_molar pregnancy性葡萄胎妊娠课件

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 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 A d 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 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. Therapeutic abortion when it is performed to: 1.save the life of the pregnant woman 2.preserve the womans physical or mental health 3.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. An elective abortion: When it is performed at the request of the woman “for reasons other than maternal health or fetal disease. 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. 1. History Mild vaginal bleeding. No abdominal pain or mild abdominal pain 2.Examination Good general condition. The cervix is closed The uterus is usually the correct size for date 3.U/S which is essential for the diagnosis Showed the presence of fetal heart activity 1.Reassurance If fetal heart activity is present, 90% of cases will be progressed satisfactorily 2.Advice: Decrease physical activity (bed rest is of no therapeutic value) avoid intercourse 3.Hormones i.e. Progesterone 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 g, 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. 4.Post-abortion management. 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 20mm , an empty gestational sac with no fetal echoes seen . It is treated in a similar way to missed abortion . Spontaneous or induced termination of a pregnancy in which the mothers 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. 1.Haemorrhage . 2. Complication related to surgical evacuation ie E&C and D&C. 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 & Ashermans syndrome. Excessive curettage which may lead to Adenomyosis 3. Rh- iso immunisation if the anti D is not given or if the dose is inadequate . 4.Psychological trauma . In cases of incomplete, inevitable, complete, missed & septic abortions 1.Support: from the husband, family& obstetric staff 2.Anti D to all Rh ve, nonimmunised patients, whose husbands are Rh+ve 3. Counseling & explanation: A.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 . 3. Counseling & explanation: B. 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 C. 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 3.Counseling & explanation: D. 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 E. 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 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(24 weeks gestation) with all others ending in loss Incidence : occurs in about 1% of women of reproductive age . Causes Idiopathic recurrent abortion, in about 50%, in which no cause can be found . The known causes include the followings : 1.Chromosomal disorders: Fetal chromosomal abnormalities & structural abnormalities Parental balanced translocation 2. Anatomical disorders: Cervical incompetence: congenital and aquired Uterine causes: submucous fibroids, uterine anomalies & Ashermans syndrome Causes 3. Medical disorders: Endocrine disorders : diabetes , thyroid disorders , PCOS & corpus luteum insufficiency . Immunological disorders : Anticardiolipin syndrome & SLE. Thrombophilia: congenital deficiency of Protein C&S 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 Diagnosis : 1.History : Previous abortions : gestational age and place of abortions & fetal abnormalities. Medical history : DM , thyroid disorders, PCOS, autoimmune diseases & thrombophilia. 2.Examination : General : weight , thyroid & hair distribution Pelvic: cervix ( length & dilatation ) and uterine size. Diagnosis : 3.investigations : A. 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 ) Diagnosis : 3.investigations : B. Investigations for anatomical disorders: TV/US: fibroids, cervical incompetence & PCOS. Hystroscopy or HSG, fibroids, cervical incompetence, uterine anomalies & Ashermans syndrome C.Investigations for chromosomal disorders: Parental karyotyping: Parental balanced translocation. Fetal karyotyping: Fetal chromosomal anomalies. Management: 3.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 Management: 3.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. Pr