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Pregnancy Complications…

Pregnancy Complications…. Hydatidiform Mole. Moore LE, Ware D. Hydatidiform Mole. eMedicine. Retrieved 31 January 2006, from www.emedicine.com/med/topic1047.htm

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Pregnancy Complications…

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  1. Pregnancy Complications…

  2. Hydatidiform Mole Moore LE, Ware D. Hydatidiform Mole. eMedicine. Retrieved 31 January 2006, from www.emedicine.com/med/topic1047.htm Viera AJ, Clenney TL, Shenenberger DW. Vaginal Bleeding at 16 Weeks. [Electronic version] J Am Fam Phys 1999;59(3), Retrieved 16 November 2005, from www.aafp.org/afp/990201ap/photo.html

  3. Hydatidiform Mole Complete/Classic Mole • No identifiable fetal tissue Partial Mole • Some recognizable fetal or embryonic tissue http://www-medlib.med.utah.edu/WebPath/jpeg2/PLAC062.jpg

  4. Hydatidiform Moles • 1/1000-1500 pregnancies Risk factors • Teenagers • Women over 35(35+: 2x risk, 40+: 7x risk) • Previous miscarriage *Only 1% of subsequent conceptions result in another molar pregnancy

  5. Complete Hydatidiform Mole Signs & Symptoms • Vaginal bleeding (97%) *most common presenting symptom • Hyperemesis • due to elevated HCG • Hyperthyroidism (7%) • may present with tachycardia, tremor, warm skin • Preeclampsia (27%) • Large for date uterus

  6. Incomplete Hydatidiform Mole Signs & Symptoms (similar to incomplete or missed abortion) • Vaginal bleeding • Absence of fetal heart tones • Uterine enlargement and preeclampsia • only 3% of patients • Hyperemesis and hyperthyroidism are rare

  7. Hydatidiform Mole Diagnosis • Ultrasound • vesicular / “snowstorm” pattern • HCG levels • Elevated compared to a normal pregnancy of similar gestational age www.obgyn.net/us/ _uploads/hmole2.jpg

  8. Hydatidiform Mole Differential Diagnosis • Painless vaginal bleeding: • Placenta previa • Missed abortion Key Differential? Absence of identifiable fetal parts on ultrasound

  9. Hydatidiform Mole Treatment • Evacuation and curettage OR • Hysterectomy Must consider: • Age of the patient • Desire to preserve fertility

  10. Hydatidiform Mole • Potential precursor to gestational trophoblastic disease and choriocarcinoma • 20% develop a malignancy • metastasis occurs in 4% of complete moles • Choriocarcinoma may metastasize to: • Lungs • Vagina • Brain • Liver • Kidney

  11. Hydatidiform Mole Follow-up • bHCG* tested regularly • monthly for 6-12 months *any rise in levels should prompt a chest radiograph and pelvic examination • Contraception • must be used during the entire follow-up period • at least 1 year

  12. Ectopic Pregnancy Lozeau A, Potter B. Diagnosis and Management of Ectopic Pregnancy. Am Fam Physician 2005;72(9):1707-1714.

  13. Ectopic Pregnancy • Any pregnancy that occurs outside of the uterine cavity • Tubal • Ampulla (55%) • Isthmus (25%) • Fimbria (17%) • Cervical • Ovarian • Abdominal 97% 3%

  14. Ectopic Pregnacy • 1.9% of reported pregnancies • Leading cause of pregnancy-related death in the first trimester • Ruptured ectopic pregnancy accounts for 10-15% of all maternal deaths

  15. Ectopic Pregnancy Risk Factors • Previous tubal surgery • Previous ectopic pregnancy • In utero DES exposure • Previous genital infections • Infertility • Current smoking • Previous IUD use HIGH

  16. Ectopic Pregnancy Most common presentation: • Woman of reproductive age • Abdominal pain • Vaginal bleeding • Approx 7 weeks after amenorrhea *Nonspecific… dDx is important

  17. Ectopic Pregnancy Differential Diagnosis • Acute appendicitis • Miscarriage • Ovarian torsion • Pelvic inflammatory disease • Ruptured corpus luteum cyst or follicle • Tubo-ovarian abcess • Urinary calculi

  18. Ectopic Pregnancy Exam Findings • Normal or slightly enlarged uterus • Vaginal bleeding • Pelvic pain with manipulation of the cervix • Palpable adnexal mass (fallopian tube)

  19. Ectopic Pregnancy Suspect Rupture If… • Significant abdominal tenderness *Especially if accompanied by: • Hypotension • Abdominal guarding • Rebound tenderness

  20. Ectopic Pregnancy Diagnositc Tests • Ultrasound (*test of choice) • No intrauterine gestational sac • bHCG • Do not increase appropriately • Urine pregnancy test • Pregnant / not pregnant • Progesterone level (less reliable)

  21. Ectopic Pregnancy Treatment • Expectant management • Monitor progress • Medical treatment • Methotrexate – folic acid antagonist • Disrupts rapidly dividing trophoblastic cells • Surgery • Laparoscopy with salpingostomy, without fallopian tube removal

  22. Ectopic Pregnancy Long Term… • ~30% have later difficulty conceiving • No difference between treatment options • 5-20% rate of recurrence • 32% risk of recurrence if she’s had 2 consecutive ectopic pregnancies

  23. Spontaneous Abortion Griebel CP, Halvorsen J, Golemon, TB. Management of Spontaneous Abortion. Am Fam Physician 2005; 72(7):1243-50.

  24. Spontaneous Abortion aka “miscarriage”, “spontaneous pregnacy loss”, “early pregnancy failure” • Pregnancy loss at less than 20 weeks’ gestation

  25. Definitions • Threatened abortion • A pregnancy complicated by bleeding before 20 weeks’ gestation • Inevitable abortion • The cervix has dilated, but the products of conception have not been expelled

  26. Definitions • Complete abortion • All products of conception have been passed without need for surgical or medical intervention • Incomplete abortion • Some, but not all, of the products of conception have been passed; retained products may be part of the fetus, placenta, or membranes • Missed abortion • A pregnancy in which there is a fetal demise (usually for a number of weeks) but no uterine activity to expel the products of conception

  27. Definitions • Septic abortion • A spontaneous abortion that is complicated by intrauterine infection • Recurrent spontaneous abortion • Three (3) or more consecutive pregnancy losses

  28. Spontaneous Abortion Etiology • Chromosomal abnormality • 49% of spontaneous abortions *most are random events NOTE: • Stress • Marijuana use • Sexual activity Do NOT increase risk

  29. Advanced maternal age Alcohol use Anesthetic gas use (nitrous oxide) Caffeine use (heavy) Chronic maternal diseases poorly controlled diabetes celiac disease autoimmune diseases Cigarette smoking Cocaine use Conception within 3-6 months after delivery IUD use Maternal infections Bacterial vaginosis TORCH STD’s Medications Multiple previous elective abortions Previous spontaneaous abortions Toxins Uterine abnormalities Spontaneous Abortion Risk Factors

  30. Spontaneous Abortion • Up to 20% of recognized pregnancies • ~30% actual miscarriage rate • Often mistaken for late onset of menses • ~50% of pregnancies complicated by bleeding before 20 weeks’ gestation will end in spontaneous abortion • dDx?

  31. Differential Diagnosis:First Trimester Vaginal Bleeding • Idiopathic bleeding in a viable pregnancy • Ectopic pregnancy • Molar pregnancy • Spontaneous abortion • Subchorionic hemorrhage • Infection of the vagina or cervix • Cervical abnormalities • Malignancy, polyps, trauma • Vaginal trauma

  32. Spontaneous Abortion Diagnosis • HCG levels • Progesterone levels • Ultrasound • Status of the pregnancy • Intrauterine? Ectopic? • Exam: dilated cervix ~> inevitable abortion *the risk for spontaneous abortion decreases from 50% to 3% when a fetal heartbeat is identified on ultrasound labs

  33. Abortion? or not?

  34. Spontaneous Abortion Management • Surgical evacuation (D&C) • Patient is unstable • Heavy bleeding • Septic abortion • Patient choice • Medical therapy • Missed spontaneous abortion • Expectant management • Completed spontaneous abortion • Incomplete spontaneous abortion • No need for surgical intervention 80-95% of the time

  35. Spontaneous Abortion Considerations… • Feelings of guilt • Grieving process • Anxiety & depression counseling www.compassionatefriends.org www.nationalshareoffice.com

  36. Spontaneous Abortion - Tips • Acknowledge and attempt to dispel guilt • Acknowledge and legitimize grief • Assess level of grief and adjust counseling accordingly • Counsel how to tell family and friends of the miscarriage • Include the patient’s partner in psychologic care • Provide comfort, empathy, and ongoing support • Reassure about the future • Warn about the “anniversary phenomenon”

  37. Placenta Previa Ko P, Yoon Y. Placenta Previa. eMedicine. Retrieved 5 February 2006 from www.emedicine.com/emerg/topic427.htm

  38. Placenta Previa • Implantation of the placenta over or near the internal os of the cervix • Vaginal bleeding in the 2nd and 3rd trimesters • 5/1,000 deliveries • Maternal mortality rate of 0.03%

  39. Placenta Previa • Total placenta previa • internal os is completely covered by the placenta • Partial placenta previa • internal os is partially covered by the placenta • self-correct? uterus enlarges, placental site moves cephalad • Marginal placenta previa • placenta is at the margin of the internal os • Low-lying placenta previa • placenta is implanted in the lower uterine segment • edge of the placenta is near the internal os but does not reach it

  40. Placenta Previa Risk Factors • Prior previa • Multiparity • Multiple gestations • Advanced maternal age • Previous cesarean delivery • Prior induced abortion • Smoking

  41. History Vaginal bleeding Bright red and painless (recurrent) Occurs on average at 27-32 weeks' gestation Contractions may or may not occur simultaneously with the bleeding Exam Findings Profuse hemorrhage Hypotension Tachycardia Soft and nontender uterus Normal fetal heart tones (usually) Placenta Previa

  42. Placenta Previa Differentials • Abruptio Placenta • Disseminated Intravascular Coagulation • Pregnancy, Delivery • Vasa previa • Infection • Vaginal bleeding • Lower genital tract lesions • Bloody show

  43. Placenta Previa Diagnosis • Ultrasound Management • <37 weeks without hemorrhage • expectant management • Hemorrhage or >37 weeks and in labor • delivery • C-section • trial of labor may be considered for anterior marginal previa

  44. Abruptio Placentae Gaufberg SV. Abruptio Placentae. eMedicine. Retrieved 5 February 2006 from www.emedicine.com/emerg/topic12.htm

  45. Abruptio Placentae • Separation of the normally located placenta after the 20th week of gestation (prior to birth) • 1% of all pregnancies • Results in compromised blood supply to the fetus • Severity of fetal distress correlates with the degree of placental separation

  46. Abruptio Placentae Clinical presentation • Vaginal bleeding (80%) • Abdominal or back pain and uterine tenderness (70%) • Fetal distress (60%) • Abnormal uterine contractions (35%) • Idiopathic premature labor (25%) • Fetal death (15%)

  47. Abruptio Placentae Diagnosis • Severe uterine pain and tenderness • Mild vaginal bleeding • Hypertension (HTN) • Difficult to identify on ultrasound • Can help differentiate from other causes of bleeding (i.e. placenta previa)

  48. Abruptio Placentae (Class 0-3) Class 0 • Asymptomatic • Diagnosis is made retrospectively • organized blood clot or a depressed area on a delivered placenta

  49. Abruptio Placentae (Class 0-3) Class 1 • Mild • ~48% of all cases • Characteristics : • No vaginal bleeding to mild vaginal bleeding • Slightly tender uterus • Normal maternal BP and heart rate • No coagulopathy • No fetal distress

  50. Abruptio Placentae (Class 0-3) Class 2 • Moderate • ~27% of all cases • Characteristics: • Vaginal bleeding: none to moderate • Moderate-to-severe uterine tenderness with possible tetanic contractions • Maternal tachycardia with orthostatic changes in BP and heart rate • Fetal distress • Hypofibrinogenemia (ie, 50-250 mg/dL)

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