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EARLY PREGNANCY

COMPLICATIONS
DERIAN IRAWAN– 406172061
PEMBIMBING – DR. ANDRIANA KUMALA DEWI, SP.OG
KEPANITERAAN OBSTETRI DAN GINEKOLOGI
RS SUMBER WARAS – FK UNTAR
ABORTION
ABORTION
• Defined as spontaneous or induced termination of pregnancy before fetal viability
• National Center for Health Statistics, the Centers for Disease Control and Prevention, and
the World Health Organization define abortion as pregnancy termination before 20 weeks’
gestation or with a fetus born weighing <500 g.
• Uterine pregnancies that eventuate in a spontaneous abortion are also termed early
pregnancy loss or early pregnancy failure
• Spontaneous abortion: threatened, inevitable, incomplete, complete, and missed abortion
• Septic abortion is used to further classify any of these that are complicated further by
infection.
• Recurrent abortion: used to identify women with repetitive spontaneous abortions
• Induced abortion: used to describe surgical or medical termination of a live fetus that has
not reached viability.
FIRST-TRIMESTER SPONTANEOUS ABORTION
(PATHOGENESIS)
• >80% of spontaneous abortion occur within 1st 12 weeks of gestation
• Death of the embryo or fetus nearly always precedes spontaneous expulsion
• Death -> accompanied by hemorrhage into the decidua basalis
• followed by adjacent tissue necrosis that stimulates uterine contractions and expulsion
FIRST-TRIMESTER SPONTANEOUS ABORTION
(FETAL FACTORS)
• 50% of miscarriages -> anembryonic (less acc. Term
used is blighted ovum)
• Other 50% -> embryonic miscarriages (commonly
display a develp abnor of zygote, embryo, fetus or at
times the placenta)
• Of embryonic misc, half (or25% of al) have
chromosomal anomalies (aneuploid abortion),
remaining cases are euploid abortions
FETAL FACTORS – ANEUPLOID ABORTION
• abortion rates and chromosomal anomalies decrease with advancing gestational age.
(a third of 2nd trim fetal losses and 5% of 3rd trim)
• 75%-> occurred by 8 weeks (95%-> maternal gametogenesis error, 5% by paternal
errors)
• Autosomal trisomy-> most frequent for 1st trim
• Trisomy all chrom except number 1, most common are 13, 16, 18, 21, and 22
• Monosomy X (45,X)/Turner syndrome -> single most frequent specific chromosomal
abnormality
• Triploidy -> usually assoc with hydropic or molar placental degeneration
FETAL FACTORS - EUPLOID ABORTION
• Rate of euploid abort peaks at approx. 13 weeks.
• Incidence >>> dramatically if maternal age >35 y.o
FIRST-TRIMESTER SPONTANEOUS ABORTION
(MATERNAL FACTORS - INFECTIONS)
• Pregnancy-> numerous infections-> uncommonly cause early abortion
• Chlamydia trachomatis -> present in 4% of abortus
• Polymicrobial infection from periodontal disease -> has been linked with a
two-to fourfold increased risk
MATERNAL FACTORS – MEDICAL DISORDERS
• DM and thyroid disease
• Celiac disease -> reportedly cause recurrent abortions and male and female
infertility
• Unrepaired cyanotic heart disease -> a likely risk for abortion
• Anorexia nervosa and bulimia nervosa -> have been linked with subfertility, preterm
delivery, and fetal-growth restriction (FGR)
• IBD and SLE -> may increase risk
• Chronic HT -> x appear to confer significant risk for FGR
• History of recurrent misc -> reported to be at increased risk for FGR
• Women with multi misc -> more likely to suffer a myocardial infarction
MATERNAL FACTORS - MEDICATIONS

• Oral contraceptives or spermicidal agents used in contraceptive creams and


jellies are not associated with an increased miscarriage rate
• Non-steroidal antiinflammatory drugs or ondansetron are not linked with
increased risk
• pregnancy with an intra uterine device (IUD) in situ has an increased risk of
abortion and specifically of septic abortion
• no increase in pregnancy loss rates with meningococcal conjugate or
trivalent inactivated influenza vaccines
MATERNAL FACTORS - CANCER

• Therapeutic doses of radiation are undeniably abortifacient, but doses that


cause abortion are not precisely known
• Brent (2009), exposure to < 5 rads does not increase the risk.
• two- to eightfold increased risk for miscarriages, low-birthweight and
growth-restricted infants, preterm delivery, and perinatal mortality in
women previously treated with radiotherapy
• associated increased risk for miscarriage in those given radiotherapy and
chemotherapy in the past for a childhood cancer.
MATERNAL FACTORS – DIABETES MELLITUS

• abortifacient effects of uncontrolled diabetes are well known.


• Optimal glycemic control will mitigate much of this loss
• Spontaneous abortion and major congenital malformation rates are both
increased in women with insulin-dependent diabetes.
MATERNAL FACTORS – THYROID DISORDERS

• Severe iodine deficiency -> has been assoc with >>> misc. rates
• prevalence of abnormally high serum levels of antibodies to thyroid
peroxidase or thyroglobulin is nearly 15 percent in pregnant women ->
marker for >>> misc
• Thryroxine supplementation decreases misc risk
MATERNAL FACTORS -> SURGICAL
PROCEDURE
• The risk of miscarriage caused by surgery is not well studied.
• obesity is an uncontested risk factor for miscarriage. However, currently, it is
not known if this risk is mitigated by weight-reduction surgery
• uncomplicated surgical procedures performed during early pregnancy do
not increase the risk for abortion
• Trauma seldom causes first-trimester miscarriage, Major trauma—
especially abdominal— can cause fetal loss, but is more likely as pregnancy
advances
MATERNAL FACTORS - NUTRITION

• Extremes of nutrition—severe dietary deficiency and morbid obesity—are


associated with increased miscarriage risks.
• This risk is reduced in women who consume fresh fruit and vegetables daily
• Sole deficiency of one nutrient or moderate deficiency of all does not appear to
increase risks for abortion. Even in extreme cases—for example, hyperemesis
gravidarum—abortion is rare
• Obesity -> include subfertility and an increased risk of miscarriage and
recurrent abortion
MATERNAL FACTORS – UTERINE DEFECTS

• 15 %of women with three or more consecutive miscarriages will be found to


have a congenital or acquired uterine anomaly
• Aquired -> uterine synechiae—Asherman syndrome—usually result from
destruction of large areas of endometrium.
FIRST-TRIMESTER SPONTANEOUS ABORTION
(SOCIAL AND BEHAVIORAL FACTORS)
• an increased miscarriage risk is only seen with regular or heavy alcohol use
• low-level alcohol consumption does not significant increase the abortion risk
• Ciggarette smoking -> unproven that cigarettes could cause early pregnancy
loss by a number of mechanisms that cause adverse late-pregnancy outcomes
• Excessive caffeine consumption has been associated with an increased abortion
risk.
• heavy intake of approximately five cups of coffee per day—about 500 mg of
caffeine—slightly increases the abortion risk
• “moderate”—less than 200 mg daily—did not increase the risk
FIRST-TRIMESTER SPONTANEOUS ABORTION
(OCCUPATIONAL AND ENVIRONMENTAL FACTORS)
• some chemicals as increasing miscarriage risk include arsenic, lead,
formaldehyde, benzene, and ethylene oxide
• DDT—dichlorodiphenyltrichloroethane—may cause excessive miscarriage
rates
FIRST-TRIMESTER SPONTANEOUS ABORTION
(IMMUNOLOGICAL FACTORS)
• The immune tolerance of the mother to the paternal-haploid fetal
combination remains enigmatic
• There is, however, an increased risk for early pregnancy loss with some
immune-mediated disorders.
• The most potent of these are antiphospholipid antibodies directed against
binding proteins in plasma
FIRST-TRIMESTER SPONTANEOUS ABORTION
(INHERITED THROMBOPHILIAS)
• American College of Obstetricians and Gynecologists (2013a) is of the
opinion that there is not a definitive causal link between these
thrombophilias and adverse pregnancy outcomes in general, and abortion
in particular
FIRST-TRIMESTER SPONTANEOUS ABORTION
(PATERNAL FACTORS)
• Chromosomal abnormalities in sperm reportedly had an increased abortion
risk
• Increasing paternal age was significantly associated with increased risk for
abortion (lowest before age 25 years, after which it progressively increased
at 5-year intervals)
THREATENED ABORTION
• presumed when bloody vaginal discharge or bleeding
appears through a closed cervical os during the first 20
weeks
• With miscarriage, bleeding usually begins first, and
cramping abdominal pain follows hours to days later.
• There may be low-midline clearly rhythmic cramps;
persistent low backache with pelvic pressure; or dull and
mid line suprapubic discomfort.
• Bleeding is by far the most predictive risk factor for
pregnancy loss
• Overall, approximately half will abort, but this risk is
substantially less if there is fetal cardiac activity
THREATENED ABORTION
VS
ECTOPIC PREGNANCY
• Every woman with an early pregnancy, vaginal bleeding, and pain should be evaluated. The
primary goal is prompt diagnosis of an ectopic pregnancy
• serial quantitative serum ß-hCG and progesterone levels and transvaginal sonography are
used to ascertain if there is an intrauterine live fetus.
• these are not 100% accurate to confirm early fetal death or location, repeat evaluations are
often necessary.
• robust uterine pregnancy, -> serum ß-hCG levels should increase at least 53 to 66% every
48hours
• Serum progesterone concentrations <5 ng/mL suggest a dying pregnancy, whereas values >
20 ng/mL support the diagnosis of a healthy pregnancy.
• Transvaginal sonography is used to locate the pregnancy and determine if the fetus is alive. If
this cannot be done, then pregnancy of unknown location (PUL) is diagnosed
THREATENED ABORTION - MANAGEMENT

• Acetaminophen-based analgesia will help relieve discomfort from cramping


• If uterine evacuation is not indicated, bed rest is often recommended but does
not improve outcomes.
• With persistent or heavy bleeding, the hematocrit is determined.
• If there is significant anemia or hypovolemia, then pregnancy evacuation is
generally indicated
• In these cases in which there is a live fetus, some choose transfusion and further
observation
INEVITABLE ABORTION

• 1st trimester > gross rupture of the membranes along with cervical dilatation (is
nearly always followed by either uterine contractions or infection) + a gush of
vaginal fluid without pain, fever, or bleeding
• If this is documented -> diminished activity with observation is a reasonable
course
• After 48 hours -> no additional amnionic fluid escape, bleeding, cramping, or
fever -> resume ambulation and pelvic rest
• With bleeding, cramping, or fever -> abortion is considered inevitable -> uterus
is evacuated
INCOMPLETE ABORTION

• = bleeding that follows partial or complete placental separation and dilation


of the cervical os
• fetus and the placenta may remain entirely within the uterus or partially
extrude through the dilated os
• Before 10 weeks, they are frequently expelled together, but later, they
deliver separately
• Management options -> curettage, medical abortion, or expectant
management in clinically stable women
COMPLETE ABORTION
• expulsion of the entire pregnancy may be completed before a woman presents to the hospital
• history of heavy bleeding, cramping, and passage of tissue or a fetus is common
• Importantly, during examination, the cervical os is closed.
• If an expelled complete gestational sac is not identified sonography is performed to
differentiate a complete abortion from threatened abortion or ectopic pregnancy
(Characteristic findings of complete abortion) = a minimally thickened endometrium
(<15mm)without a gestational sac)
• Unless products of conception are seen or unless sonography confidently documents, at first an
intrauterine pregnancy, and then later an empty cavity, a complete abortion cannot be surely
diagnosed.
• Serial serum hCG measurements aid clarification. With complete abortion, these levels drop
quickly
MISSED ABORTION

• Also termed early pregnancy failure or loss


• describe dead products of conception that were retained for days, weeks, or
even months in the uterus with a closed cervical os
• The mean death-to abortion interval was approximately 6 weeks
• Miller-Keane Encyclopedia and Dictionary of Medicine, Nursing, and Allied
Health, Seventh Edition -> retained in utero for more than 8 weeks
SEPTIC ABORTION
• Bacteria gain uterine entry and colonize dead conception products
• Organisms may invade myometrial tissues and extend to cause parametritis, peritonitis, septicemia,
and, rarely, endocarditis
• Particularly worrisome are severe necrotizing infections and toxic shock syndrome caused by group A
streptococcus—S pyogenes
• Deaths have been reported from toxic shock syndrome due to Clostridium perfringens
• Similar infections are caused by Clostridium sordellii
• Maternal deaths from these clostridial species approximate 0.58 per 100,000 medical abortions
(Meites, 2010).
• Management -> prompt administration of broad-spectrum antibiotics
• If there are retained products or fragments -> suction curettage
• Follow-up oral antibiotic treatment is likely unnecessary
• To prevent postabortal sepsis, prophylactic antibiotics are given at the time of induced abortion or
spontaneous abortion that requires medical or surgical intervention
• Recommended -> doxycycline, 100 mg orally 1 hr before and then 200 mg orally after a surgical
evacuation
MANAGEMENT OF SPONTANEOUS ABORTION

• Unless there is serious bleeding or infection with an incomplete abortion, any


of three options are reasonable—expectant, medical, or surgical management.
• Expectant management of spontaneous incomplete abortion has failure rates
as high as 50 percent
• Medical therapy with prostaglandin E1 (PGE1) has varying failure rates of 5 to
40 percent. In 1100 women with suspected first-trimester abortion, 81 percent
had a spontaneous resolution
• Curettage usually results in a quick resolution that is 95- to 100-percent
successful. It is invasive and not necessary for all women.
RECURRENT MISCARRIAGE
• Other terms : include recurrent spontaneous abortion,
recurrent pregnancy loss, and habitual abortion
• Classicaly defined as three or more consecutive pregnancy
losses at 20 weeks or with a fetal weight <500 grams
• Most of these are embryonic or early losses, and the
remainder either are anembryonic or occur after 14 weeks
• The American Society for Reproductive Medicine (2008)
proposed that recurrent pregnancy loss be defined as two
or more failed clinical pregnancies confirmed by either
sonographic or histopathological examination.
RECURRENT MISCARRIAGE - ETIOLOGY

• 3 widely accepted causes : parental chromosomal abnormalities (2-4%),


antiphospholipid antibody syndrome, and a subset of uterine abnormalities
• Other suspected but not proven : alloimmunity, endocrinopathies,
environmental toxins, and various infections
• Genetic factors usually result in early embryonic losses, whereas
autoimmune or uterine anatomical abnormalities more likely cause second-
trimester losses
ANATOMICAL FACTORS
• 15 percent of women with three or more consecutive
miscarriages will be found to have a congenital or acquired
uterine anomaly
• Uterine leiomyomas are found in a large proportion of adult
women and can cause miscarriage, especially if located
near the placental implantation site
• Ironically, women undergoing uterine artery embolization
of myomas had an increased risk for miscarriage in a
subsequent pregnancy
• Developmental uterine anomalies were found in
approximately 20 percent of women with recurrent
pregnancy losses
IMMUNOLOGICAL AND ENDOCRINE FACTORS

• 15 percent of more than 1000 women with recurrent miscarriage had


recognized autoimmune factors.
• Uncontrolled diabetes is has well-known abortifacient effects. Optimal
periconceptional glycemic control will mitigate much of this loss
INDUCED ABORTION

• Termination of pregnancy before the time of fetal viability


• Definitions to describe its frequency include: abortion ratio(number of
abortions per 1000 live births) and abortion rate ( number of abortions per
1000 women aged 15-44 years)
• Classification : Therapeutic abortion, Elective or voluntary abortion,
THERAPEUTIC ABORTION

• There are several diverse medical and surgical disorders that are
indications for termination of pregnancy, examples are:
• persistent cardiac decompensation, especially with fixed pulmonary
hypertension, advanced hypertensive vascular disease or diabetes, and
malignancy
• Rape or incest -> most consider termination reasonable
• most common indication currently is to prevent birth of a fetus with a
significan anatomical, metabolic, or mental deformity
ELECTIVE OR VOLUNTARY ABORTION

• The interruption of pregnancy before viability at the request of the woman,


but not for medical reasons
• it is one of the most commonly performed medical procedures
• Counseling before elective abortion:
3 basic choices : (1) continued pregnancy with its risks and parental
• Responsibilities, (2) continued pregnancy with arranged adoption, (3)
termination of pregnancy with its risks
• 1st rimester abortions TECHNIQUES FOR ABORTION
can be performed either
medically or surgically
by several methods
• Success rates: 95% for
medical and 99% for
surgical
• Medical therapy has
more drawbacks in that it
is more time consuming;
it has an unpredictable
outcome—extending for
days up to a few weeks;
and bleeding is usually
heavier and
unpredictable
CONSEQUENCES OF ELECTIVE ABORTION

• legally induced abortion, performed by trained gynecologists during the


first 2 months of pregnancy, has a mortality rate of less than 1 per 100,000
procedures (Pazol, 2011).
• Early abortions are even safer, and the relative mortality risk of abortion
approximately doubles for each 2 weeks after 8 weeks’ gestation
CONTRACEPTION FOLLOWING MISCARRIAGE
OR ABORTION
• Ovulation may resume as early as 2 weeks after an early pregnancy
termination
• Thus, it is important that unless another pregnancy is desired right away,
effective contraception should be initiated very soon after abortion
• There is no reason to delay this, and an intrauterine device can be inserted
after the procedure is completed
• Conceptions within 6 months after miscarriage had better pregnancy
outcomes compared with pregnancies conceived after 6 months
ECTOPIC
PREGNANCY
ECTOPIC PREGNANCY

• Blastocyst normally implants in the endometrial lining of the uterine cavity


• Implantation elsewhere is considered ectopic and comprises 1 to 2 percent
of all first-trimester pregnancies in the United States
• accounts for 6 percent of all pregnancy-related deaths
• chance for a subsequent successful pregnancy is reduced after an ectopic
pregnancy
• urine and serum beta-human chorionic gonadotropin (ß-hCG) assays and
transvaginal sonography have made earlier diagnosis possible.
TUBAL PREGNANCY
• Nearly 95% of ectopic pregnancies
-> implanted in various segments
of the fallopian tubes -> fimbrial,
ampullary, isthmic, or interstitial
tubal pregnancies
• Occasionally a multifetal
pregnancy is composed of one
conceptus with normal uterine
implantation coexisting with one
implanted ectopically ->
heterotopic pregnancies -> 1 per
30.000 pregnancies
RISKS
• Abnormal fallopian tube anatomy underlies many cases of tubal ectopic pregnancy
• Surgeries for a prior tubal pregnancy, fertility restoration, or for sterilization confer the highest risk
of tubal implantation
• Prior STD or other tubal infection -> common risk factor
• Peritubal adhesions may increase the risk for tubal pregnancy
• Congenital fallopian tube anomalies can lead to malformed tubes -> higher ectopic rates
• Infertility as well as the use of ART to overcome it -> substantioal increased risks for ectopic
pregnancy
• Smoking -> known association but mechanism is unclear
Some contraceptive method failures (tubal sterilization, copper and progestin-releasing IUD,
progestin-only contraceptives)-> increased risk
EVOLUTION AND POTENTIAL OUTCOMES
• Fallopian tube lacks a submucosal layer -> fertilized ovum promptly burrows through the epithelium -> zygote
comes to lie near or within the muscularis -> invaded in most cases by rapidly proliferating trophoblast ->
embryo or fetus is often absent or stunted
• Outcomes -> tubal rupture, tubal abortion, or pregnancy failure with resolution
• If rupture in the first few weeks -> most likely located in isthmic portion
• If in interstitial portion -> rupture usually occurs later
• Tubal ectopic pregnancies usually burst spontaneously but may rupture following coitus or bimanual
examination
• Alternatively, pregnancy may abort out the distal fallopian tube -> common in fimbrial and ampullary
pregnancies
• acute ectopic pregnancies are those with a high serum ß-hCG level and rapid growth
• Chronic -> abnormal trophoblast die early -> thus negative or lower, static serum ß-hCG levels are found
CLINICAL MANIFESTATIONS
• A classic presentation is characterized by the triad of delayed menstruation, pain, and vaginal bleeding or spotting
• Tubal rupture -> severe lower abdominal and pelvic pain -> freq desc as sharp, stabbing, or tearing
PF -> tenderness during abdominal palpation, bimanual pelvic exam especially cervical motion causes exquisite pain,
posterior vaginak fornix may bulge from blood in rectouterine cul-de-sac, or a tender, boggy mass may be felt to one
side of the uterus
uterus may be slightly enlarged due to hormonal stimulation, symptoms of diaphragmatic irritation (pain in the neck or
shoulder especially on inspiration) develops in around 50% of women with a sizeable hemoperitoneum
• BP will fall and pulse will rise only if bleeding continues and hypovolemia becomes insignificant
• Even after substantive hemorrhage, hemoglobin or hematocrit readings may at first show only a slight reduction
• in addition to bleeding, women with ectopic tubal pregnancy may pass a decidual cast, which is the entire sloughed
endometrium that takes the form of the endometrial cavity
• If no clear gestational sac is visually seen or if no villi are identified histologically within the cast, then the possibility of
ectopic pregnancy must still be considered.
MULTIMODALITY DIAGNOSIS

• Differential diagnosis for abdominal pain coexistent with pregnancy is extensive


• Pain may derive from :
Uterine disease :miscarriage, infection, degenerating or enlarging leiomyomas,
molar pregnancy, or round-ligament pain
Adnexal disease: ectopic pregnancy; hemorrhagic, ruptured, or torsed ovarian
masses; salpingitis; or tuboovarian abscess
Appendicitis, cystitis, renal stone, or gastroenteritis
• key components: physical findings, transvaginal sonography (TVS), serum ß-
hCG level measurement
• Algorithm use applies only to hemodynamically stable women
BETA HUMAN CHORIONIC GONADOTROPIN

• Determine pregnancy
• Current serum and urine pregnancy tests that use ELISA for β-hCG are sensitive
to levels of 10 to 20 mIU/mL and are positive in >99 percent of ectopic
pregnancies
• With bleeding or pain and a positive pregnancy test result, an initial TVS is
typically performed to identify gestation location. If a yolk sac, embryo, or fetus
is identified within the uterus or the adnexa, then a diagnosis can be made
• In many cases however -> TVS is nondiagnostic and tubal pregnancy is still a
possibility -> use the term pregnancy of unknown location (PUL) until additional
clinincal info allows determination of pregnancy location
Β-HCG – LEVELS ABOVE THE DISCRIMINATORY
ZONE
• Indicates that the pregnancy is either not alive or is ectopic
• empty uterus with a serum ß-hCG concentration >=1500 mIU/mL was 100% accurate in excluding a live uterine
pregnancy
• Some institutions however use >= 2000mIU/mL for their threshold
• Connolly and associates (2013) : with live uterine pregnancies, a gestational sac was seen 99 %of the time with a
discriminatory level of 3510 mIU/mL.
• If initial ß-hCG level exceeds the set discriminatory level and no evidence for a uterine pregnancy is seen with
TVS -> diagnosis is narrowed in most cases to a failed uterine pregnancy, completed abortion, or an ectopic
pregnancy
• If patient history or extruded uterine tissue suggests a completed abortion, then serial ß-hCG levels will drop
rapidly
• Otherwise, curettage will distinguish an ectopic from a nonliving uterine pregnancy although some do not
recommend diagnostic curettage because it results in unnecessary surgical therapy
Β-HCG – LEVELS BELOW THE DISCRIMINATORY
ZONE
• If initial ß-hCG level is below the set discriminatory value -> pregnancy location is often
not technically discernible with TVS
• With these PULs, serial ß-hCG level assays are done to identify patterns that indicate either
a growing or failing uterine pregnancy (levels that rise or fall outside expected parameters
increase concern for ectopic pregnancy)
• Women with a possible ectopic pregnancy, but whose initial ß-hCG level is below the
discriminatory threshold, are seen 2 days later for further evaluation
• Kadar and Romero (1987) : normal progressing uterine pregnancies has a mean doubling
time of approximately 48 hours for serum ß-hCG levels
• Lowest normal value for this increase was 66%, 53%/48hr with minimum 24%/24hrs (Silva
and colleagues)
• Silva and colleagues : 1/3 of women with ectopic pregnancy will have a 53% rise at 48
hours
• Approx. half of ectopic pregnancies will show decreasing ß-hCG levels, where as the other
half will have increasing levels
• Failing intrauterine pregnancy -> patterned rates of ß-hCG level will decline can be
anticipated (around 21-35%)
SERUM PROGESTERONE

• Value >25ng/mL excludes ectopic pregnancy (92.5% sensitivity)


• Values <5 ng/mL are found in only 0.3% of normal pregnancies
• Most ectopic pregnancies -> progesterone levels range between 10-25
ng/mL
TRANSVAGINAL SONOGRAPHY –
ENDOMETRIAL FINDINGS
• 4½-5 weeks : intrauterine gestational sac is usually visible
• 5-6 weeks: yolk sac appears
• 5½-6 weeks: a fetal pole with cardiac activity is first detected
• with ectopic pregnancy, a trilaminar endometrial pattern can be diagnostic (94$ specificity, but 34$
sensitivity)
• Anechoic fluid collections (pseudogestational sac and decidual cyst), which might normally suggest an
early intrauterine gestational sac, may also be seen with ectopic pregnancy
• Pseudosac is a fluid collection between the endometrial layers and conforms to the cavity shape -> if
noted -> >>> risk for ectopic pregnancy
• Decidual cyst is an anechoic are lying within endometrium but remote from the canal and often at the
endometrial-myometrial border -> if noted -> this finding represents early decidual breakdown and
precedes decidual cast formation.
TRANSVAGINAL SONOGRAPHY – ADNEXAL
FINDINGS
• sonographic diagnosis of ectopic pregnancy rests on visualization of an adnexal mass separate
from the ovary
• If fallopian tubes and ovaries are visualized and an extrauterine yolk sac, embryo, or fetus is
identified, then an ectopic pregnancy is clearly confirmed
• hyperechoic halo or tubal ring surrounding ananechoic sac can be seen. (20%)
• Alternatively : an inhomogeneous complex adnexal mass is usually caused by hemorrhage within
the ectopic sac or by an ectopic pregnancy that has ruptured into the tube. (60%)
• Have an obious gestational sac with a fetal pole (13%)
• Placental blood flow within the periphery of the complex adnexal mass—the ring of fire—can be
seen with color Doppler imaging
HEMOPERITONEUM
• In women with suspected ectopic pregnancy, evaluation for hemoperitoneum can add valuable
clinical info
• commonly, this is completed using sonography, but assessment can also be made by
culdocentesis
• Sonographically, hemoperitoneum is anechoic or hypoechoic fluid.
• Blood initially collects in the dependent retrouterine cul-de-sac, and then additionally
surrounds the uterus as it fills the pelvis (As little as 50 mL can be seen in the cul-de-sac using
TVS)
• Diagnostically, peritoneal fluid in conjunction with an adnexal mass is highly predictive of
ectopic pregnancy
• Culdocentesis -> Fluid containing fragments of old clots or bloody fluid that does not clot is
compatible with the diagnosis of hemoperitoneum.
LAPAROSCOPY

• Direct visualization of the fallopian tubes and pelvis by laparoscopy


• offers a reliable diagnosis in most cases of suspected
TREATMENT OPTIONS

• Medical and surgical approaches


• Medical therapy traditionally involves the antimetabolite methotrexate.
Surgical choices include mainly salpingostomy or salpingectomy
• Sebagai dokter umum -> rujuk ke dokter spesialis obsgyn
INTERSTITIAL PREGNANCY

• Diagnosis :implant within the proximal tubal segment that lies within the
muscular uterine wall
• Criteria that may aid sonographical differentiation include: an empty uterus,
a gestational sac seen separate from the endometrium and > 1 cm away
from the most lateral edge of the uterine cavity, and a thin, < 5-mm
myometrial mantle surrounding the sac
ABDOMINAL PREGANCY
• Abdominal pregnancy is an implantation in the peritoneal cavity exclusive of tubal, ovarian, or intraligamentous
implantations
• Although a zygote can traverse the tube and implant primarily in the peritoneal cavity, most abdominal
pregnancies are thought to follow early tubal rupture or abortion with reimplantation
• symptoms may be absent or vague
• Sonographically, findings with an abdominal pregnancy may not be recognized, and the diagnosis is often
missed
• Oligohydramnios is common but nonspecific. Other clues include a fetus seen separate from the uterus or
eccentrically positioned within the pelvis; lack of myometrium between the fetus and the maternal anterior
abdominal wall or bladder; and extrauterine placental tissue
• MR imaging can be used to confirm the diagnosis and provide maximal information concerning placental
implantation
MANAGEMENT

• termination generally is indicated when the diagnosis is made. Certainly,


before 24 weeks, conservative treatment rarely is justified
• Preoperative angiographic embolization has been used successfully in
some women with advanced abdominal pregnancy
• principal surgical objectives involve delivery of the fetus and careful
assessment of placental implantation without provoking hemorrhage
• Sebagai dokter umum -> rujuk ke spesialis obsgyn
INTRALIGAMENTOUS PREGNANCY

• Clinical findings and management mirror those for abdominal pregnancy


• laparotomy is required in most instances, a few case reports describe
laparoscopic excision of early small pregnancies
OVARIAN PREGNANCIES

• Ectopic implantation of the fertilized egg in the ovary is rare and is


diagnosed if four clinical criteria are met
• The ipsilateral tube is intact and distinct from the ovary
• the ectopic pregnancy occupies the ovary
• the ectopic pregnancy is connected by the uteroovarian ligament to the
uterus
• Ovarian tissue can be demonstrated histologically amid the placental tissue
• Classically, management for ovarian pregnancies has been surgical
CERVICAL PREGNANCY

• defined by cervical glands noted histologically opposite the placental


attachment site and by part or all of the placenta found below the entrance of
the uterine vessels or below the peritoneal reflection on the anterior uterus
• Identification of cervical pregnancy is based on speculum examination,
palpation, and TVS. Sonographic findings typical of cervical pregnancy are
shown and described. MR imaging and 3-D sonography have also been used to
confirm the diagnosis
• Management -> medically or surgically. Methotrexate has become the first line
therapy in stable women
CESAREAN SCAR PREGNANCY

• implantation within the myometrium of a prior cesarean delivery scar.


• Women with CSP usually present early, and pain and bleeding are common
• Up to 40% of women are asymptomatic and the diagnosis is made during
routine sonographic examination
• MR imaging is useful when sonography is equivocal or inconclusive before
intervention
• Management -> medical or surgical
OTHER SITES OF ECTOPIC PREGNANCY

• Ectopic placental implantations in less expected sites have been described


in case reports and include the omentum, spleen, liver, and
retroperitoneum, among others
• Ectopic placental implantations in less expected sites have been described
in case reports and include the omentum, spleen, liver, and
retroperitoneum, among others
• Management -> laparotomy is preferred
GESTATIONAL
TROPHOBLASTIC
DISEASE
GESTATIONAL TROPHOBLASTIC DISEASE
• term used to encompass a group of tumors typified by abnormal trophoblast proliferation.
• Trophoblast produce human chorionic gonadotropin (hCG)
• measurement of this peptide hormone in serum is essential for GTD diagnosis, management, and surveillance.
• histologically is divided into hydatidiform moles (characterized by the presence of villi), non molar
trophoblastic neoplasms (which lack villi), and invasive mole
• Invasive mole -> malignant due to its marked penetration into and destruction of the myovmetrium as well as
its ability to metastasize
• Nonmolar trophoblastic neoplasms choriocarcinoma, placental site trophoblastic tumor, and epithelioid
trophoblastic tumor (are differentiated by the type of trophoblast they contain)
• The malignant forms of gestational trophoblastic disease are termed gestational trophoblastic neoplasia (GTN)
: include invasive mole, choriocarcinoma, placental site trophoblastic tumor, and epithelioid trophoblastic
tumor.
HYDATIDIFORM MOLE – MOLAR PREGNANCY

• Classic histological findings include villous stromal edema and trophoblast proliferation
• The degree of histological changes, karyotypic differences, and the absence or presence
of embryonic elements are used to classify them as either complete or partial moles
• GTN more frequently follows complete hydatidiform mole
• Complete mole has abnormal chorionic villi that grossly appear as a mass of clear
vesicles (vary in size and often hang in clusters from thin pedicles)
• partial molar pregnancy has focal and less advanced hydatidiform changes and contains
some fetal tissue
EPIDEMIOLOGY AND RISK FACTORS

• increased prevalence in Asians, Hispanics, and American Indians


• strongest risk factors are age and a history of prior hydatidiform mole
• adolescents and women aged 36 to 40 years have a twofold risk. those older
than 40 have an almost tenfold risk
• For those with a prior complete mole, the risk of another mole is 1.5 percent
• previous partial mole, the rate is 2.7 percent
• After two prior molar pregnancies, Berkowitz and associates (1998) reported
that 23 percent of women had a third mole
PATHOGENESIS
• molar pregnancies arise from
chromosomally abnormal fertilizations
• Complete moles most often have a diploid
chromosomal composition (usually 46,XX
and are paternal in origin)
• Less frequentl, a similar haploid egg
may be fertilized by an unreduced
diploid 46,XY sperm
• These triploid zygotes result in some
embryonic development, however, it
ultimately is a lethal fetal condition
TWIN PREGNANCY COMPRISED OF A NORMAL
FETUS AND COEXISTENT COMPLETE MOLE
• Recognized in only 1 in 22.000 to 100.0000 pregnancies
• Important to distinguish it from a single partial molar pregnancy with its abnormal associated
fetus. Amniocentesis done for fetal karyotyping is used to confirm the diagnosis
• With continuing pregnancy, survival of the normal fetus is variable and dependent on
complications that commonly develop from the molar component (most worrisome are
preeclampsia and hemorrhage)
• Another concern for those continuing their pregnancy is the possible risk for developing
subsequent GTN. But, according to Niemann women with these twin pregnancies are not at
greater risk for subsequent neoplasia than those with a singleton complete mole
CLINICAL FINDINGS
• Typically, there are usually 1 to 2 months of amenorrhea before discovery
• In 41 women with a complete mole diagnosed at a mean of 10 weeks : 41 percent were asymptomatic
and 58 percent had vaginal bleeding and only 2 percent had anemia or hyperemesis
• Untreated molar pregnancies will almost always cause uterine bleeding (from spotting to profuse
hemorrhage
• In considerable concealed uterine hemorrhage, moderate iron-deficiency anemia develops
• Many have rapid uterine growth. The enlarged uterus has a soft consistency, but typically no fetal
heart motion is detected
• ovaries contain multiple theca-lutein cysts in 25 to 60 percent of women with a complete mole
(regress following pregnancy evacuation)
• thyrotropin-like effects of hCG ->serum free thyroxine (fT4) levels to be
elevated and thyroid stimulating hormone (TSH) levels to be decreased
• serum free T4 levels rapidly normalize after uterine evacuation
• Severe preeclampsia and eclampsia are relatively common with large molar
pregnancies
• Severe preeclampsia frequently mandates preterm delivery
DIAGNOSIS

• Most women initially have amenorrhea that is followed by irregular


bleeding that almost always prompts pregnancy testing and sonography.
• Some women will present with spontaneous passage of molar tissue.
DIAGNOSIS – SERUM Β-HCG MEASUREMENTS

• Complete molar pregnancy -> serum ß-hCG levels are commonly elevated
above those expected for gestational age.
• more advanced moles, values in the millions are not unusual.
• high values can lead to erroneous false-negative urine pregnancy test
results because of oversaturation of the test assay by excessive ß-hCG
hormone
• partial mole ->ß-hCG levels may also be significantly elevated, but more
commonly concentrations fall into ranges expected for gestational age.
DIAGNOSIS - SONOGRAPHY
• sonographic imaging is the mainstay of trophoblastic disease diagnosis
• a complete mole appears as an echogenic uterine mass with numerous anechoic cystic spaces but
without a fetus or amnionic sac. (often described as “snowstorm”)
• A partial mole has features that include a thickened, multicystic placenta along with a fetus or at
least fetal tissue
• In early pregnancy, however, these sonographic characteristics are seen in fewer than half of
hydatidiform moles
• most common misdiagnosis is incomplete or missed abortion
• Occasionally, molar pregnancy may be confused for a multifetal pregnancy or a uterine leiomyoma
with cystic degeneration
PATHOLOGICAL DIAGNOSIS
• Surveillance for subsequent neoplasia following molar pregnancy is crucial
• In pregnancies before 10 weeks, classic molar changes may not be apparent because villi may not be enlarged and
molar stroma may not yet be edematous and avascular
• One takes advantage of the differing ploidy to distinguish partial (triploid) moles from diploid entities. Complete
moles and nonmolar pregnancies with hydropic placental degeneration are both diploid
• Another technique -> histological immunostaining to identify the p57KIP2 nuclear protein (this gene is paternally
imprinted -> only maternally donated genes are expressed)
• complete moles contain only paternal genetic material, they cannot express this gene; do not produce p57 KIP2; and
thus, do not pick up this immunostain
• this nuclear protein is strongly expressed in partial moles and in nonmolar pregnancies with hydropic change
• Combined use of ploidy analysis and p57KIP2 immunostaining can be used to differentiate:
(1) a complete mole (diploid/p57KIP2-negative),
(2) a partial mole (triploid/p57KIP2-positive),
(3) and spontaneous abortion with hydropic placental degeneration (diploid/p57KIP2-positive)
MANAGEMENT

• Molar evacuation by suction curettage is usually the preferred treatment


• Dokter umum -> rujuk ke spesialis obsgyn
POSTEVACUATION SURVEILLANCE
• Close biochemical surveillance for persistent gestational neoplasia should follow hydatidiform mole evacuation
• reliable contraception is imperative to avoid confusion caused by rising ß-hCG levels from a new pregnancy
• Recommended : combination hormonal contraception or injectable medroxyprogesterone acetate (latter is good if poor compliance),
Intrauterine devices are not used until ß-hCG levels are undetectable because of the risk of uterine perforation if there is an invasive mole
• Barrier and other methods are not recommended because of their relatively high failure rates
• Biochemical surveillance is by serial measurements of serum ß-hCG. initial ß-hCG level is obtained within 48 hours after evacuation. This
serves as the baseline
• The baseline si then compared with ß-hCG quantification done thereafter every 1 to 2 weeks until levels progressively decline to become
undetectable.
• median time for such resolution is 7 weeks for partial moles and 9 weeks for complete moles
• Once ß-hCG is unde tectable, this is confirmed with monthly determinations for another 6 months. After this, surveillance is discontinued
and pregnancy allowed (has a high non-compliance rate)
• Truncated approach -> , it was shown that no woman with a partial or complete mole whose serum ß-hCG level became undetectable
subsequently developed neoplasia
• During the time during which ß-hCG levels are monitored, either increasing or persistently plateaued levels mandate evaluation for
trophoblastic neoplasia. If the woman has not become pregnant, then these levels signify increasing trophoblastic proliferation that is most
likely malignant
• Risk factors: Complete moles have a 15 to 20 percent incidence of malignant sequelae, compared with 1 to 5 percent following partial
moles
• Other risk factors are older age, ß-hCG levels >100,000 mIU/mL, uterine size that is large-for-gestational age, theca-lutein cysts > 6 cm,
and slow decline in ß-hCG levels
GESTATIONAL TROPHOBLASTIC NEOPLASIA

• Includes invasive mole, choriocarcinoma, placental site trophoblastic tumor,


and epithelioid trophoblastic tumor.
• almost always develop with or follow some form of recognized pregnancy
• Half follow hydatidiform mole, a fourth follow miscarriage or tubal
pregnancy, and another fourth develop after a preterm or term pregnancy
CLINICAL FINDINGS AND DIAGNOSIS
• characterized clinically by their aggressive invasion into the myometrium
and propensity to metastasize
• most common finding with gestational trophoblastic neoplasms is irregular
bleeding associated with uterine subinvolution
STAGING AND SCORING SYSTEM
TREATMENT

• Chemotherapy is usually the primary treatment, and repeat evacuation is


not recommended by most because of risks for uterine perforation,
bleeding, infection, or intrauterine adhesion formation.
• Dokter umum -> rujuk ke spesialis obsgyn
SUBSEQUENT PREGNANCIES

• Women with prior gestational trophoblastic disease or success fully treated


neoplasia usually do not have impaired fertility, and their pregnancy
outcomes are usually normal
• primary concern in these women is their 2-percent risk for developing
trophoblastic disease in a subsequent pregnancy
• Sonographic evaluation is recommended in early pregnancy
• At delivery, the placenta or products of conception are sent for pathological
evaluation, and a serum ß-hCG level is measured 6 weeks post partum.
HYPEREMESIS
GRAVIDARUM
HYPEREMESIS GRAVIDARUM
• Mild to moderate nausea and vomiting are especially common in pregnant women until approximately 16 weeks
• a small proportion of these, however, it is severe and unresponsive to simple dietary modification and antiemetics.
• Severe unrelenting nausea and vomiting—hyperemesis gravidarum—is defined variably as being sufficiently severe to
produce weight loss, dehydration, ketosis, alkalosis from loss of hydrochloric acid, and hypokalemia. Acidosis
develops from partial starvation.
• Other causes should be considered because hyperemesis gravidarum is a diagnosis of exclusion
• Up to 20 percent of those hospitalized in a previous pregnancy for hyperemesis will again require hospitalization
• obese women are less likely to be hospitalized for this
• Etiopathogenesis of hyperemesis gravidarum is likely multifactorial and certainly is enigmatic. It appears to be related
to high or rapidly rising serum levels of pregnancy-related hormones.
COMPLICATIONS

• Vomiting may be prolonged, frequent, and severe


MANAGEMENT
• Reported a salutary effect from several antiemetics given orally or by rectal suppository as first-line agents
• When simple measures fail, intravenous Ringer lactate or normal saline solutions are given to correct dehydration,
ketonemia, electrolyte deficits, and acid-base imbalances
• Thiamine, 100 mg, is given to prevent Wernicke encephalopathy
• If vomiting persists after rehydration and failed outpatient management, hospitalization is recommended
• Antiemetics such as promethazine, prochlorperazine, chlorpromazine, or metoclopramide are given parenterally
• There is little evidence that treatment with glucocorticosteroids is effective
• A study shows pulsed hydrocortisone therapy was superior to metoclopramide to reduce vomiting and
readmissions
• Serotonin antagonists are most effective for controlling chemotherapy-induced nausea and vomiting
• when used for hyperemesis gravidarum, ondansetron was not superior to promethazine
• With persistent vomiting after hospitalization, appropriate steps should be taken to exclude possible underlying
diseases as a cause of hyperemesis
• With treatment, most women will have a salutary response and may be sent home with antiemetic therapy
• Radio chest= 0,01 rad
• CT-chest=0,7 rad
• Ct abdomen and
pelvis=1 rad
• CT-colon-0,6 rad
• paling besar = 2,5 rad

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