Ectopic Pregnancy and Related Complications

Early Pregnancy Bleeding

• Vaginal bleeding before 20 weeks of gestation is defined as early pregnancy bleeding.
• Abortion is the termination of a pregnancy before the fetus is capable of extra-uterine survival (20 weeks or 500g birth weight)
• Types of spontaneous abortion: threatened, inevitable, incomplete, missed, septic

Causes of Bleeding in Early Pregnancy

• Related to pregnant state:
  • Abortion (various types)
  • Ectopic pregnancy (implantation outside the uterus)
  • Molar pregnancy (abnormal placental growth)
  • Implantation bleeding
• Associated with the pregnant state:
  • Cervical lesions (like erosion, polyps)
  • Ruptured varicose veins
• Other causes:
  • Genetic factors
  • Endocrine and metabolic abnormalities
  • Infections
  • Immunological disorders
  • Anatomical abnormalities
  • Environmental factors
  • Unexplained causes
  • Blood group and incompatibility
  • PROM (premature rupture of membranes)

Pathology of Miscarriage

• Hemorrhage into the decidua basalis
• Necrotic changes in adjacent tissue
• Conceptus detachment
• Uterine contractions resulting in expulsion

Mechanism of Miscarriage

• Before 8 weeks: ovum, villi, and decidual coverings expelled intact. External os may not dilate, leading to cervical miscarriage.
• Beyond 14 weeks: expulsion similar to mini-labor; fetus expelled first, followed by placenta after a variable interval

Blighted Ovum

• A pregnancy where the embryo fails to develop, leading to an empty gestational sac.

Threatened Miscarriage

• Clinical entity where miscarriage process has begun but not progressed to a point of no recovery.
  • Clinical features: brief amenorrhea, mild spotting or bleeding, mild pain, closed cervical os, positive pregnancy test, viable intrauterine fetus on ultrasound, elevated serum progesterone
  • Management: reassurance, rest, Diazepam 5mg BD, repeated ultrasound

Inevitable Miscarriage

• Miscarriage is inevitable, and the embryo cannot be saved.
  • Clinical features: amenorrhea, heavy bleeding with clots, severe lower abdominal pain, open cervical os, positive pregnancy test, non-viable fetus and blood in uterus on ultrasound
  • Management: fluids, methergin 0.2mg, evacuation (medical or surgical).

Complete Miscarriage

• All products of conception expelled.
  • Clinical features: cessation of bleeding, resolved abdominal pain, closed cervix, empty uterus on ultrasound
  • Management: U/S, Anti-D gamma globulin injection.

Incomplete Miscarriage

• Not all products of conception expelled.
  • Ultrasound shows retained products.

Missed Miscarriage

• Embryo dies but is not expelled.
  • Clinical features: gradual loss of pregnancy symptoms like breast tenderness, cessation of morning sickness, negative pregnancy test, fetal heart not detected on ultrasound.
  • Treatment: wait to see if body expels, otherwise D&C to remove the fetus.

Septic Miscarriage

• Miscarriage complicated by infection.
  • Symptoms: abdominal pain, fever, foul-smelling vaginal discharge.
  • Signs: sick appearance, fever, tender uterus, offensive vaginal discharge or bleeding, soft dilated cervix
  • Clinical Grading: Grade 1 (localized to uterus), Grade 2 (spread to parametrium), Grade 3 (generalized peritonitis/endotoxic shock, jaundice, renal failure)
  • Management: resuscitation, IV fluids, insert catheter, monitoring input/output, blood tests, antibiotics (cephalosporins), anti-tetanus serum, evacuation (by the uterine contents removal)

Recurrent Miscarriage

• Three or more consecutive pregnancy losses. Etiology: genetic factors, endocrine issues, anatomical causes, infections, immunological problems

Ectopic Pregnancy

• Fertilized ovum implants and develops outside the normal uterine cavity.
• Incidence: increased by pelvic inflammatory disease, intrauterine devices (IUDs), tubal surgeries, Assisted Reproductive Techniques (ART) - Average rate: 1 in 100 pregnancies
  • ART increased risk: 5%
• Types of ectopic implantation sites: interstitial, isthmic, ampullary, infundibular, ovarian tubal, abdominal, intramural.
• Fates of tubal pregnancy:
  • Tubal mole (sac surrounded by blood clot)
  • Tubal abortion (sac expulsion)
  • Tubal rupture (bleeding into peritoneal cavity)
  • Clinical features: acute, unruptured, subacute (chronic)

Clinical features of ectopic pregnancy:

• Early symptoms: either absent or subtle
• Mean time of presentation: 7.2 weeks after last normal menstrual period
  • Range: 5 to 8 weeks
• Common presenting symptoms:
  • Amenorrhea
  • Lower abdominal pain
  • Abnormal vaginal bleeding
  • Signs
    • Patient looks quiet, conscious, but perspires and looks blanched (pale)
    • Pallor (paleness)
    • Features of shock
    • Tensing, tender, and distended abdomen.
    • Pelvic examination reveals white vaginal mucosa, somewhat enlarged uterus, cervix tenderness
    • Tenderness in uterine fornix area on palpation or movement of the cervix
    • Uterus floats/feels “watery” during examination
    • Unruptured tubal pregnancy symptoms: delayed period, spotting, unilateral flank pain (or colicky nature)
    • Chronic or old ectopic presentation: amenorrhea, lower abdominal pain, vaginal bleeding - Patient appears ill - Pallor, persistent high pulse even at rest, shock features, possibly slightly elevated temperature - Abdomen: tenderness, muscle guarding (tensing), lower abdomen especially on affected side; possible mass in lower abdomen and tender (irregular) - Cullen's sign (dark bluish discoloration) might indicate intraperitoneal hemorrhage

Diagnosis of Ectopic Pregnancy

• Positive pregnancy tests (82.5% are positive)
• Hematocrit
• White blood cell count

Management of Ectopic Pregnancy

• Emergency treatment (immediate surgical intervention, anti-shock measures, warm fluids, oxygen)
• Surgical treatment (laparoscopic techniques)
• Medical treatment (medications, like methotrexate)
• Supportive treatment (antibiotics, iron therapy, high-protein diet)
• Unruptured tubal pregnancy: expectant management (observation, monitoring serum hCG levels, gestational sac size, for spontaneous resolution)

Cervical Pregnancy

• Clinically diagnosed by:
  • Soft, enlarged cervix at least as large as the uterine fundus
  • Uterine bleeding during previously amenorrheic phase
  • Products of conception confined to the endocervix, firmly attached to same
  • Closed internal cervical os; partially opened external cervical os
  • Confirmed by histological presence of villi within cervical stroma (on pathology sample)

Gestational Trophoblastic Disease (GTD)

• Category of inter-related diseases originating from the placental trophoblast.
• Classification:
  • Hydatidiform mole (complete or partial)
  • Invasive mole
  • Choriocarcinoma
  • Placental site trophoblastic tumor
• WHO classification:
  • Hydatidiform mole: complete, partial
  • Invasive mole
  • Placental site trophoblastic tumor
  • Choriocarcinoma: non-metastatic disease/ metastatic disease

Risk Factors for GTD

• Disease duration (<4 months for low risk, >4 months for high risk)
• Initial hCG level (<40,000 for low risk, >40,000 for high risk )
• Metastasis (limits to lungs/vagina for low risk)
• History of chemotherapy
• Prior term delivery

Complications of GTD

• Maternal death (1 in 1000 ectopic pregnancies)
• Untreated/mistreated ruptured ectopic pregnancies (8-12% of all maternal deaths)

Complications of Septic Abortions

• Immediate: hemorrhage, peritonitis, pelvic abscess, endometritis, septicemia, septic/hemorrhagic shock
• Late: Pelvic inflammatory disease (PID), pelvic adhesions, secondary infertility

Hydatidiform Mole

• Abnormal condition of the placenta characterized by partly degenerative and partly proliferative changes in the chorionic villi.
• Types: complete, incomplete
  • Complete: absence of fetus, 46 xx or xy karyotype, complete molar degeneration and hydropic villi swelling
  • Incomplete: presence of a fetus, 69 XXX or XXY karyotype, focal molar degeneration and variable, focal-diffuse villi swelling