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EARLY PREGNANCY COMPLICATIONS

EARLY PREGNANCY COMPLICATIONS. AKINNAGBE A. FERNANDEZ NATIONAL HOSPITAL, ABUJA. Abortion. Spontaneous abortion. Induced abortion. Abortion. Defined as delivery occurring before the 28th completed week of gestation Fetus weighing less than 5 00g

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EARLY PREGNANCY COMPLICATIONS

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  1. EARLY PREGNANCY COMPLICATIONS AKINNAGBE A. FERNANDEZ NATIONAL HOSPITAL, ABUJA

  2. Abortion Spontaneous abortion Induced abortion

  3. Abortion • Defined as delivery occurring before the 28th completed week of gestation • Fetus weighing less than 500g • US ( before the 20th completed week of gestation) • Early abortion and late abortion • 15% of clinically evident pregnancies • 80% of abortions prior to 12 weeks’ gestation

  4. Etiology • Abnormal karyotype: 50% • Maternal factors: infection (TORCH) endocrine factors immunologic factors maternal systemic disease anatomic defects trauma • Toxic factors

  5. anatomic defects

  6. Pathology • Hemorrhage into the decidua basalis • Necrosis and inflammation • Uterine contractions and cervical dilatation • Expulsion of most or all of the products of conception

  7. Clinical Findings Amenorrhea Bleeding Pain

  8. Clinical Findings Threatened Abortion Without cervical dilatation Without extrusion of products of conception Inevitable Abortion Cervical dilatation Without extrusion of products of conception

  9. Clinical Findings Bleeding severe Incomplete Abortion Expulsion of some, but not all, of the products of conception Complete Abortion Expulsion of all of the products of conception

  10. Clinical Findings Missed Abortion Embryo or fetus death, products of conception in utero Pain Septic Abortion Infection of the uterus

  11. Clinical Findings Habitual Abortion ≥three times abortion

  12. Laboratory Findings Gestational sac and viable embryo with heart motion Ultrasonography Pregnancy tests HCG Blood count Anemic

  13. Complication Life threatening Severe hemorrhage Infection Intrauterine synechia Perforation

  14. Diagnosis Medical history Physical examination ? Accessory examination

  15. Threatened Abortion Inevitable Incomplete Missed

  16. Treatment Threatened Abortion Bed rest Forbid sexual life Progesterone

  17. Treatment pathological examination D&C/MVA InevitableAbortion Oxytocin/misoprostol Ultrasound Antibiotics

  18. Treatment D&C/MVA Promptly IncompleteAbortion Blood type and cross-match Fluid infusion Antibiotics

  19. Treatment Products of conception Examine Complete Abortion Ultrasound Bleeding

  20. Treatment DIC Missed Abortion D&C/MVA Second Misoprostol

  21. Treatment Genetic error Anatomic defect Hormonal abnormalities Infection Systemic disease Immunologic factors Habitual Abortion Cause Cervical cerclage Progesterone

  22. Treatment Antibiotics Septic Abortion D&C/MVA Cervical cultures

  23. Ectopic pregnancy

  24. Definition A fertilized ovum implants in an area other than the endometrial lining of the uterus.

  25. Animation of intrauterine implantation

  26. Animation of ectopic implantation

  27. Sites of ectopic pregnancy >95% ectopic pregs in fallopian tubes 70% ampulla 12% isthmic 11.1% fimbrial 3.2% ovarian 2.4% interstitial 1.3% abdominal

  28. Etiology • Tubal Factors (salpingitis, previous tubal surgery) • Zygote Abnormalities (chromosomal abnormalities) • Ovarian Factors (ovum into contralateral tube) • Exogenous Hormone (oral contraceptives) • Other Factors (endometriosis, IUD)

  29. Pathology • Lackage of resistance to invasion by the trophoblast • Abdominal pregnancy -1:15000 pregnancies • Enlarged uterus and endometrium changes

  30. Termination of the pregnancy Abortion Rupture

  31. Temination of the pregnancy • Tubal:abortion or missed abortion • Interstitial,Angular,Cornual:rupture into the uterine cavity,the broad ligament or the peritoneal cavity. • Cervical:rupture into the cervical canal • Abdominal:rupture into the peritoneal cavity,into the retroperitoneal space • Ovarian:rupture into the peritoneal cavity

  32. Clinical Findings • Symptoms of early pregnancy (amenorrhea, breast tenderness, and nausea) • Bleeding (usually spotting) • Diffuse lower abdominal pain • Over 15% of ectopic pregnant as surgical emergencies.

  33. Symptoms Secondary amenorrhea (68%) Pain • Pelvic or lower abdominal pain (99%) • Generalized pain (44%) • Unilateral lower abdominal pain (33%) • Subdiaphragmatic pain or sharp shoulder pain (22%) Abnormal uterine bleeding (75%) Syncope (37%)

  34. Signs • Abdominal tenderness (80%) • Adnexal tenderness (75%) • Adnexal mass(a unilateral adnexal mass:53%) • Uterine changes (normal size:71%,6-8 weeks’ size:26%, 9-12 weeks’ size:3%) • Fever (only about 2% of patients)

  35. Laboratory Findings • Pregnancy tests (postive-82.5%) • Hematocrit • White blood cell count • A negative test does not rule out an ectopic gestation

  36. Special Examinations • Utrasonically scanning • Culdocentesis • Dilatation and curettage • Laparoscopy • Exploratory laparotomy

  37. Differential Diagnosis • Appendicitis • Salpingitis • Ruptured corpus luteum cyst • Uterine abortion • Twisted ovarian cyst • Urinary tract disease • Degenerating leiomyomas

  38. Essentials of Diagnosis • Amenorrhea followed by irregular vaginal bleeding • Adnexal tenderness or mass • Ultrasonographic evidence of adnexal mass and no intrauterine gestation • Positive ß-hCG

  39. Complications • About I in 1000 ectopic pregnancies result in maternal death • Untreated or mistreated ruptured ectopic tubal pregnancy 8-12% of all materal deaths • The majority of these deaths are preventable Death

  40. Complications • Chronic salpingitis • Infertility or sterility • Intestinal obstruction may develop after hemoperitoneum and peritonitis Tubal damage

  41. Treatment • Emergency Treatment Immediate surgery,anti-shock(warm,oxygen) • Surgical treatment laparoscopic techniques • Medical treatmemt-MTX • Supportive treatment antibiotic,iron therapy, a high-proteindiet

  42. Salpingectomy

  43. Indications for Conservative Drug Therapy • No signs of active intra-abdominal bleeding • Diameter of mass ＜3cm • Serum ß-hCG ＜2000U/L • No embryonic blood vessle pounding • No contraindication for MTX application • Normal liver and kidney function • Normal RBC count

  44. Prognosis • Another tubal pregnancy will occur in 10-20% of patients treated • Infertility develops in approximately 50% of patients

  45. Hyperemesis Gravidarum

  46. Prolonged and severe nausea/ vomiting associated with dehydration, weight loss, or electrolyte disturbances when pregnancy Definition

  47. Etiology • Unknown • Hormonal, neurologic, metabolic, toxic, and psychosocial factors (underlying emotional disorder) • Degree of biochemical hyperthyroidismh • The level of beta-HCGlevel o

  48. Clinical Findings • Severe nausea, Waste Away • Ketonuria, Increased urine specific gravity • Elevated hematocrit and BUN level • Hyponatremia,Hypokalemia,Hypochloremia • Metabolic acidosis • Wernicke-Korsakoff • Deficiency of VitaminK

  49. Diagnosis and Differential Diagnosis • Urine • Blood • Serum Beta-HCG (Molar pregnancy) • Thyroid function • Ultrasound • EKG • Fundus oculi

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