EARLY PREGNANCY

COMPLICATIONS

By Dr Amy, Dr Zul
Supervisor: Dr Sumayyah

Learning Outcome

Hyperemesis Gravidarum
Miscarriage
Molar Pregnancy
Gestational Trophoblastic Neoplasia

MISCARRIAGE

Definition

Spontaneous loss of pregnancy before fetus

reaches viability (< 24 gest wk)
Recurrent miscarriages = loss of > 3
consecutive pregnancy
Occur in 20-30% of pregnancy

Etiology
Chromosomal
Abnormalities

Endocrine
Disorders

Chemical
agents
Ten Teachers

50 % of all miscarriages
Eg Downs syndrome

Diabetes
Hypothroidism
Polycystic ovarian
syndrome
Drugs (Isotretinoin for
acne)
Chemicals (benzene,
arsenic, ethylene oxide,
pesticides, lead, mercury,
cadmium)

Etiology
Trauma

Invasive intrauterine procedures/trauma

chorionic villus sampling
Amniocentesis
Cervical incompetence

Abnormalitie
s of Uterus

Uterine septum (bicornuate uterus)

Submucosal leiomyoma
Intrauterine adhesions (post curettage)

Infections

UTI
Parvovirus, Rubella, HSV, CMV,
Chlamydia

Immunological APS, SLE, Thrombophilia

Ten Teachers

Terminolog
y
Threatene
d
miscarriag
e
Inevitable
miscarriag
e
Incomplete
miscarriag
e

Clinical
Presentation
Slight PV bleed
+ Pain

Examination
Cervical os
CLOSED

Variable PV bleed Cervical os

Pain

Variable PV bleed
Pain
H/o passing out
POC
Complete No PV bleed
miscarriag No pain
e
H/o passing out
POC
Missed
With or without
miscarriag
pain or bleeding.
e

US
Findings
IUP (viable)
FH+
IUP

OPEN
Cervical os
open
POC seen
Cervical os
closed
Cervical os
closed

Retained
product of
conception
(RPOC)
No RPOC

Gest. Sac
+
FH -

Management
Counselling

Aim: helps them to identify and express their

feelings
Counselor: obstetrician, specialist,
neonatologist, nurse or social worker
Holistic Approach:
Empathy
Explain
Reassurance
Watch out Sx of depression
Refer to support group
Provide information to plan for future
pregnancy

Management
Expectant

Wait and see approach

Advise pt that passage of pregnancy may a/w
severe pain + bleeding + pass out POC
TCA 2/52 to repeat scan
Offer ERPOC if fail
Medical
Vaginal Pessary Cervagem
Synthetic prostaglandin E1 contract uterus
to expel GS within 24 hours
S/E: Diarrhea, abdominal pain, vomit
Repeat scan 3/52 after expulsion of POC
If septic abortion: IV Unasyn + IV Gentamycin

Management
Medical

If Rhesus Isoimunisation:
Occur in Rh ve Mother carrying a Rh +ve
Fetus
IM RhoGAM 300mcg/2ml (1 ampoule)
For Miscarriage > 12 gest wk
Surgical
ERPOC + HPE of POC
TCA Gynae clinic 2/12 to review HPE
Counsel
20% Risk of recurrent in future pregnancy

Hyperemesis
Gravidarum

Referrence:
1.
https://www.rcog.org.uk/globalassets/documents/guidelines/
green-top-guidelines/gtg69-hyperemesis.pdf
2.https://www.rcog.org.uk/globalassets/documents/guideline
s/gtg_38.pdf
3.Kevin haye,Simon Jackson Lawrence Impey page Oxford
Handbook of Obstetric and Gynaecology 3 rd edition 2013

Definition

Defined as HG can be diagnosed when there is

protracted NVP with the triad of
more than 5% prepregnancy weight loss,
dehydration and
electrolyte imbalance.
*

should only be diagnosed when onset is in the first trimester of

pregnancy and other causes of nausea and vomiting have been
excluded.

classification

Rhodes Index score can be used to determine

whether the NVP is mild, moderate or severe

History

Inability to tolerate solid/liquid food, anything

precipitates the nausea, reduced weight
Frequency and volume of vomiting
Infection such as UTI symptom,AGE
Drug induced? Iron supplement, antibiotics
Metabolic: hyperthyroidism symptoms (heat
intolerance, diarrhea, palpitation), DKA

Examination

General examination look for dehydration,

weight loss, tachycardia, postural hypotension
Weight patient
Neck exmination look for thyroid swelling
Fundus examination look for papilloedema
Abdominal examination

Investigation

FBC
RP (Watch out hyponatremia & hypokalemia)
TFT (abnormal in 60% if hyperemesis
gravidarum patient) aka: Transient
Hyperthyroidism of Hyperemesis Gravidarum
UFEME (UTI and Urine Ketone)
Daily Urine Ketone
USG (exclude multiple and molar pregnancy)

Management

HyperM Regime (1pint HM in 30mins, 1pint HM

in 1hour, 1pint HM in 1hour)
Be careful of rapid correction of
hyponatraemia which will cause
Repeat Urine ketone
Antiemetic (IV Metoclopramide 10mg TDS, T.
Veloxin 1/1 OD)
B1 (thiamine) and B6 (pyridoxine) supplement

Molar pregnancy

An abnormal pregnancy in which the

developing fetus and placenta are replaced by
proliferation of trophoblastic tissue

Mechanism

Clinical features

Irregular vaginal bleeding

Excessive vomiting
Uterine larger than date
Early failed pregnancy
Doughy abdomen
Rare: hyperthyroidism, early onset preeclampsia

USG finding

Snowstorm
No fetal part
Theca lutein cyst

Management

Send FBC, Serum B hcg, CXR

Suction curretage ASAP
Risk of hemorrhage, perforation, infection and
hysterectomy
If size of uterus >24w, S&C done by registrar or
specialist with 4 pints in OT
Oxytocin infusion 40U in 500cc NS AFTER S&C to
assist uterine contraction
Anti-D for rhesus ve patient
Monitor sign of bleeding as in patinet for 24hours

Follow up

Serum BHcg 2 weekly till normalised (<4IU)

If revert within 56days, then follow up 6 monthly from
uterine evacuation
If not revert within 56days, then follow up 6 monthly from
the day of normalisation
Advice for barrier method contraception till 6 months after
normalisation of BHcg
Women who undergo chemotherapy not to conceived for 1
year after completion of treatment
All women with prior molar pregnancy should notify the
PAC at the end of any future pregnancy, whatever the
outcome of the pregnancy as there is risk of recurrence

Gestational Trophoblastic Neoplasia

Gestational
Trophoblastic
Neoplasia

Post Molar Follow up

Post-Evacuation Follow
up

Repeat US 1/52 post Suction and Curretage

To access the presence of Molar tissues

Serial Qualitative B-hCG (gold standard)

Normalized (< 4IU/mL): 8-12 weeks after
evacuation

Follow up for 1 year

If B-hCG rise Suspect persistent

trophoblastic diseases or malignancies
Chemotherapy
80%: Spontaneous regression
15%: Persistent Mole (GTN)
3-5%: Choriocarcinoma

Counselling

Pregnancy should be avoided for the duration of

chemo and 1 year post chemo pregnancy
increase b-hcg (difficult to detect persistent mole)
MUST use Contraception!
Only Barrier Method

Recurrences are most common within the first

year
Pregnancies occur < 6mth post chemo increased
risk of miscarriage, stillbirths, and repeat moles.
Pregnancies occur > 6mth post chemo chemo
dont impact future fertility, spontaneous abortion,
congenital malformation or child development

Braga A, Maest I, Michelin OC, et al. Maternal and perinatal outcomes of first pregnancy after chemotherapy for gestational trophoblastic
neoplasia in Brazilian women. Gynecol Oncol 2009; 112:568

Indications for Chemo

Plateauing of beta-hCG levels >

3wk
> 10% rise in beta-hCG for > 3
values > 2wk
Persistence of beta-hCG > 6mth
The histologic identification of
choriocarcinoma
Metastases to anywhere.

1. Kohorn EI. Negotiating a staging and risk factor scoring system for gestational trophoblastic neoplasia. A progress report. J Reprod Med

FIGO Prognostic Scoring System (Anatomical Staging)

I

Disease confined to the uterus.

II

GTN extends outside of the uterus, but is limited to the genital structures
(adnexa, vagina, broad ligament).

III

GTN extends to the lungs, with or without known genital tract involvement.

IV

All other metastatic sites.

Modified WHO Prognostic Scoring System as Adapted by FIGO b

Scores

Age

<40

40

Antecedent
pregnancy

mole

abortion

term

Interval months
from index
pregnancy

<4

46

712

>12

Pretreatment
<103
serum hCG (iu/1)

103104

104105

>105

Largest tumor
size (including
uterus)

<3

34 cm

5 cm

Site of
metastases

lung

spleen, kidney

gastrointestinal

liver, brain

Number of
metastases

14

58

>8

Previous failed

single drug

2 drugs

Low Risk: Prognostic score < 7

Single agent chemo eg Methotrexate X 6

cycles
High Risk: Prognostic score > 7
Combined chemo eg EMA-CO X 6 cycles
[Etoposide, Mathotrexate, Dactinomycin,
Cyclophosphamide, Vincristine]
Follow up
Give chemo cycle until Serial b-hcg
Normalized
Emphasize on Reliable contraception
method until 1 year post chemo.

Thank You!