English Case

BLIGHTED OVUM
ON G1P0A0L0 11 - 12 WEEKS OF PREGNANCY

Presented by:
dr. Rizki Oktavian
Resident of Obstetrics and Gynecology

Mentor :
Prof. Dr. dr. Hj Yusrawati, SpOG (K) - KFM

OBSTETRICS AND GYNECOLOGY DEPARTMENT

MEDICAL FACULTY OF ANDALAS UNIVERSITY
DR. M. DJAMIL CENTRAL GENERAL HOSPITAL
PADANG
2021
 PROGRAM PENDIDIKAN DOKTER SPESIALIS (PPDS)
OBSTETRI DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS ANDALAS
RSUP DR. M. DJAMIL PADANG

LEMBAR PENGESAHAN

Nama : dr. Rizki Oktavian

Semester : II (dua) / Patologi I
Telah menyelesaikan English Case dengan judul:

BLIGHTED OVUM ON G1P0A0L0 11 - 12 WEEKS OF PREGNANCY

Padang, 10 September 2021

Mengetahui / menyetujui Peserta PPDS

Pembimbing Obstetri & Ginekologi

Prof. Dr. dr. Hj Yusrawati, SpOG (K) – KFM dr. Rizki Oktavian

Mengetahui :

KPS PPDS OBGIN

FK UNAND RS. Dr. M. DJAMIL PADANG

Dr. dr. Bobby Indra Utama, Sp.OG (K)-Urogin

ii
 PROGRAM PENDIDIKAN DOKTER SPESIALIS (PPDS)
OBSTETRI DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS ANDALAS
RSUP DR. M. DJAMIL PADANG

LAPORAN HASIL PENILAIAN

Nama : dr. Rizki Oktavian

Semester : II (dua) / Patologi I
Telah menyelesaikan English Case dengan judul:

BLIGHTED OVUM ON G1P0A0L0 11 - 12 WEEKS OF PREGNANCY

Hasil Penilaian

NO KRITERIA PENILAIAN NILAI KETERANGAN

1 Pengetahuan

2 Keterampilan

3 Attitude

Padang, 15 September 2021

Mengetahui/Menyetujui
Pembimbing

Prof. Dr. dr. Hj Yusrawati, SpOG (K) – KFM

iii
 PPDS I OBSTETRI & GINEKOLOGI

FK UNAND/RSUP.Dr. M. DJAMIL PADANG

NAMA : dr. Rizki Oktavian

NO. CHS :
SEMESTER : II (Dua)
JENIS : English Case
PEMBIMBING : Prof.Dr. dr. Hj. Yusrawati Sp.OG(K)-KFM
JUDUL : BLIGHTED OVUM ON G1P0A0L0 11-12
WEEKS OF PREGNANCY

No Tanggal Koreksi Paraf Ket

Pembimbing

Prof.Dr. dr. Hj. Yusrawati, Sp.OG(K)-KFM

iv
 TABLE OF CONTENT

LEMBAR PENGESAHAN .................................................................................. ii

LAPORAN HASIL PENILAIAN ....................................................................... iii
PPDS I OBSTETRI & GINEKOLOGI ............................................................. iv
TABLE OF CONTENT .........................................................................................v
LIST OF FIGURES ............................................................................................. vi
CHAPTER I INTRODUCTION..........................................................................1
1.1 Introduction ....................................................................................................1
CHAPTER II CASE REPORT ............................................................................2
2.1 Identity ...........................................................................................................2
2.2 Chief Complaint .............................................................................................2
2.3 Present Illness History ...................................................................................2
2.4 Previous Illness History .................................................................................3
2.5 Family Illness History ....................................................................................3
2.6 Obstetric History ............................................................................................3
2.7 Physical Examination .....................................................................................3
2.8 Ultrasound ......................................................................................................5
2.9 Laboratorium Results .....................................................................................5
2.10 Diagnosis ......................................................................................................5
2.11 Management .................................................................................................6
2.12 Plan...............................................................................................................6
CHAPTER III LITERATURE REVIEW ..........................................................8
3.1 Definition .......................................................................................................8
3.2 Epidemiology .................................................................................................8
3.3 Etiology ..........................................................................................................8
3.4 Risk Factors..................................................................................................10
3.5 Pathophysiology ...........................................................................................10
3.6 Clinical Symptoms .......................................................................................13
3.7 Diagnosis ......................................................................................................13
3.8 Differential Diagnosis ..................................................................................14
3.9 Management .................................................................................................15
3.10. Prognosis ....................................................................................................18
3.11. Complication ..............................................................................................18

v
CHAPTER IV DISCUSSION ............................................................................19
CHAPTER V CONCLUSION ...........................................................................22
REFFERENCES ..................................................................................................23

vi
 LIST OF FIGURES

Figure 2.1 Large uterus showing a single gestational sac with irregular borders with no fetus or
Fetal ........................................................................................................................... 12

vi
 CHAPTER I
INTRODUCTION

1.1 Introduction

Anembryonic pregnancy or blighted ovum is a leading cause of early

miscarriage. The American Pregnancy Association estimates that blighted ovum
causes approximately 50 percent of all first-trimester miscarriages. About 20
percent of all pregnancies result in miscarriage.1

The American College of Obstetricians and Gynecologists defines early

pregnancy loss as a nonviable, intrauterine pregnancy with either an empty
gestational sac or a gestational sac containing an embryo or fetus without fetal heart
activity within the first 12 6/7 weeks of gestation. Early pregnancy loss is common,
occurring in 10% of all clinically recognized pregnancies. Approximately 80%of
all cases of pregnancy loss occur within the first trimester.2

In general, there are 3 options for management of anembryonic pregnancy:

expectant, medical, and surgical management. Expectant management consists of
no intervention and awaiting natural passage of tissue. Medical management uses
medication to expel uterine tissue. Surgical management is defined by mechanical
removal of tissue from the uterus. Medical management allows patients to avoid
surgery and anesthesia. Patients may also feel that medical management is more
private, and under their control.1

1
 CHAPTER II
CASE REPORT

2.1 Identity

Patient
• Name : Mrs. R
• Age : 21 years old
• Medical record : 12.29.98
• Address : Salimpaung
• Occupation : House Wife
• Education : Senior high school
• Admission date : May 20th 2020
Husband
• Name : Mr. A
• Age : 24 years old
• Adress : Salimpaung
• Occupation : Driver
• Education : Senior high school

2.2 Chief Complaint

A 21 years old woman was admitted to Emergency Room of Prof. Dr. M

th
Ali Hanafiah General Hospital, May 20 2021 at 18.30 diagnosed with
G1P0A0L0 11-12 weeks of pregnancy + incomplete abortion

2.3 Present Illness History

• Bleeding came from the vagina since 3 days ago,then about the last 6
hours the bleeding got worsened , red blackish colour, patient had 3
times pad changes.
• 7 days before, the patient controls to Obstetrician and the patient is
diagnosed with suspek blighted ovum, the patient is recommended to
control 2 weeks later for further evaluation.

2
 • Feeling of pain from waist to region (-)
• A mass like a fish eye came out through vagina (-),
• A mass like a meat came out through vagina (-),
• Amenorrhea since 3 months ago.
• First date of last menstrual period was January 26th, 2021
• Estimation date of delivery was November 3rd, 2021
• History of early pregnancy: nausea (+), vomitus (-), vaginal bleeding (-)
• Prenatal care : control to midwife at first month pregnancy, controlled to
obstetrician on 10 weeks of pregnancy

• Menstruation history: menarche at 13 years old, regular cycle once for

every 28 days, 2-3 times pad changes / day without menstrual pain

2.4 Previous Illness History:

There was no previous history of heart, lung, liver, kidney, DM and

hypertension.

2.5 Family Illness History

There was no history of hereditary disease, contagious and psychological

illness in the family

2.6 Obstetric History

• Marriage History : Once, December 2020

• History of pregnancy/Abortus/Labour : 1/0/0
1. Present
• History of Contraception : (-)
• History of immunization : (-)
• History of education : Academic
• History of Habitually : Cigarete (-), Drug (-)

Alkohol (-)

3
2.7 Physical Examination

General examination

GA Cons BP HR RR Temp.
Moderate CMC 120/70 80 x/mnt 20 x /mnt 36,7 oC

• BW : 55 cm
• BH : 155 cm
• BMI : 22,89 kg/m2 (normoweight)
• Head : Normocephaly
• Eyes : Conjunctiva wasn’t anaemic, sclera wasn’t icteric
• Neck : JVP 5–2 cmH2O, there is no enlargement in thyroid gland
• Chest : Heart and Lung : no abnormality was found
• Abdomen : Obstetrical record
• Genitalia : Obstetrical record
• Extremity : oedema -/-, Physiological reflex +/+, Pathological reflex -/-

Obstetric examination
Abdomen
• Inspection : distension (-), cicatric (-)
• Palpation : Uterine fundal was not palpable
Abdominal tenderness (-), rebound tenderness (-), Defans

Muscular (-)
• Percussion : Tympani
• Auscultation : Peristaltic sound was normalGenitalia
• Inspection : V/U normal, vaginal bleeding (+)
• Bimanual Examination

Vagina : tumor (-)

Portio : NP, tumor (-), the size of an adult thumb
CUT : Anteflexion, the size of a duck egg
AP : left weak = right
CD : not protrude

4
 • Inspeculo
Vagina : Tumor (-) laserasion (-) fluxus (+) there was blood pooling
in the Forniks posterior.

Portio : NP, as size of adult thumb, tumor (-) laserasion (-)

Fluxus (+) visible red blood flowing from canalis servicalis, tissue
(+) OUE was opened 1-2 cm.

2.8 Ultrasound

• Gestasional sac intrauterine, with size 4,22 cm x 4,58 cm

• Fetal Pole (-)
• Impression : Blighted ovum

5
2.9 Laboratorium Results

− Haemoglobin : 11,6 gr/dl

− Leukocyte : 8,600 / mm3
− Eritrocit : 4,62 / mm3
− Haematocrit : 35,9 %
− Platelete : 256.000/mm3
− Plano test : (+)
− HBsAg : non reactive
− HIV : non reactive
− Blood glucose : 87 mg/dl
− Plano test : Positif

2.10 Diagnosis

G1P0A0L0 11-12 weeks of pregnancy + Blighted Ovum

2.11 Management

• Monitor general appearance, vital sign, vaginal bleeding

• Informed consent
• IVFD RL 20 drops/minute
• Consult Anesthesiologist

2.12 Plan

Curettage

April 21th 2021, at 08.30 AM

Curettage with narcose was performed
There was 50 grams of the rest of conception
Bleeding during operation  40 cc

Diagnosis
P0A1H0 post curettage due to blighted ovum

6
Management:
Post-delivery monitoring (Vital Sign, Vaginal bleeding)
IVFD RL + oxcytosin : metergin 1:1 amp  20 drops/minute
Cefixime 200 mg 2x1 tab
Mefenamic Acid 500 mg 3 x 1
Metilergometrin 0,125 mg 3 x 1 tab
Vit C 50 mg 3 x 1 tab

Follow up on April 22th 2020, at 08.00 AM

S / Fever (-), vaginal bleeding (-)
O /
GA Cons BP HR RR Temp.
Moderate CMC 110/70 80 x/mnt 20 x /mnt 36,9oC
Eyes : Conjunctiva wasn’t anaemic, sclera wasn’t icteric
Abdomen :
Inspection : distension (-), cicatric (-)
Palpation : Uterine fundal was not palpable
Abdominal tenderness (-), rebound tenderness (-), Defans
muscular (-)
Percussion : Tympani
Auscultation : Peristaltic sound was normal
Genitalia
Inspection : V/U were normal, vaginal bleeding (-)

A / P0A1H0 post curettage due blighted ovum

Mother was in care
P / Control GA, VS, Mobilization
Therapy :
− Cefixime 200 mg 2x1 tab
− Mefenamic Acid 500 mg 3 x 1
− Metilergometrin 0,125 mg 3 x 1 tab
− Vit C 50 mg 1 x 1 tab
− Acc for going home
7
 CHAPTER III
LITERATURE REVIEW

3.1 DEFINITION

Blighted Ovum is a condition in which a woman feels pregnant but there is no baby in the
womb. A woman who experiences it also feels pregnancy symptoms such as late menstruation, nausea
and vomiting in early pregnancy (morning sickness), hardened breasts, and an enlarged abdomen,
even when a pregnancy test is done, both a test pack and a laboratory test are positive.1
Blighted ovum or empty pregnancy, sometimes in some societies there is a connection with
mystical things. Some say that the pregnancy was lost by a creature or the baby was transferred to
someone else, etc. Because it seems that the baby disappears, even though pregnant women who
experience Blighted Ovum experience signs and body changes like a normal pregnancy, but when
ultrasound checks the fetus does not exist / does not develop. Therefore, an examination to detectthe
presence of Blighted Ovum is needed.1,2

3.2 EPIDEMIOLOGY

It is estimated that worldwide Blighted Ovum is 60% of the causes of miscarriage cases, in
the ASEAN (association of Southeast Asian Nations) it reaches 51%, in Indonesia it is found 37% of
every 100 pregnancies. Mothers who experience abortion due to Blighted Ovum have characteristics
such as age, parity and pregnancy distance. In addition, age, parity and pregnancy distance are also
factors that cause the occurrence of Blighted Ovum. 1 Abu Bakr et al in their study said that the
prevalence of Blighted Ovum they encountered in the 1st trimester of pregnancy was 15.6%. In
addition, the prevalence of Blighted Ovum increased significantly with increasing maternal age and
also, they found that there was a statistically significant relationship between earlypregnancy failure
and previous history of early miscarriage.1,3

3.3 ETIOLOGY

The exact etiology of blinded ovum or anemberionic pregnancy is difficult to determine. The
causes of blighted ovum that are often mentioned are chromosomal abnormalities (duplication or
deletion), genetic disorders (gene mutations), poor quality of eggs and sperm, maternal age, endocrine
and immunological factors.4 The etiological factors for blighted ovum are generally understood and
studied in the broader context of early miscarriage (EPL) which includes embryonic

8
and anembryonic pregnancies.5 Etiology includes:
1) Embryo morphological abnormalities that prevent implantation or prevent long-term survival of
the embryo after implantation. This morphological abnormality is thought to be related to
chromosomal abnormalities.5
2) Chromosomal abnormalities that collectively include autosomal trisomy, polyploidy, sex
chromosome polysomy, and X monosomy are likely the most common etiologies for EPL.
Trisomy is a major fetal chromosomal abnormality in cases of sporadic miscarriage (30% of all
miscarriages) and 60% of chromosomal abnormal miscarriage (recurrent miscarriage). Trisomy
with X monosomy (15% to 25%) and triploidy (12% to 20%) accounts for more than 90% of all
chromosomal abnormalities found in cases of sporadic miscarriage. According to a study by
Edmonds in 1992, trisomy 16 was found to cause immature embryo growth with an empty bag,
while other trisomies often resulted in premature embryo death.5
3) Other genetic and chromosomal disorders including translocation, inversion, single gene
disorders, and placental mosaic. The related marriages that resulted in the blighted ovum have
also been noted, suggesting the determining role of a single gene. There is a possible link between
DNA damage in sperm and miscarriage.5
4) Obesity and advanced maternal age are factors associated with early miscarriage.5
5) Tuberculosis in developing countries as well as reproductive tract infections worldwide can
predispose to miscarriage. Complications of genital tract infections that include intrauterine
adhesions can inhibit implantation and embryo growth.5
6) Uterine malformations that include the didelphic, bicornuate, and septate uterus can prevent or
prevent long-term implantation of the embryo.
7) Immunological disorders in mother such as NK cell dysfunction, autoantibodies, heredity, and
acquired thrombophilia, among others) can cause immunological rejection of the mother to
implantation of the embryo in the uterus resulting in miscarriage.5
8) Hormonal factors (such as low progesterone levels) and endocrinological disorders (thyroid
autoimmunity and thyroid dysfunction) play a complex role in miscarriage. PCOS has also been
associated with infertility and miscarriage.5
9) Nikotin and Alcohol consumption plays a role in increasing the risk of miscarriage.5

9
3.4 RISK FACTORS

1) Age

According to Nuzul's research, regarding the factors of the occurrence of Blighted Ovum in
pregnant women, it was found that actors aged 3,667 were more likely to have Blighted Ovum in
pregnant women because age had a high risk of pregnancy and childbirth. The age that is not likely
to be a high risk at the time of pregnancy and childbirth is the age of 20-35 years, because at that age
the uterus is ready to accept pregnancy, is mentally mature and is able to care for the baby and himself.
Meanwhile, age <20 years and> 35 years is the age that has a high risk of pregnancy and childbirth.1
Maternal age at delivery also affects morbidity and mortality of both mother and child.
Mothers who are less than 20 years of age, the uterus and other parts of the body are not ready to
accept pregnancy and tend to pay less attention to their pregnancy. Mothers aged 20-35 years, the
uterus and other body parts are ready to receive and are expected to pay attention to her pregnancy.
Mothers who are more than 35 years of age, the uterus and other body parts have decreased function
and the mother's body health is not as good as at the age of 20-35 years.1
2) Parity

According to Nuzul's research, the age factor is 3.504 times more at risk of developing
Blighted Ovum in pregnant women. because the greater the number of births experienced by a mother,
the higher the risk of experiencing complications of pregnancy, childbirth and the puerperium. Parity
2-3 is the safest parity in terms of maternal mortality and is not threatened by the threat of mortality
and morbidity both to the mother and the fetus. Pregnant women who have given birth more than 5
times or have a high risk of pregnancy which will result in the death of the fetus.1
Second and third deliveries are safe deliveries, while the risk of complications increases in
pregnancy, childbirth and the puerperium after the third and so on. Likewise, parity of 0 and more
than 4 is a high risk pregnancy. The risk at parity 1 can be managed with better obstetric care, while
the risk at high parity can be reduced or prevented with family planning.1

3.5 PATHOPHYSIOLOGY

Pregnancy is the growth and development of the intrauterine fetus from conception and the
onset of labor. The gestation period starts from conception until the birth of the fetus, the length of
normal gestation is 280 days (40 weeks or 9 months 7 days) calculated from the first day of the last
menstruation. Pregnancy is divided into 3 trimesters, namely the first trimester starting from

10
conception until 3 months, the second trimester from the fourth month to 6 months, the third trimester
from the seventh month to 9 months.6
Pregnancy is the growth and development of the intrauterine fetus from conception and the
onset of labor. The gestation period starts from conception until the birth of the fetus, the length of
normal gestation is 280 days (40 weeks or 9 months 7 days) calculated from the first day of the last
menstruation.6
Blighted ovum is a pathological pregnancy in which the embryo does not form from the outset
even though the gestational sac is still formed. Apart from the mudigah, the yolk sac is also not
formed. This disorder is a disorder that is only detected after the development of ultrasonography.
Blighted ovum is a pregnancy without a fetus (anembryonic pregnancy), so there is only the gestation
bag (pregnancy bag) and amniotic fluid.1,6
Human Leukocyte Antigen-E has a very important role in the development of pregnancy.
Class I antigen expressed on trophoblasts can help the fetus to avoid attacks by the mother's immune
system and act on the fetoplacental connection site via the NK CD94 / NKG2A cell receptor which
causes normal pregnancy.4
In the study of Sulistyowati et al4, the definition of HLA-E expression in trophoblasts is lower,
and NK cell expression is higher in Blighted Ovum when compared to normal pregnancies. Their
results according to the study conducted by Fotoohi showed that HLA-E was lower in repeated
spontaneous abortions. This includes Blighted Ovum versus normal pregnancy because HLA-E is an
antigen that interacts with NKG2A which is an NK cell inhibitor receptor. This helps the fetus when
there is a mother's immune response so that when HLA-E deficiency occurs, thefetus will be more
susceptible to attack by NK cell activity which will result in Blighted Ovum.4
Human Leucocyte Antigen ( HLA)-E is a non-classical class I HLA, which plays an
important role in regulating cytokine secretion as a thromblast invasion roller and regulating
immune tolerance locally in the placenta. HLA-E is predominantly expressed in extra-vili
trophoblasts in the placenta and in the formation of hematopoetic systems derived from
extraembrionic yolk sacks. HLA-E can protect the trophoblasts from maternal-fetal immune
intolerance and allow trophoblast cells to invade the uterus. 4.

One of the causes of Blighted ovum is the lack of antibodies that work to protect the fetus
from the mother's immune system, namely HLA-E, HLA-G, which eventually the father's
genetics will be recognized as foreign objects to the body so that when sperm penetrates the
ovum, it will be considered as a foreign body. Furthermore, in desidua stimulated Large
Granullar Lymphocytes (LGLs) one of which is Natural Killer Cell (NK Cell) that serves to

11
destroy target cells that do not express enough HLA-E. In normal pregnancies, HLA-E increases
significantly in placental tissue during the first trimester of pregnancy, especially on the extravilli
membrane, while on the intravilli membrane part occurs in the final trimester of pregnancy.
HLA-E binds to NK cells through CD94/NKG2A receptors and influences the formation of
trophoblasts, placental implantation, vascular remodeling, fetal development and maintaining
pregnancy by preventing excessive expression of embryotoxic cytokines s uc h a s TNF-α.,
TGFβ and IFN-γ. 4
Sufficient expression of HLA-E in the trophoblasts is necessary for the trophoblasts to
invade the desidua and maternal vascular system properly resulting in an increase in uterine
perfusion required during pregnancy. However, if HLA-E is reduced or not expressed, the
ability of trophoblast cells will be reduced and prevented from invading the uterus or
considered as non-cells that have antigen properties so as to activate T and NK cells and
trigger the formation of embryotoxic cytokines s uc h a s TNF-α., TGFβ and IFN-γ that will
attack the trophoblast cells themselves so as to cause disruption of fetal development4 .

Maternal Paternal

Conception

Low HLA-E High HLA-E

High NK cells Low NK cells

TNF-α TNF-α
IFN-γ IFN-γ
TGFβ TGFβ
→ Embriotocsic ↑ → Embriotocsic ↓
Type equation here.

Disturbed the process of Normal the process of

conception, embryonic conception, embryonic
and placentation and placentation

BO / IUFD Normal pregnancy

12
3.6 CLINICAL SYMPTOMPS

Blighted ovum often causes no symptoms at all. Symptoms and signs may include, namely
late menstrual periods, abdominal cramps, minor vaginal or bleeding spots, a positive pregnancy test
at the time of symptoms, found after a spontaneous miscarriage in which complaints of bleeding occur,
similar to normal pregnancy, non-specific symptoms, was accidentally discovered by ultrasound.6
Blighted ovum in early pregnancy goes well and normally without any signs of abnormality.
Pregnancy sac is clearly visible, urine pregnancy test is positive. Blighted ovum is detected when the
mother performs an ultrasound at 6-7 weeks of pregnancy.6

3.7 DIAGNOSIS

The diagnosis of Blighted Ovum is confirmed at 7-8 weeks of gestation when the ultrasound
examination shows that the gestational pouch is not developed or in a diameter of 2.5 cm which is not
accompanied by an appearance of an embryo. If at the time of the first ultrasound we get a picture
like this it is necessary to do an ultrasound evaluation 2 weeks later. If there is still no mudigah
structure or yolk sac and the diameter of the gestation bag has reached 25 mm, it can be stated as
Blighted Ovum.6,8
Blighted ovum can be diagnosed when no embryo is seen on USG-TV in the gestational sac
with a mean sac diameter (MSD) of ≥15 mm or on USG-TA in the gestational sac with a mean sac
diameter (MSD) of ≥ 25 mm or there is no embryo on the follow-up TV/TA ultrasound namely; ≥11
days after scan showing gestational sac with yolk sac, but no embryo, or ≥ 2 weeks after scan showing
gestational sac without yolk sac or embryo.5,9

Figure 2.2 Large uterus showing a single gestational sac with irregular borders with no fetus or fetal
heart activity in it. GS (MSD) = 22 mm.5

13
 The assessment of interval mean sac diameter growth (MSD) has been shown to be less
accurate in the diagnosis of blighted ovum, due to overlapping gestational sac growth rates from viable
and non-live pregnancies. Additional features have been described, and could be considered a poor
prognostic factor, but do not contribute to a formal diagnosis of pregnancy failure. These include: no
yolk sac when MSD> 8 mm on transvaginal ultrasound (TVUS) poor decidual reaction: often <2 mm
irregular gestational sac shape abnormally low sac position.5,9

3.8 DIFFERENTIAL DIAGNOSIS

1) Ectopic Pregnancy

Ectopic pregnancy can be associated with any factor that impairs the integrity of the fallopian
tubes or impairs the function of the fimbriae. Pelvic inflammatory disease is one of the main causes
of an ectopic pregnancy. The most common location for an ectopic pregnancy is the fallopian tube
but it can occur in other areas such as the stomach, ovaries, or cervix, which are less common.10
Patients with ectopic pregnancies that do not rupture usually present with first trimester
bleeding and abdominal pain. Transvaginal ultrasound is recommended over transabdominal
ultrasound to directly visualize ectopic masses. However, the gestational sac cannot be visualized by
ultrasound until the β-hCG level is between 1500 and 2000 mIU/mL.10
2) Gestational trophoblast disease

Gestational trophoblast disease, also known as hydatidiform mole or complete mole, is the
result of fertilization occurring in one of two ways: 1) an egg without a mother nucleus fertilized by
a normal sperm, producing duplicated paternal DNA; or 2) an egg without a mother's nucleus which
is fertilized by two sperm. This type of pregnancy usually has a fetus, with possible viability, and
amniotic fluid.10
Patients usually present with hyperemesis gravidarum, pelvic pressure, and a rapidly
expanding abdomen. Transvaginal ultrasound will show the presence of cystic lesions or a classic
"blizzard" image. Some patients may experience this cyst or mass "like wine" through the vaginal
canal. As in other types of pregnancy, serial β-hCG levels should be measured. However, compared
to normal pregnancy, β-hCG levels in trophoblast disease are much higher, usually in the range of
hundreds of thousands.10
Although most hydatidiform moles are benign and can be managed conservatively
withmeasures such as dilation and curettage or suction evacuation, there is still the possibility of
transformation into malignant gestational trophoblast disease or cardiocarcinoma.

14
3.9 MANAGEMENT
Pregnancy loss is a common obstetric complication and affects > 30% of conception.
The majority of these losses occur in the 1st trimester, including spontaneous abortion,
anembryonic gestation and embryonic or fetal death. Accepted treatment options for early
pregnancy loss include expectant management, medical treatment or surgical evacuation.
Although these options differ significantly in process, all have been shown tobe reasonably
effective and accepted by patients.2
1. Expectant management
Because of a lack of safety studies of expectant management in the second trimester and
concerns about hemorrhage, expectant management generally should be limited to gestations within
the first trimester without bleeding and stable hemodynamics and then we evaluated 2 weeks later.
Patients undergoing expectant management may experience moderate to heavy bleeding and
cramping.2
2. Medical management

Medical management for early pregnancy loss can be considered in women

without infection, hemorrhage, severe anemia, or bleeding disorders who want to shorten
the time to complete expulsion but prefer to avoid surgical evacuation. Compared with
expectant management, medical management of early pregnancy loss decreases the time
to expulsion and increases the rate of complete expulsion without the need for surgical
intervention. Protocol for the medical management of early pregnancy loss includes
Misoprostol 800 micrograms vaginally, with one repeat dose as needed, no earlier than 3
hours after the first dose and typically within 7 days if there is no response to the first dose.
A dose of mifepristone (200 mg orally) 24 hours before misoprostol administration should
be considered when mifepristone is available. Prescriptions for pain medications should
be provided to the patient. Women who are Rh (D) negative and unsensitized should
receive Rh(D)-immune globulin within 72 hours of the first misoprostol administration.
Follow-up to document the complete passage of tissue can be accomplished by ultrasound
examination, typicaly within 7-14 days. Serial serum β-hCGmeasurements may be used
instead in settings where ultrasonography is unavailable. Patient-reported symptoms also
should beconsidered when determining whether complete expulsion has occurred. If
medical management fails, the patient may opt for expectant management, for a time
determined by the woman and her obstetrician-gynecologist or other gynecologic
provider or suction curettage.2
15
 Misoprostol is an option for the medical management of early pregnancy failure,
including anembryonic pregnancies and embryonic demise, For early pregnancy failure,
the most commonly used regimen is a single dose of 800 µg of vaginal misoprostol. For
incomplete abortion, effective misoprostol regimens include a single dose of 600 µg orally,
a single dose of 800 µg vaginally, or a single dose of 400 µg sublingually. Induction of
labor with misoprostol in the setting of a previous cesarean delivery scar, although
contraindicated in the third trimester, can be safely performed in the second trimester. The
optimal dose, schedule, and route of administration have not been determined. Several
randomized, controlled trials exist examining the different doses and schedules. The doses
used in these randomized trials range from 200 µg to 800 µg administered vaginally, and
the interval between dosing ranged from every 3 to every 12 hours. No conclusive
evidence of superiority of one dose or schedule over another can be clearly drawn from
these studies. An important study aimed at answering the question of dose optimization
was performed by Dickinson and Evans, who administered vaginal misoprostol either 200
µg every 6 hours, 400 µg every 6 hours, or a 600 µg loading dose followed by 200 µg
every 6 hours. Both the 400 µg and 600/200 µg regimens were superior to the 200 µg
regimen in terms of median time to delivery. The 600/200 µg regimen caused more side
effects than the other 2 dosing schedules. Side effects of misoprostol noted in several
studies include maternal fever, chills, and gastrointestinal symptoms such as nausea,
vomiting, diarrhea, and abdominal pain. Therefore, it makes sense to administer the lowest
dose of misoprostol that is most effective, thereby decreasing the side effects. Although
the optimal dose for fetal death or termination of pregnancy in the second trimester has
not been established, a reasonable approach may be to start with 400 µg vaginally every
6 hours for a 48-hour period.15
3. Surgical management
Surgical uterine evacuation has long been the traditional approach for women
presenting with early pregnancy loss and retained tissue. Women who present with
hemorrhage, hemodynamic instability, or signs or infection should be treated urgently with
surgical uterine evacuation. Surgical evacuation also might be preferable in other
situations, including the presence of medical comorbidities such as severe anemia,
bleeding disorders or cardiovascular disease. Many women prefer surgical evacuation to
expectant or medical treatment because it provides more immediate completion of the
process with less follow-up. In the past, uterine evacuation often was performed with sharp
curettage alone. However, studies show that the use of suction curettage is superior to the
16
use of sharp curettage alone. Furthermore, the routine use of sharp curettage along with
suction curettage in the first trimester does not provide any additional benefit as long as
the obstetrician-gynecologist or other gynecologic provider is confident that the uterus is
empty. Suction curettage also can be performed in an office setting with an electric vacuum
source or manual vacuum aspirator, under local anesthesia with or without the addition of
sedation.2
Other surgical management includes uterine evacuation with a manual vacum. This
method is frequently employed in patients with hemodynamic instability. Uterine
aspiration/evacuation is quicker to complete, especially when performed on an outpatient
basis.8 Dilatation and curettage has been the primary treatment option for early pregnancy
loss in many countries. In 1995, Nielsen and Hahlin conducted a small randomized study
of expectant and surgical management of early nonviable pregnancies, which suggested
that the outcomes were similar, including complications and the need for a second or
emergent curettage. Additional studies have supported the role of expectant management
as a treatment option in early pregnancy loss. However, reported success rates have ranged
widely from 25% to 76%. According to Luise et al.’s study in 2002, expectant management
in patients with anembryonic pregnancies had a less favorable success rate compared to
patients with incomplete abortion or embryonic fetal death. Patients with failure of
expectant management eventually required surgical evacuation to remove the products of
conception. In contrast, based on a randomized trial conducted by Wieringa-de Waard et
al., up to 40% of surgeries can be avoided by a waiting period of 7 days, which could be
offered to well-informed women. Huang et al. conducted a study where 45 out of 12
women with an ultrasound diagnosis of anembryonic pregnancy elected expectant
management. The overall success rate was 83.3% in the expectant group and 97.3% in the
surgical group. No significant complications were noted in either group. They concluded
that expectant management with a 3-week waiting period is an efficacious and safe option
with a low risk of infection and hemorrhage. Nevertheless, the success rate of surgical
treatment has been superior to that of expectant management in both reviewed literature
and clinical practiceand expectant management can be justified as an alterna

17
3.10 PROGNOSIS

The prognosis and successful management of early miscarriage depends on various factors
including gestational age. The prognosis is generally considered good with all three management
options.
1) Expectative management

In a meta-analysis of 20 studies, pregnancy management and medical management were

identified as acceptable treatment options for incomplete abortions.5
2) Pharmacological management

Pharmacologic management is more successful with multiple-dose misoprostol regimens.

Patients with incomplete abortion are treated more successfully with medical management than with
expectant management.5
3) Surgical Treatment

At least one large randomized control trial determined a higher success rate in surgical
treatment than medical management, with general conclusions about the general safety of both
treatment options.5

3.11 COMPLICATIONS

1) Bleeding

Bleeding that occurs in the mother can cause anemia, which can put you at risk of death.
Bleeding can be resolved by emptying the uterus from the remains of the product of conception. Death
due to bleeding can occur if help is not given on time.6
2) Infection

Infection in the uterus or its surroundings may occur in the blighted ovum, but is usually seen
in incomplete abortions and more frequently in artificial abortions performed without regard toasepsis
and antisepsis. If the infection is widely spread, generalized peritonitis or sepsis may be followed by
shock.6
3) Shock

Shock in abortion can occur due to bleeding (hemorrhagic shock) and severe infection
(endoceptic shock).6

18
 CHAPTER IV
DISCUSSION

In this case we discussed about blighted ovum or anembryonic pregnancy.

This case reported a 21-years-old patient with G1P0A0L0 11-12 weeks of pregnancy
+ blighted ovum.
his patient came to the ER with chief complaint Bleeding came from the
vagina since 4 days ago,then about the last 6 hours the bleeding got worsened , red
blackish colour, patient had 3 times pad changes. . There was no pain from waist to
pubic region, no fish- eye-like mass and meat-like-mass that came out from the vagina.
This patient experienced amenorrhea since 3 months ago and her first date of last menstrual
period was January 26th, 2021

Examination of vital sign showed a blood pressure of 120/70 mmHg, pulse

of 80 x /min, respiration rate of 20 x/minute and temperature of 36.70C. Conjunctiva
wasn’t anemic. Uterine fundal was not palpable, abdominaltenderness was absent,
rebound tenderness was absent, muscular defans was absent. From the auscultation,
peristaltic sound was normal. From the genital examination, vaginal bleeding was
positive, fluxus (+) and the OUE was opened Bimanual examination was performed
and there was no tumor found, the portio was the size of an adult thumb and the
corpus uterine was the size of a duck egg. From the laboratorium result, blood test
was within normal limits, plano test was positive, HbsAg and HIV rapid was non-
reactive. From the ultrasound, Gestasional sac intrauterine , with size 4,22 cm x
4,58 cm was seen. Fetal pole (-),Impression: Blighted Ovum
The patient underwent curettage resulting in 50 grams of the rest of the
conception. Patient was given uterotonic, antibiotic and painkillers post curettage.
The patient was treated in the midwifery ward for 1 day.
There are a number of things that will be discussed, including:
1. Has the diagnosis been made correctly?
Common symptoms of early pregnancy loss as a result to blighted ovum
include vaginal bleeding and uterine cramping. These symptoms are also common
in normal gestation, ectopic pregnancy and molar pregnancy. Therefore,evaluation
is needed to make a definitive diagnosis. In combination with a

19
thorough medical history and physical examination, ultrasonography and serum β-
hCG testing can be helpful in making a highy certain diagnosis. 2 An anembryonic
pregnancy may be diagnosed when there is no embryo seen on endovaginal
scanning in a gestational sac with mean sac diameter (MSD) ≥25 mm4 or if there
is no embryo on follow-up endovaginal scan ≥11 days after scan showing
gestational sac with yolk sac, but no embryo, or ≥ 2 weeks after a scan showing
gestational sac without yolk sac or embryo. Other supplementary features such as
absent yolk sac when MSD >8 mm on transvaginal ultrasound (TVUS), poor
decidual reaction: often <2 mm, irregular gestational sac shape and abnormally low
sac position have been described but may be considered poor prognostic factors.11

This patient came to the ER with vaginal bleeding 6 hours prior to

admission. From the genital examination, vaginal bleeding was positive, fluxus (+)
and the OUE was opened. Bimanual examination was performed and there was no
tumor found, the portio was the size of an adult thumb and the corpus uterine was
the size of a duck egg. Bimanual examination was performed and there was no
tumor found, the portio was the size of an adult thumb and the corpus uterine was
the size of a duck egg. An enlarged portio and corpus uterine and a positive plano
test indicates that this patient indeed is pregnant however vaginal bleeding and a
closed external ostium uterus indicates an incomplete abortion. This finding was
later on confirmed with the ultrasound. From the ultrasound, Gestasional sac
intrauterine , with size 4,22 cm x 4,58 cm was seen. Fetal pole (-), Impression:
Blighted Ovum. The ultrasound in this patient showed an Bligthted Ovum, because
the patient came to the ER after bleeding has occurred. Ultrasound of a blighted
ovum may have been found if ultrasound was done before the bleeding.

2. Is the management of this patient appropiate?

Management for this case is correct because dilatation and curettage has
been the primary treatment option for early pregnancy loss in many countries.1
Surgical management has long been considered the standard of care for early
pregnancy failure. Surgical evacuation of the uterus is accomplished using either

20
electric suction evacuation or manual vacuum aspiration. It is the treatment of
choice in the setting of hemodynamic instability, uncontrolled vaginal bleeding,
infection, discomfort unresponsive to analgesia, or patient preference.
Complications from curettage include incomplete evacuation, uterine perforation,
pelvic infection, and haemorrhage requiring transfusion, but complications are the
exception.12 Surgical evacuation results in faster and more predictable complete
evacuation. The success of surgical uterine evacuation of early pregnancy loss
approaches 99%.11
Surgical evacuation of the uterus for management of incomplete
miscarriage usually involves vacuum aspiration or sharp metal curettage. Bleeding
and infection generally result if the uterus is not emptied after incomplete
miscarriage (where parts of the products of conception are left in the uterus).13
When a dead fetus is retained in the uterus beyond 5 weeks, consumptive
coagulopathy and hypofibrinogenemia mayoccur. If anembryonic gestation or fetal
death is diagnosed by ultrasound, dilation and curettage or medical termination
should be performed if the pregnancy is not spontaneously passed within 6 weeks
of diagnosis.14

21
 CHAPTER V
CONCLUSION

Blighted ovum or anembryonic pregnancy is a condition in which a woman feels that she is
pregnant with no baby in the womb. A woman who experiences it also feels pregnancy symptoms
such as late menstruation, nausea and vomiting in early pregnancy (morning sickness), hardened
breasts, and an enlarged stomach, even a positive pregnancy test is done.
The cause is difficult to determine but is related to the presence of chromosomal abnormalities,
genetics, poor quality of ovum and sperm, maternal age, endocrine and immunological factors. The
diagnosis of Blighted Ovum is confirmed by ultrasound examination, both transabdominal and
transvaginal, which reveal a gestational sac without a yolk sac or embryo. The diagnosis can be
differentiated from ectopic pregnancy and hydatidiform mole.

Management of Blighted Ovum includes expectative management, pharmacological

and surgical approaches. In pharmacology, Misoprostol is recommended to be used to stop
pregnancy without embryos. dilatation and curettage has been the primary treatment option
for early pregnancy loss in many countries.1 Surgical management has long been considered
the standard of care for early pregnancy failure. It is the treatment of choice in the setting of
hemodynamic instability, uncontrolled vaginal bleeding, infection, discomfort unresponsive
to analgesia, or patient preference. Surgical evacuation results in faster and more predictable
complete evacuation. The success of surgical uterine evacuation of early pregnancy loss
approaches 99%.11
Complications that can occur in women with Blighted Ovum can occur bleeding, infection
and shock due to abortion that occurred.

22
 REFFERENCES

1. ZA RN, Rosdiana E. Faktor-Faktor yang Mempengaruhi terjadinya Blighted Ovum (BO) pada
Ibu Hamil di Rumah Sakit dr. Zainoel Abidin Kota Banda Aceh Tahun 2015. J Healthc Technol
Med. 2019;2(2):135. doi:10.33143/jhtm.v2i2.246
2. Andriani F, Mardhiyah I. Blighted Ovum detection using convolutional neural network. AIP
Conf Proc. 2019;2084(March). doi:10.1063/1.5094276
3. A. Mitwally AB, M. Abd El Aal DE, Taher N, Abbas AM. Prevalence of blighted ovum in first
trimester of pregnancy: a hospital based study. Int J Reprod Contraception, Obstet Gynecol.
2018;8(1):94. doi:10.18203/2320-1770.ijrcog20185402
4. Sulistyowati S, Rahadian F, Respati SH, Soetrisno S. Blighted Ovum: Roles of human
leukocyte antigen-E and natural killer cells. Bali Med J. 2017;6(2):381.
doi:10.15562/bmj.v6i2.580
5. Chaudhry K, Siccardi MA. Blighted Ovum (Anembryonic Pregnancy). StatPearls Publishing;
2019. Accessed May 6, 2021. http://www.ncbi.nlm.nih.gov/pubmed/29763113
6. Sari HP, Dayaningsih S, Ningsih S. Asuhan Kebidanan Ibu Hamil Patologi Pada Ny. E Umur
20 Tahun G1 P0 A0 Umur Kehamilan 13 Minggu Dengan Blighted Ovum di RSUD
Karanganyar. Indones J Med Sci. 2015;2(2):3-9.
https://ejournal.ijmsbm.org/index.php/ijms/article/download/56/55
7. Moshtaghi A, Vaziri H, Sariri R, Shaigan H. Polymorphism of MnSOD (Val16Ala) gene in
pregnancies with blighted ovum: A case-control study. Int J Reprod Biomed. 2017;15(8):503-
508. doi:10.29252/ijrm.15.8.503
8. Aroke D, Ngek LT, Tindong M, et al. Blighted ovum and tubal pregnancy: A rare form of
heterotopic pregnancy: Case report. BMC Res Notes. 2018;11(1):2-5. doi:10.1186/s13104-
018-3345-2
9. Gupta N, Angtuaco TL. Embryosonology in the First Trimester of Pregnancy. Ultrasound Clin.
2007;2(2):175-185. doi:10.1016/j.cult.2007.07.006
10. Chaudhry AN, Tiesenga FM, Mellacheruvu S, Sanni RR. Blighted Ovum: A Case Report.
Women’s Heal – Open J. 2020;6(1):3-4. doi:10.17140/whoj-6-135
11. Tatco, V., Gaillard, F. Anembroynic prengnacy. In Radiopaedia [Internet].
12. Akhtar S, Jan R. Out Patient Medical Management of Anembryonic Pregnancy Using
Misoprostol. Biomedica. 2013;29:212-215.
13. Cowett, A. A., & Lichtenberg, E. S. (2007). Pregnancy Loss and Termination.
eneral Gynecology, 225–256. doi:10.1016/b978- 032303247-6.10010-3
23
14. Tunçalp, Ö., Gülmezoglu, A.M. and Souza, J.P., 2010. Surgical procedures for
evacuating incomplete miscarriage. Cochrane Database of Systematic
15. Allen R, O’Brien BM. Uses of misoprostol in obstetrics and gynecology. Reviews in
obstetrics and gynecology. 2009;2(3):159.

24