First Trimester Micarriage

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First Trimester Micarriage Trophoblastic
Diseases

• Dr. Ahmed Al Harbi
• Obstetrics / Gynaecology
• Consultant

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Development Of The Blastocyst

• Composed of
• Trophoblastic Ring
• Extra-Embryotic Mesoderm
• Amniotic Cavity
• Primary Yolk Sac

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Miscarriages

• The miscarriage of an early pregnancy is the
  commonest medical complication in humans.

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Epidemiology Of Early Pregnancy Disorders
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Variable Percentage ()
Total loss of conception 50-70
Total rate of clinical miscarriages 25-30
Before 6 weeks 18
Before 6 and 9 weeks 4
After 9 weeks 3
After 14 weeks 2
Rate of miscarriages in primigravidae 50-70
Rate of miscarriages in primigravidae aged lt40 years 6-10
Rate of miscarriages in primagravidae aged 40 years 30-40
Rate of recurrent miscarriages 1-2
Rate of recurrent miscarriage after three miscarriages 25-30
Ectopic pregnancies 2
Complete hydatidiform 0.1
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Chromosomal Abnormalities and maternal age

• Its incidences increases with maternal age.
• Approximately 50-60 of chromosomal defect of the
  conceptus.
• The frequency of abnormal chromosomal complement
  increases when embryotic demise occurs earlier in
  gestation (up to 90)

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Disturbance of placentation

• In most cases early pregnancy failure there is an
  inadequate placentation. In particular, there is
  a defective transformation of the spiral arteries
  and a reduced trophoblastic penetration into the
  decidua and into the spiral arteries.
• This defect of placentation is more pronounced in
  chromosomal abdnormalities.
• In pregnancies complicated by hypertension, there
  is probable relationship between the severity of
  the disease and the degree of inadequate
  placentation.

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The 4 clinical forms of Miscarriages
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Threatened Miscarriage

• Is defined as painless vaginal bleeding occurring
  any time between implantation and 24 weeks
  gestation.
• The diagnosis is usually based on clinical
  examination.
• The role of ultrasound and endocrinology in
  predicting this type of early pregnancy
  complication remains controversial.
• Nevertheless, the evaluation of the size of the
  gestational sac or the embryo and demonstration
  of embryotic heart action are important in the
  management of this common pregnancy.
• Within the context, ultrasound probably plays its
  most important role in reassuring the patient
  that the fetus is alive and developing normally.

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Missed Miscarriage

• A gestational sac containing a dead embryo/fetus
  before 20 weeks gestation without clinical
  symptoms of expulsion.
• The diagnosis is usually made by failure to
  identify a fetal heart beat on ultrasound.
• When the gestational sac is more than 25mm in
  diameter and no ebryonic/fetal part can be seen,
  the terms blighted ovum and anembryonic
  pregnancy are often used by pathologists and
  more commonly by obstetricians.
• The explanation for this feature is the early
  death and resorption of the embryo with
  persistence of the placental tissue rather than a
  pregnancy originally without an embryo.

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Inevitable Miscarriage

• This can be complete or imcomplete, depending on
  whether or not all fetal and placental tissues
  have been expelled from the uterus.
• The typical features of incomplete abortion are
  heavy, sometimes intermittent, bleeding with
  passage of clots and tissue, together with lower
  abdominal cramps.
• If these symptoms improve spontaneously, a
  complete abortion is more likely.

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Recurrent Miscarriage

• Is defined as three or more consecutive
  spontaneous abortions.

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Clinical Features
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• History
• Amenorrhea
• Vaginal Bleeding
• Low Abdominal Pain
• Positive Pregnancy Test
• General Examination
• Pulse Rate
• Blood Pressure
• Assessment of the palm
• Conjunctival colour will give an idea about
  secondary anaemia.
• Speculum Examination

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• Ultrasound Examination
• This will confirm the intrauterine location of
  the gestational sac and establish the vaibility
  of the pregnancy.
• Laboratory Investigations
• Full Blood Count
• Blood Group
• Human chorionic gonadotrophin
• Patients who are Rhesus negative must
  systematically receive a dose of anti-D in case
  of bleeding during pregnancy.

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Management
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• Surgical
• The mechanical dilatation and curettage of the
  uterus.
• Complications are uncommon and include
• Cerical Tears
• Uterine Perforation
• Creation of false passage
• Medical Treatment

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• Follow up
• Although the majority of miscarriages are not
  treatable, the prognosis for future pregnancies
  is directly dependent on the type of abnormality
  and on whether the mother or her partner carries
  it.
• For couples with recurrent miscarriages (more
  than 3 consecutive miscarriages) investigation
  should include parental and fetal karyotype to
  exclude a translocation, gynaecological
  examination to exclude a uterine abnormality, and
  blood tests (glucose level, thyroid function
  tests, antiphospholid and anti cardiolipin
  antibodies, lupus anticoagulant.

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• Gestational Trophoblastic Disorder (GTD)
• Is a term commonly applied to a spectrum of
  inter-related diseases originating from the
  placental trophoblast.
• The main categories
• Complete or classical hydatidiform mole
• A generalized swelling of the villous tissue
• Partial hydatidiform mole
• Characterized as a focal swelling of the villous
  tissue
• Choriocarcinoma

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Epidemiology Risk Factors
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• Incidence Rate
• The estimated incidence of complete mole is 1 per
  1000-2000 pregnancies.
• Incidence of the partial mole is around 1 per 700
  pregnancies.
• The incidence of choriocarcinoma varies from 1 in
  10000 to 1 in 50000 pregnancies or expressed as a
  percentage of hydatidiform mole, 3-10

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• Risk Factor
• High maternal age
• Previous history of molar pregnancy.
• Dietary habits
• The ABO blood groups of the parents appear to be
  a factor in choriocarcinoma development, i.e.
  women with blood group A have been shown to
  have greater risk than blood group O women.

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UnderstandingThePathophysiology
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• Complete Hydatidform Moles
• These have A diploid chromosomal constitution
  totally derived from the paternal genome and
  usually resulting from the fertilization of an
  oocyte by a diploid spermatozoon.
• The maternal chromosomes may be either
  inactivated or absent, remaining only inside the
  mitochondria.

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• Partial Moles
• They are usually triploid and od diandric origin,
  having two sets of chromosomes from paternal
  origin and one from maternal origin.
• Most have a 69XXX or 69XXY genotype derived from
  a haploid ovum, with either reduplication of the
  paternal haploid ser a single sperm or, less
  frequently, from dispermic fertilization.
• Triploidy of digynic origin, due to a double
  maternal contribution, is not associated with
  placental hydatidform changes.

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• Choriocarcinoma
• Is a highly malignant tumour that arises from the
  trophoblastic epithelium and metastasizes readily
  to the lungs, liver and brain.
• Around 50 of chorioncarcinoma follow a molar
  pregnancy, 30 occur after a miscarriage and 20
  after an apparently normal pregnancy.
• Choriocarcinomas can occur after an extrauterine
  pregnancy and will present with signs and
  symptoms similar to those classically outlined
  for ectopic pregnancy.
• There have been a few well-documented examples of
  choriocarcinoma arising from villous tissue in an
  otherwise normally developed placenta, suggesting
  that most or possibly all choriocarcinomas that
  follow an apparently normal pregnancy are reality
  metastases from a small intraplacental
  choriocarcinoma.

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Clinical Features
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General Gynaecological Examination

• Vaginal Bleeding
• Uterine enlargement greater than expected for
  gestational age
• An Abnormality high level of serum hCG
• Pregnancy induced hypertension
• Hyperthyroidism
• Hyperemesis
• Anaemia
• Ovarian theca lutein cysts
• Ovarian hyperstimulation and enlargement of both
  ovaries may subsequent lead to ovarian torsion or
  rupture of theca lutien cyst.
• The primary sysmptoms of choriocarcinoma are
  gynaecological, i.e. vaginal bleeding, in only
  50-60 of the cases. Many women will present with
  dyspnoea, neurological symptoms and abdominal
  pain a few weeks or months and sometimes up to
  10-15 years after their last pregnancy.

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Ultrasound Examination

• Reveals a uterine cavity filled with multiple
  sonolucent areas of varying size and shape
  (snow-storm appearance).

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Laboratory Examination

• The measurement of plasma hCG is pivotal in the
  diagnosis and follow up of GTD.

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• Following uterine evacuation, 18-19 of patients
  with complete mole and 1-11 of patients with a
  partial mole will develop a persistent
  trophoblastic tumour.
• Pulmonary complications due to trophoblastic
  embolization are frequently observed following
  the evacuation of a molar pregnancy.
• Serial measurement of hCG levels is the gold
  standard for diagnosis and monitoring the
  therapeutic response of GTD.
• After evacuation of a molar pregnancy, the hCG
  level should be monitored weekly until
  detectable, followed by monthly monitoring for
  6-24 months.

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