10_ Early abn of pregnancy.pdf

Summary of EARLY ABNORMALITIES OF PREGNANCY: MISCARRIAGE AND EXTRA-UTERINE PREGNANCY (Dr Agu) Outline: o Miscarriage  Introduction  Aetiology  Types  Treatment o Extra-uterine pregnancy  Introduction  Risk factors  Pathophysiolo...

Summary of EARLY ABNORMALITIES OF PREGNANCY: MISCARRIAGE AND EXTRA-UTERINE PREGNANCY (Dr Agu) Outline: o Miscarriage  Introduction  Aetiology  Types  Treatment o Extra-uterine pregnancy  Introduction  Risk factors  Pathophysiology  Management  Prognosis Miscarriage Introduction: o It is the spontaneous termination of pregnancy before the age of viability o Rate decreases with increase in gestational age o It is a common gynecological emergency o Occur in 20 – 30% of clinical pregnancies, and ≥ 50% when subclinical pregnancies are included Aetiology: o Chromosomal abnormalities:  Trisomy 16, 22, 21, 15  Monosomy (45X), triploidy, tetraploidy o Endocrine causes:  Luteal phase inadequacy o Maternal diseases:  Poorly controlled DM   Thyroid disease  SLE o Autoimmune diseases:  Antiphospholipid syndrome o Uterine abnormalities:  Congenital uterine abnormalities  Submucous fibroids  Incarcerated retroverted gravid uterus o Cervical insufficiency o Immunological factors  Rhesus incompatibility o Infections:  TORCH infections Types: o Threatened miscarriage:  Vaginal bleeding and abdominal pain  Cervix is not dilated  Fetus is alive  Diagnosed with USS o Inevitable miscarriage:  Vaginal bleeding and abdominal pain  Cervix is dilated  USS indicates presence of a fetus o Incomplete miscarriage:  Vaginal bleeding and abdominal pain  Cervix is dilated  USS indicates presence of products of conception (but no fetus) o Missed miscarriage:  There is miscarriage without clinical symptom of expulsion  USS shows a dead fetus in the uterus  Investigations:  FBC: to rule out infection  Clotting profile: to rule out coagulopathy  USS  Blood grouping and cross-matching o Recurrent miscarriage:  3 or more consecutive miscarriages   Occurs in 1% of pregnant women  Causes:  Luteal phase deficiency  Structural uterine abnormalities  Balanced translocation in one of the parents  Thrombophilic defects (e.g. antithrombin III deficiency)  Antiphospholipid syndrome  Investigations:  Parental karyotyping, pelvic USS, hysterosalpingography  Lupus anticoagulant, anticardiolipin and antiphospholipid antibodies assay Treatment: o Threatened miscarriage: counsel and reassure the mother o Inevitable, incomplete, missed: misoprostol, mifepristone, oxytocin o Incomplete, missed: manual vacuum aspiration o Recurrent miscarriage:  Surgical: for uterine abnormalities  Medical: low dose aspirin and low dose heparin for antiphospholipid syndrome Extra-uterine Pregnancy Introduction: o This is pregnancy outside the uterine cavity o Most commonly occurs in the fallopian tube (98% of cases) o Others (2%): cervix, ovary, abdomen o It is a gynecological emergency Risk factors: o Increasing maternal age o Smoking o Multiple partners o Previous PID (pelvic inflammatory disease) o Previous ectopic pregnancy o History of infertility o Previous tubal surgery  o IUCD-in-situ o Exposure to DES (diethylstilbestrol) in-utero o Conception following IVF Pathophysiology: o When the fallopian tube is damaged (due to infection, adhesions or surgery), there is delayed transport of the embryo to the uterine cavity o As a result, the embryo implants in the tube o Since the tube is indistensible, this leads to pain and rupture o For ectopic pregnancy in other sites, implantation is due to extrusion of the embryo from the tube Management: o Symptoms:  Abdominal pain, abnormal uterine bleeding, amenorrhea  Syncope, dizziness, pregnancy symptoms o Signs:  Abdominal tenderness, peritonism, adnexal mass or tenderness  Cervical motion tenderness, uterus may be normal or enlarged  Temperature > 37°C, pallor o Investigations:  Laparoscopy (gold standard)  USS: TVUS (Transvaginal USS) or TAUS (Transabdominal USS), abdominopelvic USS  Biochemistry: serum hCG, progesterone < 5ng/ml  PCV, culdocentesis, paracentesis abdominis o Treatment:  Expectant management:  Criteria: for patients with serum hCG < 1000iu/l, gestational sac < 3cm, no rupture, no or minimal abnormal bleeding  Based on the assumption that a significant proportion of all ectopic pregnancies will resolve without any treatment  Medical management:  Criteria: for patients who are clinically stable with serum hCG < 3000iu/l, gestational sac < 3cm, no collections in the pouch of Douglas  Administer methotrexate, actinomycin D, mifepristone etc.  Surgically administered medical management (SAM):   Criteria same as for medical management  Give laparoscopic injection of anti-trophoblastic substances like methotrexate, PGF2α, KCl, 50% hyperosmolar glucose  Surgical management:  Laparoscopic surgery  Laparotomy: salpingectomy, salpingostomy, segmental resection, fimbrial expression Prognosis: o Chances of recurrence: 10 – 20% o Chances of intrauterine pregnancy after:  Salpingectomy: 40%  Conservative tubal surgery: 60%  Medical treatment: 87%