Early pregnancy complications are common. Miscarriage can lead to significant physical and psychological disorders. Ectopic pregnancy can potentially lead to death. It is important to understand that serum hormone level testing and ultrasound are important in the diagnosis of early pregnancy complications. Transvaginal ultrasound is a particularly favorable diagnostic tool. Spontaneous abortion can be managed non-surgically in many patients. Gravidas require surgical removal of uterine contents because the risk of metastasis requires close follow-up. Nonsurgical management of ectopic pregnancies is also becoming common, but requires careful patient selection, rigorous and reliable follow-up, and surgery. I. hCG and progesterone levels associated with early pregnancy (i) Early pregnancy bleeding There are many causes of early pregnancy bleeding. Once bleeding occurs in early pregnancy, it may be a miscarriage, ectopic pregnancy; rarer early pregnancy bleeding such as gestational trophoblastic disease, cervical cancer; and some common, but easily overlooked without gynecological examination, such as cervical polyps, easy bleeding, cervical trauma. (B) early pregnancy laboratory tests The first and most important thing to do is to do gynecological examination, which helps to understand whether the pregnant woman has cervical problems. For example, tumors of the cervix are very important for differential diagnosis. Laboratory indicators of normal early pregnancy, early pregnancy β ~ hCG levels quantitatively related to the gestational week, special ultrasound examination. Checking beta to hCG levels at least twice at 2 to 3 days apart can help determine if the pregnancy is progressing normally. In normal early pregnancy, quantitative β-hCG levels should double every 2 to 3 days and increase to 4 to 8 times in a few weeks. decreasing or unchanged β-hCG levels are strong evidence of an abnormal pregnancy outcome, but do not differentiate between spontaneous abortions and ectopic pregnancies. Progesterone levels in the first 8 weeks of pregnancy can also help predict pregnancy outcome. In contrast to elevated β~hCG levels, progesterone levels are stable during the first 9 to 10 weeks of pregnancy. Unlike beta~hCG, a single progesterone level can predict pregnancy outcome. Progesterone levels less than 5 ng/ml may be associated with poor pregnancy outcomes (e.g., spontaneous abortion or ectopic pregnancy), whereas a progesterone level greater than 25 ng/ml is suggestive of an intrauterine pregnancy that is viable. In areas where ultrasonography is not available, waiting time for serial measurements of β-hCG is impractical, and a single serum progesterone indicator is able to indicate whether the pregnancy is developing normally. (The correlation between laboratory and ultrasound ultrasonography and β-hCG is also indicative of pregnancy status. Transvaginal ultrasound can show the gestational sac when the β-hCG level reaches approximately 1,800 mIU/mL IRP (international unit of measurement). When β~hCG levels reach approximately 1800 to 3500 mIU/mL IRP, transabdominal ultrasound can show the gestational sac, depending on the sensitivity of the instrument and the proficiency of the operator. As an example, assuming the patient presents with vaginal bleeding and cramping, if the ultrasound does not reveal a gestational sac in the uterine cavity with a beta hCG test value of 5000 mIU/ml, either transabdominal ultrasound or transvaginal ultrasound should be able to detect the gestational sac in the case of a normal intrauterine pregnancy. It suggests the presence of ectopic pregnancy or GTD trophoblastic disease. II.EARLY PREGNANCY ULTRASOUND DIAGNOSIS (a) Indications for early pregnancy Ultrasound diagnosis in early pregnancy Diagnostic ultrasound is a favorable diagnostic tool in the study of early pregnancy.In 1984, a National Institutes of Health (NIH) study group developed the major indications for ultrasound during pregnancy, which have been used to this day. Of the 28 indications, nearly half are for early pregnancy. Indications for ultrasound: suspected miscarriage or stillbirth; vaginal bleeding; gestational week (uncertainty or size/gestational week discrepancy); in conjunction with special maneuvers, such as chorionic villus biopsy; suspected multiple pregnancy; suspected gravidity; suspected ectopic pregnancy; localization of intrauterine device; suspected uterine anomaly; uterine size discrepancy with gestational week; and examination of clinically detected pelvic masses in pregnant women. Ultrasound in early pregnancy synthesizes the patient’s history, physical examination, and appropriate laboratory tests such as serum β~hCG and progesterone to obtain an accurate diagnosis. Because ultrasound is so helpful, many physicians use it as a primary means of evaluating early pregnancy complications when they can utilize it, and use beta~hCG and/or progesterone as a secondary means only when ultrasound results are questionable. Transabdominal and transvaginal ultrasound techniques can be applied when performing early pregnancy ultrasound. Transabdominal ultrasound provides a wider and deeper field of view, helping the examiner to avoid missing findings high or deep in the pelvis. Transvaginal ultrasound is relatively more sensitive than transabdominal ultrasound. (ii) Normal gestational sac At 5 to 7 weeks of menopause, transvaginal ultrasound can sequentially detect the gestational sac, yolk sac and embryo. The gestational sac can be seen on ultrasound only when β-hCG reaches 1800 mIU/ml IRP. When the gestational sac is seen for the first time at 5 weeks of gestation, it appears to be empty and it is difficult to distinguish it from the “false gestational sac” that occurs in ectopic pregnancies. The normal gestational sac in early pregnancy is round, located at the fundus, and surrounded by a “ring” of echogenicity. At 6 weeks of menopause, the yolk sac appears. It is an anechoic, round structure within the gestational sac. The yolk sac looks more like an “=” than a circular sign because of its thin walls and the fact that its sidewalls are parallel to the beam of light and cannot be easily seen. If there is a gestational sac, the yolk sac needs to be looked for carefully at every angle because it is not visible at all levels. Because the yolk sac is an embryonic structure, its presence confirms an intrauterine pregnancy and excludes false sacs in ectopic pregnancies. The fluid in the gestational sac is the extraembryonic body cavity, not amniotic fluid At 7 weeks of menopause, the embryo appears and the fetal heartbeat can be seen. Transvaginal ultrasound recognizes the embryo one week earlier than transabdominal ultrasound. Fetal buds initially resemble small “dots” on the side of the yolk sac and grow rapidly at a rate of 1mm per day. Fetal heartbeat is often seen when the head and buttocks are 5 mm long. A membrane is often seen around the embryo. This is the amniotic membrane, which gradually expands to replace the extra-embryonic cavity in the following weeks. (c) Estimation of gestational week by head and hip length The fetal sac should be more than 2 centimeters in diameter, and the presence of fetal buds should be detected inside the sac. If the length of the bud is more than 5 mm, the fetal heartbeat can be detected on ultrasound. At 5-6 weeks of menopause, when the gestational sac is present but the embryo cannot be seen, the week of pregnancy can be estimated by measuring the average diameter of the gestational sac (length + width + height/3), by referring to a standardized table of values or by using the software of the ultrasound machine. With modern real-time transvaginal ultrasound, the embryo can be seen at 6 weeks and the gestational week can be estimated by directly measuring the head-butt length. Alternatively, after the embryo is seen between 8 and 13 weeks of gestation, the week of gestation can be calculated by measuring the head and hip length using a simple formula: week of gestation (weeks) = head and hip length (cm) + 6.5. III. Miscarriage (a) Definition of miscarriage Regarding the definition of miscarriage, the definition of miscarriage in domestic textbooks and the United States textbooks will be slightly different. In the United States, 20 weeks has always been used as the standard, while in China, 28 weeks is now used as the standard. Spontaneous miscarriage refers to the spontaneous loss of pregnancy before 20 weeks of gestation. Pre-eclampsia is defined as uterine bleeding, closure of the cervix, and absence of pregnancy products. Incomplete miscarriage is when not all, but some, of the pregnancy products pass through the uterus. An inevitable miscarriage is one in which the cervix is open, but the pregnancy tissue has not been expelled. Retained miscarriage is a stillbirth with no tissue expulsion and a closed cervix, often manifested by no increase in uterine size or absence of fetal heartbeat. An infected abortion is an upstream infection in the case of an incomplete abortion. Empty egg is the presence of a gestational sac and placental tissue but no embryo. Subchorionic hemorrhage is when there is bleeding between the chorion and the uterine wall. Meconium is the endometrium of the pregnancy that is expelled as part of the aborted tissue (ii) Pathophysiology of Miscarriage At least half of spontaneous miscarriages are the result of major genetic abnormalities such as triploidy, trisomy, and haploidy, which means that the embryo is genetically predisposed to cause miscarriage in a pregnant woman. Spontaneous abortion is also associated with internal environmental factors such as uterine malformations, maternal exposure to ethylestradiol (DES), uterine fibroids, cervical insufficiency, progesterone deficiency due to luteal phase deficiency, and immunologic factors. External environmental factors include smoking, alcohol and drug use, exposure to radiation, infections and occupational chemical exposures. The incidence of spontaneous abortion increases with the age of the mother. The etiology of early spontaneous abortion can rarely be identified in clinical practice. (c) Clinical course Pregnancy is initially diagnosed by menopause, typical symptoms and a positive pregnancy test. At the start of the miscarriage, the hCG level is unchanged or decreases and pregnancy signs disappear. Then vaginal bleeding begins. Vaginal bleeding is the most common manifestation of a possible miscarriage, occurring in 30% of all pregnancies. Half of those who bleed will miscarry, and the rest will continue to survive, but with an increased incidence of complications and a poorer prognosis than in non-bleeding pregnancies. The poor prognosis of the pregnancy is not recognized until vaginal bleeding occurs, even though the pregnancy may have died a few weeks earlier. Then, lower abdominal pain and back pain occur frequently and the prognosis of the pregnancy becomes worse. Finally, discharge of the products of pregnancy is accompanied by cramping abdominal pain with severe vaginal bleeding. (d) Physical examination Abdominal examination should pay special attention to the location of pain, pressure, rebound pain and muscle tension, which can indicate intra-abdominal hemorrhage caused by rupture of ectopic pregnancy. Speculum examination can exclude bleeding caused by non-uterine factors and clarify whether the cervix is open. Dilatation of the cervix is checked using the oval forceps, as the top of the oval forceps cannot pass through the cervical opening in a normal, undilated cervix. A bimanual examination should also be done to check the size of the uterus and the presence of adnexal masses. An experienced examiner will be able to estimate the week of gestation from uterine size within 2 weeks, but obesity, pain, poor patient cooperation, and a posterior uterus can affect accuracy. A uterus smaller than the expected gestational week suggests miscarriage (v) Fetal heart sounds If the patient is 9 to 10 weeks pregnant and the embryo is viable, the fetal heart can be heard by Doppler. The sensitivity to hearing the fetal heart can be increased by elevating the uterus with bimanual palpation. However, in obese patients or when the uterus is posterior, the fetal heart may not be heard until 11-12 weeks after the last menstrual period. Any transvaginal expulsion of tissue should be examined. This test is very effective and can be performed in an outpatient clinic or emergency disposal room. It often provides important diagnostic information. If the gestational sac, embryo, or chorionic tissue is intact, it can diagnose miscarriage and, except in the very rare case of simultaneous intrauterine and extrauterine pregnancies, is able to rule out ectopic pregnancy. To look for chorionic villi, the tissue is soaked and rinsed with saline. A low magnification, dark field is used to find the tissue to the best of one’s ability. The expelled tissue is also sent for formal pathologic examination, which can clarify the diagnosis in a suspicious history. (vi) Chorionic villus floating test If villi are seen at the cervical opening, miscarriage is inevitable. It is gently removed with oval forceps. Further operations to remove the remaining tissue need to be discussed with the patient and anesthetic or sedative drugs applied. When the diagnosis is unclear through clinical findings, transvaginal ultrasound can clarify the diagnosis. Patients with “induced abortion” do not expel any tissue. An empty gestational sac can be seen as a ring of echoes without a healthy chorionic villi surrounding it. There may also be no embryo (“empty egg”, “pregnancy without embryo”, “embryo ablation”). Stillbirths may also be seen. A gestational sac with an average diameter of 2 cm should have fetal buds. A bud with a head and hip length of 5mm should have a fetal heart. If there is any doubt about the ultrasound findings and the patient is stable, she should be followed up and rechecked after a few days. (In a complete spontaneous abortion, the uterine evacuation is characterized by a clear “endometrial line”, suggesting that the uterine wall tissue has returned to approach the other side of the uterine wall. The patient has a history of expulsion of tissue or blood clots, which can help determine whether the miscarriage is complete and whether dilatation and curettage (D&C) is necessary. (viii) Management of miscarriage The likelihood of miscarriage is 50% when there is vaginal bleeding, and further increases if accompanied by abdominal pain. Ultrasound findings change the prognosis. The later the week of gestation at first examination, the greater the likelihood of embryo survival. The presence of a fetal heart is a sign of a good prognosis. The likelihood of miscarriage if the ultrasound shows a fetal heart in a patient with vaginal bleeding ranges from 2.1% (for those under 35 years of age) to 16.1% (for those over 35 years of age). Therefore, expectant therapy should be performed with caution in patients with vaginal bleeding with fetal heartbeat in early pregnancy. The prognosis cannot be predicted in every case, and the patient’s hope of continuing the pregnancy should be supported, but with the explanation that there is no treatment available to stop the miscarriage. Most early miscarriages are spontaneous and complete without the need for pharmacologic or surgical intervention. Physical examination is primarily to identify patients with incomplete miscarriages because they may experience vaginal bleeding, infection, and effective pharmacologic or surgical intervention. After a miscarriage, patients are usually advised to use contraception for a period of time before having another pregnancy. Miscarriage rates are high for pregnancies in the first 3 months after termination of a single pregnancy. If the patient desires long-term contraception, an intrauterine device (IUD) can be placed immediately after a spontaneous or early miscarriage, which is both safe and effective. In addition to surgery, there are a number of medications that can be used for abortion. The table below shows the comparable success rates of management with Miso and surgical management. MVA refers to manual aspiration, a manual negative pressure suction device that terminates the pregnancy by means of a negative pressure device through a syringe. For the management of embryonic abruption, the success rate of treatment with Miso and surgical treatment is also comparable. IV. Ectopic pregnancy (a) Definition of ectopic pregnancy Ectopic pregnancy is a pregnancy outside the uterus, commonly in the fallopian tubes. The incidence of ectopic pregnancy in the United States is 1:100 pregnancies. Despite advanced diagnostic and therapeutic techniques, it remains the second leading cause of death in pregnant women. It can also lead to injury, infertility, and impairment of reproductive function. Early diagnosis is necessary to prevent serious complications and may also allow the use of conservative treatments that help preserve fertility. All health workers working with women of childbearing age should have clinical experience of ectopic pregnancy and be highly vigilant about it in any woman with vaginal bleeding and/or abdominal pain in early pregnancy. (ii) Risk factors for ectopic pregnancy Risk factors for ectopic pregnancy include a history of previous ectopic pregnancy, a history of tubal surgery, a history of inflammation of the oviducts, progestogen-only contraception, intrauterine device (IUD) contraception, and a history of intrauterine exposure to ethylestradiol. Ectopic pregnancy may occur in women with no risk factors ! (C) Ectopic Pregnancy Pathophysiology and Symptoms Ectopic pregnancy occurs when the fertilized egg does not reach the uterus but is deposited elsewhere, usually in one of the fallopian tubes. It is usually initially indistinguishable from an intrauterine pregnancy. The patient also presents with menopause, feels pregnant, and has a positive pregnancy test. However, the pregnancy eventually fails gradually as the oviduct overstretches and invades the blood vessels. At this point, the function of the placenta and corpus luteum gradually declines and blood hormone levels drop. The lining of the pregnancy, the meconium, which has been supported by the progesterone secreted by the corpus luteum, begins to peel off and bleed. Occasionally large portions of the meconium are shed, called meconium tubularis. At this time the beta~hCG produced by the placenta shows no change or decreases. Pregnancy material can invade the tubal walls and blood vessels, resulting in intra-abdominal hemorrhage. Bleeding can be catastrophic or slow. Ectopic pregnancies behave in a variety of ways, including spontaneous disappearance, discharge abortion at the end of the oviduct, formation of a chronic hematoma, or even re-implantation of the pregnancy product to form an abdominal pregnancy. Pain and vaginal bleeding are typical symptoms of ectopic pregnancy. Pain is almost universal and is usually lower abdominal and unilateral. Vaginal bleeding after short-term menopause is also common. Finally, signs and symptoms of intra-abdominal hemorrhage and shock can occur, including a distended, tense “slab-like abdomen,” shoulder pain, protrusion of the Douglas fossa into the posterior vaginal vault, and hypotension. (Laboratory tests Laboratory tests are very helpful. Serum β~hCG rises normally for a short time and then remains unchanged or falls. A systematic β~hCG test fails to rise up to twofold in 48 hours. This can predict pregnancy failure but does not identify miscarriage or ectopic pregnancy. Abnormally low serum progesterone levels also suggest pregnancy failure, but not the site of the pregnancy. 2, ultrasound on diagnosis Ultrasound is very helpful in diagnosis. Transvaginal ultrasound has more diagnostic value than transabdominal ultrasound. Two kinds of ultrasound seen have diagnostic value: clear intrauterine pregnancy can be ruled out ectopic pregnancy; outside the uterus to see the gestational sac and the embryo with fetal heartbeat, proving ectopic pregnancy; if β ~ hCG reaches or exceeds 1,800 mIU/ml IRP or more, and still do not see the fetal sac, it is highly suggestive of ectopic pregnancy; in the ultrasound diagnosis there are a few important pitfalls: the uterus can be seen in the pseudo-gestational sac, which will be mistaken for an intrauterine pregnancy. It is a small translucent area in the uterus due to overstimulated meconium or endometrium. The differential diagnosis is characterized by the absence of an echogenic ring around the chorionic villi and the absence of a yolk sac or fetal bud within it. The second controversial presentation is caused by the corpus luteum. If the corpus luteum is unbroken, a cystic mass is visible in the adnexa, which can be mistaken for a fetal sac, and if the corpus luteum is ruptured, the presentation is characterized by a shiny, echogenic area, sometimes a complex structure in the adnexal area, and a free fluid collection in the pelvis. For the current diagnosis and differential diagnosis of ectopic pregnancy, laparoscopic exploration is a gold standard, and nowadays, because of the minimally invasive nature of laparoscopy it has become a very good method for more and more hospitals to deal with and diagnose ectopic pregnancy. (1) Ectopic pregnancy ~ extra-uterine mass Ultrasound performance, if you do not see anything inside the uterine cavity, see a hypoechoic mass outside the uterus, alert the patient to the presence of a ectopic pregnancy mass. (2) Extrauterine ultrasound manifestations of ectopic pregnancy Ultrasound manifestations Risk of ectopic pregnancy ————————————— No mass or free fluid 20% Some free fluid 71% Mixed echogenic mass 85% Moderate to large amount of fluid 95% Mixed echogenic mass with fluid 100% 3. Posterior fornix puncture An additional diagnostic Another diagnostic test that was popular in the past, but has declined since the introduction of ultrasound, is the retrobulbar puncture. An 18- or 20-needle syringe is inserted into the posterior vaginal vault and fluid is aspirated. If it is a bloody fluid with a hematocrit of more than 15%, active intra-abdominal bleeding is suspected and requires urgent management. Posterior vault puncture is important in differentiating between small, pink fluid in ruptured ovarian cysts, which can be managed with expectant therapy, and ruptured ectopic pregnancies, which require surgical intervention. Laparoscopy is often used as the gold standard for diagnosis and is certainly applied when intra-abdominal bleeding is suspected. In most cases the diagnosis can be confirmed and surgically treated. However, pharmacologic treatment is also appropriate in patients with unruptured ectopic pregnancies who are appropriately selected by clinical and ultrasonographic examination alone. (E) Treatment of ectopic pregnancy 1. Expectant therapy Four methods of treatment of ectopic pregnancy are currently applied, including expectant therapy, drugs, laparoscopy and open surgery. Laparoscopic surgery is the most suitable treatment in most women with ovarian pregnancy. Expectant therapy or drug therapy is the treatment for patients who are hemodynamically stable and have been carefully selected and informed according to certain criteria. Expectant therapy is appropriate in women with β~hCG levels below 1000 that are declining. A randomized study conducted in 1955 showed that half of the patients treated with expectant therapy did not have to be operated on because some ovarian pregnancies may be spontaneously aborted or absorbed. Applicable criteria for expectant therapy include: mild pain and minimal bleeding; reliable patient follow-up; no evidence of ovarian rupture; initial β-hCG level less than 1000 and declining; ectopic or adnexal mass less than 3 cm, or undetected; absence of a fetal heartbeat; and the diagnosis of an ectopic pregnancy is usually only guesswork given the above criteria. Expectant therapy is usually used in cases where the location of the pregnancy is not certain. β-hCG levels are low and decreasing. Ultrasonography does not provide diagnostic evidence, and the patient is asymptomatic. The only test to differentiate between miscarriage and ectopic pregnancy resorption is dilatation and curettage (D&C), which looks for chorionic villi in the scrapings. This invasive test can be performed or postponed according to clinical need. Randomized trials have demonstrated the safety and reliability of methotrexate (MTX), a tetrahydrofolate inhibitor, in the conservative treatment of appropriately selected patients; it is less expensive than conservative surgery and has a comparable or better chance of secondary pregnancy. the key factor in the success of MTX treatment is patient selection. These patients must be able to adhere to a complex follow-up program, manage the pelvic pain associated with this treatment. There are a range of criteria that remain controversial. Reasonable criteria include: stable vital signs and minimal symptoms; no contraindications to MTX medication (normal liver enzymes, blood counts, and platelet counts); unruptured ectopic pregnancy; absence of fetal heart beats; an adnexal mass of 4 cm or less; and an initial β-hCG level of less than 5,000 mIU/ml. A variety of protocols have been published for MTX therapy, including single or high-dose intramuscular injections or direct injection of the ectopic pregnancy through the laparoscopic injection directly into the ectopic pregnancy mass. Single-dose intramuscular regimens are often calculated using 1 mg/kg or 50 mg/cm2 . Serum β~hCG levels are checked on days 4 and 7 after treatment and then repeated weekly until the level falls to 5 mIU/ml, which may take 3 to 4 weeks. β~hCG levels rise mildly initially but should fall by 15% between days 4 and 7, otherwise the dose should be repeated or surgical treatment should be performed. MTX therapy should be repeated only once before surgery is recommended. Serum progesterone levels should be followed in addition to β~hCG; a decline to 1.5 mg/ml is the target for treatment success and frequently occurs at 2 to 3 weeks. Because there are a variety of MTX regimens available, and some patients may not respond to ultimately require surgery, the physician applying MTX must have a range of treatment options to choose from, patient follow-up, and the ability to perform surgery if necessary. 3, Surgical management Surgical treatment of ectopic pregnancy has been the mainstay of treatment for many years and is still the primary option. It can be categorized into conservative and radical surgery. Conservative means preserving the oviduct. Radical means removing the oviduct. Both procedures can be done laparoscopically or openly depending on the patient’s condition, the skill of the operator, public standards and feasibility. Criteria for surgical treatment include: patient’s vital signs are unstable or signs of intra-abdominal hemorrhage; unknown diagnosis; progression of ectopic pregnancy (high β-hCG levels, large masses, presence of fetal heartbeat); unreliable follow-up; and any contraindications to expectant therapy or MTX. Some ectopic pregnancies (in the uterine horn, interstitium, cervix, chronic broad ligament, and others) are particularly dangerous and difficult to treat. Counseling is essential for non-surgical physicians. V. Gestational Trophoblastic Disease (a) Concept of Gestational Trophoblastic Disease Gestational trophoblastic disease, or gravidarium, has three basic forms: complete gravidarium, partial gravidarium, and recurrent gravidarium that can progress to metastatic choriocarcinoma. Because it is a rare cause of bleeding in early pregnancy, this disease, unless confirmed, should be considered in the differential diagnosis. Complete staphylococcus is defined as the absence of a fetus and placenta accreta. The placental villi are swollen and resemble a bunch of grapes. The chromosomal composition of most complete gravidas is 46,XX and is of complete paternal origin. Partial gravida is defined as gravida + nonviable fetus. The chromosomal composition is 69, XXY.EpidemiologyThe incidence of trophoblastic disease in the United States is 1:1000 to 1500 pregnancies. It is very common in other countries, especially in Southeast Asia. Two factors predict trophoblastic disease: pregnancy at the end of the reproductive period (especially in women older than 45 years), and a history of previous gravidity (ii) Clinical manifestations of gestational trophoblastic disease Patients with trophoblastic disease are characterized by the following features occurring with varying frequency: vaginal bleeding in early or early-midtrimester pregnancy, which is often dark brown and results in anemia. If it progresses to mid-trimester, it discharges grape-like vesicles; higher than expected β~hCG levels; a uterus larger than the gestational week and inability to hear the fetal heartbeat; severe gestational vomiting, hyperemesis gravidarum and/or hyperthyroidism that develops in the early trimester; and overstimulation of the ovaries due to high levels of hCG levels, which produces luteinized cysts that appear as enlarged ovaries. (iii) Ultrasound diagnosis of gravidarium Early diagnosis relies on a high degree of vigilance. Ultrasound is the gold standard for diagnosis, showing multiple small vesicular areas in the uterus without a fetus. Enlarged cystic ovaries are common. Figure : Ultrasound image of hyperemesis gravidarum (iv) Treatment Rapid evacuation of the uterus is the initial treatment. After evacuation of a complete gravidarium, all patients should be contracepted for one year and followed up with monitoring of β~hCG levels for six months to one year. If the β~hCG level remains the same or rises, the disease is considered to have recurred and chemotherapy (MTX) is given. Counseling is recommended because of the relative rarity of the disease and the many possible complications that arise. Flavinized cysts do not require treatment and disappear on their own after expulsion of the gravida. Approximately 20% of complete gravidarians recur, as evidenced by invasion of the grapes into the myometrium or further metastasis. Partial hyperemesis gravidarum is less common than complete hyperemesis gravidarum and has a lower risk of recurrence. The prognosis for future pregnancies is that although there is a 1 to 2% chance of recurrence, most patients are able to carry to term and have a normal fetus. Chemotherapeutic agents used to treat recurrences do not affect future pregnancies. The special challenge for the clinician is the psychological impact of being involved in this dangerous situation. VI.PROCESS OF EARLY PREGNANCY BLEEDING VII.DUCTION AND CLEANING (D&C) (a) Indications for performing D&C Clinically stable patients with miscarriage are not surgical emergencies. In the past, it was emphasized that D&C should be performed for all early miscarriages, but more recently the view has been to treat expectantly, i.e., to allow spontaneous abortion to occur, in terms of safety and cost-benefit ratio. Indications for D&C: Heavy vaginal bleeding; patient is stable (no bleeding or abdominal pain), but embryonic death is confirmed and the patient does not want to wait for spontaneous abortion; when ectopic pregnancy needs to be excluded. It is usually clinically difficult to distinguish ectopic pregnancy from intrauterine pregnancy. If chorionic villi are seen in the D&C tissue, it is an intrauterine pregnancy. Very rarely, intrauterine and ectopic pregnancies coexist, making clinical management difficult and dangerous. Contraindications to D&C: Medical contraindications are rare but include pelvic infection and coagulation disorders; failure of the patient, the physician, or both to satisfactorily confirm the death of the embryo; the patient chooses to wait for a spontaneous abortion for one reason or another (religious beliefs, expense, unwillingness to undergo a surgical maneuver, etc.). (ii) D&C is not required D&C is not required in the following cases: Small, hard uterus. There is little or no vaginal bleeding. No tissue has been expelled, can be examined, and tissue is intact. Patient follow-up is reliable. Ultrasound (transvaginal preferred) suggests an empty uterine cavity. (C) D&C operation Open intravenous access; check hematocrit, Rh blood group; oxytocin 20 IU/L fluid; give sedation/anesthesia; check uterine size, position; speculum to expose cervix, cervical forceps clamp; perform paracervical block for anesthesia; dilate cervix gradually, if necessary; probe uterus carefully for orientation; insert suction along uterine axis; attach suction tubing, check switches; move in and out of uterine cavity, and Rotate the suction device; observe and deliver the tissue; repeat the curettage; choose a sharp spatula; remove the negative pressure to avoid touching the vaginal wall; observe the bleeding; give Rh immunoglobulin if Rh negative. In addition to the machine-operated suction device, a hand-operated negative pressure aspirator, or MVA, can be used, which is a simple hand-operated plastic suction tube that generates its own negative pressure. This device is inexpensive, easy to use and does not require electricity. It is appropriate for ending very early pregnancies. It is very suitable in clinics where suction devices are not available. It is also suitable in developing countries where electricity is not available. (As with all surgical procedures, complications can occur with D&C. Complications can be prevented by careful handling, consulting with an experienced doctor if necessary, and recognizing those who are at high risk for complications. Perforation; Incomplete aspiration; Bleeding infection; Late complications (intrauterine adhesions, depression and psychological problems) VIII. The following points are key points in giving initial counseling to abortion patients: Perception and attempts to let go of feelings of guilt. Many women believe that some of their behaviors have partially caused or contributed to the miscarriage. The patient must be made to recognize that it was not she who caused the miscarriage; to recognize and rationalize the grief, recognizing that the miscarriage is the death of the child, in order to rationalize their grief; to give appropriate, sympathetic, and continuous help, listening to her thoughts, holding her hand, or telling her that you are grieving for her can help her through this stage of grief; and to give assurances about the future. Grief subsides with time. Most patients have a chance for a normal pregnancy. If there are fewer than 3 miscarriages, the risk of future miscarriages is not higher than in the general population; advise the patient on how to inform family and friends about the miscarriages. If family and friends know about the pregnancy, have a designated person inform them of the news. This allows them to express sympathy and offer moral support warning the patient of the anniversary phenomenon. They may have a renewed attack of grief on the date or anniversary of the miscarriage. It may also occur when a friend has a baby; include sexual partners in counseling. Sexual partners are often distressed by this and should be included in counseling; evaluate the degree of grief and change counseling strategies accordingly.