First Trimester BleedingFirst Trimester Bleeding
Prepared By :Prepared By :Ass,Professor Dr Fahmi El-UriAss,Professor Dr Fahmi El-Uri
MB,ChB(Hons), MRCOG,FRCOGMB,ChB(Hons), MRCOG,FRCOG
First Trimester Bleeding First Trimester Bleeding Causes;Causes;
11 - -Spontaneous abortion / miscarriage Spontaneous abortion / miscarriage 2- Ectopic pregnancy2- Ectopic pregnancy
33--Trophoblastic diseaseTrophoblastic disease 44 - -Cervical polypsCervical polyps 55 - -Friable cervixFriable cervix 66 - -TraumaTrauma 77 - -Cervical cancerCervical cancer
First Trimester Laboratory TestsFirst Trimester Laboratory Tests
11 - -Quantitative Quantitative ββhCGhCG a- Correlate with gestational age& U/Sa- Correlate with gestational age& U/S
b- 2 measurements,2days apart-doublingb- 2 measurements,2days apart-doubling c- Falling or plateauing ,signal problemc- Falling or plateauing ,signal problem
22 - -ProgesteroneProgesterone a- < 5ng/ml likely predicts poor outcomea- < 5ng/ml likely predicts poor outcome b- > 25 ng/ml associated with living IUPb- > 25 ng/ml associated with living IUP
Lab & Ultrasound correlatesLab & Ultrasound correlatesGestational Gestational
age by age by LMPLMP
TAS TAS AbdominalAbdominal
scanscan
TVSTVS VaginalVaginal
scanscan
Serum Serum ββhCGhCG
mIU/mlmIU/ml
> >55 weeksweeks NoneNonePossible Possible gestational gestational
sacsac
15001500
5-65-6 weeksweeks Gestational Gestational sacsac
Gestational Gestational sac,yolk sac,yolk
sacsac
4000-60004000-6000
77 weeksweeks 5-10mm 5-10mm embryoembryo
Same as Same as TAS with TAS with
FHFH
< <20,00020,000
Indications for First Trimester Indications for First Trimester UltrasoundUltrasound
11 - -Suspect miscarriage or fetal deathSuspect miscarriage or fetal death 22 - -Vaginal bleedingVaginal bleeding 33 - -Gestational age (uncertain dates )Gestational age (uncertain dates ) 44 - -Adjunct to procedures ( e.g. CVS )Adjunct to procedures ( e.g. CVS ) 55 - -Suspected multiple gestationSuspected multiple gestation 66 - -suspected hydatidiform molesuspected hydatidiform mole 77 - -suspected ectopic pregnancysuspected ectopic pregnancy 88 - -IUD localizationIUD localization 99 - -Evaluation of maternal pelvic massesEvaluation of maternal pelvic masses
First Trimester UltrasoundFirst Trimester Ultrasound - -Best when performed in combination with Best when performed in combination with
history,physical examination & relevant history,physical examination & relevant laboratory testslaboratory tests
- -Often used as primary tool in evaluating Often used as primary tool in evaluating first trimester complicationsfirst trimester complications
- -Transvaginal and transabdominal should Transvaginal and transabdominal should be obtainedbe obtained
MiscarriageMiscarriage
11 . .A variety of terms have been used to describe A variety of terms have been used to describe and define early pregnancy lossand define early pregnancy loss
22 . .We have to differentiate between abortion & We have to differentiate between abortion & miscarriagemiscarriage
33 . .Abortion Abortion means terminate of unwanted means terminate of unwanted pregnancies by a variety of methods , and illegal pregnancies by a variety of methods , and illegal abortion has been the source of considerable abortion has been the source of considerable maternal morbidity and mortalitymaternal morbidity and mortality
MiscarriageMiscarriageDefinitionDefinition
The loss of an early pregnancy is the commonest The loss of an early pregnancy is the commonest medical complications of the first trimester of medical complications of the first trimester of pregnancypregnancy
Many conceptions are lost during the first month Many conceptions are lost during the first month after the last menstrual period and are often after the last menstrual period and are often ignored, particularly if they occur around the time ignored, particularly if they occur around the time
of an expected menstrual periodof an expected menstrual period
DefinitionsDefinitions 11 - -Spontaneous miscarriageSpontaneous miscarriage
Involuntary loss during the first 20 weeksInvoluntary loss during the first 20 weeks
22 - -Threatened miscarriageThreatened miscarriage Uterine bleeding, closed cervix, no productsUterine bleeding, closed cervix, no productsof conception passedof conception passed
33 - -Incomplete miscarriageIncomplete miscarriage
Some , but not all , products have passedSome , but not all , products have passed
44 - -Inevitable miscarriageInevitable miscarriage Cervix dilated , products not passedCervix dilated , products not passed
Definitions ( continue )Definitions ( continue )
55 - -Missed miscarriageMissed miscarriage Fetus dead, but no tissue passed, cervix Fetus dead, but no tissue passed, cervix
closedclosed . .66 - -Septic miscarriageSeptic miscarriage
Incomplete miscarriage with ascending Incomplete miscarriage with ascending infectioninfection . .
77 - -Blighted ovumBlighted ovum Identifiable sac & placental tissue, but no Identifiable sac & placental tissue, but no
embryoembryo . .
Definitions ( continue )Definitions ( continue )
88 - -Subchorionic hemorrhageSubchorionic hemorrhage Blood between chorion and uterine wallBlood between chorion and uterine wall . .
99 - -DeciduaDecidua Endometrium of pregnancy that is frequently Endometrium of pregnancy that is frequently
passed as part of a miscarriagepassed as part of a miscarriage . .When the decidua is passed intact it is When the decidua is passed intact it is called a called a decidual castdecidual cast, which often , which often
signifies an ectopic pregnancysignifies an ectopic pregnancy. .
Pathophysiology of miscarriagePathophysiology of miscarriage
11 - -Major genetic anomalyMajor genetic anomaly At least one half of all spontaneous miscarriages are the result of a At least one half of all spontaneous miscarriages are the result of a major genetic anomaly , trisomy,triploidy or monosomymajor genetic anomaly , trisomy,triploidy or monosomy
22 - -Internal environmental factorsInternal environmental factors Uterine : anomalies, leiomyomata, incompetent cervixUterine : anomalies, leiomyomata, incompetent cervix
Maternal diethylstillbestrol ( DES ) exposureMaternal diethylstillbestrol ( DES ) exposure Luteal phase defectLuteal phase defect Immunologic factorsImmunologic factors
33 - -External environmental factorsExternal environmental factors Tobacco, alcohol, cocaineTobacco, alcohol, cocaine
IrradiationIrradiation InfectionInfection
Occupational chemical exposureOccupational chemical exposure
44 - -Advanced maternal ageAdvanced maternal age
Clinical course of miscarriageClinical course of miscarriage
11 - -Missed menses, pregnancy symptomsMissed menses, pregnancy symptoms 22 - -Positive Positive ββhCGhCG
33 - -Vaginal bleedingVaginal bleeding 4- 4- ββhCG falls or plateaus hCG falls or plateaus
55 - -Lower abdominal cramping, backacheLower abdominal cramping, backache 66 - -Products of conception passedProducts of conception passed
Physical ExaminationPhysical Examination
11 - -Abdominal examAbdominal exam Pain location , rebound, distensionPain location , rebound, distension
22 - -Speculum examSpeculum exam
To assess cx dilatationTo assess cx dilatation To rule out non-uterine causes of bleedingTo rule out non-uterine causes of bleeding
33 - -Bimanual examBimanual exam To assess uterine size, adnexal massesTo assess uterine size, adnexal masses
Fetal Heart tonesFetal Heart tones
Listen after 9-10 weeks with DopplerListen after 9-10 weeks with Doppler Sensitivity enhanced by elevating uterus Sensitivity enhanced by elevating uterus during bimanual examduring bimanual exam
Management of MiscarriageManagement of Miscarriage
11 - -50%50% loss when bleeding presentloss when bleeding present 22 - -Presence of FHTs reassuringPresence of FHTs reassuring 33 - -Majority do not require medical or surgical Majority do not require medical or surgical
interventionintervention 44 - -Identify patients at risk for bleeding, Identify patients at risk for bleeding,
infectioninfection55 - -Address contraceptive needsAddress contraceptive needs
Ectopic PregnancyEctopic Pregnancy
Pregnancy outside the uterus , usually in thePregnancy outside the uterus , usually in theFallopian tubeFallopian tube . .
Occurs in >1:100 pregnanciesOccurs in >1:100 pregnancies . . Second most common cause of M. MortalitySecond most common cause of M. Mortality..
Early diagnosis criticalEarly diagnosis critical ! !
DefinitionDefinition It is a gestation that implants outside the It is a gestation that implants outside the
endometrial cavityendometrial cavity . .<<95%95% of ectopic pregnancies implant in of ectopic pregnancies implant in
various anatomic segment of ‘ fallopian various anatomic segment of ‘ fallopian tube includingtube including ; ;
1%1% in the interstitialin the interstitial 5%5% in the isthmicin the isthmic
85%85% in the ampullary portionin the ampullary portion 9%9% in the infundibular & fimbrial portionin the infundibular & fimbrial portion . .
Other sites of ectopicOther sites of ectopic
Other less sites of ectopic pregnancies areOther less sites of ectopic pregnancies are;;The ovary , cervix , the peritoneal cavityThe ovary , cervix , the peritoneal cavity. .
IntroductionIntroductionThe Diagnosis & management of ectopic The Diagnosis & management of ectopic pregnancy has undergone a revolution a century pregnancy has undergone a revolution a century after Lawson after Lawson TaitTait successfully performed a successfully performed a laparotomy to ligate ‘broad ligament& remove a laparotomy to ligate ‘broad ligament& remove a ruptured tube in 1883(Tait 1884)ruptured tube in 1883(Tait 1884)..
Improved technology allows to diagnose ectopic Improved technology allows to diagnose ectopic pregnancy before it ruptures thus making less pregnancy before it ruptures thus making less invasive treatment possibleinvasive treatment possible,,
Resulting in reduced Maternal Mortality andResulting in reduced Maternal Mortality andMorbidityMorbidity . .
IncidenceIncidence 11 - -In USA deaths due to ectopic pregnancy was In USA deaths due to ectopic pregnancy was
9% of all maternal deaths in 1992and its 9% of all maternal deaths in 1992and its incidence has apparently increased fourfold incidence has apparently increased fourfold (from 4.5 to 20/1000pregnancies between 1970 (from 4.5 to 20/1000pregnancies between 1970 & & 1992(Centers of Disease Control1992(Centers of Disease Control 19951995 ) )
22 - -In UK it represent 4.2% of Maternal death in In UK it represent 4.2% of Maternal death in 1991-1993, its incidence apparently doubling 1991-1993, its incidence apparently doubling between 1973-75 and1991-93 (from 4.9 to 9.6 between 1973-75 and1991-93 (from 4.9 to 9.6 per 1000pregnancies) per 1000pregnancies) Department ofDepartment of Health1994Health1994..
Risk factors for EctopicRisk factors for Ectopic1- History of previous ectopic pregnancy1- History of previous ectopic pregnancy2-Prior tubal surgery 2-Prior tubal surgery 3-Prior tubal infection 3-Prior tubal infection 4-Progestin-only contraception4-Progestin-only contraception5-Contraceptive IUD 5-Contraceptive IUD 6- In utero Diethylstilbestrol(DES) exposure6- In utero Diethylstilbestrol(DES) exposureMany occur in women with no risk Many occur in women with no risk
factors!factors!
Clinical PresentationClinical PresentationIt can vary from vaginal spotting of old blood It can vary from vaginal spotting of old blood
to vasomotor shock with to vasomotor shock with hematoperitoneum.hematoperitoneum.
The classic triad of ;The classic triad of ;a- Delayed menses ,a- Delayed menses ,B- Irregular vaginal bleeding ,B- Irregular vaginal bleeding ,C- Abdominal pain ,C- Abdominal pain ,The above is not commonly encountered The above is not commonly encountered
( speroff el al 1994 ) ( speroff el al 1994 )
General ExaminationGeneral Examination
A- Pulse rate & blood pressure , because in A- Pulse rate & blood pressure , because in vascular instability BP is low ,fainting, vascular instability BP is low ,fainting, dizziness and rapid Heart rate .dizziness and rapid Heart rate .
B- Shoulder pain , occurs due to blood B- Shoulder pain , occurs due to blood irritating the diaphragm as a result of irritating the diaphragm as a result of rupture ectopic causing intra-abdominal rupture ectopic causing intra-abdominal bleeding .bleeding .
Gynaecological ExaminationGynaecological Examination
Speculum or Bimanual examination must be Speculum or Bimanual examination must be performed in Hospital because it may lead performed in Hospital because it may lead to rupture of the tube .to rupture of the tube .
Diagnosis of EctopicDiagnosis of Ectopic11 - -Failure of Failure of ββhCG to double in 48 hourshCG to double in 48 hours
22 - -Low serum progesteroneLow serum progesterone33 - -Ultrasound ( transvaginal )Ultrasound ( transvaginal )
a- IUP rules out ectopica- IUP rules out ectopic b- No gestational sac+b- No gestational sac+ββhCG>1500, highlyhCG>1500, highly
suggestivesuggestive c- Gestational sac/embryo outside of uterus confirms c- Gestational sac/embryo outside of uterus confirms
ectopicectopic d- Pitfalls: pseudogestational sac,ruptured corpus luteumd- Pitfalls: pseudogestational sac,ruptured corpus luteum
44 - -Laparoscopy – gold standardLaparoscopy – gold standard
Extrauterine signs of EctopicExtrauterine signs of Ectopic
Finding Risk of EctopicFinding Risk of EctopicNo mass or free fluid 20%No mass or free fluid 20%Any free fluid 71%Any free fluid 71%Echogenic mass 85%Echogenic mass 85%Moderate to large amount of fluid 95%Moderate to large amount of fluid 95%Echogenic mass with fluid 100%Echogenic mass with fluid 100%
CuldocentesisCuldocentesisThe test is used to exclude hemoperitoneum The test is used to exclude hemoperitoneum which is associated with ruptured ectopic which is associated with ruptured ectopic pregnancy, therefore it is not useful in pregnancy, therefore it is not useful in
detecting an early ectopic pregnancydetecting an early ectopic pregnancy. . 1818 or 20 gauge needle passed through the or 20 gauge needle passed through the
posterior fornix to aspirate for fluidposterior fornix to aspirate for fluid. . Bloody fluid with hematocrit >15%representsBloody fluid with hematocrit >15%represents
active intraperitoneal bleedingactive intraperitoneal bleeding. . TVS has replaced nowadays culdocentesisTVS has replaced nowadays culdocentesis..
hCG & Vaginal ultrasoundhCG & Vaginal ultrasound
hCGhCG can be detected in the urine as early as can be detected in the urine as early as 14days(Post conception), by sensitive 14days(Post conception), by sensitive enzyme-linked immunosorbent assays enzyme-linked immunosorbent assays (detection limits 25-40IU/L, and sensitivity (detection limits 25-40IU/L, and sensitivity
98%-100%)98%-100%). . It can be detected in the serum 5-9 days It can be detected in the serum 5-9 days post-conception by immuno-radioactive post-conception by immuno-radioactive assaysassays..
hCG ( Continue )hCG ( Continue )Between 2-4 weeks after ovulation serum hCG Between 2-4 weeks after ovulation serum hCG levels double approximately every levels double approximately every 2days(48hours) in normal pregnancy ,and a 2days(48hours) in normal pregnancy ,and a lesser increase ( <66% over 48 hours) is lesser increase ( <66% over 48 hours) is associated with ectopic pregnancy and associated with ectopic pregnancy and
spontaneous abortionspontaneous abortion. . However,15%of normal pregnancy will have an However,15%of normal pregnancy will have an abnormal doubling time and 13% of ectopic abnormal doubling time and 13% of ectopic
pregnancy will have a normal doubling timepregnancy will have a normal doubling time. .
CONTINUECONTINUE
Therefore in order to increase the sensitivity of Therefore in order to increase the sensitivity of Quantitative hCG ,a discriminatory zone Quantitative hCG ,a discriminatory zone DZDZ has has been described whereby a titre of 1000-been described whereby a titre of 1000-1500IU/L will be associated with the presence of 1500IU/L will be associated with the presence of an INTRA-UTERINE sac on transvaginal Scan an INTRA-UTERINE sac on transvaginal Scan and 4500-6500 IU/L for trans-abdominal Scanand 4500-6500 IU/L for trans-abdominal Scan..
In multiple pregnancy the Discriminatory zone In multiple pregnancy the Discriminatory zone would be a little higher, requiring an extra 2-3 would be a little higher, requiring an extra 2-3
days for a sac to become visibledays for a sac to become visible. .
CONTINUECONTINUE11 - -The demonstration of a viable IUP does not The demonstration of a viable IUP does not
exclude ‘ possibility of exclude ‘ possibility of HeterotopicHeterotopic Pregnancy Pregnancy frequency 1 in 30,000 eventfrequency 1 in 30,000 event. .
22--TVS( Transvaginal scan), has resulted in the TVS( Transvaginal scan), has resulted in the diagnosis of normal & abnormal pregnancy diagnosis of normal & abnormal pregnancy approximately 1 week earlier than using Trans approximately 1 week earlier than using Trans abdominal scan TASabdominal scan TAS..
In Ectopic there are an empty uterus,pseudo-sac, In Ectopic there are an empty uterus,pseudo-sac, a tubal ring ( doughnut or bagel sign) with fluid in a tubal ring ( doughnut or bagel sign) with fluid in
the pouch of douglasthe pouch of douglas. .
Management Of Ectopic Management Of Ectopic PregnancyPregnancy
11 - -Expectant ManagementExpectant Management22 - -Medical ManagementMedical Management 33 - -Surgical ManagementSurgical Management
Expectant ManagementExpectant Management
Criteria includeCriteria include: : a- Minimal pain or bleedinga- Minimal pain or bleeding
b- Reliable follow-upb- Reliable follow-up c- No evidence of tubal rupturec- No evidence of tubal rupture
d- d- ββhCG < 1000 and fallinghCG < 1000 and falling e- Adnexal mass < 3cm, or not detectede- Adnexal mass < 3cm, or not detected
f- No embryonic heart beatf- No embryonic heart beat
Medical Management:Medical Management:MethotrexateMethotrexate
11 - -Safe, effective ,less costly than surgerySafe, effective ,less costly than surgery 22 - -Equal or better fertility preservationEqual or better fertility preservation
33 - -Criteria for useCriteria for use: : Stable vital signs , few symptomsStable vital signs , few symptoms
No contraindication to drugNo contraindication to drug Unruptured ectopicUnruptured ectopic
Absence of embryonic heart activityAbsence of embryonic heart activity Ectopic mass ≤ 4cmEctopic mass ≤ 4cm
ββhCG levels < 5000 mIU/mlhCG levels < 5000 mIU/ml
Methotrexate DosingMethotrexate Dosing
11--Single dose IM regimen with 1mg/kg or 50mg/m²Single dose IM regimen with 1mg/kg or 50mg/m²Obtain Obtain serum serum ββhCGhCG on 4 on 4thth & 7 & 7thth day post- day post-treatment ( fall 15% should be expected )& treatment ( fall 15% should be expected )& continue follow up until level reaches 5mIU/ml in continue follow up until level reaches 5mIU/ml in 3-4 weeks3-4 weeks
22--Serum progesteroneSerum progesterone, a drop to 1.5mg/ml , a drop to 1.5mg/ml means successful treatment & usually occurs by means successful treatment & usually occurs by about 2-3 weeksabout 2-3 weeks
33--Surgical consultationSurgical consultation if we need more than one if we need more than one dosedose
Surgical ManagementSurgical Management Mainstay of treatmentMainstay of treatment
-Conservative Conservative – conservation of tube– conservation of tube-ExtirpationExtirpation removal of tube removal of tube -Criteria for selecting surgeryCriteria for selecting surgery
- Unstable vital signs or hemoperitoneumUnstable vital signs or hemoperitoneum- Uncertain diagnosisUncertain diagnosis
- Advanced ectopic pregnancyAdvanced ectopic pregnancy - Unreliable follow-upUnreliable follow-up
- Contraindication to expectant or methotrexate Contraindication to expectant or methotrexate managementmanagement
Gestational Trophoblastic DiseaseGestational Trophoblastic DiseaseGTDGTD
Definition It is a term commonly applied to a spectrum of inter-related diseases originating from
the placental trophoblast
Trophoblastic DiseaseTrophoblastic DiseaseGestational trophoblastic disease , has three basic Gestational trophoblastic disease , has three basic configurationsconfigurations::
A- A- CompleteComplete hydatidiform mole hydatidiform moleB- B- PartialPartial mole mole
C- C- MoleMole recurrencerecurrence → → metastatic metastatic choriocarcinomachoriocarcinoma..
GTDGTD is an occasional cause of first trimester is an occasional cause of first trimester bleeding & should be considered in the bleeding & should be considered in the
differential diagnosis until proven otherwisedifferential diagnosis until proven otherwise. .
GTD ( Continue )GTD ( Continue )
Complete hydatidiform moleComplete hydatidiform mole It consists of placental proliferation in theIt consists of placental proliferation in the absence of a fetus. The placental villi areabsence of a fetus. The placental villi are
swollen & often resemble bunches of swollen & often resemble bunches of grapesgrapes..
Most complete moles have a 46XX Most complete moles have a 46XX chromosomal composition , all derived chromosomal composition , all derived from paternal sourcesfrom paternal sources
ContnueContnue
Partial Mole; This refers to molar placenta occuring together with a fetus , which is usually non-viableGenetic testing usually reveals triploidy
)69 XXY( Partial mole is less common than a complete mole & carries a lower risk of recurrence
Recurrence 0f trophoblastic Recurrence 0f trophoblastic diseasedisease
AAbout 20% 0f women with a complete mole will experience recurrence in the form of mole that invades the myometrium or becomes aggressively metastatic (metastatic choriocarcinoma)
EpidemiologyEpidemiology
GTDGTD occurs in the USA at a rate of in one in 1000 occurs in the USA at a rate of in one in 1000 to 1500 pregnancies, in Asian women in the to 1500 pregnancies, in Asian women in the USA ( 1 in 800 )USA ( 1 in 800 )Higher incidence in Asia ( Taiwan 1in every 125 to Higher incidence in Asia ( Taiwan 1in every 125 to 200 pregnancies )200 pregnancies )
Two factors predispose to trophoblastic diseaseTwo factors predispose to trophoblastic disease : : A- Pregnancy at the extremes of reproductive A- Pregnancy at the extremes of reproductive life( specially women over 45) B- Previous molar life( specially women over 45) B- Previous molar
diseasedisease
Clinical ManifestationsClinical Manifestations 11--Vaginal bleeding 1Vaginal bleeding 1stst/early 2/early 2ndnd trimester trimester
Which is often dark in colorWhich is often dark in color Grape-like vesicles are passed in cases that progress in Grape-like vesicles are passed in cases that progress in the 2the 2ndnd trimester trimester
22--Higher than expected Higher than expected ββhCG levelshCG levels 33--Uterine size>dates without heart toneUterine size>dates without heart tone
44--HyperemesisHyperemesis 55--Early pregnancy-induced hypertensionEarly pregnancy-induced hypertension
66--ThyrotoxicosisThyrotoxicosis77--Ovarian enlargement( theca-lutein cysts ) due to high Ovarian enlargement( theca-lutein cysts ) due to high
hCG levelshCG levels
DiagnosisDiagnosis
A high index of suspicion is required for A high index of suspicion is required for early diagnosisearly diagnosis
UltrasoundUltrasound is the gold standard for is the gold standard for diagnosis and will show multiple vesicular diagnosis and will show multiple vesicular spaces within the uterus ,with an absence spaces within the uterus ,with an absence of a fetusof a fetusEnlarged cystic ovaries are commonEnlarged cystic ovaries are common
Treatment of GTDTreatment of GTD
11 - -Prompt evacuation of the uterus is the Prompt evacuation of the uterus is the primary treatmentprimary treatment
22 - -Serial Serial ββhCG monitoring for 6-12 months hCG monitoring for 6-12 months with contraceptionwith contraception
33--Recurrence occurs in 20% with complete Recurrence occurs in 20% with complete mole invades myometrium or become mole invades myometrium or become metastases, so treat with chemotherapy metastases, so treat with chemotherapy ( methotrexate )( methotrexate )
Most can conceive , carry normal pregnancyMost can conceive , carry normal pregnancy
Treatment of GTD
Treatment has 3 componentsTreatment has 3 components; ; 11 - -Evacuation of the uterusEvacuation of the uterus
The standard therapy for hydatidiform mole is The standard therapy for hydatidiform mole is suction evacuation followed by sharp curettage suction evacuation followed by sharp curettage of ‘ uterine cavity ,regardless of ‘ duration of of ‘ uterine cavity ,regardless of ‘ duration of pregnancypregnancy..
IV oxytocin is given simultaneously to help IV oxytocin is given simultaneously to help stimulate uterine contraction & ↓ blood loss. This stimulate uterine contraction & ↓ blood loss. This technique is associated with low incidence of technique is associated with low incidence of uterine perforation & trophoblastic embolizationuterine perforation & trophoblastic embolization
Treatment ( Continue )Treatment ( Continue )
22 - -Monitoring levels of the Monitoring levels of the ββhCGhCG Following ‘ evacuation of a hydatidiform Following ‘ evacuation of a hydatidiform mole, ‘ patient must be monitored with mole, ‘ patient must be monitored with weekly serum assays of weekly serum assays of ββhCG , the level hCG , the level should decline to 1-5 mIU/ml usually within should decline to 1-5 mIU/ml usually within 12-16 weeks12-16 weeks..
Treatment ( Continue )Treatment ( Continue )
33 - -ChemotherapyChemotherapyProphylactic chemotherapy is not indicated in Prophylactic chemotherapy is not indicated in patients with molar pregnancy because 90% of patients with molar pregnancy because 90% of
these individuals have spontaneous remissionsthese individuals have spontaneous remissions. . If the If the ββhCG levels plateau or rise at any time hCG levels plateau or rise at any time
ChemotherapyChemotherapy should be initiated should be initiated; ; Methotrexate 1mg/Kg/day on days 1,3,5,7 followed Methotrexate 1mg/Kg/day on days 1,3,5,7 followed 24hr later by 0.1mg/kg/day of folinic acid on 24hr later by 0.1mg/kg/day of folinic acid on
days 2,4,6,8days 2,4,6,8
Prognosis for Future PregnanciesPrognosis for Future Pregnancies
There is 1-2% recurrence rate, most patients There is 1-2% recurrence rate, most patients can conceive & carry a normal pregnancy can conceive & carry a normal pregnancy after trophoblastic diseaseafter trophoblastic disease
Chemotherapeutic agents used to treat Chemotherapeutic agents used to treat recurrences have not been shown to affect recurrences have not been shown to affect future pregnanciesfuture pregnancies
Clinician should help their patients to Clinician should help their patients to overcome the psychological impact of this overcome the psychological impact of this bizarre conditionbizarre condition
Summary of first trimester bleedingSummary of first trimester bleeding
Miscarriage can cause significant physical & Miscarriage can cause significant physical & psychological morbiditypsychological morbidity
Ectopic pregnancy is a potential cause of Ectopic pregnancy is a potential cause of maternal mortalitymaternal mortality
Serum hormone testing & ultrasonography Serum hormone testing & ultrasonography important in diagnosisimportant in diagnosis
Many patients can be managed Many patients can be managed nonsurgicallynonsurgically