First trimester bleeding

DDs Miscarriages
Ectopic pregnancy
GTD-H-mole

Hx-

Maternal age- risk (of all 3 conditions) with maternal age

Parity & no: of children
LRMP POA
How the pregnancy was confirmed or not?
Urine hCG (+) & at which POA?
USS done/not? & at which POA?

About bleeding-
Amount of blood loss & colour-
Ectopic- old blood in small amount
Miscarriage-mild (in threatened M:) / fresh & heavy (in inevitable M:)
H-mole- heavy bleeding
Passage of clots & products- In miscarriages
Passage of vesicles In H-mole
How many episodes
Purulent vaginal discharge with fever in septic abortions

Associated abdominal pain-

Pain Mild bleeding Ectopic
Bleeding Pain - Miscarriages

Localized U/L lower abdominal pain (distension of tubes)

Ectopic Pregnancy
Generalized pain +/- shoulder tip pain (following rupture)

Dull, lower abdominal pain miscarriages

No abdominal pain missed miscarriage

Pregnancy symptoms-
N, V, dizziness, vertigo
How did they progress? Whether ed (in H-mole) hyperemesis gravidarum
ed / disappeared (in missed miscarriage)

Recent sexual intercourse Genital tract trauma

Risk factors-

Ectopic-
ing maternal age
Hx of PID (Gonorrhoea, Chlamydia)
Hx of ectopic pregnancies
Hx of pelvic Sx- Tubal reconstruction (salphingotomy, salphingectomy)
LRT
Contraception- IUCD
Hx of subfertility Assisted fertility methods IUI
Multiple sexual partners

Miscarriages
Abnormalities of uterus- ed fibroids in past
Uterine septa
Endometrial adhesions (post- curettage & Ashermans Xn)
Cervical incompetence
Maternal infections - rubella, malaria, toxoplasmosis, CMV.
Maternal diseases- DM, SLE, hypothyroidism, PCOS, anti phospholipid Xn
Smoking
Irradiation /chemotherapy
Previous episodes of miscarriages recurrent miscarriages

H-mole -
Previous molar pregnancies

Social Hx If suspect illegal / legal termination of pregnancy,

Interventions done to terminate the pregnancy
Reason
Social issues
Married/unmarried
Family support
Educational level/ occupation
Family support
Future fertility wishes
Sexual promiscuous behavior - Cervicitis

Ex

General Ex - well/ill looking

Febrile/not
Dyspnoeic
In pain/not
Pallor
Hydration
Features of hyperthyroidism in H-mole (because sub unit of hCG similar to TSH)
CVS Ex - PR tachycardia
BP
Pulse pr shock
CRT
Cold clammy peripheries

Abd Ex Guarding, rigidity

Localized/ generalized tenderness Ectopics/septic abortions
Free fluids

Uterine size - < POA - Miscarriages

Ectopic slightly enlarged uterus, but < POA
Uterine size -> POA H-mole

Speculum Ex - Bleeding from OS

Miscarriages
Parts, clots, blood in posterior fornix

Bleeding outside the OS Cervicitis, Genital tract trauma

VE OS opened Incomplete / inevitable miscarriages

OS closed Threatened / missed / complete

Cervical excitation Ectopic

Adnexeal tenderness / adnexeal masses - septic abortions, ectopic pregnancy
Bulging membranes from OS- inevitable miscarriage
Investigations
T1 bleeding

Urine hCG

Uterus abdominally palpable

Yes No

USS abdomen TVS

Intra-uterine pregnancy

Yes No (ectopic) Look for pregnancy in an ectopic site

Look for,

Fetal parts (+) Threatened S. hCG level

Only products Incomplete

FHB (+) Threatened miscarriage:

Snow storm appearance H-mole

CXR

Look for lung metastases

Discussion

Ectopic pregnancy -
Definition- Any pregnancy where the fertilized ovum gets implanted & develops in a site other than
normal uterine cavity.
Incidence 1 in50 to 1 in 300 pregnancies
Sites fallopian tubes - 95 -98% (from this >50% in ampulla)
Abdominal
Ovarian
Cervical, Broad ligament
Risk factors & aetiology as above
Symptoms- as above
Diagnosis
degree of suspicion- Hx & Ex
Urine hCG as a ward test
*(-)ve urine hCG does not exclude an ectopic
*Absence of POA does not exclude an ectopic

Ix
Serum hCG
Normal pregnancy- 66% rise in 48 hrs
If the rise is <66% ectopic pregnancy
Failing pregnancy
(But 12% of ectopic pregnancies have normal hCG rise & 12% of normal pregnancies
have ed hCG rise)

If serum hCG levels >1500iu/L, TVS should show an IUP. Otherwise look for an ectopic

TVS-
To locate pregnancy
Presence of IUP generally excludes an ectopic
Rarely, an ectopic may co-exist with an IUP heterotopic pregnancy

Laparoscopy
Gold standard of
Once ed, can treat at the same time

Rx
1) Surgical- (laparoscopy / laparotomy)

Salpingectomy Removal of affected tube.

Standard Rx if the other tube is normal.
Salpingotomy Indicated when tube is abnormal.
Remove the products of conceptus by making an incision on the tube.

Chance of getting pregnant again is similar in both salpingotomy & salpingectomy.

But, there is a 20% more risk of getting a subsequent ectopic pregnancy in salpingotomy than in
salpingectomy.

2) Medical
o For haemodynamically stable pts (asymptomatic & unruptured)
o Fetus not viable
o Serum hCG <3500iu/L
o Methotrexate 50 mg/m2 IM single dose
SE gastritis, stomatitis, conjunctivitis, N, V, headache, thrombocytopenia
o Follow up with serum hCG levels
o Advices Avoid sexual intercourse during Rx
Ample fluid intake
Avoid pregnancy for 3 months due to risk of teratogenecity
o Other medical agents Prostaglandin, KCl, hyperosmolar glucose.
 3) Expectant Mx-
o As there is incidence of spontaneous regression of tubal pregnancies.
o For stable pts with ing symptoms, falling hCG levels or Ex is normal.
o Serial monitoring of hCG levels twice wkly
Expect <50% of its initial level & Reduction in the size
of adnexal mass within 7 days.
Thereafter wkly hCG & TVS until serum hCG levels
are <20iu/L
o Can discharge pt when serum hCG is <20iu/L,as the risk of rupture is very low.

Fx of ruptured ectopic

Yes No

Surgical conservative Mx surgical

Salpingectomy open Basal S. hCG level salpingotomy

Laparoscopic (open/ laparoscopic)

<1500iu/L <3000iu/L + fetus notviable

Expectant Mx medical Mx(methotrexate)

Miscarriages
Definition
Expulsion of conceptus via female genital tract prior to 24 wks of gestation.
Types
Threatened
Inevitable
Incomplete
Complete
Missed
*Septic abortions
 Threatened Inevitable Incomplete Complete Missed

Abd pain Minimal +++ ++ _ _

Bleeding + +++ ++ _ Brownish

vaginal
discharge
Size of uterus = POA =POA <POA <POA <POA

Os Closed Opened Opened Closed Closed

Viable fetus + Usually + _ _ _

(USS)

Aetiology as above

Ix- confirmed by USS

FBC
Blood grouping & Rh typing
hCG, Progesterone & other placental hormones limited use

Threatened miscarriage
Definition- painless vaginal bleeding occurring before 24 wks of pregnancy with no evidence of
fetal demise.
May resolve spontaneously in few days, and never to recur or,
May continue or,
Stop & start over several days or weeks.
Mx Reassurance
Bed rest
Anti D- if POA>12wks to Rh mothers

Inevitable /Incomplete miscarriage

Part of fetus is lost.
Heavy intermittent bleeding with spasmodic pain
Mx surgical evacuation ERPC
Medical induction less useful
Anti D prophylaxis

Missed miscarriage
Definition Gestational sac containing a dead embryo /fetus before 20 wks of POG without
clinical symptoms of expulsion.
Disappearance of pregnancy symptoms
Mx counsel the pt
 Heamodynamically stable/unstable

Stable unstable

Conservative Mx surgical evacuation

(Await spontaneous expel- 2wks)

TVS /USS

Products of conceptus

(+) (-)

Medical Mx Rh mother > 12wks

Misoprostol-PGE1-800g
Vaginally
Anti D prophylaxis
TVS

Folic acid
Products

Discharge
(+) (-)

Surgical evacuation
(ERPC)

Rh (-) mother irrespective of POA

Complete miacarriage
Mx counsel mother & the family
Expectant Mx - Rx of choice
If mother Rh (-) anti D prophylaxis + folic acid
Recurrent miscarriages
Definition loss of 3 consecutive pregnancies before viability (<24 wks of POA)

1% of fertile couples suffer from recurrent miscarriages

Aetiology- same as for spontaneous miscarriages

.
Mx Treat the cause

APS & other thrombophilic conditions combination therapy with Aspirin &
Heparin
Infections appropriate Rx
Uterine anomalies hysteroscopic correction
Cervical incompetence cervical cerclage

GTD H-mole
Abnormal proliferation of trophoblastic tissue
Spectrum of benign to malignant

Spectrum of GTD pre malignant- partial hydatidiform mole

Complete hydatidiform mole

Malignant Invasive mole (chorioadenoma destruens)

Placental site trophoblastic tumors
Gestational choriocarcinoma

Complete H-mole Partial H-mole

Fertilization of an ovum that has lost its Fertilization of an ovum by 2 sperms

chromosomes by 1 or 2 sperms 69 XXY - triploid
46XX / 46XY diploid
Both chromosomes of paternal origin
All villi cystic Partially cystic

No fetal parts Sometimes present

Diffuse trophoblastic hyperplasia Focal trophoblastic hyperplasia

Choriocarcinoma Rare CAs

More frequent

Risk factors as above

Clinical features Irregular vaginal bleeding
Hyperemesis
Excessive uterine enlargement
Early failed pregnancy
Rare presentations - Hyperthyroidism, early onset pre-eclampsia or abdominal distension
due to theca lutein cysts
Very rarely - Present with acute respiratory failure or neurological symptoms such as seizures
(due to metastatic disease.)
** H-mole is the only condition which shows distant mets with no malignancy.
(show cannon ball appearance on CXR )

Diagnosis USS Snow storm appearance definitive diagnosis - by histological confirmation

serum & urine hCG levels

Mx
Suction curettage - Method of choice - For complete molar pregnancies.
Method of choice for partial molar pregnancies except when the size of the
fetal parts deters the use of suction curettage (then medical evacuation can be used)
If the extrusion has begun-
Dilate the cervix & encourage to expel it.
IVI Oxytosin is given.
PG also can be given.
Before extrusion-
Suction evacuation histological confirmation
Can induce by Misoprostole or Mifeprostone
IVI Oxytosin/Ergometrine given to control bleeding
*** Medical induction has a risk of dissemination, thus better to avoid.

Methotrexate for non resolving cases

Histologically proven malignancies

Anti D prophylaxis complete mole Anti- D prophylaxis is not required, Because of poor
vascularisation of the chorionic villi and absence of the anti-D
antigen in complete mole
partial mole Anti D prophylaxis required

Follow up
Monitoring S. hCG level 2 wkly till back to normal, then monthly up to 1 yr.

** Normal hCGlevels for 2 yrs after evacuation of H-mole, the risk of chorio CA is non
Existent.
Advices to the pt
Should not get pregnant during the follow up period - (due to confusion in interpreting hCG level)
Next 6 months Incomplete mole
Next 1 yr Complete mole
Type of contraceptive method during follow up
OCP Contra indicated oestrogen stimulate growth of trophoblastic tissue.
Can use when hCG level return to normal.
IUCD & Depot avoided, as it give rise to irregular menstrual bleeding & cause a tic
confusion & IUCD has a risk of uterine perforation
Barrier method accepted method.

Choriocarcinoma
Most malignant end of the spectrum of disease
Majority (50-60%) secondary to a pre existing molar pregnancy
Rest either secondary to a normal pregnancy, ectopic pregnancy, or abortion

Fx of H-mole associated with a risk of transformation to chorio CA,

Larger molar pregnancy
Greater titre of hCG
Short POG at the time of
Presence of theca lutein cysts

Metastasis lungs mainly

Liver, kidney, brain, vertebral column & lower vagina rarely

Clinical Fx
Same as in H-mole, but exaggerated

Classified in to & risk, depending on certain risk factors

High risk cases
Pts > 40 yrs
Multiparous (>3)
CA secondary to a molar pregnancy
CA occurs >4 months after the antecedent pregnancy
Serum hCG level > 100,000mIU/ml at
Pts with blood group A & AB

Low risk cases

Pt <40 yrs
Low parity (<3)
CA occurs within 4 months after the antecedent pregnancy
Serum hCG level <40,00 mIU/ml at
Blood group O

Mx depends on whether she is high risk or low risk, the dosage of chemotherapy is decided accordingly
Can be completely Rxed (cure rate around 90%) by evacuation followed by appropriate chemotherapy
Single agent (methotrexate) or multi agent chemotherapy
Drugs used cisplatin
Cyclophosphamide
Actinomycin D

Require oncological referral

In older pts hysterectomy is performed followed by chemotherapy

Lifelong follow up is necessary

These pts can undergo a normal pregnancy subsequently under supervision