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Hydatidiform Molar Pregnancy

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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 ... – PowerPoint PPT presentation

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Title: Hydatidiform Molar Pregnancy


1
Hydatidiform Molar Pregnancy
2
  • 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

3
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

4
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

5
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

6
  • 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

7
(No Transcript)
8
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.

9
Categories of Abortions
  • These include
  • Threatened
  • Inevitable
  • Incomplete
  • Complete
  • Septic

10
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

11
  • Following a miscarriage, the chance of having
    another miscarriage with the next pregnancy is
    about 1 in 6.

12
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.

13
Causes
  • Anatomical conditions
  • Uterine conditions
  • Cervical conditions
  • Chromosomal disorders
  • Endocrine disorders
  • Immune factors
  • Lifestyle factors
  • Infection

14
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

15
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.

16
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.

17
Induced abortion
  • An elective abortion
  • When it is performed at the request of the woman
    "for reasons other than maternal health or fetal
    disease.

18
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.

19
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

20
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 .

21
Inevitable abortion
  • A condition in which
  • Vaginal bleeding has been profuse
  • The cervix has become dilated
  • Abortion will invetably occur.

22
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

23
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

24
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.

25
Complete Abortion
26
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

27
Complete abortion (Management)
  • - Evacuation curettage in the presence of
    RPOC.
  • Post-abortion management.

28
Missed abortion
  • Retention of products for several weeks
  • No increase in fundal height
  • Absence of FHT
  • Regressions of signs of pregnancy
  • Loss of wight

29
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

30
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 .

31
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

32
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.

33
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
    .

34
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.

35
 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 .

36
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 .

37
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

38
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 ..

39
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 .

40
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  

41
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

42
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.

43
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 )

44
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.

45
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

46
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.

47
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.

48
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.
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