Texila American University

OBSTETRICS AND
GYNAECOLOGY

Dr Yahavivi Aguila Nogueira.

Specialist in Family Medicine.
Specialist in Obstetrics and Gynaecology.
Medical Registrar of MOH
Master in Comprehensive Care to Woman.
Assistant Professor of ISCM Havana. Cuba.
 DIDACTIC LECTURE 2

TOPIC 2

TITLE: COMPLICATIONS OF
PREGNANCY
 SUBTOPIC 2.1

TITLE: OBSTETRICAL
HAEMORRHAGE
 SUMMARY

Abortion.

Ectopic Pregnancy .

Gestational Trophoblastic Disease .

 ABORTION

The word abortion derives from the Latin aboriri—to

miscarry. According to the New Shorter Oxford
Dictionary (2002), abortion is premature birth before
a live birth is possible, and in this sense it is
synonymous with miscarriage. It also means an
induced pregnancy termination to destroy the fetus.
Although both terms are used interchangeably in a
medical context, popular use of the word abortion
by laypersons implies a deliberate pregnancy
termination. Thus, many prefer miscarriage to refer
to spontaneous fetal loss before viability.
 TYPES

• Spontaneous abortion is the most common

complication of pregnancy and is defined as the
passing of a pregnancy prior to completion of the
20th gestational week. It implies delivery of all or
any part of the products of conception, with or
without a fetus weighing less than 500 g.
• Threatened abortion is bleeding of intrauterine
origin occurring before the 20th completed week,
with or without uterine contractions, without
dilatation of the cervix, and without expulsion of the
products of conception.
• Complete abortion is the expulsion of all of the
products of conception before the 20th completed
week of gestation.
 TYPES

• Incomplete abortion is the expulsion of some, but

not all, of the products of conception.
• Inevitable abortion refers to bleeding of intrauterine
origin before the 20th completed week, with
dilatation of the cervix without expulsion of the
products of conception.
• Missed abortion, the embryo or fetus dies, but the
products of conception are retained in utero.
• Septic abortion, infection of the uterus and
sometimes surrounding structures occur.
• Hemorrhagic abortion.
 CAUSES

• FETAL FACTORS: Early spontaneous abortions commonly

display a developmental abnormality of the zygote, embryo,
fetus, or at times, the placenta. Of 1000 spontaneous
abortions analyzed by Hertig and Sheldon (1943), half had a
degenerated or absent embryo. In 50 to 60 percent of
spontaneously aborted embryos and early fetuses,
abnormalities in chromosomal numbers account for most
wastage. Chromosomal errors become less common with
advancing pregnancy and are found in approximately a third
of second-trimester losses but in only 5 percent of third-
trimester stillbirths
 CAUSES

MATERNAL FACTORS:
• Infections: Organisms such as Treponema pallidum,
Chlamydia trachomatis, Neisseria gonorrhoeae,
Streptococcus agalactiae, herpes simplex virus,
cytomegalovirus, and Listeria monocytogenes have been
implicated in spontaneous abortion.
• Diseases: Endocrine disorders such as hyperthyroidism
and poorly controlled diabetes mellitus; cardiovascular
disorders, such as hypertensive or renal disease; and
connective tissue disease, such as systemic lupus
erythematosus, may be associated with spontaneous
abortion.
 CAUSES

MATERNAL FACTORS:
• Uterine Defects: Congenital anomalies that distort or
reduce the size of the uterine cavity, such as unicornuate,
bicornuate, or septate uterus, carry a 25–50% risk of
miscarriage. A diethylstilbestrol (DES)-related anomaly, such
as a T-shaped or hypoplastic uterus, also carries an
increased risk of miscarriage. Acquired anomalies,
particularly submucous or intramural myomas, have been
associated with spontaneous abortions as well. Previous
scarring of the uterine cavity following dilatation and
curettage (D&C; Asherman's syndrome), myomectomy, or
unification procedures has been implicated in spontaneous
miscarriage, as has anatomic or functional incompetence of
the uterine cervix.
 CAUSES

MATERNAL FACTORS:
• Toxic Factors: Agents such as radiation, antineoplastic
drugs, anesthetic gases, alcohol, and nicotine have been
shown to be embryotoxic. Other agents such as lead,
ethylene oxide, and formaldehyde have also been
implicated.
• Others: Trauma, Immunologic disorders, Maternal surgery.
 CLINICAL FEATURING AND TREATMENT

Threatened Miscarriage: Any bloody vaginal discharge or uterine

bleeding that occurs during the first half of pregnancy has
traditionally been assumed to be a threatened. Bleeding is typically
scanty, varying from a brownish discharge to bright red bleeding. It
may occur repeatedly over the course of many days and usually
precedes uterine cramping or low backache. On pelvic examination,
the cervix is closed and uneffaced, and no tissue has passed. The
differential diagnosis includes ectopic pregnancy, molar pregnancy,
vaginal ulcerations, cervicitis with bleeding, cervical erosions,
polyps, and carcinoma.
Women presenting with threatened miscarriage should receive an
ultrasound examination to determine location, viability, and
gestational age. Accurate knowledge of gestational age is necessary
for proper interpretation, as a sonographically empty uterus may
imply an abnormal intrauterine or ectopic pregnancy when it actually
represents a normal early gestation.
• Uterine cramping
• Low Backache
• Bleeding p/v

• Cervix is closed
• Uneffaced
• No tissue
Inevitable and Incomplete Miscarriage: Miscarriage is considered
inevitable when bleeding and cramping is accompanied by gross
rupture of the membranes or cervical dilation. The miscarriage is
incomplete when the products of conception have partially passed
from the uterine cavity, are protruding from the external OS, or are in
the vagina with persistent bleeding and cramping. There is no viable
conceptus in most instances of inevitable or incomplete miscarriages.
Women with incomplete or inevitable miscarriage typically present
with bleeding that can be profuse occasionally and produce
hemodynamic instability. A careful pelvic examination is usually
sufficient to establish the diagnosis, although ultrasound examination
is often performed. Evacuation of the uterus is advisable to prevent
further maternal hemorrhage or infection. Clinically stable patients
can be treated as outpatients by either medical or surgical means.
However, patients with uncontrolled bleeding should be transferred to
the operating room for an examination under anesthesia and
immediate surgical evacuation of the uterus. They should be
observed postoperatively for several hours and discharged when
considered stable.
• Uterine cramping
• Low Backache
• Bleeding p/v intense

• Cervix is opened
• Effaced
• Tissue are passing
• Amniotic fluid
 • Curettage
• Suction
• D&E

• Misoprostol
• Oxytocin
Complete Miscarriage: Patients followed for a threatened
miscarriage should be instructed to save all tissue passed for
later inspection. When the entire products of conception have
passed, pain and bleeding soon cease. If the diagnosis is
certain, no further therapy is necessary. In questionable cases,
ultrasound is useful to confirm an empty uterus. In some cases,
curettage may be necessary to be sure that the uterus is
completely evacuated. Removal of remaining necrotic decidua
decreases the incidence of bleeding and shortens the recovery
time.
Missed Miscarriage
The reason that expulsion of a dead conceptus does not occur
despite a prolonged period is uncertain. The patient's symptoms of
pregnancy typically regress, quantitative β-hCG levels fall, and no
fetal heart motion is detected by ultrasound. While most patients
eventually abort spontaneously, and coagulation defects due to
retention of the conceptus are rare, expectant management is
emotionally trying, and many women prefer to have the uterus
evacuated. Either medical or surgical evacuation of uterine contents
is acceptable. In the second trimester, the uterus can be emptied by
dilation and evacuation (D&E) or induction of labor with intravaginal
prostaglandin E2 (PGE2) or misoprostol. D&E is an extension of the
traditional dilation and curettage (D&C) and vacuum curettage. It is
especially appropriate at 13 to 16 weeks gestation, although many
proponents use.
this procedure through 20 weeks. The cervix is usually first prepared
by using misoprostol or passively dilated with laminaria to avoid
trauma, and the fetus and placenta are mechanically removed with
suction and instruments.
Septic Miscarriage
Septic abortion, once a leading cause of maternal mortality, has
become less frequent, primarily because of changes in abortion
laws making pregnancy terminations more easily available to
women with unwanted pregnancies. However, any type of
spontaneous miscarriage can also be complicated by
endometritis, which can progress to parametritis and peritonitis.
The clinical presentation typically includes fever, abdominal
tenderness, and uterine pain.
Septicemia and shock may occur if the local infection is left
untreated. The polymicrobial infection mirrors the endogenous
vaginal flora and includes Escherichia coli and other aerobic,
enteric, gram-negative rods, group B-hemolytic streptococci,
anaerobic streptococci, Bacteroides species, staphylococci,
and microaerophilic bacteria.
Recurrent Miscarriage
Recurrent miscarriage (RM), traditionally defined as three or
more consecutive first-trimester spontaneous losses, affects up
to 1% of couples. Primary RM is diagnosed in women without
any prior successful pregnancy, while secondary RM refers to
those whose repetitive losses follow a live birth. There is no
specific classification for women who have multiple
miscarriages interspersed with normal pregnancies. It is
generally agreed that a workup for possible causes of RM is
indicated in most patients after two or three consecutive
miscarriages.
 ECTOPIC PREGNANCY

The blastocyst normally implants in the endometrial lining of

the uterine cavity. Implantation anywhere else is considered
an ectopic pregnancy. It is derived from the Greek ektopos—
out of place. According to the American College of
Obstetricians and Gynecologists (2008), 2 percent of all first-
trimester pregnancies in the United States are ectopic, and
these account for 6 percent of all pregnancy-related deaths.
The risk of death from an extrauterine pregnancy is greater
than that for pregnancy that either results in a live birth or is
intentionally terminated. Moreover, the chance for a
subsequent successful pregnancy is reduced after an
ectopic pregnancy. With earlier diagnosis, however, both
maternal survival and conservation of reproductive capacity
are enhanced.
TYPES
 D
DD RISK FACTORS
D
II
I
• Tubal damage and infection.
• Previous ectopic pregnancy.
• Cigarette Smoking.
• Intrauterine devices.
• Infertility.
• Tubal corrective surgery.
 D
DD DIAGNOSIS
D
II
I
• Pain.
• Abnormal bleeding.
• Abdominal and pelvic tenderness.
• Uterine changes and adnexal mass.
• Syncope .

Amenorrhea
 D
DD
D DIAGNOSIS
II
I
• HCG
• Abdominal US
• TV US.
• Laparoscopy.
• Culdocentesis.
 D MANAGEMENT
DD
D
II
I
• Expectant.
• Medical.
• Surgical.
 GESTATIONAL TROPHOBLASTIC
SIGNOS DE ALTA DISEASE.
PROBABILIDAD
The term gestational trophoblastic disease refers to a spectrum of
pregnancy-related placental tumors. Gestational trophoblastic disease is
divided into molar and nonmolar tumors. Nonmolar tumors are grouped
as gestational trophoblastic neoplasia. The American College of
Obstetricians and Gynecologists (2004) terms these as malignant
gestational trophoblastic disease. Although these tumors are
histologically distinct and have varying propensities to invade and
metastasize, it became evident during the 1970s that histological
confirmation was not necessary to provide effective treatment. Instead, a
system was adopted based principally on clinical findings and serial
serum measurements of human chorionic gonadotropin (-hCG). A
number of schemas have been used over the past 30 years to classify
these tumors on the basis of malignant potential, and to direct clinical
staging and optimal treatment. The International Federation of
Gynecology and Obstetrics (FIGO) trophoblastic disease classification
scheme is frequently used. When these management algorithms are
followed, most gestational tumors—both benign and malignant—are
eminently curable
 CLASSIFICATION.

Hydatidiform mole:
• Complete.
• Incomplete.
Gestational Trophoblastic Neoplasia:
• Invasive mole.
• Choriocarcinoma.
• Placental site trophoblastic tumor.
 ESSENTIALS OF DIAGNOSIS.

• Uterine bleeding in first trimester.

• Absence of fetal heart tones and fetal structures.
• Rapid enlargement of the uterus or uterine size
greater thanEssentials
anticipatedofbyDiagnosis
dates.
• human chorionic gonadotropin (-hCG) titers
greater than expected for gestational age.
• Vaginal expulsion of vesicles.
• Hyperemesis gravidarum.
• Theca lutein cysts.
• Onset of preeclampsia in the first trimester.
 MANAGEMENT

• Evacuation by suction.
• Methotrexate + Folinic A
• HCG following.
• Hysterectomy.
THANKS