1、Hydatidiform Molar Pregnancy,Defined as proliferation and degeneration of the chorion A benign neoplasm of the chorion The embryo fails to develop in most cases Occurs in 1 of 2000 pregnancies More often in low socioeconomic groups with low protein diets More often is the younger or older mother,Sym
2、ptoms of a Molar Pregnancy,Uterus expands faster and reaches landmarks earlier More morning sickness Earlier signs of PIH Vaginal bleeding in the 4th month Discharge with grape-like vesicles,Treatment and nursing care with Molar Pregnancy,A d & c is done to evacuate the mole Follow-up care is very i
3、mportant Tends to be carcinogenicchoriocarcinoma Recommend no future pregnancies for at least a year Evaluate HCG levels closely Chest x-rays at interverals,Incompetent Cervix,Cervix dilates prematurely, painlessly, when the fetus is of sufficient weight to put pressure on the cervix. Signs/symptoms
4、:mucousy, pink dischargeROMOnset of contractionsBirth of the fetus,Treatment/Care -Incompetent Cervix Cervical circlage done between 4-6 months Earliest time maybe 14 weeks Success rate as good as 80 % Must be removed prior to the onset of labor,Abortion,Loss of a pregnancy during the first 20 weeks
5、 of pregnancy, at a time that the fetus cannot survive. Such a loss may be involuntary (a “spontaneous“ abortion), or it may be voluntary (“induced“ or “elective“ abortion). Miscarriage is the term used for spontaneous abortion, an unexpected 1st trimester pregnancy loss.,Categories of Abortions,The
6、se include: Threatened Inevitable Incomplete Complete Septic,Facts about abortion,Such losses are common, occurring in about one out of every 6 pregnancies. These losses are unpredictable and unpreventable. About 2/3 are caused by chromosome abnormalities. About 30% are caused by placental malformat
7、ions and are similarly not treatable. The remaining miscarriages are caused by miscellaneous factors but are not usually associated with: Minor trauma Intercourse Medication Too much activity,Following a miscarriage, the chance of having another miscarriage with the next pregnancy is about 1 in 6.,H
8、abitual abortion,Habitual abortion, recurrent miscarriage or recurrent pregnancy loss (RPL) is the occurrence of three or more pregnancies that end in miscarriage of the fetus, usually before 20 weeks of gestation. RPL affects about 0.34% of women who conceive.,Causes,Anatomical conditions: Uterine
9、conditions Cervical conditions Chromosomal disorders Endocrine disorders Immune factors Lifestyle factors Infection,Spontaneous,Spontaneous abortion (also known as miscarriage) is the expulsion of an embryo or fetus due to accidental trauma or natural causes before approximately the 22nd week of ges
10、tation; the definition by gestational age varies by country.Most miscarriages are due to incorrect replication of chromosomes; they can also be caused by environmental factors,Induced,A pregnancy can be intentionally aborted in many ways. The manner selected depends chiefly upon the gestational age
11、of the embryo or fetus, which increases in size as the pregnancy progresses. Specific procedures may also be selected due to legality, regional availability, and doctor-patient preference. Reasons for procuring induced abortions are typically characterized as either therapeutic or elective.,Induced
12、abortion,Therapeutic abortion when it is performed to: save the life of the pregnant woman preserve the womans physical or mental health terminate pregnancy that would result in a child born with a congenital disorder that would be fatal or associated with significant morbidity or selectively reduce
13、 the number of fetuses to lessen health risks associated with multiple pregnancy.,Induced abortion,An elective abortion: When it is performed at the request of the woman “for reasons other than maternal health or fetal disease.,Threatened Abortion,A threatened abortion means the woman has experience
14、d symptoms of bleeding or cramping. At least one-third of all pregnant women will experience these symptoms. Half will abort spontaneously. The other half , bleeding and crampingwill disappear and the remainder of the pregnancy will be normal. These women who go on to deliver their babies at full te
15、rm can be reassured that the bleeding in the first trimester will have no effect on the baby and that you expect a full-term, normal, healthy baby.,Threatened abortion (Features),History Mild vaginal bleeding. No abdominal pain or mild abdominal pain Examination Good general condition. The cervix is
16、 closed The uterus is usually the correct size for date U/S which is essential for the diagnosis Showed the presence of fetal heart activity,Threatened abortion (Management),Reassurance If fetal heart activity is present, 90% of cases will be progressed satisfactorily Advice: Decrease physical activ
17、ity (bed rest is of no therapeutic value) avoid intercourse Hormones i.e. Progesterone & hCG Which are used in the first trimester to support pregnancy, (but they are of no proven value) Anti- D: An adequate dose of anti-D should be given to all Rh ve,non-immunised patients, whose husbands are Rh +v
18、e ANC as high risk patients Because those patients are liable to late pregnancy complications such as APH and preterm labour .,Inevitable abortion,A condition in which: Vaginal bleeding has been profuse The cervix has become dilated Abortion will invetably occur.,Inevitable and incomplete abortions
19、(Features),History Heavy vaginal bleeding. with no passage of products conception (inevitable)with the passage of products of conception (incomplete abortion) Severe lower abdominal pain which follows the bleeding,Inevitable and incomplete abortions (Features),Examinations Poor general condition.The
20、 cervix is dilating and products of conception may be passing trough the os The uterus may be the correct size for date (inevitable abortion) or small for date (incomplete abortion) U/S Fetal heart activity may or may not present in inevitable abortion or retained products of conception ( RPOC ) in
21、incomplete abortion,Inevitable and incomplete abortions (management),CBC , blood grouping , XM 2 units of blood Resuscitation large IV line, fluids & blood transfusion Oxytoxic drugs Ergometrine 0.5 mg IM + Oxytocin infusion (20-40 units in 500 cc saline) Evacuation & curettage. Post-abortion manage
22、ment.,Complete Abortion,Complete abortion (Features),History Heavy vaginal bleeding which has been stopped.lower abdominal pain which follows the bleeding which has been stopped. Examination The cervix is closed U/S showed empty uterine cavity or PROP,Complete abortion (Management),- Evacuation & cu
23、rettage in the presence of RPOC. Post-abortion management.,Missed abortion,Retention of products for several weeks No increase in fundal height Absence of FHT Regressions of signs of pregnancy Loss of wight,Missed abortion (Features),Most of missed abortions are diagnosed accidentally during routine
24、 U/S in early pregnancy .In some cases there may be a history of : Episodes of mild vaginal bleeding Regression of early symptoms of pregnancy . Stop of fetal movements after 20 weeks gestation.Examination The uterus may be small for date,Missed abortion (Features),U/S (which is essential for diagno
25、sis ) diagnosed if two ultrasound ( T/V or T/A) at least 7days apart showed an embryo of 7 weeks gestation ( CRL 6mm in diameter and gestational sac 20 mm in diameter ) with no evidence of heart activity .,CBC , blood grouping Platelets count, to exclude the risk of DIC NB : DIC does not occur befor
26、e 5 weeks of missed abortion or IUFD and if occurred will be of mild grade,Missed abortion (Management),Options of treatment Conservative treatment: if left alone spontaneous expulsion will occur Surgical evacuation of the uterus; by D & C:Indicated in 1st trimester missed abortion Medical terminati
27、on of pregnancy: by Misoprostol (PGE1) Cytotec: Indicated in 1st & 2nd trimesters missed abortions. Cytotec vaginal ( is the best) or oral tab. 200 g, 2 tab/ 3 hrs/ up to 5 doses daily, which can be repeated next day if there is no response in the first day Subsequent surgical evacuation is needed i
28、n cases of RPOC The main side effects of cytotec are nausea, vomiting and fever. Post-abortion management.,Missed abortion (Management),It is due to an early death and resorption of the embryo with the persistence of the placental tissue It is diagnosed if two ultrasound ( T/V or T/A) at least 7 day
29、s apart showed after 7 weeks of gestation i.e. gestational sac 20mm , an empty gestational sac with no fetal echoes seen . It is treated in a similar way to missed abortion .,Anembryonic pregnancy (Blighted ovum),Septic abortion,Spontaneous or induced termination of a pregnancy in which the mothers
30、life may be threatened because of the invasion of germs into the endometrium, myometrium, and beyond. The woman requires immediate and intensive care Massive antibiotic therapy Evacuation of the uterus Emergency hysterectomy to prevent death from overwhelming infection and septic shock.,Haemorrhage
31、.Complication related to surgical evacuation ie E&C and D&C. Uterine perforation- which may lead to rupture uterus in the subsequent pregnancy. Cervical tear & excessive cervical dilatation which may lead to cervical incompetence. Infection which may lead to infertility & Ashermans syndrome. Excessi
32、ve curettage which may lead to AdenomyosisRh- iso immunisation if the anti D is not given or if the dose is inadequate . Psychological trauma .,Complications of abortion,Post - abortion management,In cases of incomplete, inevitable, complete, missed & septic abortions Support: from the husband, fami
33、ly& obstetric staff Anti D to all Rh ve, nonimmunised patients, whose husbands are Rh+veCounseling & explanation: Contraception (Hormonal, IUCD, Barrier) Should start immediately after abortion if the patient choose to wait , because ovulation can occur 14 days after abortion and so pregnancy can oc
34、cur before the expected next period .,Post - abortion management,Counseling & explanation: When can try again : Best to wait for 3 months before trying again . This time allow to regulate cycles and to know the LMP, to give folic acid, and to allow the patient to be in the best shape (physically and
35、 emotionally) for the next pregnancy Why has it happened In the fiIn the majority of cases there is no obvious cause In the first trimester abortion , the most common cause is fetal chromosomal abnormality,Post - abortion management,Counseling & explanation:Can it happen againAs the commonest cause
36、is the fetal chromosomal abnormality which is not a recurrent cause , so the chance of successful pregnancy next time in the absence of obvious cause is very high even after 2 or 3 abortionsNot to feel guilty as it is extremely unlikely that anything the patient did can cause abortion No evidence th
37、at intercourse in early pregnancy is harmful No evidence that bed rest will prevent it ,Recurrent abortion,Definition : Is defined as 3 or more consecutive spontaneous abortions It may presented clinically as any of other types of abortions . Types : Primary : All pregnancies have ended in loss Seco
38、ndary : One pregnancy or more has proceeded to viability(24 weeks gestation) with all others ending in loss Incidence : occurs in about 1% of women of reproductive age .,Recurrent abortion,CausesIdiopathic recurrent abortion, in about 50%, in which no cause can be found . The known causes include th
39、e followings : Chromosomal disorders: Fetal chromosomal abnormalities & structural abnormalities Parental balanced translocation Anatomical disorders: Cervical incompetence: congenital and aquired Uterine causes: submucous fibroids, uterine anomalies & Ashermans syndrome,Recurrent abortion,CausesMed
40、ical disorders: Endocrine disorders : diabetes , thyroid disorders , PCOS & corpus luteum insufficiency . Immunological disorders : Anticardiolipin syndrome & SLE. Thrombophilia: congenital deficiency of Protein C&S and antithrombin III, & presence of factor V leiden. Infections ToRCH - CMV may be a
41、 cause of recurrent abortion, but ToRH are not causes of recurrent abortion. Genital tract infection e.g Bacterial vaginosis Rh isoimmunization,Recurrent abortion,Diagnosis : History : Previous abortions : gestational age and place of abortions & fetal abnormalities. Medical history : DM , thyroid d
42、isorders, PCOS, autoimmune diseases & thrombophilia. Examination : General : weight , thyroid & hair distribution Pelvic: cervix ( length & dilatation ) and uterine size.,Recurrent abortion,Diagnosis : investigations : Investigations for medical disorders: Blood grouping & indirect Coombs test in Rh
43、 ve women Endocrinal screening: Blood sugar , TFT & LH /FSH ratio Immunological screening: Anti anticardiolipine antibodies & lupus inhibitor. Thrombophilia screening: Protein C & S, antithrombin III levels, factor V leiden, APTT and PT. Infection screening High vaginal & cervical swabs ToRCH profil
44、e ( which scientifically is not necessary ),Recurrent abortion,Diagnosis : investigations : Investigations for anatomical disorders: TV/US: fibroids, cervical incompetence & PCOS. Hystroscopy or HSG, fibroids, cervical incompetence, uterine anomalies & Ashermans syndrome Investigations for chromosom
45、al disorders: Parental karyotyping: Parental balanced translocation. Fetal karyotyping: Fetal chromosomal anomalies.,Recurrent abortion,Management: in idiopathic recurrent abortion. With support and good antenatal care , the chance of successful spontaneous pregnancy is about 60-70% Support : from h
46、usband, family & obstetric staff. Advice : stop smoking & alcohol intake, decrease physical activity Tender loving care Drug therapy Progesterone & hCG: start from the luteal phase & up to 12 weeks. Low dose aspirin ( 75 mg/day ) start from the diagnosis of pregnancy & up to 37 weeks LMWH (20-40 mg/
47、day) start from the diagnosis of fetal heart activity & up to 37 ws,Recurrent abortion,Management: In the presence of a cause treatment is directed to control the cause Endocrine disorders Control DM and thyroid disorders before pregnancyOvulation induction drugs , ovarian drilling or IVF in PCOS.Pr
48、ogesterone or hCG in corpus luteum insufficiency . :In anti-cardiolipin syndrome: Low dose aspirin ( 75 mg/day ) & prednisilone ( 20-30 mg / day), starting when pregnancy is diagnosed till 37 weeks. These drugs are not teratogenic.,Recurrent abortion,Management: In thrombophilia: Low dose aspirin (
49、75 mg/day) starting when pregnancy is diagnosed and low molecular weight heparin ie LMWH ( 20-40 mg/day) starting when fetal heart activity diagnosed & to continue both till 37 weeks . In uterine disorders Cervical cerclage in cervical incompetence, best time at the 14 weeks of pregnancy. Myomectomy
50、 in submucus fibroid, excision of uterine septum in septate & subseptate uterus & adhesolysis in Ashermans syndrome.,Recurrent abortion,Management: In infection: treatment of the genital tract infection. In Rh isoimmunization: Repeated intrauterine transfusion In parental balanced translocation Explain the risk of fetal chromosomal disorders ( about 30% ) Encourage to try again or adoption.,
