Hydatidiform Molar Pregnancy

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Hydatidiform Molar Pregnancy
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• 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

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Symptoms 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

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Treatment and nursing care with Molar Pregnancy

• A d c is done to evacuate the mole
• Follow-up care is very important
• Tends to be carcinogenicchoriocarcinoma
• Recommend no future pregnancies for at least a
  year
• Evaluate HCG levels closely
• Chest x-rays at interverals

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Incompetent Cervix

• Cervix dilates prematurely, painlessly, when the
  fetus is of sufficient weight to put pressure on
  the cervix.
• Signs/symptoms
• mucousy, pink discharge
• ROM
• Onset of contractions
• Birth of the fetus

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• 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

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Abortion

• Loss of a pregnancy during the first 20 weeks 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.

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Categories of Abortions

• These include
• Threatened
• Inevitable
• Incomplete
• Complete
• Septic

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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 malformations
  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

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• Following a miscarriage, the chance of having
  another miscarriage with the next pregnancy is
  about 1 in 6.

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Habitual 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.

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Causes

• Anatomical conditions
• Uterine conditions
• Cervical conditions
• Chromosomal disorders
• Endocrine disorders
• Immune factors
• Lifestyle factors
• Infection

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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 gestation 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

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Induced

• A pregnancy can be intentionally aborted in many
  ways. The manner selected depends chiefly upon
  the gestational age 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.

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Induced abortion

• Therapeutic abortion when it is performed to
• save the life of the pregnant woman
• preserve the woman's 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 the number of fetuses to
  lessen health risks associated with multiple
  pregnancy.

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Induced abortion

• An elective abortion
• When it is performed at the request of the woman
  "for reasons other than maternal health or fetal
  disease.

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Threatened Abortion

• A threatened abortion means the woman has
  experienced 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 term 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.

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Threatened abortion(Features)

•  History ? Mild vaginal bleeding.
• ? No abdominal pain or mild abdominal
  pain 
• Examination ? Good general condition.
• ? The cervix is 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

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Threatened abortion(Management)

• Reassurance If fetal heart activity is present,
  gt 90 of cases will be progressed satisfactorily
• Advice Decrease physical activity (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 ve
• ANC as high risk patients
• Because those patients are liable to late
  pregnancy complications such as APH and preterm
  labour .

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Inevitable abortion

• A condition in which
• Vaginal bleeding has been profuse
• The cervix has become dilated
• Abortion will invetably occur.

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Inevitable and incomplete abortions(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

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Inevitable and incomplete abortions(Features)

• Examinations
• Poor general condition.
• The 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 incomplete abortion

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Inevitable and incomplete abortions(management)

1. CBC , blood grouping , XM 2 units of blood
2. Resuscitation ? large IV line, fluids blood
   transfusion
3. Oxytoxic drugs ? Ergometrine 0.5 mg IM
   Oxytocin infusion (20-40 units in 500 cc saline)
4. Evacuation curettage.
5. Post-abortion management.

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Complete Abortion
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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

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Complete abortion(Management)

• - Evacuation curettage in the presence of
  RPOC.
• Post-abortion management.

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Missed abortion

• Retention of products for several weeks
• No increase in fundal height
• Absence of FHT
• Regressions of signs of pregnancy
• Loss of wight

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Missed abortion(Features)

• Most of missed abortions are diagnosed
  accidentally during routine 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

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Missed abortion(Features)

1. U/S (which is essential for diagnosis )
   diagnosed if two ultrasound ( T/V or T/A) at
   least 7days apart showed an embryo of gt 7 weeks
   gestation ( CRL gt 6mm in diameter and gestational
   sac gt 20 mm in diameter ) with no evidence of
   heart activity .

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Missed abortion(Management)

• CBC , blood grouping
• Platelets count, to exclude the risk of DIC
• NB DIC does not occur before 5 weeks of missed
  abortion or IUFD and if occurred will be of mild
  grade

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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 termination of pregnancy by Misoprostol
  (PGE1)
• Cytotec Indicated in 1st 2nd trimesters missed
  abortions.
• Cytotec vaginal ( is the best) or oral tab. 200
  µg, 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 in cases
  of RPOC
• The main side effects of cytotec are nausea,
  vomiting and fever. 
• Post-abortion management.

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Anembryonic pregnancy (Blighted ovum)

• 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 days apart showed after 7 weeks of
  gestation i.e. gestational sac gt 20mm , an empty
  gestational sac with no fetal echoes seen .
• It is treated in a similar way to missed abortion
  .

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Septic abortion

• Spontaneous or induced termination of a pregnancy
  in which the mother's 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.

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 Complications of abortion

• Haemorrhage .
• Complication related to surgical evacuation ie
  EC and DC.
• 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
  Asherman's syndrome.
• Excessive curettage which may lead to
  Adenomyosis
•  Rh- iso immunisation ? if the anti D is not
  given or if the dose is inadequate .
• Psychological trauma .

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Post - abortion management

• In cases of incomplete, inevitable, complete,
  missed septic abortions
• Support from the husband, family obstetric
  staff
• Anti D to all Rh ve, nonimmunised patients,
  whose husbands are Rhve
• Counseling 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 occur
  before the expected next period .

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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
  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

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Post - abortion management

• Counseling explanation
• Can it happen again
• As the commonest cause 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 abortions
• Not to feel guilty ? as it is extremely unlikely
  that anything the patient did can cause abortion
• No evidence that intercourse in early pregnancy
  is harmful
• No evidence that bed rest will prevent it ..

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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
• Secondary One pregnancy or more has proceeded
  to viability(gt24 weeks gestation) with all
  others ending in loss
• Incidence
• occurs in about 1 of women of reproductive age .

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Recurrent abortion

• Causes
• Idiopathic recurrent abortion, in about 50, in
  which no cause can be found .
• The known causes include the 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  

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Recurrent abortion

• Causes
• Medical disorders
• Endocrine disorders diabetes , thyroid
  disorders , PCOS corpus luteum insufficiency .
  
• Immunological disorders Anticardiolipin
  syndrome SLE.
• Thrombophilia congenital deficiency of Protein
  CS and antithrombin III, presence of factor V
  leiden.
• Infections
• ToRCH - CMV may be a cause of recurrent abortion,
  but ToRH are not causes of recurrent abortion.
• Genital tract infection e.g Bacterial vaginosis
• Rh isoimmunization

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Recurrent abortion

• Diagnosis
• History
• Previous abortions gestational age and place of
  abortions fetal abnormalities.
• Medical history DM , thyroid disorders, PCOS,
  autoimmune diseases thrombophilia.
• Examination
• General weight , thyroid hair distribution
• Pelvic cervix ( length dilatation ) and
  uterine size.

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Recurrent abortion

• Diagnosis
• investigations
• Investigations for medical disorders
• Blood grouping indirect Coombs test in Rh 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 profile ( which scientifically is not
  necessary )

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Recurrent abortion

• Diagnosis
• investigations
• Investigations for anatomical disorders
• TV/US fibroids, cervical incompetence PCOS.
• Hystroscopy or HSG, fibroids, cervical
  incompetence, uterine anomalies Asherman's
  syndrome
• Investigations for chromosomal disorders
• Parental karyotyping Parental balanced
  translocation.
• Fetal karyotyping Fetal chromosomal anomalies.

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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 husband, 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/day) start from the diagnosis of
  fetal heart activity up to 37 ws

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Recurrent abortion

• Management
• In the presence of a cause treatment is directed
  to control the cause
• Endocrine disorders
• Control DM and thyroid disorders before pregnancy
• Ovulation induction drugs , ovarian drilling or
  IVF in PCOS.
• Progesterone 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.

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Recurrent abortion

• Management
• In thrombophilia
• Low dose aspirin ( 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 in submucus fibroid, excision of
  uterine septum in septate subseptate uterus
  adhesolysis in Asherman's syndrome.

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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.