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Reproductive Health (Y4) > 4- Early pregnancy complications (ectopic, miscarriage and molar) > Flashcards

4- Early pregnancy complications (ectopic, miscarriage and molar) Flashcards

1
Q

ectopic pregnancy

A

pregnancy implanted outside uterus

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2
Q

RF for ectopic pregnancy

A
  • Previous ectopic pregnancy
  • Previous pelvic inflammatory disease
  • Previous surgery to the fallopian tubes
  • Intrauterine devices (coils)
  • Older age
  • Smoking
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3
Q

when does ectopic pregnancy present

A

6-8 weeks gestation

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4
Q

when to suspect ectopic pregnancy

A

Have a low threshold for suspecting an ectopic pregnancy, even in atypical presentations. Always ask about the possibility of pregnancy, missed periods and recent unprotected sex in women presenting with lower abdominal pain.

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5
Q

The classic features of an ectopic pregnancy include:

A
  • Missed period
  • Constant lower abdominal pain in the right or left iliac fossa
  • Vaginal bleeding
  • Lower abdominal or pelvic tenderness
  • Cervical motion tenderness (pain when moving the cervix during a bimanual examination)

It is also worth asking about:

Dizziness or syncope (blood loss)
Shoulder tip pain (peritonitis)

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6
Q

investigation for ectopic prgenancy

A
  • Pregnancy test
  • Transvaginal US
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7
Q

what may be seen on a Transvaginal US if ectopic pregnancy

A
  • A gestational sac containing a yolk sac or fetal pole may be seen in a fallopian tube.
  • When a mass containing an empty gestational sac is seen, this may be referred to as the “blob sign”, “bagel sign” or “tubal ring sign”
  • An empty uterus
    Fluid in the uterus, which may be mistaken as a gestational sac (“pseudogestational sac”)
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8
Q

how to differentiate tubal ectopic pregnancy from the corpus luteum

A

A mass representing a tubal ectopic pregnancy moves separately to the ovary. The mass may look similar to a corpus luteum; however, a corpus luteum will move with the ovary.

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9
Q

A pregnancy of unknown location (PUL)

A

is when the woman has a positive pregnancy test and there is no evidence of pregnancy on the ultrasound scan. **

I**n this scenario, an ectopic pregnancy cannot be excluded, and careful follow up needs to be in place until a diagnosis can be confirmed.

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10
Q

investigations for pregnancy of unknown origin

A

tracking of hCG over time
- hCG repeated after 48 hours to measure the change from baseline

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11
Q

hCG level trajectory in an intrauterine pregnancy

A

hCG will roughly double every 48 hours

This will not be the case in a miscarriage or ectopic pregnancy.

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12
Q

An hCG rise of more than 63% after 48 hours is likely to indicate

A

an intrauterine pregnancy.

A repeat ultrasound scan is required after 1 – 2 weeks to confirm an intrauterine pregnancy.

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13
Q

A pregnancy should be visible on an ultrasound scan once the hCG level is above

A

1500 IU / l.

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14
Q

An hCG rise of less than 63% after 48 hours may indicate

A

an ectopic pregnancy. When this happens the patient needs close monitoring and review.

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15
Q

A fall of more than 50% is likely to indicate a

A

Miscarriage

A urine pregnancy test should be performed after 2 weeks to confirm the miscarriage is complete.

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16
Q

management of ectopic pregnancy

A

1) Pregnancy test in anyone with abdominal/pelvic pain
2) if positive-> refferal to early pregnancy assessment unit
3) all ectopic pregnancies must be terminated

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17
Q

There are three options for terminating an ectopic pregnancy:

A
  1. Expectant management (awaiting natural termination)
  2. Medical management (methotrexate)
  3. Surgical management (salpingectomy or salpingotomy)
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18
Q

Criteria for expectant management

A
  • Follow up needs to be possible to ensure successful termination
  • The ectopic needs to be unruptured
  • Adnexal mass < 35mm
  • No visible heartbeat
  • No significant pain
  • HCG level < 1500 IU / l
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19
Q

Criteria for methotrexate

A

are the same as expectant management, except:

  • HCG level must be < 5000 IU / l
  • Confirmed absence of intrauterine pregnancy on ultrasound
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20
Q

methotrexate use in ectopic pregnancy

A
  • intramuscular injection into a buttock. This halts the progress of the pregnancy and results in spontaneous termination
  • highly teratogenic
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21
Q

Women treated with methotrexate are advised not to get pregnant for…

A

3 months following treatment. This is because the harmful effects of methotrexate on pregnancy can last this long.

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22
Q

Common side effects of methotrexate include:

A
  • Vaginal bleeding
  • Nausea and vomiting
  • Abdominal pain
  • Stomatitis (inflammation of the mouth)
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23
Q

surgical mangement of ectopic pregnancy

A
  • Pain
  • Adnexal mass > 35mm
  • Visible heartbeat
  • HCG levels > 5000 IU / l
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24
Q

There are two options for surgical management of ectopic pregnancy:

A
  • Laparoscopic salpingectomy
  • Laparoscopic salpingotomy
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25
Q

Laparoscopic salpingectomy

A

is the first-line treatment for ectopic pregnancy. This involves a general anaesthetic and key-hole surgery with removal of the affected fallopian tube, along with the ectopic pregnancy inside the tube.

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26
Q

Laparoscopic salpingotomy

A

may be used in women at increased risk of infertility due to damage to the other tube. The aim is to avoid removing the affected fallopian tube. A cut is made in the fallopian tube, the ectopic pregnancy is removed, and the tube is closed.

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27
Q

Laparoscopic salpingectomy vs
Laparoscopic salpingotomy

A

here is an increased risk of failure to remove the ectopic pregnancy with salpingotomy compared with salpingectomy. NICE state up to 1 in 5 women having salpingotomy may need further treatment with methotrexate or salpingectomy.

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28
Q

prophylaxis for rhesus negative women having surgical management of ectopic pregnancy

A

Anti-rhesus D prophylaxis

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29
Q

miscarriage

A

Miscarriage is the spontaneous termination of a pregnancy
- 15% of pregnancies
- Early miscarriage is before 12 weeks gestation (common gynae presentation)
- Late miscarriage is between 12 and 24 weeks gestation.

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30
Q

missed miscarriage

A

the fetus is no longer alive, but no symptoms have occurred

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31
Q

Threatened miscarriage

A
  • vaginal bleeding/pain with a closed cervix and a fetus that is alive
  • up to 24/40 weeks with a viable ongoing pregnancy
32
Q

Inevitable miscarriage

A

– vaginal bleeding with an open cervix
- products of cocneption have not been passed yet but they will

33
Q

Incomplete miscarriage

A
  • Some POC have been passed
  • Some tissues and blood clot remain within the uterus
  • Cervix stays open
  • Bleeding and pain usually persist
34
Q

Complete miscarriage

A
  • All products of conception have been passed
  • Complete sac may be identifiable
  • Bleeding and pain reducing
  • Cervix now closed
  • Cannot diagnose with USS –
  • this can be helpful but
  • no strict cut offs
  • Caution required if no previous
  • USS
35
Q

Anembryonic pregnancy

A

– a gestational sac is present but contains no embryo

36
Q

risk factors for miscarriage

A
  • Advanced maternal age (>/= 40)
  • Previous miscarriage
  • Smoking
  • Alcohol (moderate to heavy) and drug use
  • NSAIDs and Aspirin
  • Street drugs
  • Folate deficiency
  • Consanguinity
  • Opportunity for health promotion
    *
37
Q

USS classification of miscarriage

A

1) Missed miscarriage / Early fetal demise
- Failed pregnancy with no cardiac pulsations on USS

2) Blighted ovum / Anembryonic pregnancy
- Failed pregnancy with empty gestation sac i.e. no fetus present

3) Incomplete miscarriage / Retained products of conception
- Echogenic mass of blood clot and tissue within the uterine cavity >20mm in Anterior-posterior (AP) diameter

4) Complete miscarriage
- Empty uterine cavity – Rough guide AP <20mm
- MUST have seen an Intrauterine pregnancy (IUP) on scan before or Pregnancy of unknown location (PUL)

38
Q

causes of miscarriage

A
  • Idiopathic (particularly in older women)
  • Antiphospholipid syndrome
  • Hereditary thrombophilias
  • Uterine abnormalities
  • Genetic factors in parents (e.g. balanced translocations in parental chromosomes)
  • Chronic histiocytic intervillositis
  • Other chronic diseases such as diabetes, untreated thyroid disease and systemic lupus erythematosus (SLE)
39
Q

investigation for suspected miscarriage

A

transvaginal ultrasound scan

40
Q

There are three key features that the sonographer looks for in an early pregnancy.

A

These appear sequentially as the pregnancy develops. As each appears, the previous feature becomes less relevant in assessing the viability of the pregnancy. These features are:

Mean gestational sac diameter
Fetal pole and crown-rump length

41
Q

transvaginal US and heartbeat

A

When a fetal heartbeat is visible, the pregnancy is considered viable.

A fetal heartbeat is expected once the crown-rump length is 7mm or more.

42
Q

When there is a crown-rump length of 7mm or more, without a fetal heartbeat, the scan is repeated after one week before confirming

A

a non-viable pregnancy.

43
Q

A fetal pole is expected once the mean gestational sac diameter is

A

25mm or more.

44
Q

When there is a mean gestational sac diameter of 25mm or more, without a fetal pole, the scan is repeated after one week before confirming an

A

anembryonic pregnancy

45
Q

management: bleeding less than 6 weeks gestation

A
  • Expectant management before 6 weeks gestation involves awaiting the miscarriage without investigations or treatment.
  • An ultrasound is unlikely to be helpful this early as the pregnancy will be too small to be seen.
  • A repeat urine pregnancy test is performed after 7 – 10 days, and if negative, a miscarriage can be confirmed.
  • When bleeding continues, or pain occurs, referral and further investigation is indicated.
46
Q

management: bleeding more than 6 weeks gestation

A

The early pregnancy assessment unit will arrange an ultrasound scan. Ultrasound will confirm the location and viability of the pregnancy. It is essential always to consider and exclude an ectopic pregnancy.

There are three options for managing a miscarriage:

  • Expectant management (do nothing and await a spontaneous miscarriage)
  • Medical management (misoprostol)
  • Surgical management
47
Q

expectant management in women with bleeding more than 6 weeks gestation

A

first line management (for those without RF for heavy bleeding)

  • 1-2 weeks given to allow miscarriage to occur spontaneously
  • repeat urine pregnancy test 3 weeks after bleeding and pain settle to confirm miscarriage

Persistent or worsening bleeding requires further assessment and repeat ultrasound, as this may indicate an incomplete miscarriage and require additional management.

48
Q

medical management of bleeding more than 6 weeks gestation

A

Misoprostol (vaginal suppository or oral dose)

49
Q

Misoprostol MOA

A

Misoprostol is a prostaglandin analogue, meaning it binds to prostaglandin receptors and activates them.

Prostaglandins soften the cervix and stimulate uterine contractions.

50
Q

side effects of misoprostol

A
  • Heavier bleeding
  • Pain
  • Vomiting
  • Diarrhoea
51
Q

surgical management of miscarriage >6 weeks gestation

A

Prostaglandins (misoprostol) are given before surgical management to soften the cervix.

  1. Manual vacuum aspiration under local anaesthetic as an outpatient
  2. Electric vacuum aspiration under general anaesthetic
52
Q

Manual vacuum aspiration

A

involves a local anaesthetic applied to the cervix. A tube attached to a specially designed syringe is inserted through the cervix into the uterus. The person performing the procedure then manually uses the syringe to aspirate contents of the uterus. To consider manual vacuum aspiration, women must find the process acceptable and be below 10 weeks gestation. It is more appropriate for women that have previously given birth (parous women).

53
Q

Electric vacuum aspiration

A

is the traditional surgical management of miscarriage. It involves a general anaesthetic. The operation is performed through the vagina and cervix without any incisions. The cervix is gradually widened using dilators, and the products of conception are removed through the cervix using an electric-powered vacuum.

54
Q

why must incomplete miscarriage me treated

A

Retained products create a risk of infection.

55
Q

management of incomplete miscarriage

A
  1. Medical management (misoprostol)
  2. Surgical management (evacuation of retained products of conception)
56
Q

Evacuation of retained products of conception (ERPC)

A

is a surgical procedure involving a general anaesthetic. The cervix is gradually widened using dilators, and the retained products are manually removed through the cervix using vacuum aspiration and curettage (scraping).

A key complication is endometritis (infection of the endometrium) following the procedure.

57
Q

recurrent miscarriage is class as

A

3 or more consecutive miscarriages

58
Q

The risk of miscarriage increases with

A

age, with the rate of miscarriage approximately:

10% in women aged 20 – 30 years
15% in women aged 30 – 35 years
25% in women aged 35 – 40 years
50% in women aged 40 – 45 years

59
Q

Investigations for miscarriage are initiated after:

A
  • Three or more first-trimester miscarriages
  • One or more second-trimester miscarriages
60
Q

recurrent miscarriage and antiphospholipid syndrome

A
  • disorder associated with antiphospholipid antibodies, where blood becomes prone to clotting. The patient is in a hyper-coagulable state. The main associations are with thrombosis and complications in pregnancy, particularly recurrent miscarriage.

The risk of miscarriage in patients with antiphospholipid syndrome is reduced by using both:

  • Low dose aspirin
  • Low molecular weight heparin (LMWH)
61
Q

investigations for recurrent miscarriage

A
  • Antiphospholipid antibodies
  • Testing for hereditary thrombophilias
  • Pelvic ultrasound
  • Genetic testing of the products of conception from the third or future miscarriages
  • Genetic testing on parents
62
Q

causes of antiphospholipid syndrome

A

can occur on its own, or secondary to an autoimmune condition such as systemic lupus erythematosus.

63
Q

Several uterine abnormalities can cause recurrent miscarriages:

A
  • Uterine septum (a partition through the uterus)
  • Unicornuate uterus (single-horned uterus)
  • Bicornuate uterus (heart-shaped uterus)
  • Didelphic uterus (double uterus)
  • Cervical insufficiency
  • Fibroids
64
Q

Chronic Histiocytic Intervillositis

A

Chronic histiocytic intervillositis is a rare cause of recurrent miscarriage, particularly in the second trimester.

  • It can also lead to intrauterine growth restriction (IUGR) and intrauterine death.
65
Q

Chronic histiocytic intervillositis pathophysiology

A

The condition is poorly understood. Histiocytes and macrophages build up in the placenta, causing inflammation and adverse outcomes. It is diagnosed by placental histology showing infiltrates of mononuclear cells in the intervillous spaces.

66
Q

Management of recurrent miscarriage depends on the

A

underlying cause.

67
Q

Management of recurrent miscarriage depends on the

A

underlying cause.

68
Q

molar pregnancy background

A

a type of tumour - hydatidiform mole
- grows like a pregnancy inside the uterus
- a gestational trophoblastic disease (GTD0

69
Q

there are two types of molar pregnancy:

A

a complete mole and a partial mole

70
Q

complete mole

A
  • 2 sperm fertilise an empty ovum
  • these sperm combine genetic material and divide and grow into a tumour
  • no fetal material will form
71
Q

partial mole

A
  • 2 sperm fertilise a normal ovum at the same time
  • new cell has 3 sets of chromosome
  • cell divides and multiples into a tumour
  • some fetal material may form
72
Q

diagnosis of molar

A

Diagnosis

Molar pregnancy behaves like a normal pregnancy. Periods will stop and the hormonal changes of pregnancy will occur. There are a few things that can indicate a molar pregnancy versus a normal pregnancy:

  • More severe morning sickness
  • Vaginal bleeding
  • Increased enlargement of the uterus
  • Abnormally high hCG
  • Thyrotoxicosis (hCG can mimic TSH and stimulate the thyroid to produce excess T3 and T4)
  • **

Diagnostic: Ultrasound and histology after evacuation

73
Q

Ultrasound of the pelvis in a molar pregnancy shows a

A

characteristic “snowstorm appearance” of the pregnancy.

74
Q

Management of molar pregnancy

A
  • evacuation of uterus to rmeove mole
  • histological examination to confirm molar
  • referral to **gestational trophoblastic disease centre
  • hCG monitored until they return to normal**
75
Q

why may patient with molar pregnancy require systemic chemotherapy

A

Occasionally the mole can metastasise (moles an be malignant)
- invasive moles
- choriocarcinoma

76
Q

psychosocial support for loss of a baby

A
  • Miscarriage AND ectopic pregnancy are both loss of a baby
  • Choose your words carefully- it matters!
  • A significant, distressing unexpected event for parents (variable)
  • They remember way they were treated,
  • on ‘the worst day of their lives’
  • Miscarriage Association
  • Written information / leaflets
  • Counselling and Support
    *

Reproductive Health (Y4) (34 decks)

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