OBSTETRICS 2
BLEEDING IN THE FIRST HALF OF PREGNANCY
Therese Beriña-Mallen, MD
First Shift: August 15, 2018
Table of Contents
REMEMBER
G
TEXTBOOK
&
EDITOR
!
I. ABORTION ......................................................................... 1
A. Pathogenesis .............................................................. 1
Majority of the content are lifted from Dra. Mallen’s PPT with a
little bit of handpicked items from Williams 25th ed. There are
some changes in the latest edition so if you are using a
previous trans, try to cross-reference it with Williams 25th ed.
When in a rush, skip to the last page for the summary.
Happy studying!
B. Fetal Factors .............................................................. 1
C. Maternal Factors ........................................................ 2
D. Classification of Abortion ............................................ 2
E. Classification of Spontaneous Abortion ...................... 2
F. Early Pregnancy Loss ................................................. 3
G. Induced Abortion | & (not discussed) ....................... 3
H. Recurrent Abortion ..................................................... 4
I. Incompetent Cervix ...................................................... 4
J. Septic Abortion ............................................................ 4
I. ABORTION
II. ECTOPIC PREGNANCY ................................................... 5
A. Heterotropic Pregnancy .............................................. 5
B. Risk Factors ............................................................... 5
C. Outcomes ................................................................... 5
D. Clinical Manifestations ............................................... 5
E. Differential Diagnosis for Abdominal Pain in Pregnancy
F. Diagnosis .................................................................... 6
5
• Spontaneous or induced termination of pregnancy before
fetal viability | & (new definition from Williams 25th ed)
• Defined as spontaneous or induced termination
of pregnancy (old definition from Williams 24th ed)
o Prior to 20 weeks AOG or
o With a fetus weighing <500g
• Bleeding is most predictive risk factor for pregnancy loss |
&G
G. Threatened Abortion vs Ectopic Pregnancy............... 6
H. Dead fetus .................................................................. 6
I. Medical Management .................................................. 6
J. Surgical Management ................................................. 7
III. GESTATIONAL TROPHOBLASTIC DISEASE ................ 8
A. Classification .............................................................. 8
B. Strongest Risk Factors ............................................... 8
C. Racial Predilection ..................................................... 8
D. Epidemiology and Risk factors | & ........................... 8
E. Partial vs Complete Mole ........................................... 8
F. Clinical Manifestations ................................................ 8
G. Diagnosis ................................................................... 8
H. Sonography ................................................................ 8
I. Pathology | & ............................................................. 9
J. Management | & ........................................................ 9
K. Molar Pregnancy Termination .................................... 9
L. Gestational Trophoblastic Neoplasia .......................... 9
M. FIGO Staging for GTN ............................................. 10
N. Modified WHO Prognostic Scoring System .............. 10
O. HIGH YIELD SUMMARY ......................................... 11
A. Pathogenesis
• More than 80% of spontaneous abortions occur within the
first 12 weeks of gestation | &
Bleeding into the decidua basalis following fetal death
(recall that the decidua basalis is the deepest layer in the
pregnant endometrium)
↓
Necrosis of adjacent tissues
↓
Uterine contractions initiated
↓
Expulsion
B. Fetal Factors
• Abortions due to fetal factors usually occur < 8-10 weeks
• Most aneuploid abortions (95%) occur because of
maternal gametogenesis errors
• Incidence of euploid abortions increases after maternal age
35 | G
o Euploid pregnancies abort later than aneuploid ones | &
• Monosomy X (45, X) or Turner Syndrome
o Single most frequent specific chromosomal abnormality
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C. Maternal Factors
• Abortions due to maternal factors occur at a later time > 810 weeks
• Central factor is stress | G
o Stress promotes the release of CRH which causes the
uterus to lose its quiescent state | G
• Age (>35)
• Infections
• Medical disorders (poorly controlled DM, thyroid disease,
obesity, SLE)
• Cancer and its treatment (radiotherapy, chemotherapy)
• Surgical procedures
o Uncomplicated procedures performed during early
pregnancy are unlikely to increase abortion risk
o Exception: early removal of corpus luteum or the ovary in
which a tumor resides
• Nutrition
o Obesity raises pregnancy loss rates
o Sole deficiency of one nutrient or moderate deficiency of
all does NOT appear to increase risk
o Underweight is NOT associated with greater risk
• Social and behavioral factors
o Regular and heavy alcohol intake
o Cigarette smoking
o > 5 cups of coffee/day
• Occupational and environmental factors
o Bisphenol A, phthalates, polychlorinated biphenyls, and
dichlorodiphenyltrichloroethane or DDT; radiation
exposure, nitrous oxide)
• Uterine defects (eg. myoma)
D. Classification of Abortion
• Spontaneous - most occur prior to 12 weeks
o Threatened
o Inevitable
o Incomplete
o Complete
o Missed
• Induced
• Recurrent
• Septic - abortion complicated by infection
E. Classification of Spontaneous Abortion
• Remember the clinical presentation (uterine size, cervix
closed/dilated) and management | !
1. Threatened Abortion
a. Clinical presentation
§
§
§
§
§
Lower abdominal/hypogastric crampy pain/discomfort
Bloody vaginal discharge/vaginal bleeding
Cervix closed | G
Uterine size is compatible with AOG based on LMP | G
Subchorionic hemorrhage may also be a sign | G
b. Management
§ Bed rest | G
* Why bed rest? Lying in a supine position may
decrease the pressure of gravity on the uterus and
implanted fetus. It is also important to address the
other problems which may have caused the bleeding
(eg. infection) | !
* In practice, they sometimes give tocolytics but the
primary management is still BED REST | G
§ Acetaminophen-based analgesia will help relieve
discomfort from cramping | &
§ Hematocrit and blood type is determined. if there is
significant anemia or hypovolemia, perform evacuation
(but if fetus is live, some opt for transfusion and further
observation)
2. Inevitable Abortion
o Preterm premature rupture of membranes (PPROM) at a
previable gestational age
a. Clinical presentation
§
§
§
§
(+) bleeding, pain
(±) fever
(+) cervical dilatation | G
Gross rupture of membranes | G
b. Confirmation of membrane rupture
§ A gush of vaginal fluid seen pooling during sterile
speculum examination confirms the diagnosis
* May lumabas na fluid through the cervix after bearing
down or Valsalva maneuver | !
§ In suspected cases:
* (+) ferning
* pH > 7.0
* Oligohydramnios on sonography
* AF Positive for proteins placental alpha microglobulin1 and insulin growth factor binding protein-1
§ According to Dra. Mallen, in practice, the best measure
is the physical evidence of the fluid pooling at the cul
de sac | G
c. Management
§ Uterine evacuation | G
* No choice but to evacuate the uterus because the
membranes have ruptured! This is a point of no return
as membrane rupture puts the woman at risk for
infection, specifically chorioamnionitis | !
3. Incomplete Abortion
o If <10 weeks, fetal and placental parts expelled together
o If >10 weeks, separately (thus, tissue may remain entirely
within the uterus or partially extrude through the cervix)
a. Clinical presentation
§ (+) bleeding, pain
§ (+) cervical dilatation | G
* The cervix remains dilated because there are still
some tissues left in the uterus. The uterus is not yet
done with its job of expelling its contents and may
ilalabas pa so the ‘door’ (cervix) remains open | !
§ (+) passage of placental (“meaty”) tissues | G
§ Uterine size usually smaller than expected based on
LMP
* Because some of its contents have already been
expelled | !
b. Management
§ Completion curettage | G
* Completion curettage is preferred because it may take
time for the uterus to respond to the uterotonics
eventually making the woman prone to infection | !
§ Medical (Misoprostol)
§ Expectant
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c. Disadvantages of medical and expectant management
§ Unpredictable bleeding (anemia due to blood loss)
§ May eventually end up doing curettage
§ Deferred in clinically unstable women or those with
uterine infection
4. Complete Abortion
a. Clinical presentation
§ (+) heavy bleeding, pain
§ (+) cervix closed | G
* The cervix is now closed because ALL of the fetus
has been expelled. :( The uterus has fulfilled its job
and wala na siyang mabubuga so the ‘door’ (cervix) is
now closed
§ (+) passage of placental (“meaty”) tissues | G
§ Uterine size either normal or slightly enlarged
b. To confirm diagnosis
§ Patient presents to you the expelled placental tissues or
collapsed sac
§ On TVS, minimally thickened endometrium without a
gestational sac | G
§ Serial B-hCG levels drop quickly with complete abortion
Table 1| Percentage decline following complete
spontaneous abortion (nice to know only)
Initial ß-HCG (mIU/ml) By Day 2 By Day 4 By Day 7
50
68
78
88
100
68
80
90
300
70
83
93
500
71
84
94
1000
72
86
95
2000
74
88
96
3000
74
88
96
4000
75
89
97
5000
75
89
97
c. Management
§ Reassurance/Observe | G
5. Missed Abortion
o Dead products of conception retained for days to months
in utero, with a closed cervical os
* According to Dra. Mallen, basically, tinamad yung
uterus. Ideally, the uterus expels the fetus when it
dies. But since tinamad yung uterus, it DID NOT
contract and the dead fetus remained in uterus with a
CLOSED cervix. If left untreated, the woman may
have an infection or worse, progress into DIC | !
o Currently, missed abortion is used interchangeably with
early pregnancy loss/wastage
b. Diagnosis
§ Diagnosis is imperative prior to intervention and avoids
interruption of a potentially live IUP | &
§ Rapid confirmation of fetal death is possible with VS
and serial ß-HCG
* Primary tool: transvaginal ultrasound | &
* Check via UTZ for fetal heart tone | G
§ Mean death-to-abortion interval is 6 weeks
c. Management
§ Dilation & curettage | G
* Mechanical dilators (eg. laminaria) or PGE may be
used to dilate the cervix | !
* Mechanical is faster acc. to Dra. Mallen | !
F. Early Pregnancy Loss
• A nonviable, intrauterine pregnancy (IUP) with either:
o An empty gestational sac or
o A gestational sac containing an embryo or fetus without
fetal heart activity within the first 12 6/7 weeks of gestation
1. Criteria for diagnosis of early pregnancy loss
o Acc. To Dra. Mallen, no need to study this daw, pang-
fellow level na daw ito | !
a. Sonographic findings
§ CRL ≥ 7 mm and no heartbeat
§ MSD ≥ 25 mm and no embryo
§ An initial US scan shows a gestational sac with yolk
sac, and after ≥ 11 days no embryo with heartbeat is
seen
§ An initial US scan shows a gestational sac without yolk
sac, and after ≥ 2 weeks no embryo with heartbeat is
seen
G. Induced Abortion | & (not discussed)
• Medical or surgical termination of pregnancy before the time
of fetal viability
1. Types of Induced Abortion
a. Therapeutic abortion
§ Termination for medical indications (most frequent:
prevent birth of fetus with significant anatomical,
metabolic, or mental deformity)
§ Based on our med ethics class: NOT ETHICAL
b. Elective/voluntary abortion
§ Interruption of pregnancy before viability at the request
of the woman, but not for medical reasons
§ Also NOT ETHICAL
a. Clinical presentation
§ Early part of pregnancy appeared to be normal (with
signs and symptoms related to intrauterine pregnancy)
§ After embryonic death, spontaneous miscarriage will
eventually ensue
§ Cervix closed | G
§ If kamamatay lang ng fetus, the uterine size may still be
compatible with AOG. If there is a longer interval, mas
maliit na ang uterus | !
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H. Recurrent Abortion
• Aka Recurrent Pregnancy Loss/Habitual Abortion
• Defined as 2 or more consecutive abortions confirmed by
sonographic or histopathological examination | G& (new
definition from Williams 25th ed)
1. Types of Recurrent Abortion
a. Primary RPL
§ Multiple losses in a patient who has never delivered a
liveborn
b. Secondary RPL
§ Multiple losses in a patient with prior live birth
2. Etiology
o Three widely accepted causes of RPL | &
§ Parental chromosomal abnormalities
§ Antiphospholipid antibody syndrome
§ Structural uterine abnormalities
o Genetic factors usually result in early embryonic losses |
&
o Autoimmune or uterine anatomical abnormalities are more
likely cause 2nd trimester losses | &
Table 2| Factors implicated in recurrent pregnancy losses
ETIOLOGY
EXAMPLES
• Balanced Translocation
Chromosomal
• Robertsonian Translocation
abnormalities
• Mosaicism
• Asherman’s Syndrome
Anatomical
• Myomas | G
factors
• Congenital malformations
Immunological
• APAS (Antiphospholipid Antibody Syndrome)
factors
• Alloimmune factors
• Uncontrolled DM
Endocrine
• Hypothyroidism
factors
• Luteal phase defect
I. Incompetent Cervix
• Aka Cervical Insufficiency | &
• Painless cervical dilatation in the second trimester | G &
• Can be followed by prolapse and ballooning of membranes
into the vagina and expulsion of an immature fetus | &
1. Risk factors
o Previous cervical trauma
§ Dilatation and curettage
§ Conization (excision of cervical tissue)
§ Cauterization
2. Diagnosis
o TVS
§ Cervical length < 2.5 cm
§ Funneling (ballooning of the membranes into a dilated
internal os but with closed external os)
Figure 1 | Cervical funnel shapes
3. Management
o Cerclage (ideally between the 12th-14th week AOG)
o Surgical indications:
§ Unequivocal hx of 2nd trimester painless delivery
(prophylactic cerclage)
§ Physical finding of early dilation of the internal cervical
os (may be an indicator of insufficiency)
§ Funneling on TVS
o With imminent abortion or delivery, the suture should be
removed at once because uterine contractions can tear
through the uterus or cervix
Figure 2 | Cerclage for incompetent cervix
J. Septic Abortion
• Acc. to Dra. Mallen, septic abortion may complicate all the
other types of abortion discussed above. However, this is
more common in induced abortions (esp. in unsterile
settings), and inevitable abortions.
• Abortion complicated by infection (uterine, parametrial,
peritoneal, sepsis, endocardial)
o Most bacteria causing septic abortion are part of the
normal vaginal flora | &
o Particularly worrisome are severe necrotizing infections
and toxic shock syndrome caused by group A
streptococcus (S. pyogenes) | &
1. Clinical presentation and diagnosis
• (+) post-abortal fever, foul smelling discharge/bleeding
• Cervix dilated; (+) uterine and/or adnexal tenderness
• Ancillary: TVS, CBC, C/S
2. Management
o Curettage, if there are retained products of conception
o Broad-spectrum IV antibiotics
o Intensive care, if necessary (septic shock)
3. Prophylaxis
o Doxycycline, 100mg 1 hour prior to evacuation; 200 mg
post evacuation
§ Doxcycline is used because it covers Chlamydia | G
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II. ECTOPIC PREGNANCY
• Implantation of the blastocyst in areas other than the
endometrial lining
• Sites:
o Tubal (fimbrial, ampullary, isthmic, interstitial) – 95%
§ Ampulla (70%) is the most frequent site
§ Followed by isthmic (12%), fimbrial (11%), and
interstitial tubal pregnancy (2%) | &
o Abdominal
o Intraligamentous
o Ovarian
o Cervical
o Cesarean Scar
D. Clinical Manifestations
• Classic triad
o Missed menses
o Pain (sharp, stabbing, or tearing) | &
o MINIMAL vaginal bleeding or spotting
• (±) Passage of decidual cast
o Sloughed endometrium that takes the shape of the
endometrial cavity | &
1. Unruptured Ectopic Pregnancy
o Uterus slightly enlarged due to hormonal stimulation
o Adnexal mass
o Tenderness on palpation of the lower abdomen and
adnexa
o Cervical motion tenderness
2. Ruptured Ectopic Pregnancy
o Severe lower abdominal pain
o Direct/rebound tenderness, board-like rigidity all point to an
acute abdomen secondary to a tubal rupture | G
o On PE:
Figure 3 | Sites of ectopic pregnancy
Generalized tenderness on palpation of the abdomen
Cervical motion tenderness (“wiggling tenderness”)
Bulging cul de sac (because of hemoperitoneum)
Pain in the neck or shoulder, especially on inspiration
(indicates diaphragmatic irritation secondary to sizable
hemoperitoneum)
§ Hypotension, tachycardia and pallor may present only
when hypovolemia becomes significant
§
§
§
§
A. Heterotropic Pregnancy
• A multifetal pregnancy composed of one conceptus with
normal uterine implantation coexisting with one implanted
ectopically
B. Risk Factors
•
•
•
•
•
•
Prior tubal surgery - greatest risk factor! | G
Tubal infection (PID/STD)
Salpingitis
Previous tubal pregnancy
Peritubal adhesions (appendicitis, endometriosis)
Smoking (has an effect that reduces the peristaltic
movement of the fallopian tubes, slowing down the travel of
the fertilized egg to the uterus) | G
• Infertility and ART use
• Salpingitis isthmica nodosa - epithelium-lined diverticula
extend into a hypertrophied muscularis layer | &
• Congenital fallopian tube anomalies, secondary to in utero
diethylstilbestrol exposure | &
E. Differential Diagnosis for Abdominal Pain in Pregnancy
UTERINE
•
•
•
•
Miscarriage
Abortion
Infection
Enlarging or
degenerating
myoma
[leiomyomas]
• Molar pregnancy
• Round-ligament
pain
ADNEXAL
• Ectopic pregnancy
• Complicated
ovarian mass
(ruptured, torsed,
hemorrhagic)
NON-GYNE
•
•
•
•
Appendicitis
Cystitis
Gastroenteritis
Urolithiasis
C. Outcomes
• Tubal Rupture
o Early rupture – isthmic (narrowest portion) | G
o Late rupture – interstitial | G
• Tubal Abortion
o Common in fimbrial and ampullary tubal pregnancies
o According to Dra. Mallen, this type may subside on its own
o Uncommonly, an aborted fetus will implant on a peritoneal
surface and become an abdominal pregnancy | &
• Pregnancy Failure with Resolution
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F. Diagnosis
• Clinical findings
• CBC
o For ruptured ectopic pregnancy, Hgb and Hct levels do not
usually reflect the hemodynamic status of the patient until
after several hours later
• TVS
• B-hCG if TVS results are nonconclusive
• Laparoscopy
Figure 5 | Ring of fire
1. Interpreting B-hCG levels
o Discriminatory zone – 1500 mIU/mL
§ ABOVE the discriminatory zone
* Plus failure to visualize an intrauterine pregnancy on
ultrasound = ECTOPIC pregnancy (or a non-viable
pregnancy)
§ BELOW the discriminatory zone
* Do serial B-hCG determinations (every 2 days)
* If values double every 2 days: live intrauterine
pregnancy
* If values decrease according to anticipated patterns:
failing intrauterine pregnancy
* Otherwise, it is ectopic pregnancy
G. Threatened Abortion vs Ectopic Pregnancy
• Both may present with missed menses, pain and vaginal
bleeding
• PROMPT diagnosis of ectopic pregnancy is of utmost
importance
• Means of ascertaining an INTRAUTERINE pregnancy:
o TVS: demonstration of intrauterine gestational sac rules
out ectopic pregnancy
o Serial B-hCG: doubling time every 48 hours
o Serum progesterone level
§ < 5 ng/mL: dying pregnancy/ectopic pregnancy
§ > 20 ng/mL: healthy pregnancy
• TVS
o Gestational sac 4.5 weeks B-hCG 1500-2000 mIU/mL
o Yolk sac
5.5 weeks 10mm GS diameter
o Embryo
5-6 weeks embryonic length 1-2mm
o Fetal ❤ activity 6-6.5 weeks embryonic length 1-5mm
MSD 13-18mm
H. Dead fetus
Figure 4 | Expected rate of decline in B-hCG levels for failing
pregnancies
2. TVS Findings in Ectopic Pregnancy
a. Endometrial findings
o Thickened endometrium, usually trilaminar
o Decidual cyst
o Pseudogestational sac
b. Adnexal findings
o Visualization of an inhomogenous complex adnexal
mass separate from the ovary; or an extrauterine
gestational sac/yolk sac with or without an embryo
o With Doppler imaging, “ring of fire” is demonstrated
(representing placental blood flow at the periphery of the
mass) | G
c. Cul de sac
o Anechoic or hypoechoic fluid in the cul de sac may signify
hemoperitoneum (as little as 50ml can be detected by
TVS)
• No embryo within a sac with a mean sac diameter (MSD) of
16-20mm (>20mm)
• No cardiac activity in a 5-mm embryo (>10mm)
• Be wary of a pseudogestional sac which may be seen in
ectopic pregnancies
o Intrauterine fluid accumulation (possibly blood)
I. Medical Management
• Methotrexate (folic acid antagonist) | G
• For UNRUPTURED ectopic pregnancy | G
• Patient should be asymptomatic, compliant, motivated
1. Criteria for patient selection |
o Initial B-hCG level < 1000 mIU/mL
§ Single best prognostic indicator of successful treatment
with single-dose MTX | &
o Ectopic mass size < 3.5cm
o Absent fetal cardiac activity (for ethical reasons)
o Rationale: The larger the size or the higher is the hCG
level, the longer it may take for treatment to be successful.
That’s why a low hCG and a size of <3.5 cm is preferred. |
!
3. Culdocentesis
o Has been largely replaced by TVS
o Used to diagnose presence of hemoperitoneum
o Fragments of old clots or non-clotting blood indicate a
hemoperitoneum
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J. Surgical Management
• Either via Laparoscopy or Laparotomy
o Laparoscopy is the preferred surgical treatment for
ectopic pregnancy unless the patient is hemodynamically
unstable | &
1. Salpingostomy
§ Size < 2cm
* Preserving that portion of the tube if the size is > 2 cm
will only predispose the woman to future ectopic
pregnancies! | G
§ Location: distal third of the fallopian tube
§ Linear incision made on the antimesenteric border,
contents evacuated, and incision is left unsutured to
heal by secondary intention | G
2. Salpingotomy
§ Same as salpingostomy except that the incision is
closed by suturing
3. Salpingectomy
§ For ruptured and unruptured cases
* Primarily for ruptured ectopic pregnancies | G
§ Entire length of the affected tube is removed
§ Complete excision to minimize recurrence of pregnancy
in the tubal stump
SALPINGECTOMY
• Ruptured
• Live ectopic, even
if unruptured
SALPINGOTOMY/
SALPINGOSTOMY
• Unruptured
• Distal third of FT
• < 2 cm size
LAPAROSCOPY
• Unruptured
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POSTPARTUM HEMORRHAGE
III. GESTATIONAL TROPHOBLASTIC DISEASE
A. Classification
1. Hydatidiform mole (+) villi
F. Clinical Manifestations
• Missed menses, irregular bleeding, passage of grape-like
molar tissues
o Complete mole
o Partial mole
o Invasive mole (GTN)
2. Non-molar trophoblastic neoplasm (-) villi
o Choriocarcinoma (GTN)
o Placental site trophoblastic tumor (GTN)
o Epithelioid trophoblastic tumor (GTN)
• Hydatidiform moles: excessively edematous immature
placentas | &
• Invasive mole: deemed malignant due to marked
penetration and destruction of the myometrium and its ability
to metastasize | &
• Histological confirmation is not used to diagnose and treat
GTNs. Instead, measurement of serum hCG levels
combined with clinical findings are utilized. They are
effectively treated as a group. | &
B. Strongest Risk Factors
• Both extremes of reproductive age
o Adolescents
o Women >40 (10-fold risk)
• History of molar pregnancy
C. Racial Predilection
• Asians, Hispanics, American Indians
D. Epidemiology and Risk factors |
• Adolescents, and women aged 36-40 y/o → two-fold risk
• > 40 y/o → almost 10x risk
E. Partial vs Complete Mole
• One difference is that in a PARTIAL mole, there may still be
some embryonal tissue, hence may show fetal heart tones
on UTZ | G
Figure 6 | Grape-like appearance
• Symptoms tend to be more pronounced with complete mole
than partial moles | G&
o High hCG levels account for possible HPN and tachycardia
(because of the thyrotropin like effects of HCG) | G
• Complete mole
o Uterus soft/boggy consistency; usually larger than dates
o No FHT appreciated
o Cystic ovarian masses may be palpated (theca-lutein
cysts)
o Medical complications include thyrotoxicosis, early-onset
pre-eclampsia, hyperemesis
o Complete moles have a greater chance to develop into a
malignancy | G
G. Diagnosis
• Clinical findings
• B-hCG
o High values can lead to erroneous false-negative urine
pregnancy test results, termed a “hook effect,” wherein
excessive b-hCG hormone levels oversaturate the assay’s
targeting antibody and create a falsely low reading (this is
especially true for complete moles) | &
• Sonography
• Histopathology
H. Sonography
• Mainstay of trophoblastic disease diagnosis
• Complete mole
o Echogenic uterine masses with numerous anechoic cystic
spaces (“snowstorm appearance”) | G
o NO fetus or amniotic sac
• Partial mole
o Thickened multi-cystic placenta along with a fetus or fetal
tissue | G
• Most common mimics: incomplete or missed abortion | &
• Molar pregnancy may be confused for a multifetal
pregnancy or uterine leiomyoma w/ cystic degeneration | &
Figure 7| L: Sagittal view of complete hydatidiform mole,
with ‘snowstorm’ appearance; R: Partial hydatidiform mole
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POSTPARTUM HEMORRHAGE
I. Pathology | &
• Surveillance for subsequent neoplasia following molar
pregnancy is crucial
• Before 10 weeks, villi may still not be enlarged
• Molar stroma may not yet be edematous and avascular
• Immunohistochemical staining for p57 expression enhances
histopathological evaluation
• p57(KIP2): nuclear protein whose gene is paternally
imprinted and maternally expressed
• Strongly expressed in normal placentas, pregnancy losses
with hydropic degeneration, and partial hydatidiform moles
(the three can be distinguished by molecular genotyping)
• Complete moles: contain only paternal genes; does not take
up the stain
J. Management |
• Preoperative evaluation attempts to identify known potential
complications such as:
o Preeclampsia,
o hyperthyroidism,
o anemia,
o electrolyte depletions from hyperemesis, and
o Metastatic disease
• Chest radiography: most recommended
K. Molar Pregnancy Termination
1. Evacuation of uterine contents by suction curettage
o Preferred treatment since it’s faster | G
o Cervix must be dilated to accommodate the suction curette
(hygroscopic dilator/laminaria is frequently used) (typically
10-14mm diameter)
o As evacuation is begun, oxytocin is infused to limit
bleeding
o If bleeding continues, other uterotonic agents are given
(methylergonovine, misoprostol) | &
2. Hysterectomy with ovarian preservation
o For women > 40 (completed childbearing)
§ The ovaries are preserved to prevent unwanted effects
of “surgical menopause” due to low estrogen levels (eg.
cardiovascular diseases, osteoporosis) | G
o Theca-lutein cysts seen at the time of hysterectomy do not
require removal; they spontaneously regress following
molar termination
3. Post-evacuation surveillance for GTN (serial B-hCG)
o Post-evacuation prophylactic chemotherapy to prevent
persistent GTD is NOT recommended
o Initial B-hCG within 48 hrs after evacuation as baseline for
further tests
o Subsequent determinations done at 1-2 week intervals
until b-hCG levels are undetected
§ After 7 weeks for PARTIAL moles
§ After 9 weeks for COMPLETE moles
o Monthly B-hCG for 6 months thereafter
o Prevent new pregnancy during this period. It will interfere
with B-hCG monitoring
• If a woman has not become pregnant but B-hCG levels
increase or remain persistently plateaued at high levels, this
signify increasing trophoblastic proliferation that is most
likely malignant. | &
•
L. Gestational Trophoblastic Neoplasia
• Aka Malignant GTD or Persistent GTD
• Follows
o H moles in 50%
o Abortion or ectopic pregnancy in 25%
o Term or preterm pregnancy in 25%
• Invades the myometrium; metastasizes
1. Risk Factors for GTN
o Prior Complete mole
§ Hydatidiform mole > Ectopic > Term/Preterm pregnancy
o Older age
o B-hCG > 100,000 mIU/mL
o Theca-lutein cysts >6 cm
o Slow decline in b-hCG
2. Examples of GTN
a. Invasive mole
§ Most common GTN that follows an H-mole | G
§ Characterized by extensive tissue invasion
trophoblast and whole villi | &
§ Locally aggressive but less prone to metastasize
by
b. Gestational Choriocarcinoma
§ Most common GTN that follows an abortion or a term
pregnancy | G
§ Contains no villi
§ Most common sites of metastasis: vagina, lungs
§ Metastases often develop early and generally bloodborne | &
c. Placenta site trophoblastic tumor
§ Associated with only moderately elevated B-hCG
§ Preferred treatment is hysterectomy because tumor is
usually resistant to chemotherapy | &
d. Epithelioid trophoblastic tumor
§ Main site: uterus
§ Typical findings: low hCG levels and bleeding | &
3. Clinical Findings
o Irregular bleeding (continuous or intermittent) associated
with uterine subinvolution
o May present with massive intraperitoneal hemorrhage
following myometrial perforation from trophoblastic growth
4. Diagnosis
o Plateau
of serum B-hCG level (+10%) for four
measurements during a period of 3 weeks or longer – days
1,7,14,21
o Rise of serum b-hCG level > 10% during 3 weekly
consecutive measurements or longer, during a period of 2
weeks or more days 1,7,14
o Serum B-hCG level remains detectable for 6 months or
more
o Histological criteria for choriocarcinoma
o It is stressed that diagnosis is usually made by persistently
elevated serum B-hCG levels without confirmation of
tissue study | &
o Additional laboratory procedures ff diagnosis of GTN:
§ CBC, SGPT, SGOT, BUN, Crea
§ TVS
§ CXR or Chest CT
§ Cranial CT or MRI
§ Abdominal CT
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POSTPARTUM HEMORRHAGE
5. Treatment
N. Modified WHO Prognostic Scoring System
a. Chemotherapy
§ Single-agent
* Methotrexate or Actinomycin-D
* For low-risk, non-metastatic neoplasia
§ Multi-agent
* EMA-CO (Etoposide, Methotrexate, Actinomycin-D,
Cyclophosphamide, Oncovicin/Vincristine)
* For high-risk disease
b. Hysterectomy
* For PSTT and ETT, which are generally resistant to
chemotherapy
o Serosurveillance should be done for 1 year following
undetectable B-hCG levels
o Women who have completed GTN chemotherapy are
advised to delay pregnancy for 12 months | &
M. FIGO Staging for GTN
o FIGO=International
Federation
of
Gynecology
and
Obstetrics
STAGE
STAGE 1
STAGE 2
STAGE 3
STAGE 4
DESCRIPTION
Disease confined to the uterus
GTN extends outside of the uterus but is limited
to the genital structures (adnexa, vagina, broad
ligament)
GTN extends to the lungs, with or without known
genital tract involvement
All other metastatic sites
SCORES
Age
Antecedent
pregnancy
Interval after
index
pregnancy
(mo.)
Pretreatment
serum b-hCG
(mIU/mL)
Largest tumor
size incl.
uterus
Size of
metastases
Number of
metastases
Previously
failed
chemotherapy
drugs
STAGE 1
0
<40
1
> 40
2
-
4
-
Mole
Abortion
Term
-
<4
4-6
7-12
>12
<103
103 – 104
104– 105
> 105
<3cm
3-4cm
>5cm
-
-
Spleen,
kidney
GI
Liver,
brain
-
1-4
5-8
>8
-
1
>2
Disease confined to the uterus
GTN extends outside of the uterus but is limited
STAGE 2
to the genital structures (adnexa, vagina, broad
ligament)
GTN extends to the lungs, with or without known
STAGE 3
genital tract involvement
STAGE 4
All other metastatic sites
• LOW RISK = WHO score of 0-6
• HIGH RISK = WHO score of >7
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POSTPARTUM HEMORRHAGE
O. HIGH YIELD SUMMARY
TYPE
CLINICAL PRESENTATION
PE FINDINGS
Threatened
Vaginal bleeding with or without
hypogastric pain
“Spotting”
Closed cervix
Uterus enlarged to AOG
Inevitable
Incomplete
Complete
Missed
Septic
Unruptured
ectopic
Ruptured
ectopic
Molar
Gross rupture of membranes
No passage of products of
conception
History of watery vaginal discharge
Passage of meaty tissues
Vaginal bleeding
Hypogastric pain
Passage of “meaty” tissues
Vaginal bleeding
Hypogastric pain
No passage of “meaty” tissues
+/- Vaginal bleeding
+/- Hypogastric pain
May symptoms then nawala | !
Fever
Foul vaginal discharge
History of instrumentation
Stable BP
Wiggling tenderness
Lower abdomen & adnexal
tenderness
Hypotension (hypovolemia)
Wiggling tenderness
Generalized tenderness
Passage of “grape-like” tissues
Dilated cervix
Uterus enlarged to AOG
Dilated cervix
Uterus smaller to AOG
Closed cervix
Uterus normal-sized
Closed cervix
Uterus enlarged to AOG
or smaller than AOG
ULTRASOUND FINDINGS
Live, intrauterine pregnancy
(fetal pole, gestational sac
within the endometrial cavity)
Subchorionic hemorrhage
Live, intrauterine pregnancy
Products of conception/
Placental tissues still seen
within the endometrial cavity
Minimally-thickened
endometrial lining without
gestational sac
Dead fetus within the
endometrial cavity
MANAGEMENT
Bed rest
Expectant
management →
Curettage
Antibiotic coverage
Completion
curettage
Reassurance
Dilatation and
curettage
Curettage,
IV antibiotics,
Intensive care
Doxy prophylaxis
Methotrexate or
Laparoscopy or
Salpingostomy or
Salpingotomy
Dilated cervix
Uterine and/or adnexal
tenderness
-
Closed cervix
Uterus slightly enlarged
Adnexal mass
Pseudogestional sac
“Ring of fire”
Fluid in the culdesac
(hemoperitoneum)
-
Salpingectomy
“Snowstorm” appearance, no
fetus (complete)
Suction curettage
or
Hysterectomy with
ovarian
preservation for
>40 y/o
Uterus enlarged,
soft/boggy
Thickened multicystic
placenta with fetus
(incomplete)
- END -
REFERENCES
• PPT from Dra. Mallen
• Williams 25th ed
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