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    Early Pregnancy Complication

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    Hizami Norddin
    Early pregnancy complications can include miscarriage, ectopic pregnancy, molar pregnancy, and nausea/vomiting. Miscarriage is the most common, occurring in 8-20% of known pregnancies before 13 weeks usually due to chromosomal abnormalities. Ectopic pregnancies implant outside the uterus, most commonly in the fallopian tubes. Molar pregnancies are abnormal fertilizations that result in gestational trophoblastic tumors. Nausea and vomiting are also common in early pregnancy and may require medical treatment or hospitalization for dehydration.

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    Early Pregnancy Complication

    Uploaded by

    Hizami Norddin
    50 views31 pages
    Early pregnancy complications can include miscarriage, ectopic pregnancy, molar pregnancy, and nausea/vomiting. Miscarriage is the most common, occurring in 8-20% of known pregnancies before 13 weeks usually due to chromosomal abnormalities. Ectopic pregnancies implant outside the uterus, most commonly in the fallopian tubes. Molar pregnancies are abnormal fertilizations that result in gestational trophoblastic tumors. Nausea and vomiting are also common in early pregnancy and may require medical treatment or hospitalization for dehydration.

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    Early pregnancy complication

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    Early pregnancy complications can include miscarriage, ectopic pregnancy, molar pregnancy, and nausea/vomiting. Miscarriage is the most common, occurring in 8-20% of known pregnancies before 13 weeks usually due to chromosomal abnormalities. Ectopic pregnancies implant outside the uterus, most commonly in the fallopian tubes. Molar pregnancies are abnormal fertilizations that result in gestational trophoblastic tumors. Nausea and vomiting are also common in early pregnancy and may require medical treatment or hospitalization for dehydration.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    50 views31 pages

    Early Pregnancy Complication

    Uploaded by

    Hizami Norddin
    Early pregnancy complications can include miscarriage, ectopic pregnancy, molar pregnancy, and nausea/vomiting. Miscarriage is the most common, occurring in 8-20% of known pregnancies before 13 weeks usually due to chromosomal abnormalities. Ectopic pregnancies implant outside the uterus, most commonly in the fallopian tubes. Molar pregnancies are abnormal fertilizations that result in gestational trophoblastic tumors. Nausea and vomiting are also common in early pregnancy and may require medical treatment or hospitalization for dehydration.

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    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 31

    Early pregnancy

    complication
    Chong Cai Wen
    INTRODUCTION
    • Early pregnancy defined as pregnancy less than 13 weeks.
    • Common complaint in early pregnancy
    • Per vaginal bleeding
    • Abdominal pain
    • Nausea vomiting
    CONTENT
    1. Miscarriage
    2. Ectopic pregnancy
    3. Molar pregnancy
    4. Nausea and vomiting
    MISCARRIAGE
    Introduction
    • In Malaysia, a fetus weighting less than 500g or less than 22 weeks of
    gestation is considered as miscarriage
    • Commonest complication of early pregnancy
    • Effect 8-20% of known pregnant women
    • Usually occur between 9th to 13th weeks

    PORTAL MyHEALTH. 2021. Miscarriage - PORTAL MyHEALTH. [online] Available


    at: <http://www.myhealth.gov.my/en/miscarriage/> [Accessed 9 November
    2021].
    Causes
    Fetal Factors Maternal Factors
    • Chromosomal abnormality • Maternal medical condition
    • Advanced maternal age
    • Previous history of miscarriage
    • Smoking
    • Alcohol
    • Trauma
    • Infection
    • Physical stress
    Types of miscarriage
    Threatened Min PV bleed Slight or no Cervix closed FH +ve on -95% will progress
    miscarriage abdominal pain ultrasound well
    - T Duphaston
    40mg stat, 10mg
    TDS
    Missed May have PV No ssx of Cervix closed FH absent on Fetus not viable
    miscarriage bleed miscarriage ultrasound

    Inevitable Profuse PV bleed Significant lower Cervix opened Fetal may or Fetal usually end of
    miscarriage abdominal pain may not alive expulse

    Incomplete Profuse PV bleed Significant lower Cervix opened Some of the Pt may go into
    miscarriage abdominal pain fetal part may hypovolemic shock
    seen, absent FH if remaining not
    evacuate
    Complete Present of PV Pain reduce after Cervix may Ultrasound
    miscarriage bleed and passing POC passed out initially open show empty
    out POC then closed uterus
    after
    Treatment
    1. Conservative
    - If miscarriage occur before 13 weeks, and patient is stable, she may
    choose this option with given appt after 2 weeks
    - Successful in 50 out of 100 women
    - Fetus may expel in 1 to 2 weeks
    - UPT to repeat in 1 week
    - An ultrasound should be performed to rule out retained product of
    conception
    2. Medical management
    - Cervagerm (Gemeprost)- prostaglandin E1 analogue
    - Soften and dilate cervix, induce uterine contraction
    - 1mg 3 hourly, up to 5mg for 1 course
    - Misoprostol (oral/ vaginal), mifeprestone + misoprostol regime

    3. Surgical management
    - For patient who has heavy PV bleeding, sign and symptom of infection
    - May proceed with evacuation of POC under GA
    - Procedure preceded by priming of cervix with prostaglandin or
    hydrophilic/ osmotic dilator
    Advice to patient
    • Pt advice not to insert foreign object into vaginal for 2 weeks, e.g.
    tampon
    • Wait 2 to 3 month before trying to get pregnant again
    • No contraindication for contraception after miscarriage
    • Expecting PV bleed for 1-2 weeks
    • Advice for T Folic Acid 5mg OD 3 month prior to conception
    ECTOPIC PREGNANCY
    Definition
    • Implantation of conception outside uterine cavity
    • Common location
    • Fallopian tube (95%)
    • Ampulla (74%)
    • Isthmus (12%)
    • Fimbria end of tube (12%)
    • Interstitial (2%)
    • Ovaries (3%)
    • Peritoneal cavity (1%)
    Risk factor
    • Tubal disease, pelvic infection, e.g. Chlamydia
    • Previous ectopic pregnancy
    • Previous tubal pregnancy
    • Subfertility
    • Use of IUD
    Clinical presentation
    • PV bleeding
    • Abdominal pain localized to iliac fossa
    • Shoulder tip pain- irritation of diaphragm due to free blood in
    abdominal cavity
    • Sign and symptoms of anemia/ Hypovolemic shock

    • Bimanual examination:
    • Cervical excitation
    • tenderness in fornixes (peritoneal irritation)
    Investigation
    • Ultrasound
    • Absent of gestational sac in uterus
    • Present of adnexal mass which
    • Move separate with ovary
    • Comprising gestational sac/yolk sac/fetal pole
    • Collection of fluid in uterine cavity- pseudo sac
    • Peritoneal free fluid

    • Beta hCG
    • Taken at 0H and 48H
    • If increase >63%, possible intrauterine pregnancy
    • If decrease <50%, possible failed pregnancy
    Management
    1. Expectant
    • Offer for those who are
    • Clinically stable and pain free
    • Tubal pregnancy less than 35mm with no visible fetal heart on TVS
    • B hCG <1000IU/L

    • hCG level need to repeat on D2, 4 and 7


    • If drop by 15%, repeat weekly until negative
    • If not drop by 15%, review back the patient
    2. Medical management
    • Methotrexate- folic acid antagonist that interferes with DNA
    synthesis in rapidly dividing cells like the trophoblastic tissue
    • Can offer if patient:
    • Clinically stable, no significant pain
    • Unruptured ectopic pregnancy, adnexal mass <35mm without fetal heart
    • hCG level <1500IU/L
    • No intrauterine pregnancy
    • Pt need to take hCG level on D4 and 7, then weekly until negative. If hCG level
    did not drop, further management required
    3. Surgical management
    • For those:
    • Hemodynamically unstable, with severe pain
    • Ectopic pregnancy with >35mm, or ruptured, or present of fetal heart
    • hCG level >5000IU/L

    • Offer laparoscopic salpingectomy or salpingotomy


    • Salpingotomy done for those who have risk of infertility, e.g. contralateral tube damage

    • Pt done salpingotomy- repeat hCG at D7 post opt, then weekly until negative
    • Pt done salpingectomy- advice for UPT after 3 week
    Anti D prophylaxis
    • For all rhesus negative women, offer a dose of 250IU anti D rhesus
    prophylaxis

    • Offer for those


    • Underwent surgical procedure for ectopic pregnancy
    • Incomplete miscarriage, inevitable miscarriage, missed miscarriage
    • Partial mole
    MOLAR PREGNANCY
    Introduction

    • Tumor arise from abnormal fertilization of oocyte


    • Can be non invasive hydatidiform mole and invasive gestational
    trophoblastic neoplasia
    Types of hydatidiform mole
    • Complete mole
    • Duplication of 2 haploid sperm
    • Diffuse hydatidiform swelling of chorionic villi
    and trophoblastic hyperplasia

    • Partial mole
    • Triploids with extra set of chromosome from
    paternal
    • May have fetal or embryonic tissue
    • Focal hydatidiform swelling of chorionic villi
    and trophoblastic hyperplasia
    Clinical feature
    • Abnormal PV bleed – prune juice
    • Hyperemesis gravidarum
    • Early onset of Pre-eclampsia
    • Hyperthyroidism
    • Uterine size larger than date

    • Snowstorm appearance on USG


    • May mimic missed miscarriage in partial mole

    • Very high level of beta hCG


    Management
    • Suction and curettage is the mainstay of treatment
    • All specimen should sent for HPE
    • Definite diagnostic test for molar pregnancy is HPE

    • All women with persistent high hCG level after exclude ectopic
    pregnancy should suspect GTD (gestational trophoblastic disease)
    • All women having persistent PV bleed after a pregnancy should
    suspect GTN (gestational trophoblastic neoplasm)
    Follow up
    • Weekly hCG until negative, then monthly for 6 month
    • complete molar pregnancy,
    • if hCG has reverted to normal within 56 days of the pregnancy event then follow-up will
    be for 6 months from the date of uterine removal.
    • If hCG has not reverted to normal within 56 days of the pregnancy event then follow-up
    will be for 6 months from normalization of the hCG level.

    • partial molar pregnancy is concluded once the hCG has returned to normal on
    two samples, at least 4 weeks apart

    • Suspect GTN if persistent rise/ plateauing/ secondary rise of hCG


    NAUSEA AND VOMITING
    Introduction
    • Nausea and vomiting of pregnancy
    • Diagnosed in 1st trimester of pregnancy with all other cause of nausea and vomiting excluded

    • Hyperemesis gravidarum
    • >5% pre-pregnancy weight loss
    • Electrolyte imbalance
    • Dehydration

    Commonly happened between 4th to 7th week, resolved by 12-14 weeks


    Cause is unknown, maybe due to rise in hCG
    Think of molar pregnancy, multiple pregnancy, GIT/UTI infection
    Severity of nausea and vomiting in pregnancy determine by PUQE score
    Management
    • Antiemetic- metoclopramide, prochlorperazine
    • Encourage small, frequent diet
    • For IVD if patient dehydrate and unable to tolerate orally, Normal
    saline with electrolyte supplement is preferred
    • Stop iron medication
    • Avoid strong odor food
    • Admit if
    • Pt unable to tolerate orally
    • Ketonuria
    • Weight loss >5% despite oral antiemetic
    • PUQE >13

    • Consider giving thiamine if patient having severe vomiting to prevent


    Wernicke encephalopathy
    • Thiamine should be given before administered IV D5%
    • Correct any electrolyte imbalance

    • Criteria to discharge
    • No ketone in urine
    • Tolerating oral fluid and food without vomiting
    • Discharge with oral antiemetic
    Resources
    • PORTAL MyHEALTH. 2021. Reproductive Health Archives - PORTAL MyHEALTH. [online] Available
    at: <http://www.myhealth.gov.my/en/category/prime-years/prime-years-reproductive-health
    • Webster, K., Eadon, H., Fishburn, S. and Kumar, G., 2019. Ectopic pregnancy and miscarriage:
    diagnosis and initial management: summary of updated NICE guidance. BMJ, p.l6283.
    • No, G.T.G., 2016. The management of nausea and vomiting of pregnancy and hyperemesis
    gravidarum.
    • BJOG: An International Journal of Obstetrics & Gynaecology, 2020. Management of Gestational
    Trophoblastic Disease. 128(3).

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