Abortion, ectopic pregnancy and gestational trophoblastic diseases
- 1. ABORTION, ECTOPIC PREGNANCY AND GESTATIONAL TROPHOBLASTIC DISEASES Abhishek Prakash (5) Akhilesh Kumar (6) Aleena Rehman (7) Aman Rahul (8) Presented By-
- 2. ABORTION Abortion is the expulsion or extraction from its mother of an embryo or fetus weighing 500g or less when it is not capable of independent survival (WHO). This 500g of fetal development is attained approximately at 22 weeks of gestation. The expelled embryo or fetus is called abortus.
- 3. ABORTION Spontaneous (miscarriage) Induced (deliberate) Isolated (sporadic) Recurrent Threatened Inevitable Complete Incomplete Missed Septic(rare) Legal (MTP) Illegal (unsafe) Septic(common)
- 4. Etiology The important factors are:- • Genetics • Anatomical • Immunological • Environmental • Endocrine and metabolic • Infection • Thrombophilias • Unexplained • others
- 5. Common causes of miscarriage: First trimester 1) Genetic factors (50%) 2) Endocrine disorders (LPD, diabetes) 3) Autoimmune and alloimmune disorders 4) Infections 5) Unexplained Second trimester 1) Anatomic abnormalities • Cervical incompetence • Mullerian fusion defect • Uterine synechiae • Uterine fibroid 2) Maternal Medical Illness 3) Unexplained
- 6. Threatened miscarriage: It is a clinical entity where the process of miscarriage has started but has not progressed to a state from which recovery is impossible. Clinical features: • Bleeding per vaginum- usually slight brownish or brick red, usually stops spontaneously. • Pain- appears usually following haemorrhage. Pelvic examination reveals bleeding, if any escape through external os. Investigation: Routine investigation includes: • Blood- for Hb, haemtocrit, ABO and Rh grouping. • Urine for immunological test of pregnancy is not helpful.
- 7. Cont.. Ultrasonography : • A well formed gestation ring with central echoes from embryo indicating healthy fetus. • Observation of fetal cardiac motions. • Blighted ovum. Treatment: • Rest- the patient should be in bed for few days until bleeding stops. • Drugs- relief of pain can be ensured by diazepam 5mg twice daily.
- 8. Inevitable miscarriage: It is the clinical type of abortion where the changes have progressed to a state from where continuation of pregnancy is impossible. Clinical features: • Increased vaginal bleeding. • Aggravation of pain in lower abdomen which may be colicky in nature. Internal examination reveals dilated interal os of the cervix through which the product of conception are felt. Management: Excessive bleeding is controlled by administering Methergine 0.2mg if the cervix is dilated and the size of uterus is less than 12 weeks. Blood loss is corrected by IV fluid therapy and blood transfusion.
- 9. Complete miscarriage: When the product of conception is expelled, it is called complete miscarriage. Clinical features: • Subsidence of abdominal pain. • Vaginal bleeding becomes absent. Internal examination reveals: Uterus is smaller than the period of amenorrhea and a little firmer, cervical os is closed and bleeding is absent. Ultrasonography reveals empty uterine cavity. Management: If the uterine cavity is not empty then evacuation of uterine curettage can be done.
- 10. Incomplete miscarriage: When the entire product of conception is not expelled, instead a part of it is left inside the uterine cavity, it is called incomplete miscarriage. Clinical features: • Continuation of pain in the lower abdomen. • Persistence of bleeding. Internal examination reveals uterus smaller and expelled mass is found incomplete. Complication: the retained product may cause sepsis or placental polyp. Management: Evacuation of retained product of conception is done.
- 11. Missed miscarriage: When the fetus is dead and retained inside the uterus for a variable period, it is called missed miscarriage or early fetal demise. Pathology: The exact cause is not clear. Beyond 12 weeks, the retained fetus becomes macerated or mummified. The liquor amnii gets absorbed and the placenta becomes pale, thin and adherent. Clinical features: • Persistence of brownish vaginal discharge. • Subsidence of pregnancy symptoms. • Retrogression of breast changes. • Cessation of uterine growth. • Nonaudibility of fetal heart sound. • Cervix feels firm. • Immunological test for pregnancy becomes negative.
- 12. Management: Uterus is less than 12 weeks: Expectant management—Many women expel the conceptus spontaneously Medical management: Prostaglandin E1 (misoprostol) 800 ug vaginally in the posterior fornix is given and repeated after 24 hours if needed. Expulsion usually occurs within 48 hours. Surgical management: suction evacuation or dilation and evacuation is done either as a definitive treatment or it can be done when the medical method fails. Uterus more than 12 weeks: Prostaglandin E1 analogue 200ug tab. every 4 hours for 5 times. Oxytocin 10-20 units in 500ml of NS. Surgical evacuation could be done.
- 13. Septic Abortion: Any abortion associated with clinical evidences of infection of the uterus and its content is called septic abortion. Clinically it is considered septic when: • Rise of temp. of at least 100.4˚F for 24 hr or more. • Offensive or purulent vaginal discharge. • Other evidence of pelvic infection such as lower abdominal pain and tenderness. Mode of infection: Many organism such as Streptococci, Clostridium welchii, tetanus bacilli, Klebsiella, Pseudomonas, etc could cause septic abortion when: • Proper antiseptic and asepsis is not taken, • Incomplete evacuation, • Injury to the genitals and adjacent structure.
- 14. Clinical features: • The women looks sick and anxious, • Temperature: >36˚C • Chills and rigor, • Persistent tachycardia, • Abdominal or chest pain, • Impaired mental state, • Diarrhoea or vomiting, • Renal angle tenderness. Pelvic examination: Offensive, purulent vaginal discharge, uterine tenderness, boggy feel in the POD(pelvic abscess)
- 15. Clinical Grading: Grade I: the infection is localised in the uterus. Grade II: the infection spreads beyond the uterus to the parametrium, tubes and ovaries or pelvic peritoneum. Grade III: Generalised peritonitis and endotoxic shock or jaundice or acute renal failure. Management: Antibiotics such as piperacillin-tazobactam or carbapenem with clindamycin gives broadest range of microbial coverage. Analgesics and sedatives as required Blood transfusion is given to control anemia and body resistance
- 16. Grade 1: • Antibiotics • Prophylactic antigas gangrene serum and antitetanus serum intramuscularly • Analgesics and sedatives Blood transfusion is given to improve anemia and body resistance
- 17. Grade 2: • Antimicrobial therapy along with Grade 1 treatment. Piperacillin-tazobactam and carbapenems Vancomycin or teicoplanin Clindamycin Gentamycin Metronidazole • Surgery Evacuation of the uterus Posterior colpotomy
- 18. Grade 3: Antibiotics are used as discussed above. Clinical monitoring should be done. Supportive therapy is directed to treat generalized peritonitis by gastric suction and intravenous crystalloids infusion.
- 19. ECTOPIC PREGNANCY An ectopic pregnancy is the one in which the fertilized ovum is implanted and develops outside the normal endometrial cavity. Site of implantation could be uterine and extrauterine. Extrauterine includes: • Tubal (most common)- ampulla, isthmus, infundibulum or interstitium • Ovarian • Abdominal Uterine includes: • Cervical • Angular • Cornual • Cesarean scar
- 20. Tubal pregnancy: Etiology: I) Salpingitis and pelvic inflammatory disease. II) Iatrogenic: • Contraception failure • IUD there is relative increase in tubal pregnancy should pregnancy occur with IUD in situ. • Sterilization- the risk in highest following laproscopic tubal motility. • Use of progestin only pills. III) Tubal surgeries IV) Intrapelvic adhesion following pelvic surgery V) Prior induced abortion VI) Developmental defects of the tube VII)Transperitoneal migration of the ovum
- 21. Acute Ectopic Pregnancy Acute ectopic pregnancy is fortunately less common and it is associated with case of tubal rupture or tubal abortion with massive intraperitoneal haemorrhage. Symptoms: the classical triad of AEP are: • Abdominal pain • Amenorrhea • appearance of vaginal bleeding Signs: • The patient is quiet and conscious • Pallor could be seen in case of anaemia • Features of shock could be seen • Pelvic examination shows whitish vaginal mucosa, extreme tender cervix and floating uterus
- 22. Unruptured tubal ectopic pregnancy Symptoms: • Presence of delayed period or spotting with features suggestive of pregnancy. • Uneasiness on one side of flank which is continuous or at times colicky in nature. Signs: • Uterus is usually soft showing signs of early pregnancy. • A pulsatile small, well circumscribed tender mass may be felt through one fornix separated from the uterus.
- 23. Chronic or Old ectopic pregnancy The onset is insidious. The patient had previous attacks of acute pain from which she had recovered or she had chronic features from beginning. Symptoms: • Amenorrhea of short periods. • Lower Abdominal pain of varying degree. • Vaginal bleeding appears sooner or later following the pain. Signs: • The patient looks ill • Pallor of varying degree is present • Feature of shock are absent • Temperature may be slightly elevated • Tenderness on lower abdomen • Cullen’s sign: dark bluish discoloration around the umbilicus if found, suggest intraperitoneal haemorrhage. • Bimanual examination is painful, ill defined, boggy and extreme tender mass is felt through the posterolateral fornix extending to the pouch of Douglas.
- 24. Management of ectopic pregnancy Acute: The principle of management of acute ectopic is resuscitaton and laparotomy. Antishock treatment- • Ringer solution is started, if necessary with venesection. • Arrangement for blood transfusion. Laprotomy- • Abdomen is opened by longitudinal incision. • To grasp the uterus and draw it up undervision. • The tubes and ovary of both the sides are inspected to fin out the side of rupture. • The ipsilateral ovary and its vascular supply is preserved. Oophorectomy is done only if the ovary is damaged beyond pathology. Subtotal hysterectomy could be done.
- 25. Chronic: • The patient is kept under observation, investigations are done and the patient is put for laparotomy at earliest time. • Usually a pelvic hematocele is found. • The tube is identified and salpingectomy(surgical removal of fallopian tube/s) is done.
- 26. GESTATIONAL TROPHOBLASTIC DISEASE Gestational Trophoblastic Disease (GTD) is a spectrum of abnormal growth and proliferation of the trophoblasts of the placenta that continue even beyond the end of pregnancy of the placenta. Persistent GTN Is evidenced of molar pregnancy. This is diagnosed clinically when the patient presents with- Irregular vaginal bleeding Subinvolution of the uterus Level of hCG either elevate or fall after initial fall. GTN after non molar pregnancy is always choriocarcinoma.
- 27. Placental Site Trophoblastic Tumor The tumor arise from trophoblast of the placental bed. B-hCG secretion is low but human placental lactogen (hPL) is secreted. The entity is not responsible to chemotherapy. Hysterectomy is the preferred treatment. Serial serum hPL is reliable marker and useful for immunohistochemical staining. Invasive Mole (Chorioadenoma Destruens) Comprise 15% of all GTN and has massive invasive and destructive potentialities. The uterine wall may be perforated at multiple areas showing purple fungating growth. The neoplasm may invade the pelvic blood vessels and metastasize to vagina or distant.
- 28. Choriocarcinoma Highly malignant tumor arising from chorionic epithelium. Trophoblastic disease following a normal pregnancy is either choriocarcinoma or PSTT and not a benign or invasive mole. The primary site is anywhere in the uterus, rarely starts in tube or ovary. The lesion is usually localized nodular, red, hemorrhagic and necrotic.
- 29. Clinical features of GTN: Symptoms: • Persistent ill health • Irregular vaginal bleeding at time brisk • Continued amenorrhea Signs: • Patient look ill • Pallor of varying degree • Bimanual examination reveals subinvolution of uterus. This may be purplish red nodule in lower third of anterior vaginal wall. • Unilateral or bilateral enlarged ovaries may be palpable.
- 30. PARAMETER SCORE 0 1 2 4 Age(years) <40 >40 - - Antecedent Pregnancy Mole Abortion Term - Interval(months) <4 4-6 7-12 >=13 Pretreatment hCG <10^3 10^3 - 10^4 10^4 – 10^5 >=10^5 Largest tumor(cm) <3 3-4 >5 - Site of metastasis Lung Pelvis Spleen Kidney GI Tract Liver Brain No. of metastasis - 1-4 5-8 >8 WHO Prognostic Scoring System of GTN as modified by FIGO (2000) Total score: <6 is low and total score of >=7 is high risk.
- 31. Stage I The lesion is confined to uterus Stage II The lesion spread outside the uterus but is confined to genital organs Stage III The lesion metastasize to the lungs Stage IV The lesion metastasizes to sites such as brain, liver or GIT FIGO Anatomic staging for Gestational trophoblastic tumors:
- 32. Management of GTN Preventive Prophylactic chemotherapy in ‘at risk’ women following evacuation of molar pregnancy may be considered. ‘at risk’ women are: • Age of patient >35 years. • Initial levels of serum hCG > 100,000 IU/ml • Previous history of molar pregnancy. Selective hysterectomy. Diagnostic uterine curettage. Curative 1) Chemotherapy: Patient with non metastatic and good prognosis disease are treated effectively with single agent therapy(methotrexate or actinomycin). The patient with poor prognosis metastatic disease should be treated with combination drug regimen (EMA-CO regimen)
- 33. 2) Surgical: Indication of Hysterectomy: • Lesion confined to uterus in women aged >35 years. • Placental site trophoblastic tumor. • Intractable vaginal bleeding. • Localized uterine lesion resistant to chemotherapy. • Accidental uterine perforation during curettage. Types of surgeries: • Total Hysterectomy is enough. The ovaries if involved can be effectively cured with postoperative chemotherapy. • Lung resection in pulmonary metastasis. • Craniotomy for control of bleeding. 3) Radiation: Patients with brain metastasis require whole brain radiation therapy (3000 cGy over 10 days). Intrathecal high dose methotrexate may be given to prevent haemorrhage and tumor shrinkage.