Causes and Types of Bleeding in Early Pregnancy

Prepared by: Abdulrahman Alsagabi

 Any vaginal bleeding before 20 wks period of
gestation is defined as early pregnancy
bleeding.
Bleeding In Early Pregnanct - Suliman Alrajhi Colleges 10/14/2014 2

 The causes of bleeding in early pregnancy are broadly divided into two groups:
I. Related to the pregnant state:
 Abortion 95%.
 Ectopic pregnancy.
 Hydatidi-form mole.
2. Associated with pregnant state: Lesions are unrelated to pregnancy – either pre-existing
or aggravated during pregnancy.
 Cervical lesions.
 Vascular erosion.
 Polyps.
 Ruptured varicose veins.
 Malignancy.

Abortion
Ectopic pregnancy
Hydatidiform mole

 The expulsion or extraction from its mother of an embryo or fetus weighing 500
gm or less when it is not capable of independent survival. 500mg = approx.
22weeks (154 days) of gestation.
 Abortus: expelled embryo or fetus.
 Miscarriage: recommended terminology for spontaneous abortion.

 The incidence of abortion is difficult to work out but 10-20% of all clinical
pregnancies end in miscarriage and another optimistic figure of 10% induced
illegally.
 75% end before 16th week and 75% of these occur before 8th week of pregnancy.

Abortion
Spontaneous
(miscarriage)
recurrent
Isolated
(sporadic)
induced
Legal (MTP)
Illegal (unsafe)
Septic common
Threatened, Inevitable, Complete, Incomplete, Missed,
Septic (less common)

 Complex and obscure (embryonic or parental) are important.
 Genetic – majority 50% of early miscarriages.
 Endocrine and metabolic – 10-15% LPD, deficient progesterone, thyroid abnormalities, DM.
 Anatomic – 10-15% mostly related to 2nd trimester, cervical, uterine (congenital malformation or fibroid).
 Infection – 5% viral , bacterial, parasitic.
 Immunological – 5-10% autoimmune disease, alloimmune disease.
 Antifetal antibodies.
 Thrombophilia.
 Maternal medical illness – heart disease, haemoglobinopathies.
 Blood group incompatibility : in compatible ABO group lead to early wastage and often recurrent while
RH incompatibility rare cause of death before 28th week, couple with A husband + O wife has higher
incidence of abortion.
 Others.

 1st: 1-genetic 50%. 2-endocrine. 3- immunological. 4-infection. 5-unexplained.
 2nd: 1- anatomic. 2- maternal medical illness. 3- unexplained.

 Before the 12th week, the pregnancy sac tends to be expelled from the uterus in
one mass. After that time, the process is similar to labour. The membranes
rupture with escape of amniotic fluid then the fetus and placenta are born
separately.

 Clinical entity where the process of miscarriage has started but has not
progressed to state from which recovery is impossible.
 Clinical picture:
 S&S similar to pregnancy.
 Bleeding – usually slight or moderate due to separation of ovum.
 Pain is absent or some heaviness maybe felt in suprapubic region.
 OE/ uterus enlarged cervix closed.
 hCG +ve.
 US/ will show a viable fetus and differentiates threatened abortion from missed abortion
and hydatidiform mole

 Fate:
 Bleeding stops:
 the embryo or fetus is still alive and pregnancy continues (50%).
 the embryo or fetus dies but is retained in the uterus leading to missed abortion.
 Bleeding continuous:
 uterine contractions occur, and cervix dilates leading to inevitable abortion.
 Treatment:
 Rest (physical, mental and sexual).
 Treatment of the cause : If obvious.
 Natural Progesterone (vaginal suppository or intramuscular) is given by some if there is
evidence of progesterone deficiency. Progesterone may cause retention of the dead ovum leads to
missed abortion.

 Clinical type of abortion where the changes have progressed to a state from where
continuation of pregnancy is impossible.
 Clinical picture :
 S&S of pregnancy.
 Bleeding, usually severe.
 Pain : It is colicky intermittent felt in the supra pubic region (uterine contractions) and may
be accompanied with low backache (cervical dilatation).
 OE/ the uterus is enlarged and the internal os of the cervix is dilated. The products of
conception may be felt through the dilated cervix.
 Fate :
 Abortion will occur in spite of any treatment.
 Treatment :
 Before 12 weeks vaginal evacuation and curettage.
 After 12 weeks, oxytocin by intravenous drip or prostaglandins are given to help the uterus
expel its content. If the placenta is retained it should be removed under general anaesthesia
followed by uterine curettage.

 Part of the products of conception is expelled from the uterus and part is retained
inside the uterus.
 In clinical picture and treatment same as inevitable abortion.

 All the products of conception are expelled from uterus.
 The bleeding is slight and gradually diminishes, pain is absent, the uterus is
smaller than the period of amenorrhea and the cervix is closed or closing.
 Ultrasound is performed if the uterus is empty, nothing is done. If remnants are
seen evacuation is carried out

 The embryo or fetus are dead and retained inside the uterus.
 Symptoms of threatened abortion may or may not occur.
 Pregnancy symptoms gradually disappear as nausea, vomiting and breast
symptoms.
 Failure of the abdomen to increase in size.
 Failure to feel fetal movements or cessation of fetal movements if previously
present.
 Milk secretion may start spontaneously from the breasts, frequently in second
trimester abortion due to drop in secretion of estrogen which normally blocks the
action of prolactin on the breast.
 A dark brown vaginal discharge may occur.

 Signs :
 Uterus is smaller than the period of amenorrhea and fails to enlarge. It is firm in
consistency. The cervix is closed.
 Fetal heart sounds (FHS) cannot be heard by Sonicaide.
 Investigations :
 U.S is diagnostic. It shows absent fetal cardiac pulsations. A collapsed pregnancy sac
may be detected.
 hCG: becomes negative within two weeks after death of the embryo or fetus, sometimes
remains positive for a longer period if there is still living chorionic tissue.
 Complications : Intrauterine infection and DIC in neglected cases.
 Treatment :
 The dead conceptus is expelled spontaneously in the majority of cases. Otherwise,
evacuation of the uterus is done once sure diagnosis of missed abortion is made. Methods
are discussed later.

Type of
abortion
bleeding
pain
Cervical
dialatation
Uterine size
Products of
conception
shock
Pregnancy test
Threatened + - - Correspond amenorrhea - - +
Inevitable ++ + + Correspond amenorrhea - ± +
Incomplete ++ + + Slightly smaller + ± +
Complete + - - smaller - - +
Missed ± - - smaller - - - after 2 wks

 It is any type of abortion complicated by infection. It is usually the result of
criminal interference.
 Organisms include staphylococci, streptococci, Escherichia coli, clostridium
welchii as well as other organisms. The commonest organisms are the anaerobic
streptococci.
 Routes: Endo-Exo and autogenous.
 Clinical picture:
 General manifestation of infection.
 Abdominally: suprapubic pain or rigidity.
 Vaginally: offensive discharges.

 Investigations :
 Cervicovaginal swab.
 Full laboratory investigations including : Complete blood count (CBC), urine analysis,
liver and kidney function tests, plasma glucose and coagulation profile.
 Blood for culture (aerobic and anaerobic) and sensitivity test (if pyrexia >39°C).
 Ultrasound examination.

 Treatment :
 Hospitalization, and isolation in a separate room.
 Observation for vital signs (pulse, blood pressure, respiratory rate and
temperature) and fluid chart.
 Fluid therapy to maintain a urinary flow of at least 30 ml/hour.
 Broad-spectrum parenteral antibiotics Until C & S results.
 Evacuation of the uterus is indicated if it contains products of conception, 4-6
hours after initiation of massive antibiotic therapy.
 Ecbolics to control bleeding.
 Correct anemia.
 Symptomatic treatment in the form of antipyretics and analgesics.
 Hysterectomy is indicated in case of gas gangrene of the uterus or septic shock not
responding to treatment

 1- Peritonitis 2- Septicemia
 3- Septic shock 4- Renal failure
 5- DIC 6- hemolytic anemia
 7- Liver failure 8- Adult respiratory distress syndrome

 products of conception are separated from the uterus but retained inside the
cervical canal because of stenosed external Os due to previous cauterization or
operation in the cervix.
 cervix becomes ballooned but the bleeding is usually slight.
 Under anaesthesia the cervix is dilated, products of conception removed and
uterus curetted to remove any remnants.

 Recurrent pregnancy loss (RPL) or Habitual abortion.
 Three or more successive spontaneous abortions.
 Less than 1% of pregnancies (0.3-0.9%).
 Causes:
1. Fetal: chromosomal.3-5 %
2. Maternal:15-20%
 Local: uterine leiomyomas , Intrauterine synechiae (Asherman syndrome), Uterine anomalies, Cervical
insufficiency.
 General:
 Immunological Factors (15-20%) :
 Inherited Thrombophilias.
 Endocrinal Factors
 Infection.
3. Idiopathic 50%.

 Timing and extent of evaluation should be based on maternal age, coexistent
infertility, symptoms, and the level of anxiety :
 Karyotyping of both parents remains a critical part of evaluation.
 Hysterosalpingography (HSG), ultrasound (two, three dimensional and
sonohysterography), MRI and endoscopy (hysteroscopy and laparoscopy) are used
for anatomical factors as a cause of recurrent pregnancy loss.
 Detection of antiphospholipid antibodies.
 Thrombophilia screen.
 Endocrine workup.

 Treat the cause:
 Hysteroscopic septectomy in women who had a septate uterus.
 Submucous fibroids should be excised.
 Low-dose aspirin, or low-dose aspirin plus heparin increase live birth rates with
autoimmune factors.
 Progesterone replacement is indicated in LPD.
 Corticosteroids for SLE.
 Cervical insufficiency.

 Inability of cervix to maintain pregnancy till full term which may lead to abortion or
preterm labour.
 causes:
1. Congenital :
2. Acquired :
 (A) Gynecological caues :
 Rapid excess dilatation
 Cervical operation (amputation, conization, Fothergill’s operation).
 (B) Obstetric causes :
 Unrepaired cervical tear that may be due to forceps application or ventouse extraction
or breech extraction before full cervical dilatation.

 Character of Abortion :
 Mid-trimester (mechanical)
 Gestational age decrease by time as there is more weakness by repetition.
 Painless
 Start by rupture of membranes, then delivery of fetus, then placenta (baby is living).
 Examination and investigations :
 Between pregnancies :
 Speculum examination : You may find bilateral cervical tear and short cervix.
 Easy passage of Hegar’s four (suspicious), but if Hegar's eight is diagnostic.
 During pregnancy :
 Only ultrasonography (U/S) : Decrease cervical length <2.5 cm, funneling of the cervical canal
and herniation of the sac.

 In between pregnancies : repair of any cervical tear (Trachellorrhaphy)
 During Pregnancy : Cerclage may be abdominal or vaginal.

 It is the medical or surgical termination of pregnancy before the time of fetal
viability.
 Types:
 Therapeutic Abortion.
 Elective (Voluntary) Abortion.
 Methods:
 4-7 weeks :Medical using mifepristone and prostaglandins.
 7-12 weeks : Suction termination under general anaesthesia
 >12 weeks :Medical using mifepristone and multiple doses of PGs
 Hysterotomy. In some cases.

Medical abortion Surgical abortion
Avoids invasive procedures Involves invasive procedures
Avoids anaesthesia Needs anaesthesia
Requires two or more visits Requires usually one visit
Days to week to complete Complete in a predictable time
High success rate (95%) High success rate (99%)
Moderate to heavy bleeding for short time Minimal
Requires follow up Does not require follow up

 Any pregnancy where the fertilised ovum gets implanted & develops in a site
other than normal uterine cavity.

IMPLANTATIONS SITES
EXTRAUTERINE UTERINE
TUBAL 95-96%
OVARIAN
(1:40,000)
-Ampulla 70%
-Isthmus 12%
-Infundibulum 11%
-Interstitial &corneal 2%
ABDOMINAL
(1:10,000)
-CERVICAL
(1:18,000)
-ANGULAR
-CORNUAL
-CAESAREAN
SCAR (<1)
PRIMARY SECONDARY
Intraperitoneal
(common)
Extraperitoneal
Broad Ligament
(rare)

INCIDENCE
• Increased due to PID, use of IUCD, Tubal
surgeries, and Assisted reproductive techniques
(ART).
• Ranges from 1:25 to 1:250
• Average range is 1 in 100 normal pregnancies.
• Late marriages and late child bearing -> 2%
• Recurrence rate - 15% after 1st, 25% after 2
ectopics

ETIOLOGY:
Any factor that causes delayed transport of the fertilised
ovum through the tube.
 Fallopian tube favours implantation in the tubal mucosa
itself thus giving rise to a tubal ectopic pregnancy.
These factors may be Congenital or Acquired.

ETIOLOGY
CONGENITAL
 Tubal Hypoplasia
 Tortuosity
 Congenital diverticuli
 Accessory ostia
 Partial stenosis
 Elongation
 Intamural polyp
 Entrap the ovum on its way.

ACQUIRED -
Pelvic Inflammatory disease (6-10 times)
 Chlamydia trachomatis is most common
Contraceptive Faliure
Tubal sterilization faliure -40%
Reversal of sterilisation
Tubal reconstructive surgery (4-5 times)
 Assisted Reproductive technique
Previous Ectopic Pregnancy
 7-15% chances of repeat ectopic pregnancy

Other Risk factors
Age 35-45 yrs
Previous induced abortion
Previous pelvic surgeries
Cigarette smoking
DES Exposure in Utero
Infertility
Salpingitis Isthmica Nodosa
Genital Tuberculosis
Fundal Fibroid & Adenomyosis of tube
Transperitoneal migration of ovum

ACUTE ECTOPIC PREGNANCY
 Classical triad is present in 50% of pt with
rupture ectopic.
- PAIN:- most constant feature in 95% pt
- variable in severity and nature
- AMENORRHOEA:- 60-80% of pt
- there may be delayed period or slight
spotting at the time of expected menses.
- VAGINAL BLEEDING: - scanty dark brown
 Feeling of nausea,vomiting,fainting attack, syncope
attack(10%) due to reflex vasomotor disturbance.

 O/E
 patient is restless in agony, looks blanched, pale, sweating with
cold clammy skin. Features of shock, tachycardia, hypotension.
 abdomen tense, tender mostly in lower abdomen,shifting dullness,
rigidity may be present.
 minimal bleeding may be present
 uterus may be bulky, deviated to opposite side, fornix is tender,
excitation pain on movement of cervix. POD may be full, uterus
floats as if in water.

CHRONIC ECTOPIC PREGNANCY
 It can be diagnosed by high clinical suspicion.
 Patient had previous attack of acute pain from which
she has recovered.
 She may have amenorrhoea, vaginal bleeding with dull
pain in abdomen,and with bladder and bowel
complaints like dysuria,frequency or retention of urine,
rectal tenesmus.

 O/E:
 patient look ill, varying degree of pallor, slightly raised
temperature. Features of shock are absent.
 Tenderness and muscle guard on the lower abdomen.
A mass may be felt, irregular and tender.
 Vaginal mucosa pale, uterus may be normal in size or
bulky, ill defined boggy tender mass may be felt in one of
the fornix.

UNRUPTURED ECTOPIC
 High degree of suspicion & ectopic conscious clinician can
diagnose.
 Diagnosed accidentally in Laparoscopy or Laparotomy
– delayed period, spotting with discomfort in
lower abdomen.
– tenderness in lower abdomen
– should be done gently:
 uterus is normal size, firm
 small tender mass may be felt in the fornix

DIAGNOSIS
“Pregnancy in the fallopian tube is a black cat on a dark
night. It may make its presence felt in subtle ways and leap
at you or it may slip past unobserved. Although it is
difficult to distinguish from cats of other colours in
darkness, illumination clearly identifies it.”
--Mc. Fadyen - 1981

DIAGNOSIS
 Patient with acute ectopic can be diagnosed clinically.
 Blood should be drawn for Hb gm%, blood grouping and cross
matching, DC and TWBC, BT, CT.
 Should be catheterized to know urine output.
Bed side test:-
1. Urine pregnancy test:- positive in 95% cases.
ELISA is sensitive to 10-50 mlU/ml of β hCG and
can be detected on 24th day after LMP.

2. Culdocentesis:- (70-90%)
- Can be done with 16-18 G lumbar
puncture needle through posterior fornix
into POD.
- Positive tap is 0.5ml of non clotting blood.
 Other Investigations:-
1. Ultra Sonography-:
a) Transvaginal Sonography (TVS):
- Is more sensitive
- It detect intrauterine gestational sac at
4-5wks and at S-β hCG level as low as 1500
IU/L .

b) Color Doppler Sonography(TV-CDS):
- Improve the accuracy.
-Identify the placental shape (ring-of-
fire pattern) and blood flow
outside the uterine cavity.
c) Transabdominal Sonography:
- can identify gestational sac at 5-6 wks
- S-β hCG level at which intrauterine gestational
sac is seen by TAS is 1800 IU/L.

USG PICTURE
1.‘Bagel’ sign – Hyperechoic ring around gestational sac
in adnexal region
2. ‘Blob’ sign – Seen as small inconglomerate mass next
to ovary with no evidence of sac or embryo.
3. Adnexal sac with fetal pole and cardiac activity is
most specific.
4. Corpus luteum is useful guide when looking for EP as
present in 85% cases in Ipsilateral ovary.

Hyperechoic ring around
gestational sac in adnexal region

Ring sign — a hyperechoic ring around an extrauterine gestational sac.

2. β-HCG Assay-a)
Single β-HCG: little value
b) Serial β-HCG: is required when result of
initial USG is confusing.
- When hCG level < 2000 IU/L doubling time
help to predict viable Vs nonviable pregnancy.
-Rise of β-HCG <66% in 48 hrs indicate
ectopic pregnancy or nonviable intrauterine
pregnancy .
Biochemical pregnancy is applied to those
women who have two β-HCG values >10 IU/L

3. Serum Progesterone –
- level >25 ngm/ml is suggestive of normal
intrauterine pregnancy.
- level <15 ngm/ml is suggestive of ectopic
pregnancy.
- level <5 ngm/ml indicates nonviable
pregnancy, irrespective of its location.
4. Diagnostic Laparoscopy (Gold standard)–
- Can be done only when patient is
haemodynamically stable.
-It confirms the diagnosis and removal of
ectopic mass can be done at the same time.

5. Dilatation & Curettage –
- Is recommended in suspected case of
incomplete abortion vs ectopic pregnancy.
- Identification of decidua without chorionic
villi is suggestive of extra uterine pregnancy.
- “Arias-Stella” endometrial reaction is
suggestive but not diagnostic of ectopic
pregnancy.
6. Other hormonal Tests –
- Placenta protein (PP14) decrease in EP
- PAPPA (Pregnancy Associated Plasma Protein A),
PAPPC (schwangerchaft protein 1) has low value in
EP
- CA-125, Maternal serum creatine kinase, Maternal
serum AFP elevated in ectopic pregnancy.

SUSPECTED ECTOPIC PREGNANCY
Urine Pregnancy test positive
Transvaginal USG
IU sac No IU sac
Quantitative S-hCG
+ S progesterone
< 66% rise in 48 hr or
S progesterone < 5-10 ng/ml
D & C
Villi present Villi absent
Incomplete
abortion
Laparoscopy
>66% rise in 48 hr or
S progesterone > 5-10 ng/ml
Repeat S-hCG in 48 hrs
till USG discrimination zone
No sac IU sac
Continue to monitor

DIFFERENTIAL DIAGNOSIS
D/D of Acute Ectopic
1. Rupture corpus luteum of pregnancy
2. Rupture of chocolate cyst
3. Twisted ovarian cyst
4. Torsion / degeneration of pedunculated fibroid
5. Incomplete abortion
6. Acute Appendicitis
7. Perforated peptic ulcer
8. Renal colic
9. Splenic rupture

D/D OF CHRONIC (SUB ACUTE) ECTOPIC
1. Pelvic abscess
2. Pyosalpinx
3. Subserous uterine fibroid
4. Salpingintis
5. Retroverted gravid uterus
6. Appendicular lump

MANAGEMENT
Expectant
management
Medical
management
Surgical
management
Local Systemic
(USG or Laparoscopic)
salpingocentesis
Methotrexate
- Methotrexate
- Potassium chloride
- Prostagladin(PGF2α)
- Hypersmolar glucose
- Actinomycin D
- Mifepristone
Radical
Salpingectomy
Conservative
-Salpingostomy
-Salpingotomy
- Segmental
resection
-Milking or fimbrial
expression

MANAGEMENT OF RUPTURED ECTOPIC
PRINCIPLE: Resuscitation and Laparotomy
ANTI SHOCK TREATEMENT:
- IV line made patent, crystalloid is started
- Blood sample for Hb, blood grouping & cross matching, BT, CT
- Folley’s catheterization done
- Colloids for volume replacement
LAPAROTOMY:
Principle is ‘Quick in and Quick out’
- Rapid exploration of abdominal cavity is done
- Salpingectomy is the definitive surgery (sent for HP study)
- Blood transfusion to be given
- Autotransfusion only when donated blood not available.

OVARIAN ECTOPIC PREGNANCY
Incidence: 1:40,000
Risk factor: - IUCD
- Endometriosis on surface of ovary
Course:
C/F are same as tubal pregnancy
ruptures within 2-3 wks
Diagnosis: On Laparotomy
Spiegelberg’s Criteria
1. Ipsilateral tube is intact and separate from sac
2. Sac occupies the position of the ovary
3. Connected to uterus by ovarian ligament
4. Ovarian tissue found on its wall on HP study
M/M
Ruptured
Laparotomy
Oophorectomy
Unruptured
Ovarian wedge resection
Ovarian Cystectomy

ABDOMINAL PREGNANCY
Incidence: Rarest
MMR : 7-8 times > tubal ectopic
90 times > Intrauterine pregnancy
H/O : - Irregular bleeding, spotting
- Nausea, vomiting, flatulence, constipation,
diarrhoea, abdominal pain.
- Fetal movement may be painful and high in
the abdomen
O/E : - Abnormal fetal position, easy in palpating
fetal parts.
- uterus palpated separate from sac
- no uterine contraction after oxytocin
infusion

Diagnosis: Confirmed by USG,
CT scan, MRI, Radiography
TYPE
Primary Secondary
Studiford’s criteria
1. Both tubes and ovaries normal
2. Absence of Uteroperitonal fistula
3. Pregnancy related to Peritoneal
surface & young enough to rule
out possibility of secondary
implantation
Conceptus escapes out
through a rent from
primary site
Intraperitoneal Extraperitoneal
Broad ligament

FATE OF SECONDARY ABDOMINAL PREGNANCY :
1. Death of ovum – complete absorption
2. Placental separation – massive intraperitoneal
haemorrhage
3. Infection – fistulous communication with intestine,
bladder, vagina, or umbilicus
4. Fetus dies (majority) – mummification, adipocere
formation, or calcified to lithopaedion
5. Rarely – continue to term (malformation)
M/M:
- Urgent Laparatomy irrespective of period of gestation
- Ideal to remove entire sac fetus, placenta, membrane
- Placenta may be left if attached to vital organs, get
absorbed by aseptic autolysis

CERVICAL PREGNANCY
Implantation occurs in cervical canal at or below internal Os.
Incidence: 1 in 18,000
RISK FACTORS :
- Previous induced abortion
- Previous caesarean delivery
- Asherman’s syndrome
- IVF
- DES exposure
- Leiomyoma

Diagnosis:
CLINICAL CRITERIA: Paulman & McEllin
1. Uterine bleeding, no cramping, following
amenorrhoea
2. Cervix distended,thin walled,soft consistency
3. Enlarged uterine fundus may be palpated.
4. Internal Os is closed
5. External Os is partially opened
USG CRITERIA: American Journal of O&G
1. Echo-free uterine cavity/ pseudo-gestational
sac
2. Decidual reaction
3. Hourglass uterus with ballooned cervical canal
4. Gestational sac in endocervix
5. Closed internal Os
6. Placental tissue in Cx canal

HISTOPATHOLOGIC CRITERIA: Rubin’s
1. Cervical glands present opposite to placenta
2. Placental attachment to the cervix must be
below the entrance of uterine vessels .
3. Fetal element absent from corpus uteri.
D/d :
- Carcinoma Cx
- Cervical submucous fibroid
- Trophoblastic tumour
- Placenta previa

MANAGEMENT
Surgical
Mainstay therapy in past
Radical
surgery
Hysterectomy
Conservative
D & C
(risk of torrential bleeding)
- Cerclage Bernstein ≈ Mc Donald’s
Wharton ≈ Shirodkar’s
-Transvaginal ligation of Cx branch of
uterine artery
- Angiographic uterine A embolisation
- Intracervical vasopressin inj
- Foley’s catheter as tamponade
Medical
Recently proposed
Single or Combination
OR
Adjunct to surgery
- Methotrexate
- Actinomycin
- KCl
- Etoposide

CORNUAL PREGNANCY
SITE: Implantation occurs in rudimentary horn of Bicornuate
uterus
COURSE :Rupture of horn occurs by
12-20 wks
D/D :
1. Interstitial tubal pregnancy
2. Painful leiomyoma along with
pregnancy
3. Ovarian tumor with pregnancy
4. Asymmetrical enlargement of uterus.
Implantation into cornu of normal uterus is sometime
called Angular pregnancy .
TREATEMENT:
- Affected cornu with pregnancy is removed
- Hysterectomy
- Hysteroscopically guided suction curettage if
communication with Cx is patent

HETEROTYPIC PREGNANCY
Co-existing intrauterine and extra uterine pregnancies
Incidence: 1 : 30,000
With ART – 1:7000
With ovulation induction – 1:900
More likely:
a) Ass. reproductive technique
b) Rising HCG titre after D & C
c) More than 1 corpus luteum at laparotomy
M/M :
Depends on the site. Ectopic site may be removed
with continuation of IU pregnancy
(Rh Immunoglobulin: dose of 50 μ gm is sufficient to
prevent sensitization.)

INTERSTITAL PREGNANCY (2%)
It ruptures late at 3-4 months gestation.
Fatal rupture – severe bleeding as both uterine &
ovarian artery supply.
Early & Unruptured – Local or IM MTX with followup
Cornual resection by Laparotomy may be done.
There is high risk of uterine rupture in
subsequent pregnancy.
Rupture – Hysterectomy is indicated

CAESAREAN SCAR ECTOPIC PREGNANCY
Recently reported
USG slows on empty uterine cavity and gestational sac
attached low to the lower segment caesarean scar.
C/F : similar to threatened or inevitable abortion
Diagnosis : Doppler imaging confirms
T/t : Methotrexate injection
Hysterectomy in a multiparous women.
In young pt resection & suturing of scar may be
done (high risk of rupture).

OTHER RARE TYPES
1. Multiple Ectopic pregnancy
2. Pregnancy after hysterectomy
3. Primary splenic pregnancy
4. Primary hepatic pregnancy
5. Rectroperitoneal pregnancy
6. Diaphragmatic pregnancy
MORTALITY : In general population is 10-15% mainly
due to haemorrhage.

SUMMARY - KEY POINTS
Incidence of ectopic pregnancy is rising while maternal mortality from it is
falling.
Ectopic pregnancy can be diagnosed early (before it ruptures) with recent
advances in Immunoassay to detect S-hCG , high resolution USG, and
dignostic Laparoscopy.
There has been shift in the M/m from ablative surgery to conservative
fertility preserving therapy
Laparotomy should be done when in doubt
The choice today is Laparoscopic treatment of unruptured ectopic
pregnancy.
Careful monitoring and proper counselling of patients is mandatory.

 GTD is a clinical spectrum that includes all neoplasms that derive from abnormal
placental (trophoblastic) proliferation :
 Hydatidiform (vesicular) mole, also known as molar pregnancy :
 Complete mole.
 Partial mole.
 Gestational trophoblastic neoplasia :
 Invasive mole (chorioadenoma destruens).
 Choriocarcinoma.
 Placental site trophoblastic tumor.

 It is a benign tumor of chorionic villi and characterized by :
 Marked proliferation of the trophoblast.
 Edema or hydropic degeneration of the villi which leads to their distension and the
formation of vesicles.
 Avascularity of the villi : The blood vessels disappear from the villi, which explain
the early death of the embryo.
 Incedince:
 Asian live in Asia 1:200 while in US 1:1500 with recurrence 1-2%.

 Race : more in Asian women.
 Maternal age :
 - Less than 20 ys. OR - More than 40 ys.
 Increased paternal age.
 History of molar pregnancy.
 Smoking.
 Protein or vit. A deficiency.
 Irregular cycles

 Uterus : It is usually larger than the period of amenorrhea in complete type.
 Content :
 Vesicles :
 A large number of vesicles which are closely packed together.
 They vary in size from 2 mm – 2 cm in diameter.
 Each vesicle has a fine pedicle.
 The fluid content is clear and watery.
 Fetus :
 Absent in complete type.
 Present in partial type (usually malformed).
 The Ovaries :
 large size (10 cm or more).
 They are due to stimulation of the ovaries by the excessive human Chorionic
Gonadotrophin (hCG) produced by the proliferated trophoblast.
 Cysts disappear within few months (2-3), after evacuation of the mole.

 Symptoms :
 Symptoms of early pregnancy.
 Symptoms of pre-eclampsia: headache, and edema.
 Abnormal abdominal enlargement in some cases due to distension of the uterus with vesicles.
 Vaginal bleeding : (main complaint).
 It is due to separation of vesicles from the uterine wall.
 There may be a blood stained watery discharge, the watery part is from ruptured of vesicles.
 Prune juice discharge may occur, the blood is brown because it has been retained for some
time in the uterine cavity.
 The passage of vesicles is diagnostic.
 Pain: may be,
 Dull aching abdominal pain due to rapid distension of the uterus.
 Localized sharp pain and tenderness on the uterus due to perforating mole.
 Ovarian pain due to stretching of the ovarian capsule or complication in the ovarian cyst as
torsion.

 Ultrasonography gives a characteristic picture (snowstorm appearance) and
no fetus is seen. In cases of partial mole, ultrasonography reveals an
abnormally formed fetus.
 Very high serum level of HCG (more than 100,000 mlU/ml). The result is
compared with the level for normal pregnancy at the same age.
 X-ray of the chest should be performed in every case of trophoblastic tumor.
 Differential Diagnosis :
1. Other causes of an oversized pregnant uterus as multiple pregnancy.
2. Causes of bleeding in early months of pregnancy as abortion.

 Hemorrhage.
 Perforation of the uterus.
 Uterine infection.
 Development of choriocarcinoma.
 Hyperthyroidism .
 Disseminated intravascular coagulation (DIC).
 Trophoblastic embolization.
 Recurrent mole.

 Once the diagnosis is confirmed, the molar pregnancy is terminated to avoid
complications.

I. Post molar syndrome or persistent GTN :
 After molar evacuation, there are :
 Persistent bleeding.
 Subinvolution of the uterus.
 +ve pregnancy test.
 No malignant changes in endometrial biopsy.
 Ultrasound with Doppler examination and MRI is necessary.
 Treatment: chemotherapy.
II. Choriocarcinomas : Refer to choriocarcinoma in gynecologic oncology.

 A rare form of trophoblastic disease.
 The tumor is comprised of intermediate cytotrophoblastic cells that are locally
invasive at the site of placental implantation.
 The tumor only secretes small amounts of hCG, and can be better followed by
human placental lactogen levels.
 This tumor is rarely metastatic and is much more resistant to standard
chemotherapy.
 Hysterectomy as initial therapy is often curative.

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