Early Pregnancy Complications

Ectopic Pregnancyand Molar pregnancy : 

Ectopic Pregnancyand Molar pregnancy By: Fikri Fishoul MBBS 2006/2011

Ectopic pregnancy : 

Ectopic pregnancy Definition: abnormal implantation of fertilized ovum outside the uterine cavity (other than uterine decidua) The most common site: Fallopian tube (may occur in ampulla, isthmus, interstitial) Other site of implantation: ovary, abdominal cavity, cervical canal

Slide 3: 

Sites and frequencies of ectopic pregnancy. By Donna M. Peretin, RN. (A) Ampullary, 80%; (B) Isthmic, 12%; (C) Fimbrial, 5%; (D) Cornual/Interstitial, 2%; (E) Abdominal, 1.4%; (F) Ovarian, 0.2%; (G) Cervical, 0.2%.

causes of ectopic pregnancy : 

causes of ectopic pregnancy A delay in the passage of the fertilized ovum down the fallopian tube Pelvic inflammatory disease (PID). The presence of an IUCD. Previous surgery to the tube. Progesterone only pill (POP). Congenitally long and tortuous tubes.

Slide 5: 

Pathogenesis Reduced tubal contractility -Infectiondamagesricture+adhesions Hormonal effect: progesterone -decrease ciliary activity

Ectopic pregnancy : 

Presence with signs of ruptured or un-ruptured Symptoms: Lower abdominal or pelvic pain Mild cramping on one side of pelvis Amenorrhea Abnormal vaginal bleeding – usually scanty amount, spotting Breast tenderness Nausea, low back pain If rupture occurs, symptoms may worsen include; Severe, sharp & sudden pain in the lower abdomen syncope Referred pain to tip of shoulder Ectopic pregnancy

Ectopic pregnancy : 

Differential diagnosis: threatened abortion acute salphingitis, appendicitis with pelvic peritonitis, torsion of pedicle of ovarian cysts, Ruptured of corpus luteum Ectopic pregnancy

Ectopic pregnancy : 

Investigations;: Baseline: Hb: anemia (esp if ruptured) TWBC: Infection Diagnostic: urine pregnancy test (usually +ve), Ultrasound: trans-vaginal/ trans-abdominal (illustrates an empty uterus. Product of conception may be evidence elsewhere) laparoscopy (if doubt) Dilatation & curettage may be indicated (to rule out nonviable intrauterine pregnancy Ectopic pregnancy

management : 

management Surgical (salpingectomy or salpingotomy) either laparotomy or laparoscopy. Salpingotomy – incision is made on the fallopian tube over the ectopic site, the POC exposed, and the content removed. Then, reconstruct the tube. Salpingectomy – the whole pregnancy and the part of the fallopian tube in which it is implanted can be excised and removed. If the patient shock, resuscitates. If the diagnosis of ectopic pregnancy is only suspected, a diagnostic laparoscopy must still be done to exclude the diagnosis.

Molar pregnancy (GTD) : 

Molar pregnancy (GTD) Or hydatiform mole is an abnormal pregnancy in which the developing fetus and placenta are replaced by proliferation of trophoblastic tissue. Common in Asiatic woman especially Indonesian woman and rarely Caucasians. divided into i) complete hydatiform mole ii) partial hydatiform mole iii) choriocarcinoma

Hydatidiform mole : 

In a ‘complete mole’ the mass of tissue is completely made up of abnormal cells that would have become the placenta in a normal pregnancy. There is no fetus. In a ‘partial mole’, the mass may contain both these abnormal cells and often a fetus that has severe defects. In this case the fetus will be consumed by the growing abnormal mass very quickly. Hydatidiform mole

Choriocarcinoma : 

Choriocarcinoma malignant, trophoblastic[1] and aggressive cancer, usually of the placenta. It is characterized by early hematogenous spread to the lungs. It belongs to the far end of the spectrum of gestational trophoblastic disease (GTD), a subset of germ cell tumors.

symptoms : 

symptoms Bleeding in early pregnancy. History of passing ‘grape like structure’ from vagina. Hyperemesis gravidarum dt ↑human chorionic gonadotrophin hormone (hCG) from the proliferating trophoblast.

signs : 

signs Pallor if there has been bleeding. Occasionally ↑blood pressure indicative of pre-eclampsia. There may be sign of thyrotoxicosis. On examination, the uterus is larger than dates, absence of fetal part. Daptone examination: no fetal heart beat. Vaginal examination: presence of bilateral ovarian cyst because ↑of hCG, causes the corpus luteum to enlarge.

Diagnostic : 

Diagnostic Usually confirmed by an ultrasound examination. ~It will show the characteristic ‘snow storm’ appearance. ~No fetal part will be seen. ~Bilateral theca lutein cyst may be seen. Relevant investigation that should be done are haemoglobin level, hCG level and chest X-Ray to look for 2o in the lung so to exclude ‘invasive’ mole.

managemant : 

managemant Suction evacuation of the molar pregnancy must be done ASAP. Once an evacuation has been successfully completed, patient must be follow up closely. Serum beta chain specific HCG taken weekly. Till return to normal For the next 2 month, follow-up 2 weekly The next 2 year follow up monthly Pregnancy is discourage until 6 month after the level is returned to normal.

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