Early Pregnancy Bleeding Flashcards
Risk factor for hydatidiform mole
- Prior molar pregnancy
- Extremes of maternal age (<20 or >40)
- Blood group A and AB
- B carotene as protective factors
Different between complete and partial hydatidiform mole
> Partial
- 2 sperm + 1 egg
- Triploid (69, XXX/ XXY)
- Embryo present but dies by 8-9 weeks
- B-HCG slightly elevated (,<50 000)
- Rarely become malignant
> Complete
- Empty egg + 1 or 2 sperms
- Diploid (46, XX/ XY)
- No viable fetus
- B-HCG high (>50 000)
- Risk of subsequent choriocarcinoma
Macroscopic appearance of complete mole
- “Like bunch of grapes”
- Uterine enlargement in excess of gestational age
- Theca-lutein cyst
Clinical features of molar pregnancy
- Amenorrhea
- Hyperemesis gravidarum
- Irregular vaginal bleeding
- Passing of hydropic vesicles vaginally
- Hyperthyroidism features
Physical sign of molar pregnancy
- High BP
- Sign of hyperthyroidism
- Abdominal sign: uterus larger than date, doughy in consistency, absence of fetal parts/ heart sound in complete mole
Investigation for molar pregnancy
> Pregnancy test
- Urine pregnancy test: +ve in high dilution
- Serum b-HCG: persistently elevated
> Blood test
- FBC: assess Hb level, platelet
- +- TSH: exclude hyperthyroidism
- LFT: exclude liver metastases, assess liver function for chemotherapy
- RF: assess renal function for chemotherapy
- GXM: preparation for suction curettage
> Imaging
- Abdominal ultrasound: rule out intrauterine pregnancy, “Cluster of grapes” or “Snow-storm”
> Assessment of metastases
- Chest X-ray
- Ultrasound abdomen
- CT scan/ MRI
Management for molar pregnancy
> Dilatation, suction and curettage
- Oxytocin infusion after completion of evacuation to control bleeding
- Send tissue for HPE
> Chemotherapy
- If plateaued/ rising b-HCG after evacuation
- Histological evidence of choriocarcinoma
Follow up after suction curettage for molar pregancy
- Serial quantitative b-HCG
- Monitor weekly until it is undetectable for 3 consecutive weeks -> monthly until undetectable for 6 consecutive months -> 2 monthly for next 6 months
- Advice not to conceive until hCG levels have been normal for 6 month (will increase hCG -> difficulty to detect persistent molar pregnancy)
- Contraceptive for 2 years after treatment (eg: barrier/ sterilization)
Common site for ectopic pregnancy
> Fallopian tube (95%)
- Ampulla: commonest and least dangerous site
- Isthmus: dangerous
- Fimbrial end of tube
- Interstitium: dangerous
> Others
- Ovaries
- Peritoneal cavity
- Cervical
- Cornual
Risk factor for ectopic pregnancy
- Pelvic infection
- Previous ectopic pregnancy
- Previous tubal surgery
- Use of IUD
- Assisted reproductive technique
- Endometriosis
- Smoking
Clinical features of ectopic pregnancy
> Subacute (unruptured) - Classical triad of
- Amenorrhea
- Lower abdominal pain (localized to iliac fossa)
- Vaginal bleeding (dark red)
- Symptoms of anemia (eg: fatigue, dizziness, SOB)
> Acute (ruptured)
- Acute abdominal pain
- Shoulder tip pain
Physical sign of ectopic pregnancy
> Abdominal examination
- Distended abdomen
- Abdominal tenderness
- Rebound tenderness
- Fluid thrills
- Shifting dullness positive
> Bimanual examination
- Marked cervical excitation pain (from peritonism in adnexa)
Investigation of ectopic pregnancy
- FBC: Hb level
- Urine pregnancy test: +ve
- Serial b-hCG level: suboptimal/ not double within 48 hours
- Transvaginal ultrasound: establish the location
- Laparoscopy
Management of ectopic pregnancy
> Expectant
- Indication: asymptomatic, b-hCG <1000 mIU/ml, size <2cm on TVS
> Medical
- eg: IM methotrexate (folic acid antagonist)
- Indication: patient with one fallopian tube and fertility desired, trophoblast adherent to bowel or blood vessels
> Surgical
- eg: salpingectomy, salpingotomy, salpingo-oophorectomy
Risk factor for miscarriage
- Increase with age
- Infection
- Smoking, alcohol
- Poor nutrition
- Uterine defect (eg: septate/ bicornuate uterus, incompetent cervix)
