Complications of Early Pregnancy & Pregnancy Loss

Complications of Early Pregnancy & Pregnancy Loss
Presenttaion by: Dotun Ogunyemi, MD

TOPICS
• Spontaneous abortions :
pregnancy
termination prior to 20 weeks' gestation or
less than 500-g birthweight
• Congenital abnormalities
• Chromosomal abnormalities
• Hyperemesis gravidarum
• Ectopic pregnancy: extra-uterine
gestation
• Gestational trophoblastic disease

OBJECTIVES
• To be aware of the different types and
causes of abortions
• To understand the causes and risks
factor of birth defects
• To obtain knowledge on types of
abnormal early pregnancy
• To be aware of the effects of severe
vomiting in early pregnancy

Threatened Abortion
• Bleeding through a closed cervix in first half of
pregnancy
• Bleeding of expected menses, decidual reaction,
Cervical lesions
• No effective therapy
• Half will abort
• Increased risk for preterm delivery, low birthweight,
& perinatal death
• Vaginal sonography, serial serum quantitative
human chorionic gonadotropin (hCG) levels, serum
progesterone values
• Anti-D immunoglobulin because up to 5 % of D-
negative women become isoimmunized

Inevitable Abortion
• Leaking amniotic fluid
• Cervical dilatation
• Heavy bleeding
• Severe pain
• Impending abortion
• Risk of incomplete abortion or sepsis
• Uterine evacuation

Incomplete Abortion
• Partial expulsion with retained products
of conception (POC)
• Open internal cervical os, bleeding,
• Ultrasound or pelvic exam shows POC
• Hemorrhage, Sepsis
• Uterine evacuation
• Complete Abortion
• Closed internal cervical os
• Ultrasound = Normal endometrial stripe

Missed Abortion
• Dead products of concept is
retained inside uterus
• Maybe associated with
coagulation defects
• Expectant, medical or surgical
management

Recurrent Abortion
• 3 or more consecutive spontaneous
abortions
• Risk of 1 loss = 10-15 %,
• Risk of 2 losses = 2.3 %
• Risk of 2 losses = 0.34 %
• Parental cytogenetic analysis
• Antiphospholipid antibodies
• If previous liveborn; risk for subsequent
abortion was 30 %.
• If no liveborn, the risk of subsequent
abortion was 46 %

Frequency of chromosomal anomalies in abortuses & stillbirths.
First- and second-trimester spontaneous abortions
by maternal age.
Findings in Abortuses
Abnormality not specified
Sex chromosome polysomy
Mosaic trisomy
Autosomal monosomy G
Others—XXY, monosomy 21
Triple trisomy
Double trisomy
Structural anomaly
Tetraploidy
Triploidy
Monosomy X (45,X)
Autosomal trisomy
Abnormal (aneuploid)
Normal (euploid), 46,XY& 46,XX

Chromosomal Studies
Incidence in Percent
Chromosomal Findings in Abortuses

Etiology ofAbortions
FETAL
Abnormal Zygotic
Development (40%)
Aneuploid Abortion (50%)
MATERNAL: Systemic
Infections
Chronic Diseases
Tuberculosis
carcinomatosis.
Celiac sprue
MATERNAL: ENDOCRINE
Hypothyroidism
Diabetes Mellitus
Progesterone Deficiency
MATERNAL: Environment
Tobacco Alcohol
Caffeine
Radiation
intrauterine devices failure
anesthetic gases
MATERNAL: Systemic
Antiphospholipid
antibodies
Inherited Thrombophilia
MATERNAL: Local
Uterine leiomyomas
Asherman syndrome
Müllerian duct defects
DES offsprings
Incompetent Cervix
Physical Trauma
PATERNAL
FACTORS

Cervical Incompetence
• Painless cervical dilatation in 2nd
trimester, with prolapse and ballooning of
membranes into the vagina, followed by
expulsion of an immature fetus.
• Transvaginal ultrasound cervical length &
funneling
• Previous trauma to the cervix—dilatation
and curettage, conization, cauterization, or
amputation, delivery
• Abnormal cervical development,
diethylstilbestrol
• McDonald cerclage or Shirodkar cerclage

McDonald cerclage

Abortion Techniques
Medical Techniques
Intravenous oxytocin
Intra-amnionic hyperosmotic
fluid saline or urea
Prostaglandins
Intra-amnionic injection
Extraovular injection
Vaginal insertion
Parenteral injection
Oral ingestion
Antiprogesterones—RU 486
(mifepristone) & epostane
Methotrexate—intramuscular
& oral
Various combinations
Surgical techniques
Cervical dilatation
followed by uterine
evacuation
Curettage
Vacuum aspiration
(suction curettage)
Dilatation and
evacuation(D & E)
Dilatation and
extraction (D & X)
Menstrual aspiration
Laparotomy:
Hysterotomy
Hysterectomy

Septic Abortion
• Criminal abortion Spontaneous abortion
• Legal elective abortion
• Anaerobic bacteria; coliforms, Haemophilus
influenzae, Campylobacter jejuni, group A
streptococcus
• COMPLICATIONS:
• Severe hemorrhage
Bacterial shock
• Acute renal failure
Uterine infection
• Parametritis
Peritonitis
• Endocarditis
Septicemia
• DIC
Infertility
• TREATMENT:
• supportive care; antimicrobials & evacuation

Hyperemesis gravidarum (HEG)
• Nausea and vomiting occurs in 50-90% of
pregnancies (morning sickness)
• HEG =persistent nausea & vomiting
associated with ketosis and weight loss (>5%
of prepregnancy weight)
• ETIOLOGY
• Unknown
psychological,
• sociocultural factors,
HCG levels,
• estradiol levels,
gastric dysrhythmias
• Vestibular and olfaction dysfunction

HEG: Risk Factors
• Hyperthyroid disorders
Psychiatric d
• Previous molar disease
Gastrointestinal d.
• Pre-gestational diabetes
Asthma
• Female fetuses
Multiple fetuses
• Occupational status
Fetal anomalies
• Increased body weight
Infertility
• Nausea & vomiting in a prior pregnancy
• Prior intolerance to oral contraceptives.
• Maternal smoking & older maternal age
decreased risk.
• DIAGNOSIS OF EXCLUSION.

HEG treatment & outcome
• Intravenous fluids
Diet
• Anti-histamines
Vitamin B6
• Anti-emetics
Ginger
• Promotility agents
Parenteral Nutrition
• if low pregnancy weight gain, increased risks
of:
• Low birth weight,
• Small for gestational age,
• Preterm delivery
• 5-minute Apgar <7.

Congenital abnormalities
• Malformation: "programmed" to develop
abnormally; thus intrinsically genetically
abnormal.
• Deformation: a genetically normal structure
develops an abnormal shape because of
mechanical forces imposed by the uterine
environment
• Disruption: severe change in form or
function when genetically normal tissue is
modified due to a specific insult
• Phenocopies

Spina bifida
anencephaly

omphalocele
gastroschisis

Endocardial cushion defect
Hypoplastic Left Heart
4 chambered heart

Teratology
• Dose:
• No effect at low dose,
• Organ effect at immediate dose
• Severe effect/abortion at high dose
• Timing:
• Up to 2 weeks gestation: all or none effect
• 3-8 weeks gestation is period of
organogenesis when can birth defects occur
• After 4
th
month usually decreased growth

Oligohydramnios, growth restriction, limb
shortening, maldevelopment of calvarium
ACE Inhibitors = renal
ischemia,
Microcephaly & severe brain damage
Methyl Mercury:
neuronal
& cell division migration
skull defects, cutis aplasia, porencephaly,
subependymal/periventricular cysts, ileal
atresia, cardiac anomalies; visceral infarcts
Cocaine: vascular
disruption
ileal atresia; hydrocephaly, hand defects,
microcephaly, omphalocele, gastroschisis,
cleft lip/ palate,
Tobacco: vascular
disruption
Phocomelia; Limb-reduction defects
Thalidomide
dysmorphogenesis/disruption
CNS & skeleton defects

Antifungals
vaginal clear-cell adenocarcinoma,adenosis,
cervix/vagina defects, hypospadias
Diethylstilbestrol (DES)
25%
Ear defects, cardiac outflow tract defects ,
hydrocephaly system, & thymus aplasia
Isoretinoin

Clefts, cardiac anomalies, urinary tract
malformations
Phenobarbital 10–20%
Neural-tube defects
Carbamazepine
Valproate 1–2%
Fetal hydantoin syndrome: craniofacial
anomalies, fingernail hypoplasia, growth
deficiency, developmental delay, cardiac
defects, facial clefts
Phenytoin 5–11%
accumulation in fetal tissues of
free oxide radicals, with
toxic,carcinogenic, mutagenic
effects.
Fetal warfarin syndrome: nasal & midface
hypoplasia; stippled vertebral and femoral
epiphyses.
Dorsal CNS dysplasia, mental retardation
Coumarin: 9%
inhibiting
posttranslational carboxylation
of coagulation proteins.
hemorrhage leading
to disharmonic growth and
deformation from scarring
IUGR, craniosynostosis , microcephaly,
limb abnormalities
Anti-neoplastic drugs
Fetal alcohol syndrome: Craniofacial
anomalies; Cardiac defects; Behavior
disturbances, Failure to thrive, ADD
Alcohol

Fetal alcohol syndrome. A. At 2 ½ years. B, C. At 12 years. Note persistence of short palpebral fissures
Fetal alcohol syndrome

Toxoplasmosis
Syphilis
Rubella
CMV
HSV
Varicella
Congenital Infections

Intracranial
Infections
Hydrops: Features
Scalp edema
Ascites
Dilated ventricles with
bilateral perventricular
calcifications (arrows)
Congenital Infections
Hepatomegaly,
Splenomegaly

ANEUPLOIDY
• Trisomy: extra chromosome nondisjunction
of meiosis I increases with maternal age
• Only autosomal trisomies 13, 18, and 21
result in viable term pregnancies
• Monosomy: missing a chromosome
monosomy X,
• Polyploidy: number of haploid chromosomal
complements hydatidiform mole fertilization
of one egg by two sperm
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