hemorrhagic complication in first trimester
TRANSCRIPT
1. Hemorrhagic complications of the first
period of pregnancyLesson/Package 5
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2. At the end of this presentation students will be able to understand what
hemorrhagic complications of the first period of pregnancy
are
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3. Most common complications are:
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•Abortion •Gestational Trophoblastic Disease
4. Abortion
• Abortion is the expulsion of fetus before it reaches viability (until 22 weeks of gestation. WHO)
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5. Causes of abortion:
• Ovofetal factors• Maternal factors
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6.Varieties of abortion:
• Induced (therapeutic) abortion• Spontaneous abortion
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7. Varieties of spontaneous abortion:
• threatened• inevitable• complete or incomplete• missed • and recurrent abortion
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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.
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9.Threatened abortion
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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.
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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.
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12. Inevitable abortion
Abortion becomes inevitable if uterine bleeding is associated with strong uterine contractions which caused dilatation of the cervix.
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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.
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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.
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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
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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
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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
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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.
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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
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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
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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.
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22.Septic abortionClinical features
• Pink vaginal discharge• Pyrexia• Tachycardia (PR>120per minute)• Tender lower abdomen• Tender uterus (per vaginam) during
the bimanual examination
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23.Investigations
• A high vaginal or cervical swab• Blood culture • Serum electrolytes and coagulation
studies (in severe infections)
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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
.
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25.Gestational Trophoblastic Disease
The term gestational trophoblastic disease refers to pregnancy-related trophoblastic proliferative abnormalities.
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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
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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.
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29.Complete hydatidiform mole
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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.
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31. Partial hydatidiform mole
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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%
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33.Classification of Trophoblastic Neoplasms
Persistent Trophoblastic Disease(often malignant)
Apparently confined to the uterus-invasive mole
Usually with extra-uterine spread-choriocarcinoma
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34. Aetiology
• Genetic disorder• A defective maternal immune
response
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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
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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.
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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.
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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.
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39.Follow-up
1.Prevent pregnancy for a minimum of 6 months using hormonal contraception.
2.Monitor serum hCG levels every 2 weeks.
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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.
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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
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42. Malignant gestational trophoblastic disease
• Secretes large amounts of βhCG(>1000IU per ml)
• Has theca-lutein cyst more than 6cm in diameter
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43.Diagnosis of Malignant gestational trophoblastic disease
Recognition of the possibility of gestational trophoblastic neoplasia is the most important factor
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44.Malignant gestational trophoblastic disease-
treatment
Malignant gestational trophoblastic
disease is best managed at special centres, where meticulous follow-up is conducted.
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