This document discusses early pregnancy complications including miscarriage, ectopic pregnancy, and molar pregnancy. It defines each condition and describes their causes, clinical features, diagnosis, and management. Miscarriage is defined as expulsion of pregnancy tissue before 22 weeks gestation and can be threatened, inevitable, incomplete, missed, or complete. Ectopic pregnancy occurs when implantation occurs outside the uterus, usually in the fallopian tubes. Molar pregnancy results from abnormal fertilization and can be complete or partial hydatiform moles, or develop into choriocarcinoma. The document provides details on evaluating and treating each complication.

1. By: Dr Ismah Haron
O&G Department
8/6/2014 1

2. Miscarriage
Ectopic pregnancy
Molar pregnancy
3 main categories of early pregnancy
complications are:
8/6/2014 2

3. 8/6/2014 3

4. Miscarriage
Definition :Expulsion of product of conception (POC) before 22nd week of
period of gestation (POG), which mean before period of fetal
viability.
Aetiology factors:
• Maternal’s age >35 years old
• Trauma
• Infections (TORCHES, malaria)
• Endocrine disorders (diabetes, hypothyroidism, PCOS)
• Immunological disorders (SLE, antiphospholipid syndrome)
• Abnormalities in uterus (uterine fibroid)
• Psychological disorder (stress)
• Chromosomal abnormalities (Down syndrome)
• Exposure to chemical agents (tobacco, arsenic, pesticides)
8/6/2014 4

5. Threatened
abortion
Inevitable
abortion
Incomplete
abortion
Missed
abortion
Complete
abortion
Recurrent
abortion
TYPES OF ABORTION:
8/6/2014 5

6. THREATENED ABORTION
Definition : Painless vaginal bleeding, that occur at anytime between
implantation and 24 weeks of gestation.
: POC has threatened to abort but has not done so yet.
Clinical features:
• Bleeding (minimal, painless)
• Associated with dull aching lower abdominal pain
Examination:
• Size of uterus is correspond to period of amenorrhea (POA)
• Closed cervical os
• U/S : well-formed, rounded gestational sac
with fetus within it
Management:
• Bed rest
• Folic acid supplements
• Avoid coitus
8/6/2014 6

7. INEVITABLE ABORTION
Definition : Painful vaginal bleeding from retro-placental site
: POC is about to be aborted but not yet
It can progress to complete/ incomplete abortion depending on whether or not all
fetal & placental tissues have been expelled from uterus.
Clinical features:
• Vaginal bleeding (painful)
• Associated with cramping pain at lower abdomen
Examination:
• Size of uterus is correspond to/less than POA
• Dilated cervical os
Management
•Hospitalization
•Analgesics for control of pain
8/6/2014 7

8. INCOMPLETE ABORTION
Definition : POC has aborted but not completely
Clinical features:
• Vaginal bleeding (heavy, passed out POC as fleshy masses)
• Associated with colicky pain at lower abdomen
• +/- signs of shock
Examination:
• Size of uterus is smaller than POA
• Open cervical os
• U/S : reveal retained POC in uterine cavity
Management:
• Resuscitate if bleeding is severe, do blood group and cross match
• Give analgesia for pain
• Evacuation retained product of conception
8/6/2014 8

9. COMPLETE ABORTION
Definition : All the POC has completely aborted.
Clinical features:
• History of pain and passage of product
• Followed by absent of pain, minimal bleeding
Examination:
• Size of uterus is smaller than POA
• Closed cervical os
• U/S : empty uterine cavity
Management:
• Do U/S to look for empty of uterine cavity
8/6/2014 9

10. MISSED ABORTION
Definition : When the embryo/fetus is already died
: but still remain in the uterine cavity for a period of time
: without symptoms of miscarriage
Clinical features:
• Decreased in pregnancy symptoms
• Vaginal bleeding (absent, minimal)
Examination:
• Size of uterus is smaller than POA
• Closed cervical os
• U/S : crumpled gestational sac
: revealed fetal pole but no signs of activity (no heart activity)
Management:
• Wait for spontaneous expulsion
• ERPOC
8/6/2014 10

11. RECURRENT ABORTION
Definition : 3 or more consecutive spontaneous abortion
Can be divided into:
• Uterine abnormality (uterine fibroid)
• Endocrine (DM, thyrotoxicosis,
PCOS)
• Autoimmune (SLE)
• Infection (TORCHES)
1st trimester abortion
(<12 weeks)
• Cervical incompetence (hx of
termination of pregnancy, vigorous
dilatation of cervix, hx of cone biopsy)
• Uterine abnormalities (septate or
subseptate uterus)
2nd trimester abortion
(>12 weeks)
8/6/2014 11

12. 8/6/2014 12

13. ECTOPIC PREGNANCY
Definition : Pregnancy outside uterine cavity
1. In fallopian tube (fimbriae,
ampullary, isthmus,
interstitial)
2. In the ovary
3. In the abdominal cavity
4. In the cervical site
Sites of implantation:
8/6/2014 13

14. ◦ Previous ectopic pregnancy
◦ History of PID
◦ Induction of ovulation
◦ Previous procedure on fallopian tube
◦ Previous pelvic surgery
◦ Structural :
Uterine fibroid
Abnormal uterine anatomy
8/6/2014 14

15. Vaginal Bleeding
Lower abdominal pain, back or pelvic pain
Shoulder pain
Syncopal attacks (hemoperitoneum)
Symptoms of hypovolemic shock
8/6/2014 15

16. Vital signs – hypotension, tachycardia, fever
 Generally – pale, CRT
 Abdominal palpation : uterus not palpable, tenderness,
guarding
 Per speculum & VE – os closed, cervical excitation,
adnexa mass, bimanual examination of uterus
8/6/2014 16

17. UPT
 positive
Beta hCG
 If a patient has a beta subunit of human chorionic gonadotropin level of
1,500 mIU per mL or greater, but the transvaginal ultrasonography does not
show an intrauterine gestational sac, ectopic pregnancy should be suspected
Transvaginal ultrasound
 Empty uterus
 Presence of free fluid especially in Pouch of Douglas
Diagnostic laparoscopic
8/6/2014 17

18. Stabilize patient
Surgical : salpingectomy/salpingotomy either by
laparotomy/laparoscopy
Medical
 Methotrexate ; i.m/direct into tubal pregnancy
8/6/2014 18

19. 8/6/2014 19

20. Can be classified as
Complete hydatiform mole
- no normal fetal tissue forms
Partial hydatiform mole
- incomplete fetal tissues develop alongside molar
tissue
Choriocarcinoma (invasive mole)
- contains many villi, but these may grow into or
through the muscle layer of the uterus wall
- can spread to tissues outside of the uterus.
8/6/2014 20

21. Complete mole Incomplete mole
Most common type of hydatidiform
mole
Diffuse thropoblastic hyperplasia,
hydropic swelling of chorionic villi,
no fetal tissue or membrane
present
Hydropic villi and focal focal
trophoblastic hyperplasia are
associated with fetus or fetal parts
46XX or 46XY Often triploid (XXY,XYY,XXX) with
chromosome complement from
both parents
2 sperm fertilize 1 empty egg or 1
sperms with reduplication
Single ovum fertilized with 2
sperms
15-20 % risk of progression to
malignant sequale
8/6/2014 21

22. 8/6/2014 22

23. Clinical features
complete Incomplete
Vaginal bleeding -97%
Uterine larger than date -51%
Hyperemesis gravidarum – 26%
B-hcg > 100,000
No fetal heart beat
Presentation similar to threatened/
spontaneous/ missed abortion
8/6/2014 23

24. Investigation
◦ UPT
◦ B-hcg level
◦ U/S
Complete – no fetus, classic snow storm
Incomplete – molar degeneration of placenta +/- fetal anomalies,
multiple echogenic regions corresponding to hydropic villi and focal
intrauterine haemorrhage
◦ CXR – may show metastatic lesions
◦ Features of high risk of neoplasm
Local uterine invasion
B-hcg >100,000
Excessive uterine size
Prominent theca- lutein cyst
8/6/2014 24

25. 8/6/2014 25

26. Treatment
◦ Suction and curettage
◦ Rhogam in rhesus –ve
◦ Consider hysterectomy if pt no longer desire fertility
◦ Chemo for carcinoma
Follow up
◦ TCA 2/52 till upt –ve
◦ B-hcg 2/52 till normal
◦ Follow up monthly until 1 year
◦ Follow up 3monthly until 1 year
8/6/2014 26

27. 8/6/2014 27

28. 8/6/2014 28