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COMPLICATIONS
DERIAN IRAWAN– 406172061
PEMBIMBING – DR. ANDRIANA KUMALA DEWI, SP.OG
KEPANITERAAN OBSTETRI DAN GINEKOLOGI
RS SUMBER WARAS – FK UNTAR
ABORTION
ABORTION
• Defined as spontaneous or induced termination of pregnancy before fetal viability
• National Center for Health Statistics, the Centers for Disease Control and Prevention, and
the World Health Organization define abortion as pregnancy termination before 20 weeks’
gestation or with a fetus born weighing <500 g.
• Uterine pregnancies that eventuate in a spontaneous abortion are also termed early
pregnancy loss or early pregnancy failure
• Spontaneous abortion: threatened, inevitable, incomplete, complete, and missed abortion
• Septic abortion is used to further classify any of these that are complicated further by
infection.
• Recurrent abortion: used to identify women with repetitive spontaneous abortions
• Induced abortion: used to describe surgical or medical termination of a live fetus that has
not reached viability.
FIRST-TRIMESTER SPONTANEOUS ABORTION
(PATHOGENESIS)
• >80% of spontaneous abortion occur within 1st 12 weeks of gestation
• Death of the embryo or fetus nearly always precedes spontaneous expulsion
• Death -> accompanied by hemorrhage into the decidua basalis
• followed by adjacent tissue necrosis that stimulates uterine contractions and expulsion
FIRST-TRIMESTER SPONTANEOUS ABORTION
(FETAL FACTORS)
• 50% of miscarriages -> anembryonic (less acc. Term
used is blighted ovum)
• Other 50% -> embryonic miscarriages (commonly
display a develp abnor of zygote, embryo, fetus or at
times the placenta)
• Of embryonic misc, half (or25% of al) have
chromosomal anomalies (aneuploid abortion),
remaining cases are euploid abortions
FETAL FACTORS – ANEUPLOID ABORTION
• abortion rates and chromosomal anomalies decrease with advancing gestational age.
(a third of 2nd trim fetal losses and 5% of 3rd trim)
• 75%-> occurred by 8 weeks (95%-> maternal gametogenesis error, 5% by paternal
errors)
• Autosomal trisomy-> most frequent for 1st trim
• Trisomy all chrom except number 1, most common are 13, 16, 18, 21, and 22
• Monosomy X (45,X)/Turner syndrome -> single most frequent specific chromosomal
abnormality
• Triploidy -> usually assoc with hydropic or molar placental degeneration
FETAL FACTORS - EUPLOID ABORTION
• Rate of euploid abort peaks at approx. 13 weeks.
• Incidence >>> dramatically if maternal age >35 y.o
FIRST-TRIMESTER SPONTANEOUS ABORTION
(MATERNAL FACTORS - INFECTIONS)
• Pregnancy-> numerous infections-> uncommonly cause early abortion
• Chlamydia trachomatis -> present in 4% of abortus
• Polymicrobial infection from periodontal disease -> has been linked with a
two-to fourfold increased risk
MATERNAL FACTORS – MEDICAL DISORDERS
• DM and thyroid disease
• Celiac disease -> reportedly cause recurrent abortions and male and female
infertility
• Unrepaired cyanotic heart disease -> a likely risk for abortion
• Anorexia nervosa and bulimia nervosa -> have been linked with subfertility, preterm
delivery, and fetal-growth restriction (FGR)
• IBD and SLE -> may increase risk
• Chronic HT -> x appear to confer significant risk for FGR
• History of recurrent misc -> reported to be at increased risk for FGR
• Women with multi misc -> more likely to suffer a myocardial infarction
MATERNAL FACTORS - MEDICATIONS
• Severe iodine deficiency -> has been assoc with >>> misc. rates
• prevalence of abnormally high serum levels of antibodies to thyroid
peroxidase or thyroglobulin is nearly 15 percent in pregnant women ->
marker for >>> misc
• Thryroxine supplementation decreases misc risk
MATERNAL FACTORS -> SURGICAL
PROCEDURE
• The risk of miscarriage caused by surgery is not well studied.
• obesity is an uncontested risk factor for miscarriage. However, currently, it is
not known if this risk is mitigated by weight-reduction surgery
• uncomplicated surgical procedures performed during early pregnancy do
not increase the risk for abortion
• Trauma seldom causes first-trimester miscarriage, Major trauma—
especially abdominal— can cause fetal loss, but is more likely as pregnancy
advances
MATERNAL FACTORS - NUTRITION
• 1st trimester > gross rupture of the membranes along with cervical dilatation (is
nearly always followed by either uterine contractions or infection) + a gush of
vaginal fluid without pain, fever, or bleeding
• If this is documented -> diminished activity with observation is a reasonable
course
• After 48 hours -> no additional amnionic fluid escape, bleeding, cramping, or
fever -> resume ambulation and pelvic rest
• With bleeding, cramping, or fever -> abortion is considered inevitable -> uterus
is evacuated
INCOMPLETE ABORTION
• There are several diverse medical and surgical disorders that are
indications for termination of pregnancy, examples are:
• persistent cardiac decompensation, especially with fixed pulmonary
hypertension, advanced hypertensive vascular disease or diabetes, and
malignancy
• Rape or incest -> most consider termination reasonable
• most common indication currently is to prevent birth of a fetus with a
significan anatomical, metabolic, or mental deformity
ELECTIVE OR VOLUNTARY ABORTION
• Determine pregnancy
• Current serum and urine pregnancy tests that use ELISA for β-hCG are sensitive
to levels of 10 to 20 mIU/mL and are positive in >99 percent of ectopic
pregnancies
• With bleeding or pain and a positive pregnancy test result, an initial TVS is
typically performed to identify gestation location. If a yolk sac, embryo, or fetus
is identified within the uterus or the adnexa, then a diagnosis can be made
• In many cases however -> TVS is nondiagnostic and tubal pregnancy is still a
possibility -> use the term pregnancy of unknown location (PUL) until additional
clinincal info allows determination of pregnancy location
Β-HCG – LEVELS ABOVE THE DISCRIMINATORY
ZONE
• Indicates that the pregnancy is either not alive or is ectopic
• empty uterus with a serum ß-hCG concentration >=1500 mIU/mL was 100% accurate in excluding a live uterine
pregnancy
• Some institutions however use >= 2000mIU/mL for their threshold
• Connolly and associates (2013) : with live uterine pregnancies, a gestational sac was seen 99 %of the time with a
discriminatory level of 3510 mIU/mL.
• If initial ß-hCG level exceeds the set discriminatory level and no evidence for a uterine pregnancy is seen with
TVS -> diagnosis is narrowed in most cases to a failed uterine pregnancy, completed abortion, or an ectopic
pregnancy
• If patient history or extruded uterine tissue suggests a completed abortion, then serial ß-hCG levels will drop
rapidly
• Otherwise, curettage will distinguish an ectopic from a nonliving uterine pregnancy although some do not
recommend diagnostic curettage because it results in unnecessary surgical therapy
Β-HCG – LEVELS BELOW THE DISCRIMINATORY
ZONE
• If initial ß-hCG level is below the set discriminatory value -> pregnancy location is often
not technically discernible with TVS
• With these PULs, serial ß-hCG level assays are done to identify patterns that indicate either
a growing or failing uterine pregnancy (levels that rise or fall outside expected parameters
increase concern for ectopic pregnancy)
• Women with a possible ectopic pregnancy, but whose initial ß-hCG level is below the
discriminatory threshold, are seen 2 days later for further evaluation
• Kadar and Romero (1987) : normal progressing uterine pregnancies has a mean doubling
time of approximately 48 hours for serum ß-hCG levels
• Lowest normal value for this increase was 66%, 53%/48hr with minimum 24%/24hrs (Silva
and colleagues)
• Silva and colleagues : 1/3 of women with ectopic pregnancy will have a 53% rise at 48
hours
• Approx. half of ectopic pregnancies will show decreasing ß-hCG levels, where as the other
half will have increasing levels
• Failing intrauterine pregnancy -> patterned rates of ß-hCG level will decline can be
anticipated (around 21-35%)
SERUM PROGESTERONE
• Diagnosis :implant within the proximal tubal segment that lies within the
muscular uterine wall
• Criteria that may aid sonographical differentiation include: an empty uterus,
a gestational sac seen separate from the endometrium and > 1 cm away
from the most lateral edge of the uterine cavity, and a thin, < 5-mm
myometrial mantle surrounding the sac
ABDOMINAL PREGANCY
• Abdominal pregnancy is an implantation in the peritoneal cavity exclusive of tubal, ovarian, or intraligamentous
implantations
• Although a zygote can traverse the tube and implant primarily in the peritoneal cavity, most abdominal
pregnancies are thought to follow early tubal rupture or abortion with reimplantation
• symptoms may be absent or vague
• Sonographically, findings with an abdominal pregnancy may not be recognized, and the diagnosis is often
missed
• Oligohydramnios is common but nonspecific. Other clues include a fetus seen separate from the uterus or
eccentrically positioned within the pelvis; lack of myometrium between the fetus and the maternal anterior
abdominal wall or bladder; and extrauterine placental tissue
• MR imaging can be used to confirm the diagnosis and provide maximal information concerning placental
implantation
MANAGEMENT
• Classic histological findings include villous stromal edema and trophoblast proliferation
• The degree of histological changes, karyotypic differences, and the absence or presence
of embryonic elements are used to classify them as either complete or partial moles
• GTN more frequently follows complete hydatidiform mole
• Complete mole has abnormal chorionic villi that grossly appear as a mass of clear
vesicles (vary in size and often hang in clusters from thin pedicles)
• partial molar pregnancy has focal and less advanced hydatidiform changes and contains
some fetal tissue
EPIDEMIOLOGY AND RISK FACTORS
• Complete molar pregnancy -> serum ß-hCG levels are commonly elevated
above those expected for gestational age.
• more advanced moles, values in the millions are not unusual.
• high values can lead to erroneous false-negative urine pregnancy test
results because of oversaturation of the test assay by excessive ß-hCG
hormone
• partial mole ->ß-hCG levels may also be significantly elevated, but more
commonly concentrations fall into ranges expected for gestational age.
DIAGNOSIS - SONOGRAPHY
• sonographic imaging is the mainstay of trophoblastic disease diagnosis
• a complete mole appears as an echogenic uterine mass with numerous anechoic cystic spaces but
without a fetus or amnionic sac. (often described as “snowstorm”)
• A partial mole has features that include a thickened, multicystic placenta along with a fetus or at
least fetal tissue
• In early pregnancy, however, these sonographic characteristics are seen in fewer than half of
hydatidiform moles
• most common misdiagnosis is incomplete or missed abortion
• Occasionally, molar pregnancy may be confused for a multifetal pregnancy or a uterine leiomyoma
with cystic degeneration
PATHOLOGICAL DIAGNOSIS
• Surveillance for subsequent neoplasia following molar pregnancy is crucial
• In pregnancies before 10 weeks, classic molar changes may not be apparent because villi may not be enlarged and
molar stroma may not yet be edematous and avascular
• One takes advantage of the differing ploidy to distinguish partial (triploid) moles from diploid entities. Complete
moles and nonmolar pregnancies with hydropic placental degeneration are both diploid
• Another technique -> histological immunostaining to identify the p57KIP2 nuclear protein (this gene is paternally
imprinted -> only maternally donated genes are expressed)
• complete moles contain only paternal genetic material, they cannot express this gene; do not produce p57 KIP2; and
thus, do not pick up this immunostain
• this nuclear protein is strongly expressed in partial moles and in nonmolar pregnancies with hydropic change
• Combined use of ploidy analysis and p57KIP2 immunostaining can be used to differentiate:
(1) a complete mole (diploid/p57KIP2-negative),
(2) a partial mole (triploid/p57KIP2-positive),
(3) and spontaneous abortion with hydropic placental degeneration (diploid/p57KIP2-positive)
MANAGEMENT