abortion

• no treatment is available • If cervical incompetence (20 per

cent) diagnosed, treatment is to place a soft unabsorbable suture around the cervix at the level of the internal cervical os.


22.Septic abortionClinical features

• Pink vaginal discharge• Pyrexia• Tachycardia (PR>120per minute)• Tender lower abdomen• Tender uterus (per vaginam) during

the bimanual examination


23.Investigations

• A high vaginal or cervical swab• Blood culture • Serum electrolytes and coagulation

studies (in severe infections)


24.Treatment of septic abortion

• Antibiotics• If hemorrhaging is severe and the

uterus is not empty its contents are evacuated by careful curettage

• If the infection is not controlled in spite hysterectomy may be indicated

.


25.Gestational Trophoblastic Disease

The term gestational trophoblastic disease refers to pregnancy-related trophoblastic proliferative abnormalities.


26.Criteria for Diagnosis of Gestational Trophoblastic Disease Hydatidiform Mole:• Complete• PartialGestational Trophoblastic Neoplasia Postmolar

GTN1. Plateau of serum hCG level (±10%) for four

measurements during a period of 3 weeks or longerdays 1, 7, 14, 21.

2. Rise of serum hCG > 10% during three weekly consecutivemeasurements or longer, during a period of 2 weeks or moredays 1, 7, 14.

3. The serum hCG level remains detectable for 6 months or more.

4. Histological criteria for choriocarcinoma.TBILISI STATE MEDICAL UNIVERSITY - UNICEF GEORGIA

27.Hydatidiform Mole (Molar Pregnancy)

Molar pregnancy is characterized

histologically by abnormalities of the chorionic villi that consist of trophoblastic proliferation and edema of villous stroma. The absence or presence of a fetus or embryonic elements has been used to describe them as complete and partial moles


28.COMPLETE HYDATIDIFORM MOLE

In complete hydatiform mole, the

chorionic villi transform into a mass of clear vesicles.

The vesicles vary in size from barely visible to a few centimeters and often hang in clusters from thin pedicles.


29.Complete hydatidiform mole


30.PARTIAL HYDATIDIFORM MOLE

When the hydatidiform changes are focal and less advanced, and some element of fetal tissue is seen, the term partial hydatidiform mole is used.


31. Partial hydatidiform mole


32.Features of Partial and Complete Hydatidiform Moles

Feature Partial Mole Complete MoleEmbryo-fetus Often present AbsentAmnion, fetal red blood cells Often present Absent Villous edema Variable, focal DiffuseTrophoblastic Variable, focal, slight Variable, slight to moderate to severe

Clinical presentation Diagnosis Missed abortion Molar gestationUterine size Small for dates 50% large for

datesTheca-lutein cysts Rare 2530%Medical complications Rare FrequentGestational trophoblastic <510% 20%


33.Classification of Trophoblastic Neoplasms

Persistent Trophoblastic Disease(often malignant)

Apparently confined to the uterus-invasive mole

Usually with extra-uterine spread-choriocarcinoma


34. Aetiology

• Genetic disorder• A defective maternal immune

response


35. The diagnosis of benign gestational trophoblastic

disease• Bleeding per vaginam • The uterus is usually larger than

expected from the gestational dates and is “doughy” to the touch


36.The clinical and diagnostic features of a complete

hydatidiform mole 1. Continuous or intermittent brown or

bloody discharge evident by about 12 weeks and usually not profuse. 2. Uterine enlargement out of proportion to the duration of pregnancy in about half of the cases. 3. Absence of fetal parts and fetal heart motion.


37.The clinical and diagnostic features of a complete

hydatidiform mole 4. Characteristic ultrasonographic appearance.

5. Serum hCG level higher than expected for the stage of gestation.

6. Preeclampsia-eclampsia developing before 24 weeks.

7. Hyperemesis gravidarum.


38.Traetment of benign gestational trophoblastic

disease • Uterus evacuated using a suction

curette OR• By the administration of

prostaglandins to induce uterine contractions

• Women over the age of 40 may prefer to have a hysterectomy, to avoid potential malignancy.


39.Follow-up

1.Prevent pregnancy for a minimum of 6 months using hormonal contraception.

2.Monitor serum hCG levels every 2 weeks.


40.Follow-up

3. Chemotherapy is not indicated as long as these serum levels continue to regress.

4. Once the hCG level falls to a normal level, test the patient monthly for 6 months; then follow-up is discontinued and pregnancy allowed.


41. Malignant gestational trophoblastic disease

Women who have had a benign gestatinal trophoblastic tumour are a great risk of developing a malignancy if the women:

• Is over the age of 40


42. Malignant gestational trophoblastic disease

• Secretes large amounts of βhCG(>1000IU per ml)

• Has theca-lutein cyst more than 6cm in diameter


43.Diagnosis of Malignant gestational trophoblastic disease

Recognition of the possibility of gestational trophoblastic neoplasia is the most important factor


44.Malignant gestational trophoblastic disease-

treatment

Malignant gestational trophoblastic

disease is best managed at special centres, where meticulous follow-up is conducted.


hemorrhagic complication in first trimester

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