Learn — High-risk pregnancy & complications

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Abortion — types and management

Abortion is the expulsion or extraction of the products of conception before the fetus is viable — before 20 completed weeks or a fetal weight under 500 g in Indian practice. Between 10% and 20% of clinically recognised pregnancies end this way, four out of five of them before 12 weeks, and chromosomal abnormality is the commonest cause of an early sporadic loss.

Clinical types: threatened, inevitable, incomplete, complete, missed and septic; recurrent (habitual) abortion means three or more consecutive spontaneous losses.
Threatened — bleeding with a closed internal os, a uterus matching dates and a live fetus on scan: rest, no routine tocolysis or hormone, repeat scan; about half continue to term.
Inevitable — bleeding with an open os and cramping — and incomplete — some products passed, os open, uterus smaller than dates and bleeding continuing: resuscitate first, then evacuate by manual vacuum aspiration up to 12 weeks, misoprostol, or suction evacuation.
Complete — everything expelled, bleeding settling, os closed, empty uterus on scan: no evacuation needed. Missed — fetus dead and retained, uterus smaller than dates, no fetal heart, brownish discharge: evacuate medically (mifepristone then misoprostol) or by suction, and check coagulation if it has been retained for weeks.
Septic abortion — fever of 38 °C or more, offensive discharge, tender uterus, sometimes shock: take blood cultures, start broad-spectrum intravenous antibiotics before evacuation, evacuate once the antibiotics are running, and watch for renal failure, DIC and tetanus.
Medical abortion in India is approved up to 9 weeks (63 days): mifepristone 200 mg orally, then misoprostol 800 µg vaginally or sublingually 24–48 hours later, with a follow-up to confirm complete expulsion.
Rh-negative unsensitised women get anti-D within 72 hours of any abortion — 50 µg (250 IU) before 12 weeks and 300 µg (1500 IU) at or after 12 weeks.
Complications of evacuation: haemorrhage, uterine perforation, cervical injury, incomplete evacuation, infection and Asherman syndrome (intrauterine adhesions with secondary amenorrhoea and later infertility). Always send the tissue for histopathology to catch a molar pregnancy.

Hydatidiform mole — snowstorm appearance

A hydatidiform mole is a gestational trophoblastic disease in which the chorionic villi swell into grape-like vesicles and the trophoblast proliferates, so the uterus fills with vesicles instead of a normal pregnancy. A complete mole is diploid and entirely paternal (46,XX in about 90%, from one sperm duplicating inside an ovum that has lost its nucleus) and has no fetal tissue; a partial mole is triploid (69,XXX or 69,XXY, usually two sperms fertilising one ovum) and has some fetal parts.

Presentation: bleeding in the first trimester, a uterus larger than dates and doughy in feel, absent fetal heart and fetal parts, expulsion of grape-like vesicles, and exaggerated pregnancy symptoms.
β-hCG is extremely high, often above 100,000 mIU/mL, and drives the complications: hyperemesis gravidarum, bilateral theca-lutein cysts, pre-eclampsia appearing before 20 weeks (which never happens in a normal pregnancy) and occasionally thyrotoxicosis, because β-hCG cross-reacts with the TSH receptor.
Ultrasound in a complete mole shows the "snowstorm" or cluster-of-grapes pattern with no fetus, and theca-lutein cysts in about half; a partial mole shows a fetus with focal cystic change in a bulky placenta.
Complete mole: diploid, no fetal parts, progresses to persistent gestational trophoblastic neoplasia in about 15–20% and to choriocarcinoma in about 2–3%. Partial mole: triploid, fetal parts present, progresses in about 1–5%.
Treatment is suction evacuation under ultrasound guidance with blood cross-matched and an oxytocin infusion started only after evacuation has begun; every gram of tissue goes for histopathology. Hysterectomy is an option for an older woman who has completed her family, and it does not remove the need for follow-up.
Follow-up: serum β-hCG weekly until three consecutive normal values, then monthly for 6 months. A plateau, a rise, or new metastases means gestational trophoblastic neoplasia, which is chemosensitive — methotrexate for low-risk disease and multi-agent chemotherapy for high-risk disease.
Reliable contraception (combined oral pill or barrier — not an IUCD until the uterus is empty) for the whole follow-up period, and Indian texts advise avoiding pregnancy for one year, because a new pregnancy makes a rising β-hCG impossible to interpret.
Anti-D is given after a partial mole but is not required after a complete mole, which has no fetal red cells to sensitise the mother.

Twins — types, superfecundation, superfetation

Twinning is either dizygotic — two ova fertilised by two sperms, producing two genetically different fetuses that are always dichorionic and diamniotic — or monozygotic, where one fertilised ovum splits and the chorionicity depends on how late the split occurred. Chorionicity, not zygosity, determines the risk, so it is established by ultrasound before 14 weeks using the lambda or twin-peak sign for dichorionic twins and the T-sign for monochorionic twins.

Dizygotic twins are about two-thirds of all twins; they run in families through the mother and increase with maternal age, parity, ovulation induction and IVF. They are always dichorionic diamniotic.
Monozygotic twinning happens at a nearly constant rate of about 1 in 250 births worldwide: a split within 72 hours gives dichorionic diamniotic twins, at 4–8 days monochorionic diamniotic (the commonest monozygotic type), at 8–13 days monochorionic monoamniotic, and after 13 days conjoined twins.
Superfecundation is the fertilisation of two ova released in the same cycle by sperm from two separate acts of intercourse, possibly involving two different men. Superfetation is the fertilisation of a second ovum during an already established pregnancy, so the two fetuses differ in gestational age — it is exceedingly rare in humans.
Monochorionic twins share one placenta and are at risk of twin-to-twin transfusion syndrome (the donor is small, anaemic and "stuck" with oligohydramnios; the recipient is plethoric with polyhydramnios), selective growth restriction, and — in monoamniotic twins — cord entanglement. They are scanned every 2 weeks from 16 weeks; dichorionic twins are scanned every 4 weeks.
Maternal complications: hyperemesis, anaemia, pre-eclampsia, polyhydramnios, preterm labour (the commonest), malpresentation, and antepartum and postpartum haemorrhage from an overdistended uterus.
Delivery: aim for 37–38 weeks in dichorionic diamniotic twins, 36–37 weeks in monochorionic diamniotic twins and 32–34 weeks by caesarean in monoamniotic twins. Vaginal birth is offered when the first twin is cephalic, with an intravenous line, cross-matched blood, continuous monitoring of both hearts and an obstetrician able to deliver the second twin.
The second twin should be delivered within about 30 minutes of the first; the third stage is actively managed with an oxytocin infusion because atonic haemorrhage is likely. Locked twins (first breech, second cephalic) and monoamniotic cord entanglement are classic indications for caesarean.

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