For 3rd year midwifery students at Lira University in Uganda

1. Abnormalities of Early
Pregnancy
Lira University
Normal Midwifery
Spring 2017
Julia Rasch, CNM

2. Hyperemesis Gravidarum
1. Excessive nausea and vomiting during pregnancy
2. Differentiated from more common and more normal
morning sickness by fact that it is of greater intensity and
extends beyond the first trimester
3. Associated with weight loss, ketonemia (presence of
abnormally high concentrations of ketone bodies in the
blood), and dehydration
4. May occur in any trimester, usually beginning in the first
and may persist throughout the entire gestation

3. Hyperemesis Gravidarum
5. Etiology is unknown but is probably a combination of
hormonal changes and psychological factors.
6. Important to rule out cholecystitis, pancreatitis, hepatitis,
and thyroid disease.
7. Ptyalism, excessive production of saliva, is also associated
with severe nausea and vomiting in pregnancy. Women go
through pregnancy unable to swallow saliva and spit 1-2
liters/day

4. Hyperemesis Gravidarum
8. Signs, symptoms and effects
a. Pernicious vomiting
b. Poor appetite
c. Poor nutritional intake
d. Weight loss
e. Dehydration
f. Electrolyte imbalance
g. Extreme response to underlying psychosocial problems
h. Vomiting not controlled by conventional treatment
measures for morning sickness
i. Acidosis due to starvation
j. Alkalosis resulting from loss of hydrochloric acid in vomitus
k. Hypokalemia

5. Hyperemesis Gravidarum
9. History for woman presenting with nausea and vomiting to help
distinguish between benign form of nausea and vomiting associated
with pregnancy and this pathological situation:
a. Frequency of vomiting episodes
b. Relationship of vomiting to food intake
c. Dietary history
d. Medication history
e. elimination
f. Blood in vomitus? (peptic ulcer, or esophagitis)
g. Fever or chills

6. Hyperemesis Gravidarum
h. Exposure to viral infection
i. Exposure to contaminated food
j. Abdominal pain
k. History of eating disorders
l. History of diabetes
m. Previous abdominal surgery
n. Amount of rest she is getting
o. Family support
p. Anxieties regarding pregnancy

7. Hyperemesis Gravidarum
Physical Examination
1. Weight (and relationship to previous weights)
2. Temperature, pulse, respirations
3. Skin turgor
4. Moistness of mucous membranes
5. Condition of tongue (swollen, dry, cracked)
6. Abdominal palpation for: organomegaly, tenderness,distention
7. Bowel sounds8. Sweet odor to breath
9. Assessment of fetal growth

8. Hyperemesis Gravidarum
Laboratory
1. Urine dipstick for ketones
2. Urinalysis
3. BUN and electrolytes
4. Liver function tests (rule out hepatitis, pancreatitis,
and cholestasis)
5. TSH and T4 (rule out thyroid disease

9. Hyperemesis Gravidarum
Assessment:
1. Poor tissue turgor, dry tongue and mucous membranes, increased
pulse and respirations, decreased urinary output, increased urine
specific gravity: all indications of dehydration
2. If urine positive for ketones, there is weight loss, and breath smells
sweet, woman has had too few calories and is acidotic due to burning
fat for energy

10. Hyperemesis Gravidarum
Immediate initial treatment:
1. IV fluids with 5% dextrose: 200 ml for first liter can be used. If diabetic,
consult MD re fluids
2. NPO or ice chips or small sips of clear fluid for first few hours to let
stomach rest
3. Antiemetics:
1. Promethazine (phenergan) 25 mg in IV or rectally
2. Metaclopramide (reglan) 10 mg po qd
3. Chlorpromazine (Thorazine) rectally 25-50 mg q 6-8 hours, or 25-50 mg IM q 3-4 hours
4. Prochlorperazine (compazine) 10 mg IM or 2.5-10 mg IV q 3-4 hours or 25 mg rectally
4. After a few hours, gradually offer oral fluids; if nausea and vomiting resume, NPO
5. Increase fluids gradually if tolerated
6. Dip all urine to check for ketones: once ketones cleared, develop maintenance plan

11. Hyperemesis Gravidarum
1. Some women will be able to stop IV fluids and continue with po
fluids and food and progress with no problems
2. More commonly nausea and vomiting will persist and if antiemetics,
IV fluids and food progression not successful, consult MD
3. Treatment will then consist of sedatives, and antiemetics
4. In severe cases, TPN and medical pump may be needed
5. May be chronic in pregnancy and may cause family stress
6. Supportive care for mother and family may be needed

12. Hydatidiform Mole
1. Hydatidiform mole is a genetically abnormal pregnancy that
manifests itself as a developmental anomaly of the placenta.
2. In complete hydatidiform mole (CHM), the pregnancy is
genetically entirely from the father, usually diploid 46, XX, with no
fetal tissue apparent.
3. A partial hydatidiform (PHM)mole is usually triploid (e.g., 69,
XXY), with both villus changes and fetal tissues [5]. The placental
villi become a mass of clear, cystlike vesicles hanging in clusters
from thin pedicles, resembling a bunch of grapes.
4. A CHM is all vesicles, whereas a PHM mole also has a nonviable
fetus or amniotic sac. On rare occasion, there may be a twin
pregnancy, with one normal fetus and placenta and one molar

13. Hydatidiform Mole
1. Hydatidiform molar pregnancy is a gestational trophoblastic
disease: Complete or partial
2. May be precursor of choriocarcinoma
3. 1 in 20,000-40,000 pregnancies
4. Complete mole has 10-20% risk of progressing to cancer –
“Invasive mole”
5. A hydatidiform mole is usually a benign neoplasm, but it has
the potential for becoming malignant and often precedes the
extremely malignant but fortunately rare trophoblastic neoplasm
known as choriocarcinoma. With current chemotherapeutic
drugs, the cure rate of choriocarcinoma is nearly 100 percent [5].

14. Hydatidiform Mole/ Gestational Trophoblastic
Disease (GTD)

15. Complete Mole
1. 1 in 1500 pregnancies
2. Very high hCG
3. Trophoblastic proliferation
4. Large uterus
5. Appears like collection of hydropic vesicles
6. No fetal tissue

17. Partial Mole
1. Not as common as complete mole
2. β-hCG usually < 100,000
3. Evidence of an embryo, fetus or amniotic sac may be found
4. Death occurs around the 8th or 9th week of pregnancy
5. <5% risk of progressing to cancer

18. Risk Factors for Molar Pregnancy
1. History of molar pregnancy
2. Extremes of age
1% pregnancies at age 45
17% pregnancies at age 50
3. Older paternal age
4. Vitamin A deficiency

19. Symptoms of Molar Pregnancy
1. History: amenorrhea, exaggerated symptoms of pregnancy,
excessive vomiting (hyperemesis), spotting or profuse
bleeding by 12th week of pregnancy
2. Shortness of breath
3. Physical exam: hyperthyroid symptoms, may show signs of
shock or anemia, fundal height (size > dates), boggy uterus,
absence of FHT & fetal parts
4. PIH, pre-eclampsia or eclampsia before 24 weeks

20. Management of Molar Pregnancy
1. These findings indicate that the midwife should obtain a specimen for a
serum chorionic gonadotropin titer and a sonogram.
2. Hydatidiform mole has a characteristic pattern on ultrasonography.
3. A persistently high, or even rising, level of chorionic gonadotropin
after 100 days from the first day of the last menstrual period is indicative
of abnormal trophoblastic growth or a multiple gestation.
4. The woman is referred to the consulting physician

21. Medical Treatment Molar Pregnancy
1. Suction curettage
2. Oxytocin
3. 2 IV access lines
4. Blood available
5. Propranolol 40mg PO OD
6. Methotrexate until β-HcG < 5
x 3 draws

22. Management of Molar Pregnancy
1. Start IV – Ringer’s lactate or normal saline
Use cannula or large bore needle
Run 3 liters
2. Refer to hospital for suction curettage or evacuation with
blood donors
3. Specialty follow-up is needed
nursing education regarding risks and labs

23. Suction curettage of Molar Pregnancy

24. First Trimester Bleeding
1. Normal Pregnancy associated with amenorrhea and no vaginal
bleeding
2. Many women experience episodes of vaginal bleeding in 1st trimester
3. May be fresh (bright red) or old (dark brown)
4. May be slight and persist for a few days or have sudden and heavy
onset.
5. Only 1/3 of of women with painless vaginal bleeding in first half of –
pregnancy are having symptoms of impending abortion.

25. First Trimester Bleeding: Differential Diagnosis
1. Threatened abortion
2. Incomplete abortion
3. Complete abortion
4. Missed abortion
5. Ectopic pregnancy
6. Severe cervicitis
7. Cervical lesions or cervical polyps
8. Postcoital bleeding
9. Spotting during implantation
10. Subchorionic bleeding
11. Demise of a twin
12. Molar pregnancy (rare)
13. Cervical dysplasia, cancer

26. First Trimester Bleeding
1. Complaint of vaginal bleeding requires thorough history
2. I f ectopic pregnancy is suspected through symptoms, woman must
be examined asap
3. History should include: LMP and regularity of menses, use of
contraception prior to pregnancy, confirmation of dates by exam
and/or ultrasound
4. Pregnancy test by urine and or blood and when positive
5. Previous pregnancy history including SAB, ectopic pregnancy

27. First Trimester Bleeding
6. Contraception history, current IUD?
7. History of bleeding: when did it start? How much? Color? Need to use
pad? How often is it changed
8. Pain of cramping? When did it start? Location of pain: lower front,
midline, right or left side, back, rectal, shoulder, pain with breathing.
Mild, intense, sharp, dull?
9. Fever or UTI symptoms
10. STD in this pregancy
11. Change in pregnancy symptoms: nausea better or worse? Breast pain
improved?
12. Recent intercourse?

28. First Trimester Bleeding
1. Moderate or heavy bleeding, lower abdominal, back or generalized
pelvic pain, or if febrile and has symptoms of hypotension, come in for
evaluation
2. At appointment:
a. review/update history from phone conversation
b. evaluate BP, temperature pulse and respirations
c. confirm positive pregnancy test
d. perform abdominal exam including palpation for tenderness,
palpation for fundal height, or other masses
e. rebound tenderness?
f. auscultate for bowel sounds
g. CVA tenderness

29. First Trimester Bleeding
h. Gentle speculum exam of vagina and cervix
i. Screen for vaginitis and cervicitis with cultures and wet prep prn
j. Observe os for dilatation, fluid, blood, clots, or fetal parts
k. Gentle bimanual exam for size of uterus, cervical effacement,
dilatation and status of membranes
l. Adnexal mass or pain
m. Cervical motion tenderness
n. FHT’s?
o. Hemoglobin and Hct if necessary
p. Ultrasound if possible
q. Serial beta hcg

30. First Trimester Bleeding
1. Based on data collected at this visit, differential diagnosis may be
formulated.
2. Ultrasound can be very helpful in determination of cause:
transvaginal or abdominal
a. Can help in determination of intrauterine vs extra uterine
pregnancy, gestational age, number of fetuses, viability with cardiac
activity, adnexal mass, (ectopic pregnancy, ovarian cyst, dermoid
cyst),uterine fibroids, and presence of fluid in the cul-de-sac.
Subchorionic bleeding within the uterus can be detected as a potential
reason for bleeding without termination of the pregnancy. Incomplete
abortion with retention of products of conception can also be evaluated.

31. First Trimester Bleeding
3. Ultrasound examination is diagnostic:
a. Of a molar pregnancy
b. Evaluation of fetal anatomy is limited in the first
trimester.
c. Cardiac activity can be identified by 6 weeks gestational
age and if within normal range, incidence of spontaneous
abortion drops to 3%

32. First Trimester Bleeding
Cervical/vaginal causes of bleeding
1. In early pregnancy cervix very vascular and any situation that would
cause inflammation of cervix and vaginal tissue can cause bleeding:
sex, infection.
2. Gentle speculum exam for blood and source of bleeding: if blood from
uterus can do US and bhcg. If superficial check for STD’s or cervical
dysplasia. Also herpes lesions and yeast can cause bleeding
3. Cervical polyp can bleed and cervix if vascular can also spontaneously
bleed
4. Rarely associated with pregnancy loss

33. First Trimester Bleeding
Spontaneous abortion (SAB)
1. Abortion is termination of pregnancy by expulsion of products of
conception (POC) prior to ability of fetus to survive if born: about 20
weeks of 500 gms in weight
2. SAB, or miscarriage, occurs naturally and 10-15% of all clinically
diagnosed pregnancies are lost.
3. Primary reason is genetic abnormality: 75-90% of losses
4. Also can be due to abnormal progesterone levels, thyroid
abnormalities, uncontrolled diabetes, uterine anomalies, infection
5. Varied expressions of SAB include: threatened abortion, inevitable
abortion, missed abortion, and incomplete abortion

34. First Trimester Bleeding
Threatened abortion
1. Pregnancy considered threatened any time there is vaginal bleeding in
first half of pregnancy
2. May be accompanied by lower abdominal cramping pain or low
backache
3. If there is both bleeding and pain pregnancy prognosis is poor
4. Evaluate with physical exam, beta hcg and progesterone, and
ultrasound prn

35. First Trimester Bleeding
Inevitable abortion
1. When spontaneous abortion almost certain to occur and cannot be
stopped, called inevitable
2. Occurs with cervical dilatation and/or SROM in addition to vagina[
bleeding and lower abdominal or back pain
3. Management is either expectant at home or D and C. Details to follow
in 4th year

36. First Trimester Bleeding
Incomplete abortion
1. Occurs when placenta not expelled with fetus at time of abortion
2. Retained placenta will eventually be cause of bleeding, which may be
profuse or infection, especially if abortion occurs in 2nd trimester
Missed abortion
1. Fetus dies but POC are retained for prolonged period of time ( 2 or more
weeks)
2. Signs and symptoms include: normal early pregnancy without presumptive
and probable signs of pregnancy; vaginal spotting or bleeding or lower
abdominal or back pain; fundal height not increasing and starts to
decrease; breasts not swollen; persistent amenorrhea; no fhtones

37. First Trimester Bleeding
Habitual abortion
1. SAB has terminated the course of three or more consecutive
pregnancies
2. Genetic counselling and endrochronological workup should be
considered

38. First Trimester Bleeding
Ectopic pregnancy
1. Occurs when blastocyst implants anywhere except endometrium lining
uterine cavity: can occur in cervix, fallopian tubes, ovaries, abdomen
2. Predisposing factors include pelvic infection, IUD’s, previous ectopic
pregnancy, prior tubal surgery
3. Early symptoms are vaginal bleeding and spotting, occasionally pelvic
pain. Because beta hcg levels are low and only slowly rising woman may
not have presumptive signs of pregnancy and may not be aware she is
pregnant
4. Early diagnosis has improved outcomes: consider ectopic pregnancy in
differential of all early pregnancy vaginal bleeding and pelvic pain as well
as using serial beta hcg, serum progesterone and ultrasound
5. YOU ONLY HAVE ONE CHANCE TO MISS AN ECTOPIC

40. First Trimester Bleeding
Tubal pregnancy
1. Account for 95% or more of ectopic pregnancies
2. Signs and symptoms are those of tubal rupture or abortion and may vary
widely form woman to woman
3. Woman may not realize she is pregnant and suddenly she has sharp,
stabbing, tearing severe lower abdominal pain. Abdomen tender, vaginal
exam painful and may be hypotensive (shock). CMT extreme and may
palpate tender, boggy mass on one side of uterus. Cul-de-sac may be filled
with blood and posterior vaginal fornix may bulge. May have neck or
shoulder pain on inspiration as result of diaphragmatic irritation from
blood in peritoneal cavity. Diarrhea and rectal pressure resulting from
irritation of blood in abdomen
4. If ectopic is considered, this is medical emergency and needs medical help
asap

41. First Trimester Bleeding
Ovarian pregnancy
1. Rare. May present with vaginal bleeding or spotting
2. Symptoms similar to tubal rupture and may have rupture into
peritoneal cavity; uterus might be slightly enlarged from response of
endometrium to progesterone and beta hcg. Ovary may be enlarged
and palpation of mass may or may not be painful. Medical
management essential
Cervical pregnancy
1. Rare. Signs and symptoms include painless bleeding soon after
implantation and palpation of cervical mass with distention and
thinning of cervical wall, partial dilatation of external os, and enlarged
uterine fundus.
2. Medical management essential