1.
1. Hemorrhagic complications of
the first period of pregnancy
Lesson/Package 5
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2.
2. At the end of this presentation students will
be able to understand what
hemorrhagic complications of the
first period of pregnancy are
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3.
3. Most common complications are:
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•Abortion
•Gestational Trophoblastic
Disease

4.
4. Abortion
• Abortion is the expulsion of fetus
before it reaches viability (until 22
weeks of gestation. WHO)
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5.
5. Causes of abortion:
• Ovofetal factors
• Maternal factors
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6.
6.Varieties of abortion:
• Induced (therapeutic) abortion
• Spontaneous abortion
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7.
7. Varieties of spontaneous
abortion:
• threatened
• inevitable
• complete or incomplete
• missed
• and recurrent abortion
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8.
8. Threatened abortion
Threatened abortion is bleeding of
intrauterine origin occurring before the
20th completed week, with or without
uterine contractions, without dilatation
of the cervix, and without expulsion of
the products of conception.
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9.
9.Threatened abortion
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10.
10.Threatened abortion
The clinical diagnosis of threatened
abortion is presumed when a bloody
vaginal discharge or bleeding appears
through a closed cervical os during the
first half of pregnancy.
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11.
11.Treatment of threatened abortion
There are no effective therapies for
threatened abortion. Bed rest, although
often prescribed, does not alter the
course of threatened abortion.
Acetaminophen-based analgesia may be
given to help/relieve the pain.
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12.
12. Inevitable abortion
Abortion becomes inevitable if uterine
bleeding is associated with strong
uterine contractions which caused
dilatation of the cervix.
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13.
13.Complete and incomplete abortion
Complete abortion is the expulsion of
all of the products of conception before
the 20th completed week of gestation,
whereas incomplete abortion is the
expulsion of some, but not all, of the
products of conception.
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14.
14.Missed abortion
In a few cases of abortion the dead
embryo or fetus and placenta are not
expelled spontaneously and are retained
in utero.
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15.
15.Clinical aspects of missed
abortion
• The patients complain of a dirty brown
discharge which persists.
• The uterus fails in grow and symptoms
indicating early pregnancy disappear
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16.
16.Treatment of missed abortion
• There is no need to treat missed abortion
urgently
• If spontaneous abortion has not occurred
within 28 days, the pregnancy should be
terminated, as coagulation defects may result
• If the uterus is <12 weeks gestational size,
the uterus can be evacuated by sponge
forceps and curette after cervical dilatation
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17.
17.Treatment of missed abortion
• If the uterus is >12 weeks gestational size,
either mifepristone 600mg RU 486followed
36 hours later by misoprostol (300mg
repeated in 2 hours) or prostaglandine E2
vaginal pessaries(20mg) every 3 or 6 hours
are effective
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18.
18.Recurrent (habitual) abortion
Recurrent abortion in its broadest
definition is defined as 2 or more
consecutive pregnancy losses before 20
weeks of gestation, each with a fetus
weighing less than 500 g. Approximately
1% of women are habitual aborters.
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19.
19. Investigation
• A careful medical and obstetrical
history may reveal systemic disease or
suggest cervical incompetence
• A vaginal examination may show uterine
myomata or cervical incompetence
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20.
20. Investigation
• Diagnosis can be clarified if a
transvaginal ultrasound image is made.
Ultrasound will also detect uterine
malformations
• Although it is usual to investigate both
parents for chromosome abnormalities
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21.
21.Treatment of recurrent
abortion
• no treatment is available
• If cervical incompetence (20 per cent)
diagnosed, treatment is to place a soft
unabsorbable suture around the cervix
at the level of the internal cervical os.
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22.
22.Septic abortion
Clinical features
• Pink vaginal discharge
• Pyrexia
• Tachycardia (PR>120per minute)
• Tender lower abdomen
• Tender uterus (per vaginam) during the
bimanual examination
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23.
23.Investigations
• A high vaginal or cervical swab
• Blood culture
• Serum electrolytes and coagulation
studies (in severe infections)
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24.
24.Treatment of septic abortion
• Antibiotics
• If hemorrhaging is severe and the
uterus is not empty its contents are
evacuated by careful curettage
• If the infection is not controlled in
spite hysterectomy may be indicated
.
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25.
25.Gestational Trophoblastic
Disease
The term gestational trophoblastic
disease refers to pregnancy-related
trophoblastic proliferative
abnormalities.
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26.
26.Criteria for Diagnosis of Gestational
Trophoblastic Disease
Hydatidiform Mole:
• Complete
• Partial
Gestational Trophoblastic Neoplasia Postmolar GTN
1. Plateau of serum hCG level (±10%) for four
measurements during a period of 3 weeks or
longerdays 1, 7, 14, 21.
2. Rise of serum hCG > 10% during three weekly
consecutivemeasurements or longer, during a period
of 2 weeks or moredays 1, 7, 14.
3. The serum hCG level remains detectable for 6 months
or more.
4. Histological criteria for choriocarcinoma.
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27.
27.Hydatidiform Mole
(Molar Pregnancy)
Molar pregnancy is characterized
histologically by abnormalities of the
chorionic villi that consist of
trophoblastic proliferation and edema
of villous stroma. The absence or
presence of a fetus or embryonic
elements has been used to describe
them as complete and partial moles
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28.
28.COMPLETE HYDATIDIFORM MOLE
In complete hydatiform mole, the chorionic
villi transform into a mass of clear vesicles.
The vesicles vary in size from barely visible to
a few centimeters and often hang in clusters
from thin pedicles.
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29.
29.Complete hydatidiform mole
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30.
30.PARTIAL HYDATIDIFORM MOLE
When the hydatidiform changes are focal and
less advanced, and some element of fetal
tissue is seen, the term partial hydatidiform
mole is used.
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31.
31. Partial hydatidiform mole
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32.
32.Features of Partial and
Complete Hydatidiform Moles
Feature Partial Mole Complete Mole
Embryo-fetus Often present Absent
Amnion, fetal red blood cells Often present Absent
Villous edema Variable, focal Diffuse
Trophoblastic Variable, focal, slight Variable, slight
to moderate to severe
Clinical presentation
Diagnosis Missed abortion Molar gestation
Uterine size Small for dates 50% large for dates
Theca-lutein cysts Rare 2530%
Medical complications Rare Frequent
Gestational trophoblastic <510% 20%
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33.
33.Classification of Trophoblastic
Neoplasms
Persistent Trophoblastic Disease(often
malignant)
Apparently confined to the uterus-
invasive mole
Usually with extra-uterine spread-
choriocarcinoma
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34.
34. Aetiology
• Genetic disorder
• A defective maternal immune response
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35.
35. The diagnosis of benign
gestational trophoblastic disease
• Bleeding per vaginam
• The uterus is usually larger than
expected from the gestational dates
and is “doughy” to the touch
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36.
36.The clinical and diagnostic
features of a complete hydatidiform
mole
1. Continuous or intermittent brown or bloody
discharge evident by about 12 weeks and
usually not profuse.
2. Uterine enlargement out of proportion to
the duration of pregnancy in about half of the
cases.
3. Absence of fetal parts and fetal heart
motion.
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37.
37.The clinical and diagnostic
features of a complete hydatidiform
mole
4. Characteristic ultrasonographic appearance.
5. Serum hCG level higher than expected for
the stage of gestation.
6. Preeclampsia-eclampsia developing before
24 weeks.
7. Hyperemesis gravidarum.
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38.
38.Traetment of benign
gestational trophoblastic disease
• Uterus evacuated using a suction
curette OR
• By the administration of prostaglandins
to induce uterine contractions
• Women over the age of 40 may prefer
to have a hysterectomy, to avoid
potential malignancy.
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39.
39.Follow-up
1. Prevent pregnancy for a minimum of 6 months
using hormonal contraception.
2.Monitor serum hCG levels every 2 weeks.
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40.
40.Follow-up
3. Chemotherapy is not indicated as long as
these serum levels continue to regress.
4. Once the hCG level falls to a normal level,
test the patient monthly for 6 months; then
follow-up is discontinued and pregnancy
allowed.
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41.
41. Malignant gestational
trophoblastic disease
Women who have had a benign
gestatinal trophoblastic tumour are a
great risk of developing a malignancy if
the women:
• Is over the age of 40
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42.
42. Malignant gestational
trophoblastic disease
• Secretes large amounts of
βhCG(>1000IU per ml)
• Has theca-lutein cyst more than 6cm in
diameter
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43.
43.Diagnosis of Malignant gestational
trophoblastic disease
Recognition of the possibility of
gestational trophoblastic neoplasia is
the most important factor
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44.
44.Malignant gestational
trophoblastic disease-treatment
Malignant gestational trophoblastic
disease is best managed at special
centres, where meticulous follow-up is
conducted.
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