EMERGENCY IN

EARLY PREGNANCY
Scenario
• A 23 year old nulliparous woman
has 6 weeks of amenorrhoea.
She has not been using any
contraception. She normally has
a regular menstrual cycle every
28 days. A pregnancy test is
positive. She has noticed slight
vaginal spotting
WHAT IS THE LIKELY DIFFERENTIAL
DIAGNOSIS?
• Miscarriage
• Ectopic Pregnancy
• Molar Pregnancy
Miscarriage
• WHO definition “The expulsion
of fetus or an embryo weighing
500 g or less and also a
gestational age limit of less than
22 completed weeks of
pregnancy”
Facts...
• The gestation in which a fetus is
considered viable varies
between 20 to 24 weeks in
different countries.
• In the United Kingdom it is less
than 24 weeks gestation
• In Malaysia, a fetus weighing less
than 500gm is considered as a
miscarriage or if it is less than 24
weeks gestation
CAUSES OF MISCARRIAGE
• Fetal causes:
• Abnormal conceptus:
Chromosomal e.g. Trisomy,
monosomy
• Structural e.g. Neural tube defect.
Maternal causes
• 1. Immunological:
• Autoimmune disease:
antiphospholipid antibodies
especially lupus anticoagulant
(LA) and the anticardiolipin
antibodies (ACL)
2. Abnormalities of the uterus
• Uterine septa (bicornuate
uterus)
• Asherman’s syndrome
• Cervical incompetence
• Uterine myomas
3. Endocrine Disorder
• Diabetes
• Hypothyroidism
• Luteal phase deficiency
• Polycystic ovarian syndrome
 Infections - TORCH!
• More commonly associated with isolated
abortions – Any acute illness like typhoid
fever, malaria, pyelonephritis &
appendicitis can cause miscarriage
• Bacteria : L monocytogenes,
Compylobacter, Mycoplasma,ureaplasma
Spirochetes : Treponema Pallidum
• Parasites : Toxoplasma gondii
• Viruses :
Cytomegalovirus,Rubella,Herpes,Coxsackie
Others

• Psychological disorders
• Antiphospholipid syndrome
• Thrombophilia (hereditary)
What additional features in the history would you seek to support a
particular diagnosis?

• How much blood?

• How’s the pain?
• Do you pass out anything?
What clinical examination would you
perform and why?
• Haemodynamic status
• General exam, vitals, conjunctival colour
• Abdominal Exam To assess uterine size, to exclude acute abdomen
• Per Speculum To see if os is open , any fetal tissues, cervix.
• VE and bimanual exam Assess os, Elicit cervical excitation and adnexal
mass in ectopic pregnancy
What will u see in...
• threatened miscarriage vs inevitable???

• missed miscarriage vs incomplete miscarriage???

• Missed miscarriage - Also known as a missed abortion or a silent miscarriage, occurs
when a fetus dies, but the body does not recognize the pregnancy loss or expel the
pregnancy tissue. As a result, the placenta may still continue to release hormones, so
the woman may continue to experience signs of pregnancy
• Habitual / Recurrent Miscarriage - Recurrent miscarriage, habitual abortion,
or recurrent pregnancy loss (RPL) is three or more consecutive pregnancy losses.
Infertility differs because it is the inability to conceive.
• Septic miscarriage - Bleeding variable in amount,foul smelling,vaginal discharge,
associted with Crampy pain over lower abd pain. Others
Pyrexia,Tachycardia,dehydration,electrolyte imbalance,abdominal distension,paralytic
illeus,septic shock Abdominal Ex may show Tenderness,guarding.rigidity in lower
abd,abdominal distension,paralytic ileus P/S Blood/pus coming through cervix
More about septic miscarriage...
• Clinical criteria:
• >38 temp for 24 hours or more
• purulent discharge per vagina
• other evidence of infection as
lower abd pain + tenderness
• Causes:
• delay in evacuation
• sexually transmitted infection
• trauma
• criminal abortion (aseptic
technique)
Infecting organism in septic miscarriage
• Anerobic:
• bacteriodes as streptococci, clostridium welchii, tetanus bacillus
• Aerobic as E.coli, klebsiella, staphylococcus, pseudomonas, hemolytic
streptoccus
• septic shock causes by clostridium welchii and bacteriodes fragilis

• Grading
• grade 1 : localized in uterus
• grade 2: spread beyond the uterus to parametrium, tubes, ovaries and pelvic
peritoneum
• grade 3: generalized peritonitis with/out endotoxic shock/jaundice /acute renal failure
Management of septic miscarriage
• Broad spectrum antibiotic
• Dilatation and curettage in
hemodynamicaly stable pt
• In unstable: start IV fluid and
antibiotic, perform D&C once
stabilized
Recurrent miscarriage
• Sequence of 3 or more consecutive spontaneous misccariage before 24 weeks of
gestation
• From history, repeated misccariage without any apparent cause, starting with escape
of liquor amnii followed by painless expulsion of POC
• Investigation:
• Blood test
• hormonal - throid, DM
• immune disorder - antiphospholipid syndrome
• coag profile - inherited thrombophilia
• cervical/vaginal culture
• systemic illness
• anatomical evaluation of uterus
• parental karyotyping
Cervical incompetence
• Condition where cervix begin to dilate and not by initiation of contraction
but due to structural weakness in the cervix itself.
• Inability to hold the weight of pregnancy resulting in bulging if amniotic
membrane into vaginal canal → rupture →preterm labor usually occur
in the 2nd trimester
• Risk factor:
• history of incompetent cervix with previous pregnacy
• cervical injury - multiple D&C, repeated surgical trauma
• anatomic abnormality of cervix
• DES exposure
• Ehler Danlos syndrome
• Diagnosis:
• based on obstetric history
• transvaginal ultrasound to identify
effacement and cervical length
Management of cervical incompetence
• Serial ultrasound examination 2 weekly, and
should be initiated between 16-20 week of
gestation
• Bed rest and reduced physical activity
• Pelvic rest - limit sexual intercourse
• Cerclage
• indication: congenital or acquired visible defect
in ectocervix
• classic features
• history of losing each pregnancy at erlier
gestatitional age
• history of painless cervical dilatation up to 4-6
cm
• history of cervical trauma
How about molar pregnancy
• Slight/None Bleeding
• Slight-moderate pain
• Os : Close
• Ultrasound Classic “snow-storm”
: appearance of vesicles
Honeycomb appearance
Gestational Trophoblastic Disease (GTD)
• It is a spectrum of trophoblastic
diseases that includes:
• Complete molar pregnancy
• Partial molar pregnancies
• Invasive mole
• Choriocarcinoma
• Placental site trophoblastic
tumour

• The last 2 may follow abortion,

ectopic or normal pregnancy.
Gestational Trophoblastic Neoplasia (GTN)
• Malignant Gestational
Trophoblastic Disease
• It is a spectrum of trophoblastic
diseases that develops malignant
sequelae.
• Persistent post molar GTD
• Invasive mole
• Choriocarcinoma
• Placental site trophoblastic
tumour
Gestational Trophoblastic Disease
• Over the last 30 years major advances have taken place in our
understanding and management of gestational trophoblastic disease.
• It is now possible to diagnose a mole by ultrasonography in minutes.
• It became the most curable gynec. malignancy.
• βhCG has very important role in the diagnosis, evaluation and follow up of
GTN
Epidemiology & Risk Factors
• Incidence:USA 1/1000 South East 1/100 (Hospital)
• Risk Factors:
• Age: <20y (2fold) , > 40y(10 fold) & >50y (50% )
• Prior Molar Pregnancy
• Second molar: 1%
• Third molar : 20%
• Diet:↑ in low fat Vit. A or carotene diet
• Contraception : COC double the incidence
• Previous spontaneous abortion: double the incidence
• Repetitive H. moles in women with different partners
How do molar pregnancies present to the us?
The classic features are
• Irregular vaginal bleeding
• Hyperemesis gravidarum
• uterine enlargement & Early failed pregnancy.
• Clinicians should check a urine pregnancy test in women presenting
with such symptoms.
• Some women will present early with passage of molar tissue
• Rare presentations include:
• Hyperthyroidism
• Early onset pre-eclampsia
• Abdominal distension due to theca lutein cysts
• Very rarely
• Acute respiratory failure
• Neurological symptoms such as seizures (? metastatic disease)
What Is The Most Common Presenting
Symptom Of A Complete Molar Pregnancy?
• A. Hyperemesis
• B. Bilateral enlarged theca lutein
cysts
• C. Vaginal bleeding
• D. Uterine enlargement> than
expected for GA
• E. Pregnancy-induced
hypertension
How Is Molar Pregnancy Diagnosed?
• Ultrasound is helpful in making a pre-evacuation diagnosis but the
definitive diagnosis is made by histological examination.
• U/S: Early detection reduced from 16 weeks (passage of vesicles) to
12 ws
• βhCG levels > 2 multiples of the median may be of value in the
diagnosis

• Definite diagnosis on first U/S examination alone: 68%

• U/S + βhCG > threshold of 82,350 mIU/mL: 89%
Please take note!
• Patients with partial mole do not have the same clinical features as
those with complete mole.
• These patients usually present with signs and symptoms consistent
with an incomplete or missed abortion, including vaginal bleeding and
absence of fetal heart tones.

• https://emedicine.medscape.com/article/254657-clinical#b1
What Is The Plan of Management?
There are 2 important basic lines :
• Evacuation of the mole
• Regular follow-up to detect persistent trophoblastic diseaseIf both basic lines
are done appropriately, mortality rates can be reduced to zero.
What Is The Best Method Of Evacuating This
Molar Pregnancy?
• A. Cervical priming with
misoprostol then suction
evacuation
• B. Suction evacuation to be
repeated 1-2 weeks later
• C. Single suction evacuation
• D. Medical trial with misoprostol
& oxytocine before suction

RCOG Guideline No. 38 ; 2010

What Is The Best Method Of Evacuating A
Molar Pregnancy?
• For Complete mole is:
• Suction curettage
• Cervical preparation with
prostaglandins or misoprostol ,
should be avoided to reduce the
risk of embolisation (No
sufficient studies)
For Partial mole
It depends on the fetal parts
• Small fetal parts : Suction curettage
• Large fetal parts: Medical (oxytocics)
• In partial mole the oxytocics is safe, as the hazard to embolise and
disseminate trophoblastic tissue is very low
• Also, the needing for chemotherapy is 0.1- 0.5%.
Should Products Of Conception Be Examined
Histologically?
Histological examination is indicated in:
• Failed pregnancies (missed or molar) :
• All medically or surgical managed cases
• Products of conception, obtained after all repeat evacuations (post
abortive or p.partum)
Cont of management...
• Hysterectomy may be preferred to suction curettage
• age ≥ 40 with no desire for further pregnancies especially with other
risk factors for GTN as :
• Large theca lutein cysts( >6 cm)
• Significant uterine enlargement
• Pretreatment βhCG ≥ 105.

• Although hysterectomy does not eliminate possibility of GTN this, it

markedly reduces its likelihood
The Post-evacuation Surveillance
• How?
• A baseline serum β -hCG level is obtained within 48 hours after evacuation.
• Levels are monitored every 1 to 2 weeks while still elevated to detect
persistent trophoblastic disease (GTN).
• These levels should progressively fall to an undetectable level (<5
mu/ml).
• If symptoms are persistent, more frequent β hCG estimation and U/S
examination ± D&C are advised
What Is The Optimum Follow-up Period
Following Normalization of β hCG?
• A. For 6 months from the date of
uterine evacuation.
• B. For 6 months from normalization
of the β hCG level.
• C. For 12 months from the date of
uterine evacuation.

• https://www.rcog.org.uk/globalassets/documents/
guidelines/gtg_38.pdf
What Is Safe Contraception Following GTD?
• Barrier methods until normal β hCG level.
• Once βhCG level have normalized:
• Combined oral contraceptive (COC ) pill may be used. If oral COC was
started before the diagnosis of GTD , COC can be continue as its
potential to increase risk of GTN is very low
• IUCD should not be used until β hCG levels are normal to reduce
uterine perforation

• https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_38.pdf
How about ectopic pregnancies?
• Ectopic pregnancy is derived
from the Greek word ‘ektopas’
which means ‘out of place’.
Ectopic pregnancy
Classification:
• 1- tubal pregnancy:
• 95-98 % implant in the Fallopian tube, among these:
• 80% in the ampulla
• 10% in isthmus
• 5 % in fimbria
• 2% interstitial
• 2% in a rudimentary horn of a bicornuate uterus
Classification
• 2-Nontubal ectopic pregnancy
• Rare sites (2-5%) are;
• The ovaries,
• broad ligaments,
• Abdominal cavity and peritoneum
• cervix.
• 3. Heterotopic pregnancy?
Epidemiology
• Incidence; 22/1000 live births
• In USA from 1970 – 1992 , the risk 5x increased from 4 to 19 / 1000
pregnancies

• Fatality rate :
• fatality rate from ectopic pregnancies dropped almost 90% (from 35.5 per
1000 ectopics to 3.8 per 1000 ectopics).
• Despite the sharp improvement in the fatality rate by the end of this period of
time, ectopics were still the second leading cause of maternal mortality in the
USA (accounting for 12% of all maternal deaths in 1987)
The reason for the increase in
ectopic pregnancy during this time
period is not entirely clear, but it
was thought that the increase of
risk factors were responsible for a
significant portion of the increased
number of cases of ectopic
pregnancy.
Risk factors
• Any mechanism that interferes
with the normal function of
fallopian tube increases the risk
of ectopic pregnancy
• The mechanism canbe:
• Anatomical; scarring that blocks
transport of the egg
• Functional; impaired tubal
mobility
1-History of pelvic infection
• PID is the most common risk
factor for ectopic pregnancy
• Chlamydia (a common sexually
transmitted disease) and
Gonorrhea are both able to grow
within the fallopian tubes and
cause
2-History of surgery on the fallopian tubes or
within the pelvis
• Tubal ligation in the past 2 years
• When a bilateral tubal ligation (tubes tied) is followed by either an
unexpected pregnancy (failed tubal ligation) or is "reversed" with a
tubal reanastomosis (tubal reconstruction) there is an increased risk
of a tubal ectopic pregnancy.
• When a woman has a history of pelvic surgery that is associated with
significant adhesion formation (such as myomectomy) there is also an
increased risk of an ectopic pregnancy.
3- Prior history of ectopic pregnancy
• When an ectopic pregnancy in
the fallopian tube is treated
conservatively (by preserving the
tube), there is a roughly 10 fold
increase the risk of recurrence in
the same tube
• History of IUD use. The use of an
IUD is a classic "risk factor" for
ectopic pregnancy.
Symptoms
• Pain and discomfort
• In the lower back , abdomen, or pelvis
• Usually unilateral
• Pain may be confused with a strong stomach pain, it may also feel like
a strong cramp
• Shoulder pain.
• Pain while having a bowel movement
Bleeding
• vaginal bleeding...why?
• Internal bleeding (hematoperitoneum) is due to hemorrhage from the
affected tube.
• Dizziness, headache, weakness, fainting all may happen due to
bleeding
Signs
• General examination
• signs of early pregnancy (Breast tenderness, nausea and vomitig,
change of apettite …)
• Weakness, pallor, hypotension and tachycardia, tachypnoea due to
bleeding (anemic symptom)
• Abdominal examination
• Lower abdominal tenderness and rigidity especially on one side may be
present
Vaginal examination
• Vaginal spotting
• Bluish vagina and bluish soft cervix
• Marked pain in one iliac fossa on moving the cervix from side to side.
• Ill defined tender mass may be detected in one adnexa in which
arterial pulsation may be felt.
• Speculum or bimanual examination should not be performed unless
facilities for resuscitation are available, as this may induce rupture of
the tube
Investigations
• hormonal assay Serum β-hCG
and progesterone
• UPT
• transvaginal and abdominal
ultrasound
• diagnostic laparoscopy (gold
standard)
MANAGEMENT OF RUPTURE ECTOPIC
• PRINCIPLE:
• Resuscitation and Laparotomy/Laparoscopy
• ANTI SHOCK TREATEMENT: -
• IV line made patent,
• crystalloid is started
• Blood sample for Hb, blood grouping & cross matching
• Folley’s catheterization done
• Colloids for volume replacement
• LAPAROTOMY:
• Principle is ‘Quick in and Quick out’ - Rapid exploration of abdominal cavity is done -
• Salpingectomy is the definitive surgery (sent for HP study) -
• Laparoscopy
• Preferred method if haemodynamically stable
• Tubal Patency no significant difference
• Followed by similar number of uterine pregnancy
• shorter operative time
MANAGEMENT OF UNRUPTURED
ECTOPIC PREGNANCY
• SURGICAL
• SURGICALLY ADMINISTERED MEDICAL (SAM) TREATMENT
• MEDICAL TREATMENT
• EXPECTANT MANAGEMENT
EXPECTANT MANAGEMENT
IDENTIFICATION CRITERIA
• Tubal ectopic pregnancies only
• Haemodynamically stable
• No rupture or bleeding
• Adnexal mass of < 3.5 cm without heart beat.
• Initial β HCG <1000 IU/L and falling in titre (single best)
• SUCCESS RATE - Upto 60%
• PROTOCOL: -
• Hospitalization with strict monitoring of clinical symptom
• Daily Hb estimation
• Serum β HCG monitoring 3-4 days until it is <10 IU/L
• TVS to be done twice a week.
MEDICAL MANAGEMENT
• Medical M/m may be tried in
selected cases
• CANDIDATES FOR
METHOTREXATE (MTX)
• Unruptured sac < 3.5cm without
cardiac activity
• S-hCG < 10,000 IU/L
• Persistant Ectopic after
conservative surgery
MEDICAL MANAGEMENT
METHOTREXATE
• It can be used as oral,
intramuscular ,intravenous
usually along with folinic acid.
• Mechanism of action-
Methotrexate is a folic acid
antagonist that inactivates the
enzyme dihydrofolate reductase.
• Interferes with the DNA
synthesis leading to
trophoblastic cell death.
• Advantages
• Minimal Hospitalisation. Usually outdoor treatment
• Quick recovery
• 90% success if cases are properly selected
• Disadvantages-
• Side effects like GI & Skin
• Monitoring is essential-
• Total blood count,
• LFT &
• Serum HCG once weekly till it becomes negative
SURGICALLY ADMINISTERED
MEDICAL TT (SAM)
SURGICAL MANAGEMENT OF ECTOPIC
• Conservative Surgery Can be
done Laparoscopically or by
microsurgical laparotomy
• INDICATION:
• - Patient desires future fertility
• - Contralateral tube is damaged
or surgically removed previously
• Laparascopy OR laparatomy??
• Laparoscopy has become the recommended approach in most cases.
• Laparotomy is usually reserved for patients:
• who are hemodynamically unstable
• patients with cornual ectopic pregnancies.
• for surgeons inexperienced in laparoscopy and in patients where laparoscopic
approach is difficult
'Will I be able to get pregnant again?'
• There is still a good chance that you would be able to get pregnant in
the future, BUT...
• how healthy the other tube was
• several other factors such as: your age
• easiness for you to get pregnant before this

• 65% to 70% of women with a previous history of ectopic pregnancy

will conceive again within 18 months
Hyperemesis gravidarum
INTRODUCTION
• At least 80% of women experience nausea & vomiting.
• The term morning sickness is often used to describe this condition
when symptoms usually disappear after the first trimester.
• this mild form affects the quality of life of women & her family where
the severe form hyperemesis gravidarum results in dehydration ,
electrolyte imbalance and the need for hospitalization
CRITERIA
• Persistent vomiting
• weight loss greater than 5%
• Dehydration
• Electrolyte abnormalities
Do u know that..?
• Normal nausea and vomiting may be an evolutionary protective
mechanism
• may protect the pregnant woman and her embryo from harmful
substances in food, such as pathogenic microorganisms
• supported by studies showing that women who had nausea and
vomiting were less likely to have miscarriages and stillbirth

• https://emedicine.medscape.com/article/254751-overview#a5
Pathophysiology
• Hormonal changes
• hCG may not be independently involved
in the etiology of hyperemesis
gravidarum but may be indirectly involved
by its ability to stimulate the thyroid.
• Progesterone also peaks in the first
trimester and decreases smooth muscle
activity

• https://emedicine.medscape.com/article/254751-overview#a6
• Gastrointestinal dysfunction
• Mechanisms that cause gastric dysrhythmias include elevated estrogen or
progesterone levels, thyroid disorders, abnormalities in vagal and sympathetic
tone
• Vestibular and olfaction
• Hyperacuity of the olfactory system
• Many pregnant women report the smell of cooking food, particularly meats

https://emedicine.medscape.com/article/254751-overview#a6
Psychological issues
• interact with each woman's psychologic
state and cultural values
• In unusual instances, cases of
hyperemesis gravidarum could represent
psychiatric illness, including conversion or
somatization disorder or major
depression

https://emedicine.medscape.com/article/254751-overview#a6
 Risk factors
• Previous pregnancies with hyperemesis
gravidarum
• Greater body weight
• Multiple gestations
• Trophoblastic disease
• Nulliparity

• Cigarette smoking is associated with a

decreased risk for hyperemesis
gravidarum

• https://emedicine.medscape.com/article/254751-overview#a9
Other problems to be considered
• Drug toxicity
• Eating disorders
• Gastroparesis
• Migraines
• Ovarian torsion
• Pseudotumor cerebri
• Psychological disorders
• Tumors of the central nervous system
• Vestibular lesions
SIGNS AND SYMPTOMS
• Dehydration, causing ketosis,
and constipation
• Nutritional disorders such as
Vitamin B1 (thiamine) deficiency,
Vitamin B6 deficiency or Vitamin
B12 deficiency
• Metabolic imbalances such as
metabolic acidosis or
thyrotoxicosis
• Physical and emotional stress of
pregnancy on the body
• Urine quantity is diminished
even to the stage of oliguria.
• Epigastric pain
• Constipation
• Complications may appear if not
treated.
• ptyalism
Clinical picture (sign)
• Dehydration.
• Weight loss.
• Sunken eye
• Dry mouth.
• Hypotension
INVESTIGATIONS
• Hyperemesis gravidarum is a
diagnosis of exclusion,
investigations are performed
for :
• Confirmation of pregnancy
• Exclusion of common and
serious causes of vomiting
• Evaluating the extent of
complication
• Urinalysis
• Biochemical serum electrolytes
Sodium- hyponatremia
Potassium- hypokalemia
chloride
• Ophthalmoscopic examination
• ECG
• Biochemical hyperthyroidism
• Abnormal LFTs
• Hemoconcentration leading to
rise in Hemoglobin % RBC count
Hematocrit values
Imaging Studies
Ultrasound
• To confirm pregnancy
• To establish the number of
fetuses
• To exclude hydatidiform mole
• To exclude other conditions such
as
• Pancreatitis
• Cholecystitis
• intracranial lesions
Complication
Maternal and Fetal Risks
• Esophageal rupture or perforation
• Pneumothorax and pneumomediastinum
• Wernicke encephalopathy or blindness
• Hepatic disease
• Seizures, coma, or death

• Others complications include renal failure, pancreatitis, deep venous

thrombosis, pulmonary embolism, central pontine myelinolysis,
rhabdomyolysis, vitamin K deficiency and coagulopathy, and splenic avulsion.
Fetal Risks
No direct fetal complications
• Women with HEG who gain <7
kg during the entire pregnancy
have a slightly higher risk of Low
birth weight / small for gestational
age/ IUGR Preterm birth / born
before 37 weeks’ gestation
• If the mother develops
Wernicke’s encephalopathy-
chance of IUD
Management
• Hospitalization:
• Whenever a patient is diagnosed
as a case of hyperemesis
gravidarum, she is admitted
Fluids
• Oral Rehydration Fluid
replacement therapy should be
with either
• Hartmann’s solution
• normal saline
• Dextrose-containing fluids
should not be used
• Double-strength saline
• Potassium supplements
• Thiamine supplements Enteral
• Parenteral feeding
Monitoring
• Urine output
• Ketonuria- dipsticks
• Body weight
DIETARY AND LIFESTYLE CHANGES
• Separating solids and liquids.
• Eating small, frequent meals
consisting of bland foods.
• Avoiding fatty foods such as
potato chips.
• Avoiding drinking cold or sweet
beverages.
PHARMACOLOGICAL THERAPIES
• Vitamins Pyridoxine
• Essential for normal DNA
synthesis and play a role in
various metabolic processes
• class A - Safe in pregnancy at a
dose of 10-25mg PO qid/bd.
• PO Doxylamine 12.5 mg 3-4 times
daily
• PO Metoclopramide 5-10 mg
• PO Promethazine 12.5 mg
• PO Ondansetron 4-8 mg, can be
used intravenous
• FDA-approved drug for treating
nausea and vomiting in
pregnancy is PO doxylamine-
pyridoxine 10-20mg
Hydrocortisone
• Severe and resistant symptoms
• Unable to tolerate fluids
• Intravenous hydrocortisone 100
mg three times a day
• Prednisolone 40 mg once daily
Nutritional support
• Vit B1
• Vit B6
• Vit B12
• Vit C
• Termination of pregnancy rarely
indicated
• Intractable hyperemesis
gravidarum inspite of therapy
• Wernicke’s encephalopathy
• Jaundice
• Persistant CVS change
Reference
• RCOG guidelines (Royal college of obstetric & gynecology)
• ACOG(American college of obstetric & gynecology)
• ASRM(American society of reproductive medicine)
• www.medscape.com
• http://www.myhealth.gov.my/en/miscarriage/
• www.uptodate.com