First Trimester BleedingFirst Trimester Bleeding

Prepared By :Prepared By :Ass,Professor Dr Fahmi El-UriAss,Professor Dr Fahmi El-Uri

MB,ChB(Hons), MRCOG,FRCOGMB,ChB(Hons), MRCOG,FRCOG

First Trimester Bleeding First Trimester Bleeding Causes;Causes;

11 - -Spontaneous abortion / miscarriage Spontaneous abortion / miscarriage 2- Ectopic pregnancy2- Ectopic pregnancy

33--Trophoblastic diseaseTrophoblastic disease 44 - -Cervical polypsCervical polyps 55 - -Friable cervixFriable cervix 66 - -TraumaTrauma 77 - -Cervical cancerCervical cancer

First Trimester Laboratory TestsFirst Trimester Laboratory Tests

11 - -Quantitative Quantitative ββhCGhCG a- Correlate with gestational age& U/Sa- Correlate with gestational age& U/S

b- 2 measurements,2days apart-doublingb- 2 measurements,2days apart-doubling c- Falling or plateauing ,signal problemc- Falling or plateauing ,signal problem

22 - -ProgesteroneProgesterone a- < 5ng/ml likely predicts poor outcomea- < 5ng/ml likely predicts poor outcome b- > 25 ng/ml associated with living IUPb- > 25 ng/ml associated with living IUP

Lab & Ultrasound correlatesLab & Ultrasound correlatesGestational Gestational

age by age by LMPLMP

TAS TAS AbdominalAbdominal

scanscan

TVSTVS VaginalVaginal

scanscan

Serum Serum ββhCGhCG

mIU/mlmIU/ml

> >55 weeksweeks NoneNonePossible Possible gestational gestational

sacsac

15001500

5-65-6 weeksweeks Gestational Gestational sacsac

Gestational Gestational sac,yolk sac,yolk

sacsac

4000-60004000-6000

77 weeksweeks 5-10mm 5-10mm embryoembryo

Same as Same as TAS with TAS with

FHFH

< <20,00020,000

Indications for First Trimester Indications for First Trimester UltrasoundUltrasound

11 - -Suspect miscarriage or fetal deathSuspect miscarriage or fetal death 22 - -Vaginal bleedingVaginal bleeding 33 - -Gestational age (uncertain dates )Gestational age (uncertain dates ) 44 - -Adjunct to procedures ( e.g. CVS )Adjunct to procedures ( e.g. CVS ) 55 - -Suspected multiple gestationSuspected multiple gestation 66 - -suspected hydatidiform molesuspected hydatidiform mole 77 - -suspected ectopic pregnancysuspected ectopic pregnancy 88 - -IUD localizationIUD localization 99 - -Evaluation of maternal pelvic massesEvaluation of maternal pelvic masses

First Trimester UltrasoundFirst Trimester Ultrasound - -Best when performed in combination with Best when performed in combination with

history,physical examination & relevant history,physical examination & relevant laboratory testslaboratory tests

- -Often used as primary tool in evaluating Often used as primary tool in evaluating first trimester complicationsfirst trimester complications

- -Transvaginal and transabdominal should Transvaginal and transabdominal should be obtainedbe obtained

MiscarriageMiscarriage

11 . .A variety of terms have been used to describe A variety of terms have been used to describe and define early pregnancy lossand define early pregnancy loss

22 . .We have to differentiate between abortion & We have to differentiate between abortion & miscarriagemiscarriage

33 . .Abortion Abortion means terminate of unwanted means terminate of unwanted pregnancies by a variety of methods , and illegal pregnancies by a variety of methods , and illegal abortion has been the source of considerable abortion has been the source of considerable maternal morbidity and mortalitymaternal morbidity and mortality

MiscarriageMiscarriageDefinitionDefinition

The loss of an early pregnancy is the commonest The loss of an early pregnancy is the commonest medical complications of the first trimester of medical complications of the first trimester of pregnancypregnancy

Many conceptions are lost during the first month Many conceptions are lost during the first month after the last menstrual period and are often after the last menstrual period and are often ignored, particularly if they occur around the time ignored, particularly if they occur around the time

of an expected menstrual periodof an expected menstrual period

DefinitionsDefinitions 11 - -Spontaneous miscarriageSpontaneous miscarriage

Involuntary loss during the first 20 weeksInvoluntary loss during the first 20 weeks

22 - -Threatened miscarriageThreatened miscarriage Uterine bleeding, closed cervix, no productsUterine bleeding, closed cervix, no productsof conception passedof conception passed

33 - -Incomplete miscarriageIncomplete miscarriage

Some , but not all , products have passedSome , but not all , products have passed

44 - -Inevitable miscarriageInevitable miscarriage Cervix dilated , products not passedCervix dilated , products not passed

Definitions ( continue )Definitions ( continue )

55 - -Missed miscarriageMissed miscarriage Fetus dead, but no tissue passed, cervix Fetus dead, but no tissue passed, cervix

closedclosed . .66 - -Septic miscarriageSeptic miscarriage

Incomplete miscarriage with ascending Incomplete miscarriage with ascending infectioninfection . .

77 - -Blighted ovumBlighted ovum Identifiable sac & placental tissue, but no Identifiable sac & placental tissue, but no

embryoembryo . .

Definitions ( continue )Definitions ( continue )

88 - -Subchorionic hemorrhageSubchorionic hemorrhage Blood between chorion and uterine wallBlood between chorion and uterine wall . .

99 - -DeciduaDecidua Endometrium of pregnancy that is frequently Endometrium of pregnancy that is frequently

passed as part of a miscarriagepassed as part of a miscarriage . .When the decidua is passed intact it is When the decidua is passed intact it is called a called a decidual castdecidual cast, which often , which often

signifies an ectopic pregnancysignifies an ectopic pregnancy. .

Pathophysiology of miscarriagePathophysiology of miscarriage

11 - -Major genetic anomalyMajor genetic anomaly At least one half of all spontaneous miscarriages are the result of a At least one half of all spontaneous miscarriages are the result of a major genetic anomaly , trisomy,triploidy or monosomymajor genetic anomaly , trisomy,triploidy or monosomy

22 - -Internal environmental factorsInternal environmental factors Uterine : anomalies, leiomyomata, incompetent cervixUterine : anomalies, leiomyomata, incompetent cervix

Maternal diethylstillbestrol ( DES ) exposureMaternal diethylstillbestrol ( DES ) exposure Luteal phase defectLuteal phase defect Immunologic factorsImmunologic factors

33 - -External environmental factorsExternal environmental factors Tobacco, alcohol, cocaineTobacco, alcohol, cocaine

IrradiationIrradiation InfectionInfection

Occupational chemical exposureOccupational chemical exposure

44 - -Advanced maternal ageAdvanced maternal age

Clinical course of miscarriageClinical course of miscarriage

11 - -Missed menses, pregnancy symptomsMissed menses, pregnancy symptoms 22 - -Positive Positive ββhCGhCG

33 - -Vaginal bleedingVaginal bleeding 4- 4- ββhCG falls or plateaus hCG falls or plateaus

55 - -Lower abdominal cramping, backacheLower abdominal cramping, backache 66 - -Products of conception passedProducts of conception passed

Physical ExaminationPhysical Examination

11 - -Abdominal examAbdominal exam Pain location , rebound, distensionPain location , rebound, distension

22 - -Speculum examSpeculum exam

To assess cx dilatationTo assess cx dilatation To rule out non-uterine causes of bleedingTo rule out non-uterine causes of bleeding

33 - -Bimanual examBimanual exam To assess uterine size, adnexal massesTo assess uterine size, adnexal masses

Fetal Heart tonesFetal Heart tones

Listen after 9-10 weeks with DopplerListen after 9-10 weeks with Doppler Sensitivity enhanced by elevating uterus Sensitivity enhanced by elevating uterus during bimanual examduring bimanual exam

Management of MiscarriageManagement of Miscarriage

11 - -50%50% loss when bleeding presentloss when bleeding present 22 - -Presence of FHTs reassuringPresence of FHTs reassuring 33 - -Majority do not require medical or surgical Majority do not require medical or surgical

interventionintervention 44 - -Identify patients at risk for bleeding, Identify patients at risk for bleeding,

infectioninfection55 - -Address contraceptive needsAddress contraceptive needs

Ectopic PregnancyEctopic Pregnancy

Pregnancy outside the uterus , usually in thePregnancy outside the uterus , usually in theFallopian tubeFallopian tube . .

Occurs in >1:100 pregnanciesOccurs in >1:100 pregnancies . . Second most common cause of M. MortalitySecond most common cause of M. Mortality..

Early diagnosis criticalEarly diagnosis critical ! !

DefinitionDefinition It is a gestation that implants outside the It is a gestation that implants outside the

endometrial cavityendometrial cavity . .<<95%95% of ectopic pregnancies implant in of ectopic pregnancies implant in

various anatomic segment of ‘ fallopian various anatomic segment of ‘ fallopian tube includingtube including ; ;

1%1% in the interstitialin the interstitial 5%5% in the isthmicin the isthmic

85%85% in the ampullary portionin the ampullary portion 9%9% in the infundibular & fimbrial portionin the infundibular & fimbrial portion . .

Other sites of ectopicOther sites of ectopic

Other less sites of ectopic pregnancies areOther less sites of ectopic pregnancies are;;The ovary , cervix , the peritoneal cavityThe ovary , cervix , the peritoneal cavity. .

IntroductionIntroductionThe Diagnosis & management of ectopic The Diagnosis & management of ectopic pregnancy has undergone a revolution a century pregnancy has undergone a revolution a century after Lawson after Lawson TaitTait successfully performed a successfully performed a laparotomy to ligate ‘broad ligament& remove a laparotomy to ligate ‘broad ligament& remove a ruptured tube in 1883(Tait 1884)ruptured tube in 1883(Tait 1884)..

Improved technology allows to diagnose ectopic Improved technology allows to diagnose ectopic pregnancy before it ruptures thus making less pregnancy before it ruptures thus making less invasive treatment possibleinvasive treatment possible,,

Resulting in reduced Maternal Mortality andResulting in reduced Maternal Mortality andMorbidityMorbidity . .

IncidenceIncidence 11 - -In USA deaths due to ectopic pregnancy was In USA deaths due to ectopic pregnancy was

9% of all maternal deaths in 1992and its 9% of all maternal deaths in 1992and its incidence has apparently increased fourfold incidence has apparently increased fourfold (from 4.5 to 20/1000pregnancies between 1970 (from 4.5 to 20/1000pregnancies between 1970 & & 1992(Centers of Disease Control1992(Centers of Disease Control 19951995 ) )

22 - -In UK it represent 4.2% of Maternal death in In UK it represent 4.2% of Maternal death in 1991-1993, its incidence apparently doubling 1991-1993, its incidence apparently doubling between 1973-75 and1991-93 (from 4.9 to 9.6 between 1973-75 and1991-93 (from 4.9 to 9.6 per 1000pregnancies) per 1000pregnancies) Department ofDepartment of Health1994Health1994..

Risk factors for EctopicRisk factors for Ectopic1- History of previous ectopic pregnancy1- History of previous ectopic pregnancy2-Prior tubal surgery 2-Prior tubal surgery 3-Prior tubal infection 3-Prior tubal infection 4-Progestin-only contraception4-Progestin-only contraception5-Contraceptive IUD 5-Contraceptive IUD 6- In utero Diethylstilbestrol(DES) exposure6- In utero Diethylstilbestrol(DES) exposureMany occur in women with no risk Many occur in women with no risk

factors!factors!

Clinical PresentationClinical PresentationIt can vary from vaginal spotting of old blood It can vary from vaginal spotting of old blood

to vasomotor shock with to vasomotor shock with hematoperitoneum.hematoperitoneum.

The classic triad of ;The classic triad of ;a- Delayed menses ,a- Delayed menses ,B- Irregular vaginal bleeding ,B- Irregular vaginal bleeding ,C- Abdominal pain ,C- Abdominal pain ,The above is not commonly encountered The above is not commonly encountered

( speroff el al 1994 ) ( speroff el al 1994 )

General ExaminationGeneral Examination

A- Pulse rate & blood pressure , because in A- Pulse rate & blood pressure , because in vascular instability BP is low ,fainting, vascular instability BP is low ,fainting, dizziness and rapid Heart rate .dizziness and rapid Heart rate .

B- Shoulder pain , occurs due to blood B- Shoulder pain , occurs due to blood irritating the diaphragm as a result of irritating the diaphragm as a result of rupture ectopic causing intra-abdominal rupture ectopic causing intra-abdominal bleeding .bleeding .

Gynaecological ExaminationGynaecological Examination

Speculum or Bimanual examination must be Speculum or Bimanual examination must be performed in Hospital because it may lead performed in Hospital because it may lead to rupture of the tube .to rupture of the tube .

Diagnosis of EctopicDiagnosis of Ectopic11 - -Failure of Failure of ββhCG to double in 48 hourshCG to double in 48 hours

22 - -Low serum progesteroneLow serum progesterone33 - -Ultrasound ( transvaginal )Ultrasound ( transvaginal )

a- IUP rules out ectopica- IUP rules out ectopic b- No gestational sac+b- No gestational sac+ββhCG>1500, highlyhCG>1500, highly

suggestivesuggestive c- Gestational sac/embryo outside of uterus confirms c- Gestational sac/embryo outside of uterus confirms

ectopicectopic d- Pitfalls: pseudogestational sac,ruptured corpus luteumd- Pitfalls: pseudogestational sac,ruptured corpus luteum

44 - -Laparoscopy – gold standardLaparoscopy – gold standard

Extrauterine signs of EctopicExtrauterine signs of Ectopic

Finding Risk of EctopicFinding Risk of EctopicNo mass or free fluid 20%No mass or free fluid 20%Any free fluid 71%Any free fluid 71%Echogenic mass 85%Echogenic mass 85%Moderate to large amount of fluid 95%Moderate to large amount of fluid 95%Echogenic mass with fluid 100%Echogenic mass with fluid 100%

CuldocentesisCuldocentesisThe test is used to exclude hemoperitoneum The test is used to exclude hemoperitoneum which is associated with ruptured ectopic which is associated with ruptured ectopic pregnancy, therefore it is not useful in pregnancy, therefore it is not useful in

detecting an early ectopic pregnancydetecting an early ectopic pregnancy. . 1818 or 20 gauge needle passed through the or 20 gauge needle passed through the

posterior fornix to aspirate for fluidposterior fornix to aspirate for fluid. . Bloody fluid with hematocrit >15%representsBloody fluid with hematocrit >15%represents

active intraperitoneal bleedingactive intraperitoneal bleeding. . TVS has replaced nowadays culdocentesisTVS has replaced nowadays culdocentesis..

hCG & Vaginal ultrasoundhCG & Vaginal ultrasound

hCGhCG can be detected in the urine as early as can be detected in the urine as early as 14days(Post conception), by sensitive 14days(Post conception), by sensitive enzyme-linked immunosorbent assays enzyme-linked immunosorbent assays (detection limits 25-40IU/L, and sensitivity (detection limits 25-40IU/L, and sensitivity

98%-100%)98%-100%). . It can be detected in the serum 5-9 days It can be detected in the serum 5-9 days post-conception by immuno-radioactive post-conception by immuno-radioactive assaysassays..

hCG ( Continue )hCG ( Continue )Between 2-4 weeks after ovulation serum hCG Between 2-4 weeks after ovulation serum hCG levels double approximately every levels double approximately every 2days(48hours) in normal pregnancy ,and a 2days(48hours) in normal pregnancy ,and a lesser increase ( <66% over 48 hours) is lesser increase ( <66% over 48 hours) is associated with ectopic pregnancy and associated with ectopic pregnancy and

spontaneous abortionspontaneous abortion. . However,15%of normal pregnancy will have an However,15%of normal pregnancy will have an abnormal doubling time and 13% of ectopic abnormal doubling time and 13% of ectopic

pregnancy will have a normal doubling timepregnancy will have a normal doubling time. .

CONTINUECONTINUE

Therefore in order to increase the sensitivity of Therefore in order to increase the sensitivity of Quantitative hCG ,a discriminatory zone Quantitative hCG ,a discriminatory zone DZDZ has has been described whereby a titre of 1000-been described whereby a titre of 1000-1500IU/L will be associated with the presence of 1500IU/L will be associated with the presence of an INTRA-UTERINE sac on transvaginal Scan an INTRA-UTERINE sac on transvaginal Scan and 4500-6500 IU/L for trans-abdominal Scanand 4500-6500 IU/L for trans-abdominal Scan..

In multiple pregnancy the Discriminatory zone In multiple pregnancy the Discriminatory zone would be a little higher, requiring an extra 2-3 would be a little higher, requiring an extra 2-3

days for a sac to become visibledays for a sac to become visible. .

CONTINUECONTINUE11 - -The demonstration of a viable IUP does not The demonstration of a viable IUP does not

exclude ‘ possibility of exclude ‘ possibility of HeterotopicHeterotopic Pregnancy Pregnancy frequency 1 in 30,000 eventfrequency 1 in 30,000 event. .

22--TVS( Transvaginal scan), has resulted in the TVS( Transvaginal scan), has resulted in the diagnosis of normal & abnormal pregnancy diagnosis of normal & abnormal pregnancy approximately 1 week earlier than using Trans approximately 1 week earlier than using Trans abdominal scan TASabdominal scan TAS..

In Ectopic there are an empty uterus,pseudo-sac, In Ectopic there are an empty uterus,pseudo-sac, a tubal ring ( doughnut or bagel sign) with fluid in a tubal ring ( doughnut or bagel sign) with fluid in

the pouch of douglasthe pouch of douglas. .

Management Of Ectopic Management Of Ectopic PregnancyPregnancy

11 - -Expectant ManagementExpectant Management22 - -Medical ManagementMedical Management 33 - -Surgical ManagementSurgical Management

Expectant ManagementExpectant Management

Criteria includeCriteria include: : a- Minimal pain or bleedinga- Minimal pain or bleeding

b- Reliable follow-upb- Reliable follow-up c- No evidence of tubal rupturec- No evidence of tubal rupture

d- d- ββhCG < 1000 and fallinghCG < 1000 and falling e- Adnexal mass < 3cm, or not detectede- Adnexal mass < 3cm, or not detected

f- No embryonic heart beatf- No embryonic heart beat

Medical Management:Medical Management:MethotrexateMethotrexate

11 - -Safe, effective ,less costly than surgerySafe, effective ,less costly than surgery 22 - -Equal or better fertility preservationEqual or better fertility preservation

33 - -Criteria for useCriteria for use: : Stable vital signs , few symptomsStable vital signs , few symptoms

No contraindication to drugNo contraindication to drug Unruptured ectopicUnruptured ectopic

Absence of embryonic heart activityAbsence of embryonic heart activity Ectopic mass ≤ 4cmEctopic mass ≤ 4cm

ββhCG levels < 5000 mIU/mlhCG levels < 5000 mIU/ml

Methotrexate DosingMethotrexate Dosing

11--Single dose IM regimen with 1mg/kg or 50mg/m²Single dose IM regimen with 1mg/kg or 50mg/m²Obtain Obtain serum serum ββhCGhCG on 4 on 4thth & 7 & 7thth day post- day post-treatment ( fall 15% should be expected )& treatment ( fall 15% should be expected )& continue follow up until level reaches 5mIU/ml in continue follow up until level reaches 5mIU/ml in 3-4 weeks3-4 weeks

22--Serum progesteroneSerum progesterone, a drop to 1.5mg/ml , a drop to 1.5mg/ml means successful treatment & usually occurs by means successful treatment & usually occurs by about 2-3 weeksabout 2-3 weeks

33--Surgical consultationSurgical consultation if we need more than one if we need more than one dosedose

Surgical ManagementSurgical Management Mainstay of treatmentMainstay of treatment

-Conservative Conservative – conservation of tube– conservation of tube-ExtirpationExtirpation removal of tube removal of tube -Criteria for selecting surgeryCriteria for selecting surgery

- Unstable vital signs or hemoperitoneumUnstable vital signs or hemoperitoneum- Uncertain diagnosisUncertain diagnosis

- Advanced ectopic pregnancyAdvanced ectopic pregnancy - Unreliable follow-upUnreliable follow-up

- Contraindication to expectant or methotrexate Contraindication to expectant or methotrexate managementmanagement

Gestational Trophoblastic DiseaseGestational Trophoblastic DiseaseGTDGTD

Definition It is a term commonly applied to a spectrum of inter-related diseases originating from

the placental trophoblast

Trophoblastic DiseaseTrophoblastic DiseaseGestational trophoblastic disease , has three basic Gestational trophoblastic disease , has three basic configurationsconfigurations::

A- A- CompleteComplete hydatidiform mole hydatidiform moleB- B- PartialPartial mole mole

C- C- MoleMole recurrencerecurrence → → metastatic metastatic choriocarcinomachoriocarcinoma..

GTDGTD is an occasional cause of first trimester is an occasional cause of first trimester bleeding & should be considered in the bleeding & should be considered in the

differential diagnosis until proven otherwisedifferential diagnosis until proven otherwise. .

GTD ( Continue )GTD ( Continue )

Complete hydatidiform moleComplete hydatidiform mole It consists of placental proliferation in theIt consists of placental proliferation in the absence of a fetus. The placental villi areabsence of a fetus. The placental villi are

swollen & often resemble bunches of swollen & often resemble bunches of grapesgrapes..

Most complete moles have a 46XX Most complete moles have a 46XX chromosomal composition , all derived chromosomal composition , all derived from paternal sourcesfrom paternal sources

ContnueContnue

Partial Mole; This refers to molar placenta occuring together with a fetus , which is usually non-viableGenetic testing usually reveals triploidy

)69 XXY( Partial mole is less common than a complete mole & carries a lower risk of recurrence

Recurrence 0f trophoblastic Recurrence 0f trophoblastic diseasedisease

AAbout 20% 0f women with a complete mole will experience recurrence in the form of mole that invades the myometrium or becomes aggressively metastatic (metastatic choriocarcinoma)

EpidemiologyEpidemiology

GTDGTD occurs in the USA at a rate of in one in 1000 occurs in the USA at a rate of in one in 1000 to 1500 pregnancies, in Asian women in the to 1500 pregnancies, in Asian women in the USA ( 1 in 800 )USA ( 1 in 800 )Higher incidence in Asia ( Taiwan 1in every 125 to Higher incidence in Asia ( Taiwan 1in every 125 to 200 pregnancies )200 pregnancies )

Two factors predispose to trophoblastic diseaseTwo factors predispose to trophoblastic disease : : A- Pregnancy at the extremes of reproductive A- Pregnancy at the extremes of reproductive life( specially women over 45) B- Previous molar life( specially women over 45) B- Previous molar

diseasedisease

Clinical ManifestationsClinical Manifestations 11--Vaginal bleeding 1Vaginal bleeding 1stst/early 2/early 2ndnd trimester trimester

Which is often dark in colorWhich is often dark in color Grape-like vesicles are passed in cases that progress in Grape-like vesicles are passed in cases that progress in the 2the 2ndnd trimester trimester

22--Higher than expected Higher than expected ββhCG levelshCG levels 33--Uterine size>dates without heart toneUterine size>dates without heart tone

44--HyperemesisHyperemesis 55--Early pregnancy-induced hypertensionEarly pregnancy-induced hypertension

66--ThyrotoxicosisThyrotoxicosis77--Ovarian enlargement( theca-lutein cysts ) due to high Ovarian enlargement( theca-lutein cysts ) due to high

hCG levelshCG levels

DiagnosisDiagnosis

A high index of suspicion is required for A high index of suspicion is required for early diagnosisearly diagnosis

UltrasoundUltrasound is the gold standard for is the gold standard for diagnosis and will show multiple vesicular diagnosis and will show multiple vesicular spaces within the uterus ,with an absence spaces within the uterus ,with an absence of a fetusof a fetusEnlarged cystic ovaries are commonEnlarged cystic ovaries are common

Treatment of GTDTreatment of GTD

11 - -Prompt evacuation of the uterus is the Prompt evacuation of the uterus is the primary treatmentprimary treatment

22 - -Serial Serial ββhCG monitoring for 6-12 months hCG monitoring for 6-12 months with contraceptionwith contraception

33--Recurrence occurs in 20% with complete Recurrence occurs in 20% with complete mole invades myometrium or become mole invades myometrium or become metastases, so treat with chemotherapy metastases, so treat with chemotherapy ( methotrexate )( methotrexate )

Most can conceive , carry normal pregnancyMost can conceive , carry normal pregnancy

Treatment of GTD

Treatment has 3 componentsTreatment has 3 components; ; 11 - -Evacuation of the uterusEvacuation of the uterus

The standard therapy for hydatidiform mole is The standard therapy for hydatidiform mole is suction evacuation followed by sharp curettage suction evacuation followed by sharp curettage of ‘ uterine cavity ,regardless of ‘ duration of of ‘ uterine cavity ,regardless of ‘ duration of pregnancypregnancy..

IV oxytocin is given simultaneously to help IV oxytocin is given simultaneously to help stimulate uterine contraction & ↓ blood loss. This stimulate uterine contraction & ↓ blood loss. This technique is associated with low incidence of technique is associated with low incidence of uterine perforation & trophoblastic embolizationuterine perforation & trophoblastic embolization

Treatment ( Continue )Treatment ( Continue )

22 - -Monitoring levels of the Monitoring levels of the ββhCGhCG Following ‘ evacuation of a hydatidiform Following ‘ evacuation of a hydatidiform mole, ‘ patient must be monitored with mole, ‘ patient must be monitored with weekly serum assays of weekly serum assays of ββhCG , the level hCG , the level should decline to 1-5 mIU/ml usually within should decline to 1-5 mIU/ml usually within 12-16 weeks12-16 weeks..

Treatment ( Continue )Treatment ( Continue )

33 - -ChemotherapyChemotherapyProphylactic chemotherapy is not indicated in Prophylactic chemotherapy is not indicated in patients with molar pregnancy because 90% of patients with molar pregnancy because 90% of

these individuals have spontaneous remissionsthese individuals have spontaneous remissions. . If the If the ββhCG levels plateau or rise at any time hCG levels plateau or rise at any time

ChemotherapyChemotherapy should be initiated should be initiated; ; Methotrexate 1mg/Kg/day on days 1,3,5,7 followed Methotrexate 1mg/Kg/day on days 1,3,5,7 followed 24hr later by 0.1mg/kg/day of folinic acid on 24hr later by 0.1mg/kg/day of folinic acid on

days 2,4,6,8days 2,4,6,8

Prognosis for Future PregnanciesPrognosis for Future Pregnancies

There is 1-2% recurrence rate, most patients There is 1-2% recurrence rate, most patients can conceive & carry a normal pregnancy can conceive & carry a normal pregnancy after trophoblastic diseaseafter trophoblastic disease

Chemotherapeutic agents used to treat Chemotherapeutic agents used to treat recurrences have not been shown to affect recurrences have not been shown to affect future pregnanciesfuture pregnancies

Clinician should help their patients to Clinician should help their patients to overcome the psychological impact of this overcome the psychological impact of this bizarre conditionbizarre condition

Summary of first trimester bleedingSummary of first trimester bleeding

Miscarriage can cause significant physical & Miscarriage can cause significant physical & psychological morbiditypsychological morbidity

Ectopic pregnancy is a potential cause of Ectopic pregnancy is a potential cause of maternal mortalitymaternal mortality

Serum hormone testing & ultrasonography Serum hormone testing & ultrasonography important in diagnosisimportant in diagnosis

Many patients can be managed Many patients can be managed nonsurgicallynonsurgically