Ectopic Pregnancy, Hydatidiform Mole, Abruption Placenta, Placenta Previa

• Also known as molar pregnancy or gestational trophoblastic tumor/disease

• A benign disorder of the placenta characterized by degeneration of the chorion and death of the embryo

hydatidiform mole

The abnormal proliferation and then degeneration of the trophoblastic villi. As the cells degenerate, they become filled with fluid and appear as clear-fluid filled, grape-sized vesicles

hydatidiform mole

Hydatidiform mole is often seen in what kind of women?

• low dietary intake of animal fat or protein

• older than 35 years or younger than 15 years

• Asian heritage

• Blood group A women who marry blood group O men

S/S of hydatidiform mole

Most important:

• passage of grape-like vesicles

• rapid increase in uterine size

• snowflake pattern is seen in ultrasound

• intermittent or continuous bright red/brownish vaginal bleeding (prune juice); spotting to profuse hemorrhage

• excessive nausea and vomiting

• signs of preeclampsia before 24 weeks gestation

• absence of FHT and fetal skeleton

• elevated thyrosine levels due to high levels of hCG produced by the trophoblastic tissue

• elevated serum gonadotropin level beyond 100 days

Management of hydatidiform mole

• D & C - evacuate the abnormal trophoblast cells

• methotrexate for 1 year to prevent choriocarcinoma

• HCG monitoring for 1 year (should be negative 2-8 weeks after removal of mole)

• x-ray every 3 months for 6 months - detect metastasis

• not to get pregnant for 1 year by using reliable contraceptives (oral estrogen/progesterone) - positive pregnancy can be confused with the increasing level that occurs with a developing malignancy

• hysterectomy

• do not administer prophylactic chemotherapeutics

Implantation of the zygote outside the uterine cavity or in an abnormal location inside the uterus.

ectopic pregnancy

What is the most common site for ectopic pregnancy?

fallopian tubes (ampulla, isthmus, interstitial or fimbrial)

Causes of ectopic pregnancy

• Mechanical Factors (that delay the passage of ovum)

  • tubal damage/abnormalities

  • PID or endosalpingitis

  • previous tubal surgery

  • fallopian tube defects

• Functional Factors

  • altered tubal motility caused by smoking and hormonal factors

• Assisted Reproduction

• Failed Contraception

  • IUD

This type of ectopic pregnancy is characterized by the following:

• Most common site (95%) of implantation

• Ampulla 55%; Isthmic 25%; Fimbrial 17%

tubal

This type of ectopic pregnancy is characterized by the following:

• s/s are like tubal pregnancy or bleeding corpus luteum.

• management is cystectomy or oophorectomy

ovarian

This type of ectopic pregnancy is characterized by the following:

• Occurs 1/15,000 pregnancies

  ❖ Primary

  ❖ Secondary

abdominal

This type of ectopic pregnancy is characterized by the following:

• Often due to IVF & embryo transfer

  ✓ Signs:

  ❖ hour glass sign

  ❖ thin-walled cervix

  ❖ painless vaginal bleeding

  ❖ seldom goes beyond 20 weeks gestation

cervical

S/S of ectopic pregnancy before the rupture

• brief amenorrhea

• pelvic & abdominal pain on the side

• arias-stella reaction - benign, hormone-driven cellular change most commonly observed in the endometrium but also occurring in extra-uterine sites like the cervix; change in the cells lining in the uterus caused by pregnancy hormones

S/S of ectopic pregnancy during rupture

• sharp stabbing pain (sudden, severe, knife-like) in one of their lower abdominal quadrants, radiating to the shoulder and neck

• spotting or bleeding, scant vaginal spotting

• cullen’s sign - periumbilical bruising or bluish discoloration caused by subcutaneous hemorrhage

• hard or board-like abdomen

• tender mass palpable in douglas-cul-de-sac on vaginal examination

• signs of shock (rapid, thready pulse, rapid respiration, hypotension) if internal bleeding progresses to acute hemorrhage

Most common symptoms of ectopic pregnancy

• missed period of 2 weeks duration

• unilateral lower abdominal pain

• irregular bleeding

Diagnosis for ectopic pregnancy

• transvaginal ultrasound / endovaginal ultrasound / vaginal ultrasound

• serial HCG determination (decreases)

• pregnancy test

• culdocentesis

• serum progesterone levels

• uterine curettage

• colpotomy - A surgical incision into the wall of the vagina, typically performed to access the pelvic cavity for various procedures

• laparoscopy

• CBC

• elevation in WBC level

• ultrasonography - reveals a clear-cut diagnostic picture

What is the management for an unruptured ectopic pregnancy?

• methotrexate (IM) - advantage: tube is left intact, with no surgical scaring that could cause a second ectopic implantation

• avoid folic acid supplements - interferes with methotrexate action

• mifepristone - for contraction and dilation

• local transabdominal, transvaginal, & transuterine injections of compound (prostaglandins, methotrexate, hyperosmolar glucose to cause abortion)

• surgical management

Criteria for methotrexate therapy for ectopic pregnancy

rules of 3

• less than 3 weeks from expected menses (7 week from LMP)

• HCG level less than 3000 mIU/ml

• ectopic size less than 3 cm

• no FHT

• no renal or hepatic disease

• normal CBC (6,000 to 16,000)

Management of ruptured EP

• salpingectomy

• hysterectomy

• oophorectomy

• laparoscopy - ligate the bleeding vessels and to remove or repair the damaged fallopian tubes

This management of a ruptured EP is indicated for uncontrollable hemorrhage and severely damage tube

salphingectomy

This management of a ruptured EP is often for ruptured interstitial or cervical pregnancy

hysterectomy

This management of a ruptured RP is for ovarian pregnancy but is not required where tubal removal is required

oophorectomy

• Is the premature separation of normally transplanted placenta after 20 weeks of gestation & before delivery of the fetus (3rd trimester)

• Also called ablatio placenta, placenta abruption & accidental hemorrhage

abruption placenta

Causes of abruption placenta

• maternal hypertension (most common)

• advance maternal age

• grand multiparity

• trauma to uterus

• rapid decompression of an overdistended uterus

• short umbilical cord

• uterine leiomyoma or fibroids

• behavioral risk factors

• chorioamnionitis

• polyhydramnios

Abruption placenta is classified according to what?

• degree of placental separation

• severity of symptoms

• This type of abruption placenta separation begins at the center of placental attachment resulting in blood being trapped behind the placenta

• Concealed

covert/central abruption placenta

• This type of abruptio placenta is the separation begins at the edges of the placenta allowing blood to escape from the uterine cavity

• Revealed

overt or marginal abruptio placenta

This grade for abruptio placenta has no symptoms

grade 0

This grade for abruption placenta has the following S/S:

• some external bleeding

• uterine tetany and tenderness (may/may not be noted)

• absence of fetal distress and shock (minimal separation

grade 1

This grade for abruptio placenta has the following signs and symptoms:

• external bleeding

• uterine tetany

• uterine tenderness

• fetal distress (moderate separation)

grade 2

This grade for abruptio placenta has the following signs and symptoms:

• internal & external bleeding (more than 1000cc)

• uterine tetany

• maternal shock

• probably fetal death & DIC (extreme separation)

grade 3

S/S of abruptio placenta

• sharp-stabbing pain high on the uterine fundus - as the initial separation occurs

• painful and heavy vaginal bleeding (occurs in 80% of women)

• uterine tenderness with board-like rigidity - rigidity is due to blood infiltrating the uterine musculature, couvelaire uterus or uteroplacental apoplexy

• board like abdomen

• signs of shock & fetal distress (if bleeding is severe)

• abdominal pain (uterine irritability and low back pain)

• rapid uterine contractions

This type of abruptio placenta has the following characteristics:

• may complain of “labor pains”

• slight uterine irritation

mild AP

This type of abruptio placenta has the following characteristics:

• pain can develop gradually or abruptly

moderate AP

This type of abruptio placenta has the following characteristics:

• pain can be sudden (knife-sharp pain)

severe AP

An escalating pain in abruptio placenta can indicate what type of bleeding?

concealed or covert bleeding

Management of abruptio placenta

• large-gauge IV catheter - for fluid replacement

• bedrest at side-lying position to promote optimum placental perfusion

• insert foley catheter for accurate I&O (at least 30cc/hr)

• NPO

• oxygen therapy via nasal cannula (4-6 liters) - fetal hypoxia

• observe & record the amount & time of the bleeding at least every 30 mins or more often if necessary

• cautiously perform any abdominal, vaginal, or pelvic examination - to not disturb the injured placenta any further

• IV administration of fibrinogen or cryoprecipitate - used to elevate a patient’s fibrinogen level prior to and concurrently with surgery

How should we position the patient who experienced abruptio placenta with fetus below 36 weeks?

bedrest at side-lying or lateral position to prevent pressure on the vena cava and additional interference with fetal circulating

What kind of IVF is administered for a patient with abruptio placenta to replace blood lost?

D5LR @ 125 cc/hr

What is contraindicated for placenta previa but is indicated for abruptio placenta?

internal examinations

• Is the abnormal implantation of placenta near or over the internal opening

• Most common bleeding disorder of the 3rd trimester

• The earlier the bleeding begins, the more serious the type of previa

placenta previa

This type of placenta previa completely covers the internal opening when cervix is fully dilated

complete or total PP

This type of placenta previa is when the placenta partially covers the internal opening

partial PP

This type of placenta previa is when the edge of the placenta is lying at the margin of the internal opening

marginal PP

This type of placenta previa is when the placenta implants near the internal opening with its margin located about 2 - 5 cm from internal opening. Edges can be felt by examining during IE

low-lying PP

This type of placenta previa causes greater blood loss because the fetus’ head pushes down on the placenta during bearing down

complete PP

Causes of placenta previa

• conditions that makes implantation to the upper segment undesirable due to decreased blood supply or scarring.

• multiple pregnancy

• advance maternal age (over 35y.o)

• decreased blood supply to endometrial lining

• short umbilical cord

• bbnormal placenta: Placenta accreta, increta & percreta

• large placenta

S/S of placenta previa

• sudden painless vaginal bleeding (begins 24-30 wk) – most significant sign

• bright red bleeding (intermittent or in gushes; rarely continuous)

• fetus in transverse lie

• decrease urinary output

This is the earliest and safest diagnostic tool for placenta previa

ultrasound

What should be assess for placenta previa?

• duration of the pregnancy

• time the bleeding began

• woman’s estimation of the amount of blood

• whether there was accompanying pain

• color of the blood

• what she has done, if anything, for the bleeding (if inserted tampon - will conceal bleeding)

• whether there were prior episodes of bleeding during the pregnancy

• whether she had prior cervical surgery for premature cervical dilatation

Immediate care measure for placenta previa

• place patient on bed rest in a side-lying position

• Apt or Kleihauer-Betke test - detect whether blood originates from fetus or pregnant patient

• obtain baseline vital signs - determine whether symptoms of hypovolemic shock are present

• assess blood pressure every 5-15 minutes

• do not attempt a pelvic or rectal examination with painless bleeding late in pregnancy because any agitation of the cervix when there is placenta previa might tear the placenta further and initiate massive hemorrhage

• attach external monitoring - record FHS, uterine contractions

• detect possible clotting disorder

• monitor urine output frequently (as often as every hour) - indicator that blood volume is remaining adequate to perfuse kidneys

• IV fluid - blood replacement

Continuing care measures of placenta previa

• close observation for 24-48 hours

• betamethasone - hastens fetal lung maturity if the fetus is less than 34 weeks gestation

Postpartum care for placenta previa

• oxytocin; massage

• ligation of hypogastric arteries or hysterectomy (if oxytocic cannot manage bleeding)