defined as proliferation and degeneration of the chorion a benign neoplasm of the chorion the...
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Defined as proliferation and degeneration of the chorion
A benign neoplasm of the chorionThe embryo fails to develop in most
casesOccurs in 1 of 2000 pregnanciesMore often in low socioeconomic
groups with low protein dietsMore often is the younger or older
mother
Uterus expands faster and reaches landmarks earlier
More morning sicknessEarlier signs of PIHVaginal bleeding in the 4th
monthDischarge with grape-like
vesicles
A d & c is done to evacuate the mole
Follow-up care is very importantTends to be carcinogenic—
choriocarcinomaRecommend no future
pregnancies for at least a yearEvaluate HCG levels closelyChest x-rays at interverals
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 weeksSuccess rate as good as 80 %Must be removed prior to the onset
of labor
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.
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, 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.
Anatomical conditions:1. Uterine conditions2. Cervical conditions Chromosomal disorders Endocrine disorders Immune factors Lifestyle factors Infection
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
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.
Therapeutic abortion when it is performed to:1. save the life of the pregnant woman2. preserve the woman's physical or mental health3. 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.
An elective abortion:When it is performed at the request of
the woman "for reasons other than maternal health or fetal disease.
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.
1. History Mild vaginal bleeding. No abdominal pain or
mild abdominal pain 2. Examination Good general
condition. The cervix is closed
The uterus is usually the correct size for date
3. U/S which is essential for the diagnosis Showed the presence of fetal heart activity
1. Reassurance If fetal heart activity is present, > 90% of cases will be progressed satisfactorily
2. Advice: Decrease physical activity (bed rest is of no therapeutic value) avoid intercourse
3. Hormones i.e. Progesterone & hCG Which are used in the first trimester to support pregnancy, (but they are of no proven value)
4. Anti- D: An adequate dose of anti-D should be given to all Rh –ve,non-immunised patients, whose husbands are Rh +ve
5. ANC as high risk patients Because those patients are liable to late pregnancy complications such as APH and preterm labour .
A condition in which:Vaginal bleeding has been profuse The cervix has become dilatedAbortion will invetably occur.
1. 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
2. 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)
3. U/S Fetal heart activity may or may not present in inevitable abortion or retained products of conception ( RPOC ) in incomplete abortion
1. CBC , blood grouping , XM 2 units of blood
2. Resuscitation large IV line, fluids & blood transfusion
3. Oxytoxic drugs Ergometrine 0.5 mg IM + Oxytocin infusion (20-40 units in 500 cc saline)
4. Evacuation & curettage. 5. Post-abortion management.
1. History Heavy vaginal bleeding which has
been stopped. lower abdominal pain which follows the
bleeding which has been stopped.2. Examination
The cervix is closed 3. U/S
showed empty uterine cavity or PROP
Retention of products for several weeks
No increase in fundal heightAbsence of FHTRegressions of signs of pregnancyLoss of wight
1. 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.
2. Examination The uterus may be small for date
3. 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 .
1. CBC , blood grouping 2. Platelets count, to exclude the
risk of DICNB : DIC does not occur before 5
weeks of missed abortion or IUFD and if occurred will be of mild grade
3.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.
4.Post-abortion management.
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 .
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.
1. Haemorrhage .2. 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
Adenomyosis3. Rh- iso immunisation if the anti –D is not given or
if the dose is inadequate .4. Psychological trauma .
In cases of incomplete, inevitable, complete, missed & septic abortions
1.Support: from the husband, family& obstetric staff
2.Anti D – to all Rh –ve, nonimmunised patients, whose husbands are Rh+ve
3. Counseling & explanation:A.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 .
3. Counseling & explanation:B.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
C.Why has it happened In the fiIn the majority of cases there is no
obvious causeIn the first trimester abortion , the most
common cause is fetal chromosomal abnormality
3.Counseling & explanation:D. 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
E. 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 ..
Definition : 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 .
Causes Idiopathic recurrent abortion, in about 50%,
in which no cause can be found . The known causes include the followings :
1.Chromosomal disorders:
Fetal chromosomal abnormalities & structural abnormalities
Parental balanced translocation
2. Anatomical disorders: Cervical incompetence: →congenital and aquired Uterine causes: → submucous fibroids, uterine
anomalies & Asherman’s syndrome
Causes3. 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
Diagnosis : 1.History :
Previous abortions : gestational age and place of abortions & fetal abnormalities.
Medical history : DM , thyroid disorders, PCOS, autoimmune diseases & thrombophilia.
2.Examination : General : weight , thyroid & hair distribution Pelvic: cervix ( length & dilatation ) and uterine
size.
Diagnosis : 3.investigations :
A. 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 )
Diagnosis : 3.investigations :
B. Investigations for anatomical disorders: TV/US: fibroids, cervical incompetence & PCOS. Hystroscopy or HSG, fibroids, cervical incompetence,
uterine anomalies & Asherman's syndromeC. Investigations for chromosomal disorders: Parental karyotyping: Parental balanced translocation. Fetal karyotyping: Fetal chromosomal anomalies.
Management: 3.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
Management: 3.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.
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.