OB 102

Syllabus

Complications of pregnancy in the first trimester

Complications of pregnancy in 2nd trimester

Medical complications

Abnormal labor

WHO Partograph

Family planning

Care of infants

IMCI
 COMPLICATIONS OF PREGNANCY IN THE FIRST TRIMESTER

Learning objectives:
At the end of this session, the student will be able to:
1. Discuss the different causes of first trimester bleeding, including abortion and ectopic
pregnancy.
2. Identify the danger signs during the first trimester of pregnancy and develop skills in
assessing patients with danger signs.
3. Differentiate the types of abortion.

Complications in the 1s trimester:

1. Hyperemesis gravidarum
2. Abortion
3. Ectopic pregnancy
4. Molar pregnancy

During the first trimester, the following signs and symptoms are danger signs of pregnancy
that should be watched out: abdominal pain, vaginal bleeding, uterus smaller or larger
than expected and absent fetal heart tones with Doppler after 10-12 weeks. Around 20-25
% of women experience bleeding in the first trimester. This can be due to various causes
which can be pregnancy related or non-pregnancy related. The following are the
differential diagnosis in a patient presenting with first trimester bleeding or abdominal
pain:

 Pregnancy related:
 Normal intrauterine pregnancy
 Complete abortion
 Incomplete abortion
 Missed abortion
 Blighted ovum
 Ectopic pregnancy
 Hydatidiform mole

 Non-pregnancy related
 Appendicitis
 Adnexal torsion
 Tubo-ovarian abscess/infection
 Ureteral stone with colic
 Cystitis or pyelonephritis
 Ruptured ovarian cyst

How to arrive at the diagnosis:

A thorough clinical history and physical examination and internal examination should be
done to rule out the above causes. Medical history should include:
 LMP and PMP
  Previous pregnancy history
 Use of OCP
 Medications taken
 History of fever
 Abortion attempts
 History of tubal surgery, IUD, Pelvic inflammatory disease
 Onset, severity, duration of pain and bleeding
 Any tissue passed
 General health of the woman

After thorough clinical history is taken, physical examination should be done. The vital
signs are taken to include: Blood pressure, pulse rate, and temperature. On pelvic
examination, one should note the presence of bleeding and should note the amount of
blood. Internal examination should be done to note if the cervix is open, if there is
bleeding per vagina, if there is tenderness or pain during examination and if there is an
abnormal discharge. Laboratory and diagnostic test that should be done should include
pregnancy test, urinalysis to rule out infection (UTI or cystitis), CBC to note for the
presence of anemia, and ultrasound.

HYPEREMESIS GRAVIDARUM
- Hyper – means ‘over’ emesis means- vomiting, gravidarum means – ‘pregnant state’ so
Hyperemesis gravidarum means excessive vomiting during pregnancy. This is because B-
hCG hormone (hormone of pregnancy), which has stimulating effect on the center of
vomiting in brain. More or less all pregnant women experience the complaint of vomiting.
Mild to moderate nausea and vomiting is common until 16 weeks AOG. When the vomiting
becomes persistent, frequent and severe, it leads to health problems like weight loss,
dehydration, electrolyte imbalance like hypokalemia. Risk factors for hyperemesis
gravidarum include previous history of admission due to hyperemesis gravidarum and
family history. Hyperemesis gravidarum is increased in the following conditions: (1)
hyperthyroidism, (2) previous molar pregnancy, (3) diabetes mellitus, (4) gastrointestinal
illnesses and (5) asthma.
- Treatment include rest, Vitamin B complex, adequate amount of fluids to avoid
dehydration and antacid for mild to moderate cases. For severe cases, hospitalization is
necessary because these women usually need to be given fluids through intravenous line to
avoid dehydration and electrolyte imbalance.

ABORTION
 Definition: Pregnancy termination prior to 20 weeks gestation or with a fetus born
weighing less than 500g. Abortion is defined as the spontatneous or induced
termination of pregnancy before fetal viability. Abortion and miscarriage are terms
used interchangeably in the medical context.

 Pathogenesis: More thant 80% of spontaneous abortion occur within the first 12
weeks of gestation. With first-trimester losses, death of the embryo or fetus nearly
always precedes spontaneous expulsion, Death is usually accompanied by
 hemorrhage into the decidua basalis. This is followed by adjacent tissue necrosis
that stimulates uterine contraction and expulsion.

 Risk Factors:
 Fetal factors
 Chromosomal abnormalities (trisomy, monosomy) – Approximately
half of miscarriages are anembryonic (blighted ovum) or with no
idenfiable embrynic elements. The other 50% are embryonic
miscarriages which commonly display a developmental abnormality
of the zzygote, embryo, fetus or at times the placenta.
 Q: What are the most common chromosomal abnormalities in first
trimester abortion?
 Maternal factors
 Infection (chlamydia, listeria, campylobacter)
 Chronic debilitating disease (DM, hypothyroidism, malnutrition)
 Drug use and environmental factors (smoking, alcohol, caffeine,
radiation, contraceptives,
 Trauma

Clinical classification of spontaneous abortion:

1. Threatened abortion

Vaginal bleeding of varied severity and lower abdominal cramps with backache during the
first 20 weeks are classical symptoms with threatened abortion. The ultra sonography
shows a live baby corresponding to the period of amenorrhoea. Physical examination will
reveal a closed cervical os. There are no effective therapies but bed rest and sedation to
decrease anxiety is the most logical treatment. Hormonal support given without
conformation has questionable role. Early pregnancy bleeding increases the risk for
preterm delivery, low birth weight or perinatal death.

2. Inevitable abortion

This is defied as gross rupture of membranes, leaking amniotic fluid, in the presence of
cervical dilatation. This is nearly always followed by either uterine contraction or
infection. Treatment includes bed rest, antibiotic and expectant management. After 48
hours, if there is no more watery vaginal discharge, bleeding or fever, the woman can
resume ambulation. But if assoicated with fever, bleeding and cramping, abortion is
considered inevitable and the uterus is evacuated.

3. Incomplete abortion
Bleeding that follows partial or complete placental separation and dilatation of the cervical
os is termed incomplete abortion. Usual presentation is vaginal bleeding with or without
passage of tissues and with associated cramping. On internal examination, the cervical os
is open with the fetus and the placenta within the uterus or partially extrude through a
dilated os. Management include curettage, or expectant management in clinically stable
patients.

4. Complete Abortion

Patients usually present with history of heavy bleeding, cramping and passage of tissue or a
fetus is common. On internal examination, the cervical os is closed.

5. Missed abortion

This is also termed as early pregnancy failure or loss. The dead products of conception is
retained for days, weeks or even months within the uterus with a closed cervix. Early
pregnancy appeared to be normal with amenorrhea, nausea and vomiting, breast changes
and uterine growth. Expectant management and spontaneous passage of the fetus can be
done.

6. Septic abortion

About 1-2% of women with threatened or incomplete abortion develop pelvic infection and
sepsis syndrome. Bacteria gain entry and colonize dad conception products. Organisms
may invade myometrial tissues and extend to cause parametritis, peritonitis and
septicemia. Management include broad spectrum antibiotic and evacuation of retained
products of conception by either suction or completion curettage.

Induced abortion: medical or surgical termination of pregnancy before the time of fetal
viability.

Classification of induced abortion:

1. Therapeutic abortion

There are several diverse medical and surgical disorders that are indications for
termination of pregnancy. Examples are malignancy, pulmonary hypertension or diabetes.
In cases of rape or incest, most consider termination reasonable. The most common
indication is to prevent birth of a fetus with significant anatomical, metabolic and mental
deformities. Abortion is legal in the US and other countries but is considered illegal in the
Philippines.

2. Elective or Voluntary abortion

This is defined as interruption of pregnancy before viability at the request of the woman,
but not for medical reasons. In the US, most abortions are done as elective and it is one of
the most commonly performed medical procedures. Elective abortion is done in an
abortion clinic, in an aseptic environment. In the Philippines, because abortion is illegal,
induced abortion is performed by untrained non-medical personnel in a septic
environment, which can cause septic abortion, threatening the health of the woman.

HYDATIDIFORM MOLE (H-MOLE)/ molar pregnancy

The classic histological findings in molar pregnancy are villous stromal edema and
trophoblastic proliferation. It can be classified as complete or partial moles depending on
the degree of histological changes, karyotypic difference and the absence or presence of
embryonic elements. The 2 classification also vary in associated risk for developing
medical comorbidities and post-evacuation GTN. A complete mole has abnormal chorionic
villi that grossly appear as a mass of clear vesicles. These vary in size and often hang in

Table 11-2. Features of Partial and Complete Hydatidiform Moles

Feature Partial Mole Complete Mole

Karyotype Usually 69,XXX or 69,XXY 46,XX or 46,XY

Pathology

Embryo fetus Often present Absent

Amnion, fetal red blood cells Often present Absent

Villous edema Variable, focal Diffuse

Trophoblastic proliferation Variable, focal, slight to Variable, slight to

moderate severe
Clinical presentation

Diagnosis Missed abortion Molar gestation

Uterine size Small for dates 50% large for dates

Theca-lutein cysts Rare 25–30%

Medical complications Rare Frequent

Persistent trophoblastic disease 1–5% 15–20%

clusters from thin pedicles. In contrast, partial molar pregnancy has focal and less
advanced hydatidiform changes and contains some fetal tissues.

Risk factors of molar pregnancy include ethnic origin with increased prevalence in Asians,
Hispanics and American Indians. The strongest risk factors are age and a history of prior
hydatidiform mole. Women at both extreme reproductive age are most vulnerable
specifically adolescents and women 36-40 years old have a twofold risk, but those older
than 40yo have almost 10fold risk.

Pathogenesis Molar pregnancies arise from chromosomally abnormal fertilizations.

Complete moles most often have diploid chromosomal composition. These usually are
46XX and result from androgenesis, meaning both sets of chromosomes are paternal in
origin. An ovum is fertilized by a haploid sperm, which then duplicates its own
chromosomes after meiosis. The chromosomes of the ovum are either absent or
inactivated. Partial moles usually have a triploid karyotype (69XXX , 69 XXY or 69 XYY)
These are each composed of two paternal haploid sets of chromosomes contributed by
dispermy and one maternal haploid set.

Clinical Findings: The clinical presentation of women with a molar pregnancy usually
have 1 to 2 months amenorrhea, and vaginal bleeding. Most cases of molar pregnancy are
diagnosed early due to early prenatal care. Around 41% are asymptomatic and 58% had
vaginal bleeding. Untreated molar pregnancy will almost always cause uterine bleeding
that varies from spotting to profuse hemorrhage. Many women have uterine growth that is
more rapid than expected. The enlarged uterus has a soft consistency and no fetal heart
motion is detected. Severe preeclampsia and eclampsia are relatively common with large
molar pregnancies.

 Clinical presentation:
 1-2 months amenorrhea
 Significant nausea and vomiting
 Uterine bleeding (spotting to profuse)
 Uterine growth more rapid than expected
 Uterus has soft consistency
 No fetal heart motion detected
 Early onset pre-eclampsia

Diagnosis:

1. Serum B-HCG measurements – this is commonly elevated above those expected

fro gestational age.
2. Sonography – This is the mainstay of diagnosis for molar pregnancy.
Sonographically, complete mole appears as an echogenic uterine mass with
numerous aneachoic cystic spaces but without a fetus or amnionic sac. The
appearance is often described as “snowstorm”. A partial mole has features that
include a thickened, muticystic placenta along with a fetus or fetal tissues.

Management: Maternal deaths from molar pregnancy can be avoided with early diagnosis,
timely evacuation and vigilant post-evacuation surveillance for Gestational Trophoblastic
neoplasia. Termination of pregnancy regardless of uterine size, by suction curettage is the
preferred treatment. Hysterectomy is preferable for women who have completed
childbearing. Of women aged 40 and older, approximately a third will subsequently
develop GTN and hysterectomy markedly reduces this likelihood. Regular follow-up
should be done to detect persistent trophoblastic disease. The woman is advised to
prevent pregnancy for a minimum of 6 months. Baseline serum BHCG should be taken then
monitored every 1-2 weeks until normal levels are reached.

ECTOPIC PREGNANCY

Classification: Nearly 95% of ectopic pregnancies are implanted in the various segments
of the fallopian tube and give rise to fimbrial, ampullary, isthmic, or interstitial tubal
pregnancies. The ampulla is the most frequent site, followed by the isthmus. The
remaining 5% of nontubal ectopic pregnancies implant in the ovary, peritoneal cavity,
cervix or prior cesarean section. Occasionally, a multifetal pregnancy is composed of one
conceptus with normal uterine implantation coexisting with one implanted ectopically
known as heterotopic pregnancies.

Risk Factors: Abnormal fallopian tube anatomy underlies many cases of tubal ectopic
pregnancy. Surgeries for a prior tubal pregnancy, for fertility restoration, or for
sterilization confer the highest risk of tubal implantation. The chance of another ectopic
pregnancy is also increased with history of previous ectopic pregnancy. Prior sexually
transmitted disease or other tubal infection, which can distort normal tubal anatomy is
another common risk factor. The use of Artificial Reproductive Treatment (ART) is linked
to increased risk of tubal pregnancy. Smoking is also a known risk factor as well as use of
certain contraceptives that include tubal sterilization, IUD and progestin-only
contraceptives.

Clinical manifestation: The classic presentation is characterized by the triad of delayed

menstruation, pain, and vaginal bleeding or spotting. With tubal rupture, there is usually
severe lower abdominal and pelvic pain that is frequently described as sharp, stabbing or
tearing. There is tenderness during abdominal palpation. Bimanual pelvic examination,
especially cervical motion, causes exquisite pain.

Diagnosis: Physical examination findings, transvaginal sonography, serum BhCG level

measurement are used to diagnose ectopic pregnancy. CBC should be taken because
ruptured ectopic pregnancy can cause anemia. A transvaginal ultrasound is performed to
look for findings indicative of intrauterine or ectopic pregnancy.

Management: Medical treatment using methotrexate can be used in patients that meet the
following criteria: (1) low initial serum B-hCG level (2) small ectopic pregnancy size, and
(3) absent fetal cardiac activity.