BLEEDING IN I TRIMESTER

DR ARPITHA D DEPT OF OBGyn CSIH, BLORE

INTRODUCTION
First trimester bleeding is any bleeding noted during the first 12 weeks of pregnancy, and it is one of the most common symptoms to send a woman to her obstetrician And rightly so, because until a nonthreatening cause is identified, all first trimester bleeding is labeled "threatened miscarriage," or "threatened AB"

ETIOLOGY
The causes of bleeding in early pregnancy are broadly divided into two groups (A) Those associated with the pregnant state (B) Those related to the pregnant state

CAUSES ASSOCIATED TO THE PREGNANT STATE / CAUSES UNRELATED TO MISCARRIAGE

Lesions are unrelated to pregnancy: either pre-existing or aggravated during pregnancy Cervical lesions such as, vascular erosions, polyps, ruptured varicose veins and malignancy are important causes Cervicitis Cervicitis is a condition in which the delicate cells at the mouth of the womb (or the cervix) bleed due to the mechanical action of intercourse, the alteration of acidity in the vagina (pH), or the effects of infections on these cells. There are two causes of Cervicitis: (1) Ectopy (ectropion): With the hormonal changes of pregnancy, the fragile

internal cells peek out a bit onto the external portion of the cervix, which is a harsher environment for them. Normally nestled deeply away from sexual activity and the acidity of the vagina, they can now be battered both chemically and mechanically. They're easily damaged, causing bleeding. It must also be noted that these cells don't normally bleed with sex there is usually a predisposing condition, such as cervicitis. When these internal cervical cells are brought to a more external position, this is called ectopy

(2) Infection: Cervicitis is inflammation due to infection. Yeast is the most common culprit, and a simple prescription or even over-the-counter cream can end this concern quickly. Other infections are more worrisome. Sexually transmitted diseases (STDs), such as gonorrhea, chlamydia, trichomonas, and Gardnella can do the same, so a microscopic evaluation is the best approach rather than just assuming it's yeast. Some infections may be silent for years, meaning that even though there is no question of fidelity in a couple, there may have been an infection long before they even met each other; because of this, cultures for STDs have become standard in all pregnancies

Cervical Polyps Harmless small polyps can also cause bleeding. These are overgrowths of benign tissue, probably owing their existence to estrogen levels that made them grow. Most often they can be gently and painlessly twisted off during a physical exam. If not, they're usually destroyed by the very act of delivering the baby

Periods During Pregnancy Many women ask about having regular periods during their pregnancies. Shedding ones layer of menstrual tissue is not compatible with life. The closest thing we have to this is shedding of decidual tissue (as described above). The cycling of hormones stops because a pregnancy causes the hormone levels to remain high. This is necessary for pregnancy to continue. There are no falls in the hormones, which is what causes a period, except right before labor Although the above instances describe the causes of bleeding that do not indicate miscarriage, miscarriage should still be ruled out if you have any bleeding at all

CAUSES RELATED TO THE PREGNANT STATE

This group relates to miscarriages (95%), ectopic pregnancy (1 in 300 to 1 in 500 ie,0.33-0.2%), hydatiform mole (1 in 400 ie,0.25%) and implantational bleed The other causes are: (A) Subchorionic Hemorrhage This sounds disastrous, but it usually represents a small clot that causes bleeding and then dissolves away harmlessly. Rarely, the clot dissects between the placenta and the attachment to mother and causes a miscarriage

(B) Decidual Tissue Sometimes a small piece of tissue becomes loose and disintegrates through some unknown cause, causing spotting. It's usually a hormonally stimulated collection of menstrual-like tissue that can often be confused with a miscarriage. If it's just tissue debris, it can mean nothing. If it's actual tissue of the pregnancy (fetal or placental), then there should be serious concern, because now this "threatened miscarriage" is re-labeled as "incomplete miscarriage." No one knows why such a phenomenon occurs, but it is harmless. The stabilization of the uterine lining depends on estrogen and progesterone. The tissue is termed decidualized, because of the pregnancy-like effect on it at the hands of estrogen (C) Implantation Bleeding In the past its been thought that an egg eroding into the uterine lining would cause bleeding at the time because of a burrowing effect. Its doubtful whether theres any bleeding when this happens, and if so, it's too small an amount to notice. The myth persists because there are bleeding episodes in which no cause is ever identified and in which the pregnancy goes on successfully to term. Implantation makes sense under these criteria but cant be proven

ABORTIONS / MISCARRIAGES

DEFINITION: Abortion is the termination of pregnancy before the period of viability which is considered to occur at 28weeks. However, for international acceptance, the limit of viability is brought down to 20weeks or the fetus weighing 500g Incidence: 10-20% of all pregnancies end in miscarriages. 75% abortions occur before the 16th week & of these, about 75% occur before the 8th week of pregnancy

CLASSIFICATION OF ABORTIONS
ABORTIONS ------------------------------------------------------------------------------------ SPONTANEOUS INDUCED ------------------------------------------------------ ISOLATED RECURRENT LEGAL ILLEGAL -------------------------------SEPTIC (Common) ------------------------------------------------------------------------------------------- THREATENED INEVITABLE COMPLETE INCOMPLETE MISSED SEPTIC (Uncommon)

ETIOLOGY OF ABORTIONS

Often complex and obscure Usually divided into Ovular or Fetal Maternal environment Paternal factor Unknown

OVO-FETAL FACTORS (60%)

Ovo-fetal factors usually operate in early fetal wastage. Meticulous histological & cytological study of the abortus reveals defects in the ovum or the fetus. The defects include-chromosomal abnormalities (commonest one being autosomal trisomy), gross congenital malformation, blighted ovum (ovum without embryo), & hydropic degeration of the villi Interference with the circulation in the umbilical cord by knots, twists or entanglements may cause death of the fetus & its expulsion Low attachment of the placenta or faulty placental formation (circumvallate) may interfere with placental circulation Twins or hydraminos (acute) by rapidly stretching the myometrium may cause abortion

MATERNAL FACTORS (15%)

These factors usually operate in late abortion leading sometimes to the expulsion of a living fetus which, is too small to survive Maternal illness Viral infection: specially of rubella, cytomegalic inclusion disease produces congenital malformation & abortion if contracted in early weeks of pregnancy. The viruses of hepatitis, parvovirus, influenza have got lethal action on the fetus causing its death & expulsion. Parasitic (Malaria) & protozoal infection (Toxoplasmosis) may produce abortion if contracted in early pregnancy. Spirochaetes hardly produce abortions before 20th week due to the effective thickness of the placental barrier Hyperpyrexia may precipitate abortion by increasing the uterine irritability

Maternal hypoxia & shock: acute or chronic respiratory disease, heart failure, severe anemia or anaesthetic complications may produce anoxic state which may precipitate abortion Chronic illness: hypertension, chronic nephritis, & chronic wasting disease are responsible for late abortions by producing placental infarction resulting in fetal anoxia Endocrine factors: an increased association of abortion is found in conditions of hypothyroidism, hyperthyroidism & diabetes mellitus. Inadequate corpus luteal phase is considered to be related with unsatisfactory ovular growth & development and hence its expulsion Trauma Direct trauma: on the abdominal wall by blow or fall may be related to abortion Psychic: emotional upset or change in environment may lead to abortion by affecting the uterine activity In susceptible individuals even a minor trauma in the form of a journey along a rough road, internal examination in the early months, elicity Hegars sign or sexual intercourse in early months is enough to excite abortion

Cervico-uterine factors These are usually related to second trimester abortions Cervical incompetence: either congenital or acquired is one of the commonest causes for mid-trimester or recurrent abortions Congenital malformations of the uterus: in the form of bicornuate or septate uterus may be responsible for mid-trimester or recurrent abortions Uterine tumor (fibroid): specially of the submucous variety might be responsible not only for infertility but also for abortion due to distortion of the uterine cavity & increased uterine irritability Retroverted uterus per se, is not responsible for abortions but its association might be due to its failure to rectify between 12-14weeks due to adhesions or due to trauma during sexual intercourse or it could be due to disturbance in the uterine vascularity Immunological Presence of autoimmune factors like lupus anticoagulant & antiphospholipid Abs increase the risk of abortion. Autoimmune factors have been identified in cases of recurrent pregnancy losses Blood group incompatibility Incompatible ABO group matings maybe responsible for early pregnancy loss & often recurrent but Rh incompatibility is a rare cause of death of the fetus before 28th week. Couple with group A husband and group O wife have got a higher incidence of abortion Premature rupture of membranes inevitably leads to abortion Dietic factors as in deficiency of folic acid or vitamin E are often held responsible

PATERNAL FACTORS

Defective sperms, contributing half the number of the chromosomes to the ovum, may result in abortion, but is difficult to prove. However, women who abort habitually may have normal pregnancies following marriage with a different man

UNKNOWN (25%)

Inspite of the various mentioned factors, it is difficult in majority cases to pinpoint the cause of abortion in clinical practice Too often, more than one factor is present Immunological causes of abortion have recently gained attention

MECHANISM OF ABORTIONS

In early weeks, death of the ovum occurs first, followed by its expulsion In later weeks, maternal environmental factors are involved leading to the expulsion of the fetus which may have signs of life but is too small to survive Before 8weeks: Ovum surrounded by the villi with the decidual coverings is expelled out in toto Between 8-14weeks: Expulsion of the fetus commonly occurs leaving behind the placenta and the membranes Beyond 14weeks: The process of expulsion is similar to that of a Mini Labour i.e., fetus is expelled first followed by expulsion of the placenta after varying interval

THREATENED ABORTION

Definition: Process of abortion has started but has not progressed to a state from which recovery is impossible Symptoms: Bleeding: usually slight & bright red in color which either stops spontaneously or continues with change of color to brown or dark red or remains as bright red Pain: Bleeding is usually painless but there may be mild backache or dull pain in the lower abdomen. Pain usually appears following hemorrhage Clinical/Pelvic examination: (a) Speculum examination reveals bleeding if any, escapes through the Os (b) Local lesion in the Cx may co-exist (c) Digital examination reveals the closed external Os. In multi-parous, external Os may be patulous but the internal Os must be closed (d) Uterus corresponds to the period of gestation (e) Uterus & Cx feel soft (f) Digital examination can be avoided if USG is available

Investigations: Blood- Hb%, grouping/typing, HIV screening, HBsAg, VDRL. Urine- for pregnancy test (if not confirmed already) Special- (A) TVS: (1) Well formed gestational ring with central echoes from the embryo indicating healthy fetus (2) Observation of fetal cardiac activity ->98% chance of continuation of pregnancy (3) Blighted ovum-loss of definition of the gestational sac, smaller mean gestational sac diameter, absent fetal echoes & absent fetal cardiac movements (B) Serum progesterone: Value of 25ng/ml or more generally indicates a viable pregnancy in about 95% of cases (C) Serial serum HCG: These values are helpful to assess the fetal well-being

Treatment: (A) General measures: Pulse/BP/Temp; W/F bleeding; W/F expulsion of products; Save all pads (B) Sedation/Pain relief: Phenobarbitone (30mg) or Diazepam (5mg) BD (C) Bowel to be left alone No Enema (D) No evidence that treatment with natural progesterone or synthetic progestins improves the prognosis Advice on discharge: Limit strenuous activities for at least two weeks/Coitus is contraindicated during this period Prognosis: In an isolated case, 2/3rd continue beyond 28weeks, remaining either go in for inevitable or missed abortion

INEVITABLE ABORTION

Definition: Type of abortion where the changes have progressed to a state from where continuation of pregnancy is impossible Clinical features: Patient having features of threatened abortion develops, (1) Increased vaginal bleeding (2) Aggravation of pain in the lower abdomen which may be colicky in nature (3) General condition of the pt is proportional to the visible blood loss (4) Products at Os + on P/V examination Management: Uterus < 12weeks: Evacuate without delay-Suction evacuation/D n E/Laminaria tent Uterus > 12weeks: Induction of labour: (1) Oxytocin: 10-20units in 500ml 5%Dextrose @ 30d/min; if fails, 100units in 5% Dextrose @ 30d/min with precaution (2) PGs: More effective (a) 15methyl PGF2alpha IM 250mcg @ Q3H for a max of 10 such doses (b) PGE analog 1mg pessary Q3H insertion to a max of 5 such

RECURRENT ABORTIONS

Definition: Is defined as a sequence of 2 or more consequtive spontaneous abortions. It may be Primary or Secondary (having a previous viable birth) Incidence: Affects approx 1% of all women of the reproductive age group. Risk increases with each successive abortion reaching >30% after 3 consecutive losses Etiology: Often complex & obscure; multi-factorial; factors may be recurrent or non-recurrent (A) Genetics: Recurring aneuploidy of the conceptus/May or may not relate to maternal age/Most common-Balance translocation with a reported prevalence of about 4% in couples with recurrent pregnancy failure (0.2% in normal population) (B) Endocrinal: Poorly controlled diabetes mellitus pt/Presence of thyroid auto-Abs (Thyroid function usually N)/Luteal phase defect/PCOS (elevated LH & androgens) is too often responsible/May be disturbed endometrial PG secretion leading to sub-optimal implantation (C) Infection: Of the genital tract may be responsible for sporadic abortions; Organisms: Mycoplasma/Chlamydia/Bacterial vaginoses/Systemic infections with Toxoplasma & brucella are also implicated (D) Immunological causes: Auto-immunity: Increased circulating LAs & APLAs; Allo-immunity: Failure of maternal recognition of trophoblast lymphocyte reactive Ag (TLX) -> consequently leading to lack of production of block Abs by the mother -> due to sharing of HLA b/n partners (E) Idiopathic: In majority cases, cause remain unknown

MISSED ABORTION

Definition: When the fetus is dead & retained inside the uterus for a variable period, it is known as Missed abortion / Silent miscarriage / Early fetal demise Pathology: Before 12weeks, small repeated hemorrhages occur into the chorioresidual space, disrupt the villi from its attachment. Bleeding is slight & hence does not cause rupture of the decidua capsularis. Clotted blood with the contained ovum is called Blood Mole. By this time, ovum becomes dead & is completely absorbed & the wall becomes fleshy, hence called Fleshy or Carneous Mole Wall looks dark red in color, laminated appearance showing the presence of degenerated villi in the blood clot on microscopic examination Clinical features: Usually present with features of threatened abortion followed by, persistence of brownish vaginal discharge, subsidence of pregnancy symptoms, retrogression of breast changes, cessation of uterine growth, Cx feels firm, immunological test for pregnancy becomes negative, radiological E/O collapsed fetal skeleton if 16weeks, USG reveals an empty sac early in pregnancy or the absence of fetal motion or fetal cardiac activity later in pregnancy Complications: Psychological upset/Infection/DIC/During labour-uterine inertia, retained placenta/PPH Management: Uterus < 12weeks: Evacuate without delay-Suction evacuation/D n E/Laminaria tent Uterus > 12weeks: Induction of labour: (1) Oxytocin: 10-20units in 500ml 5%Dextrose @ 30d/min; if fails, 100units in 5% Dextrose @ 30d/min with precaution (2) PGs: More effective (a) 15methyl PGF2alpha IM 250mcg @ Q3H for a max of 10 such doses (b) PGE analog 1mg pessary Q3H insertion to a max of 5 such

SEPTIC ABORTION
Definition: Any abortion associated with clinical E/O infection of the uterus & its contents is called Septic Abortion Clinical criteria: vary (1) Rise of temperature of at least 100.4F for 24hours or more (2) Offensive or purulent vaginal discharge (3) E/O pelvic infection such a slower abdominal pain & tenderness

Micro-organisms: (A) Anaerobic: Bacteroides /Anaerobic streptococci /Cl welchii /Tetanus bacillus (B) Aerobic: E coli /Klebsiella /Staphylococcus /Psuedomonas /Hemolytic streptococcus (usually exogenous) Mixed infections are common Increased association of sepsis in illegal abortions is due to the fact that (1) Proper antiseptic precautions / asepsis are not followed (2) Incomplete abortion (3) In advent injury to the genital organs & adjacent structures, particularly the gut Pathology: In about 80%, organisms are of endogenous origin & the infection is localized to the conceptus without any myometrial involvement. In about 15%, infection either produces localized endometritis surrounded by a protective leucocytic barrier, or spreads to the parametrium, tubes, ovaries or pelvic peritoneum. In about 5%, there is generalized peritonitis & / or endotoxic shock Clinical features: HISTORY OF ILLEGAL TERMINATION BY AN UNAUTHORISED PERSON IS MOSTLY CONCEALED (1) Pyrexia: assoc with chills/rigors, suggest blood stream spread of the infection; if subnormal temp is present, is an ominous F/O endotoxic shock (2) Pain abdomen: Of varying degrees is almost always present (3) Rising pulse rate: Of 100-200/min or more is a significant finding in pyrexia, even indicates SPREAD OF INFECTION BEYOND THE UTERUS Internal examination: Reveals purulent vaginal discharge or a tender uterus usually with patulous Os or a boggy feel of the uterus with variable pelvic findings depending upon the spread of the infection

Clinical grading Grade I: Localized to the uterus Grade II: Infection spread beyond the uterus to the parametrium, tubes, ovaries or the pelvic peritoneum Grade III: Generalized peritonitis & / or endotoxic shock or jaundice or acute renal failure Grade I & II are the commonest & are usually associated with spontaneous abortions Grade III is almost always assoc with illegal induced abortions

Investigations: Routine: (1) Cervical or HVS prior to digital examination for C/S (2) Blood- Hb%, grouping/typing, TC/ DC (3) Urine R/M & C/S. Special: (1) USG of abdomen/pelvis-detects intrauterine retained products, pyometra, foreign boby, intra or extra uterine free fluid in the peritoneal cavity or POD (2) Blood C/S (3) Serum electrolytes-in the m/m of endotoxic shock (4) Coagulation profile Complications: (A) Immediate: Hemorrhage/Injury to uterus or adjacent organs/Spread of infection-generalized peritonitis,endotoxic shock,actue renal failure,thrombophlebitis (B) Remote: Chronic debility/Chronic pelvic pain or backache/Dyspareunia/Secondary infertility due to tubal block/Emotional depression

Management: Grade I: (A) Antibiotics: (1) Gram positive aerobes: (a) Aq penicillin G 5million units IV Q6H (b) Ampicillin 0.5-1g IV Q6H (2) Gram negative aerobes: (a) Genta 1.5mg/kg IV Q8H (b) Cefuroxime 1.5g IV Q8H (3) Anaerobes: Metronidazole (500mg) IV Q8H or Clindamycin (600mg) IV Q6H (B) Prophylactic ANTI-GAS GANGERENE serum 8000units & 3000units of antiserum IM (C) Analgesics/Sedatives: as need may be (D) Evacuation: As often, abortion is incomplete, evacuation should be done at a convenient time within 24hours following antibiotic therapy Grade II: (A) + (B) + (C) Blood transfusion + (D) Evacuation: To be with-held for at least 48hours of antibiotic therapy + Posterior colpotomy

ECTOPIC PREGNANCY
Defined as one in which the fertilized ovum is implanted & develops outside the normal uterine cavity IMPLANTATION SITES ------------------------------------------------------------------------------------------------------------------------------- EXTRA-UTERINE UTERINE ------------------------------------------------------------------------------------ TUBAL (95%) OVARIAN ABDOMINAL CERVICAL ANGULAR CORNUAL --------------------------------------- PRIMARY SECONDARY ----------------------------------------- INTRA-PERITONEAL EXTRA-PERITONEAL ------------------------------------------------------------------------------------------------------------------------- AMPULLA ISTHMUS INFUNDIBULUM INTERSTITIAL (55%) (25%) (18%) (2%)

TUBAL PREGNANCY (95%)

Incidence: is on the rise Could be due to prevalence of chronic PID, tubal plastic surgeries, IUCD users Varies from 1 in 300 to 1 in 150 deliveries Symptoms: (A) Acute ectopic: Has a classic triad-Amenorrhoea (6-8weeks)/Pain abdomen (Colicky)/Vaginal beed (Slight/Sanguineous/Dark colored/usually continuous) On examination: (1) Pt lies quite/conscious/perspires & looks blanched (2) Pallor usually severe (more than amount of bleeding) (3) F/O shock (4) P/A-abdomen feels tense/tender, shifting dullness may be elicited, gut may be distended, guarding is usually absent (5) P/V-blanched vaginal mucosa, uterus NS/bulky (floats as if in water), CMT / forniceal tenderness +, no mass felt thr the fornix (B) Unruptured ectopic: Short period of amenorrhoea/uneasiness on one side of the flank which is continuous or at times colicky in nature On examination: (1) Bimanual examination reveals, uterus slightly smaller than the period of amenorrhoea showing E/O pregnancy (2) Pulsatile, well circumscribed, small, tender mass may be felt thr one fornix seperated from the uterus (C) Chronic/Old ectopic: Commonest clinical type, met in day to day practice. Is assoc with pelvic hematocoele usually as a result of leaking tube following tubal mole or abortion & rarely following rupture On examination: Similar to acute ectopic Cullens sign: Dark bluish discoloration surrounding the umbilicus, if found, suggests intra-peritoneal hemorrhage

Mode of termination: (A) Tubal mole: Complete absorption/Abortion: Complete/Incomplete=>Pelvic hematocoele (B) Tubal abortion: Complete=>Pelvic hematocoele/Incomplete=>Diffuse intra-peritoneal hemorrhage (DIH) (C) Tubal rupture: Roof=>DIH/Floor=>Intra-ligamentary hematoma Tubal perforation: Roof=>Sec abdominal pregnancy/Floor=>Sec intr-ligamentary pregnancy Continuation of pregnancy: RAREST Diagnosis: (1) Clinical signs/symptoms (2) Investigations: (a) Hb%, AB0 gr & typ, TC/DC, ESR (b) Culdocentesis (c) Estimation of -HCG (i) when 2000IU/L & there is an empty uterine cavity=>ECTOPIC (ii) Failure to double in 48hrs & an empty uterine cavity =>ECTOPIC (d) Serum progesterones in order to avoid serial -HCGs, single progesterone value has been determined; i.e. value >25ng/ml =>S/O INTRA-UTERINE GEST & <5ng/ml=>S/O ECTOPIC or ABNORMAL INTRAUTERINE GEST (3) Laparotomy: (a) Milking of the tube (b) Salphingostomy (c) Salphingotomy (d) Segmental resection

HYDATIFORM MOLE / VESICULAR MOLE

Is a gestational trophoblastic disease (GTD) Definition: It is an abnormal condition of the ovum where there are partly degeneration & partly hyperplastic changes in the young chorionic villi. This results in the formation of clusters of small cysts of varying sizes. Because of its superficial resemblence to hydatid cyst, it is named as hydatiform mole It is best regarded as a benign neoplasm of the chorion with malignant potential Incidence: The highest incidence is in Philippines being 1 in 80 pregnancies& lowest in European countries and USA being 1 in 2000. The incidence, in India is about 1 in 400 Etiology: Appears to be related to the ovular defect, as it sometimes affects one ovum of a twin pregnancy

Prevalence is highest in teenage pregnancies & in those women over 35yrs of age Prevalence varies with race & ethnic origin Faulty nutrition: inadequate intake of high class protein could partly explain its prevalence in Oriental countries. Low dietary intake of carotene is associated with increased risk Increased association of AB blood group which possesses no ABO Ab Cytogenic abnormality: Complete moles have a 46XX karyotype, the molar chromosomes are derived entirely from the father. The ovum nucleus may either absent (empty ovum) or inactivated which has been fertilized by a haploid sperm. It then duplicates its own chromosomes after meiosis. Phenomenon is known as Androgenesis Infrequently the chromosomal pattern may be 46 XY or 45X H/O previous hydatiform mole increases the chance of recurrence (1:80)

Pathology: is principally a disease of the chorion Death of the ovum or the failure of the embryo to grow is essential to develop complete (classic) hydatiform mole The cysts begin to form b/n the 3rd to 5th week when the feto-maternal circulation normally has become established Secretion from the hyperplastic cells & transferred substances from the maternal blood accumulate in the stroma of the villi which are devoid of blood vessels, which results in the distension of the villi to form small cysts Vesicle fluid is interstitial fluid & is almost similar to ascitic or oedema fluid, but rich in HCG B/L lutein cysts are present in about 50% which are due to excessive production of chorionic gonadotrophin. These regress within 2months after expulsion of the mole. The cysts also contain Oestrogen & Progesterone

Clinical features Symptoms: (A) Vaginal bleeding: Commonest presentation (95%). Maybe preceded by a brownish or watery discharge. Blood may be mixed with fluid from ruptured cysts giving the appearance of discharge white current in red colored juice (B) Abdominal pain: May be due to, over distension of the uterus, concealed hemorrhage, rarely perforation of the uterus by an invasive mole, infection or uterine contractions to expel out the contents (C) Constitutional symptoms: Feeling of sickness, Vomiting of pregnancy becomes excessive, Breathlessness (D) Expulsion of grape like vesicles per vaginum is diagnostic of vesicular mole (E) Absence of history of quickening

Signs: (A) Features of early pregnancy (B) Patient looks ill, more than accounted for (C) Pallor is usually prominent, out of proportion to the visible blood loss (concealed blood loss) (D) Features of pre-eclampsia: present in about 50%. This process may be due to over distension of the uterus or more probably due to hyperactivity of the trophoblastic cells (E) P/A: Size of the uterus > than period of gestation in 70% & corresponds in about 20% & smaller in about 10%; feel of the uterus is firm elastic (doughy) which is due to the absence of amniotic fluid sac; fetal parts are not felt; absence of FHS (F) P/V: Internal ballottement absent; Unilateral or bilateral ovarian cysts may be palpable in 25-50%; vesicles in the vaginal discharge is pathognomic of hydatiform mole Investigations: (A) Full blood count, ABO & Rh grouping (B) LFT, RFT & thyroid tests (C) USG: Snow-storm appearance (D) Quantitative estimation of HCG: High HCG titre in urine diluted upto 1 in 200 to 1 in 500 beyond 100 days of gestation is very much suggestive

Differential diagnosis: Threatened abortion/ Fibroid or ovarian tumor with pregnancy/Acute hydraminos or multiple pregnancy

Complications: Immediate: (1) Hemorrhage & shock (2) Sepsis Perforation of the uterus Acute pulmonary insufficiency Coagulation failure Late: Development of choriocarcinoma following hydatiform mole is b/n 2-10% Risk factors (choriocarcinoma): Age > 35, irrespective of parity Parity > 3, irrespective of age Initial HCG levels in urine of over 1,00,000 IU/24hr Histologically proven invasive mole Previous H/O molar pregnancy Woman with blood group A or B & husband group O

Scheme of Management -------------------------------------------------------------------------------------------------------------------------------------------------------------------- In process of expulsion Inert uterus Accelerate evacuation ---------------------------------------------------------------Oxytocin drip + Patient young / Desirous of child >35yrs;Family completed;Invasive mole Suction evacuation Evacuation Hysterectomy Currettage b/n 5-7days Follow-up atleast 2yrs ---------------------------------------------------------------------------------------------------------------------------------- Vaginal (Preferred) Abdominal Hysterotomy (Limited) -----------------------------------------------------------------* Unfavourable Cx * GC poor Cx favourable Unfavourable Cx * Bleeding PV ++ Oxytocin drip + Suction evacuation Slow dilation of Cx + Oxytocin drip + Suction evacuation Currettage Immediately ---------------------------------------------------------------------- Currettage b/n 5-7days -------------------------------------------------------------------------------------------------------- Follow up as a routine atleast 2yrs

Follow up: Routine follow-up is mandatory in all cases for at least 1yr Prime objective to diagnose persistent trophoblastic proliferation that is considered malignant Occurrence of choriocarcinoma is mostly confined to this period Initially check ups are weekly until -HCG in the urine is negative by immunological tests, which usually is b/n 4-6wks Once negative, check ups are once a month up to 1yr Follow up protocol: History/Clinical examination HCG assay Chest radiograph: Atleast monthly until HCG becomes negative; then at 3, 6, 12 months Repeat currettage: Sub-involution of uterus without E/O fall of HCG titre; Continued or re-appearence of irregular bleeding; HCG titre remains positive even after 6wks following evacuation

Contraceptive advice: Advised not to conceive at least for 2yrs Patient can conceive after 12months, following the negative HCG titre IUCD is contraindicated, as its frequent association with irregular bleeding-a feature often co-exists with choriocarcinoma Combined OCPs neither retard HCG normalization nor cause stimulation of trophoblastic tumor OCPs can be started after HCG value has become negative Barrier method can also be followed safely Surgical method of sterilization is another alternative, when ones family is completed