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Woman's Health > 7.3 Early pregnancy bleeding > Flashcards

7.3 Early pregnancy bleeding Flashcards

1
Q

Miscarriage is defined as the ____________________:
• Most cases occur in the 1st trimester → biochemical pregnancy loss rate of ~30%; clinically recognised loss rate of ~15 – 20%
• Recurrent pregnancy loss occurs in 1 – 2% of women

A

loss of an intrauterine pregnancy < 24 weeks gestation

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2
Q

what is the definition of early miscarriage?

A

When pregnancy loss occurs before 12 weeks gestation (1st trimester)

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3
Q

what is the definition of late miscarriage?

A

When pregnancy loss occurs between 12 – 24 weeks (2nd trimester)

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4
Q

What is the single largest cause of sporadic miscarriage (accounts for 50%)

A

Chromosomal abnormalities
• Duplications or deletions of complete set of haploid chromosomes (aneuploidy)
• Loss of single chromosome (Turner’s syndrome; 45XO) or gain of single chromosome (Down syndrome; trisomy 21)
• Structural rearrangements of chromosomes (translocation)

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5
Q

What are maternal factors that lead to miscarriage?

A

Multiple pregnancy, advanced maternal age, stress, history of miscarriage, chronic illness (e.g. uncontrolled diabetes, thyroid disorders), autoimmune disorders (e.g. antiphospholipid syndrome, SLE)

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6
Q

What infections can lead to miscarriage?

A

Listeria, Toxoplasmosis, herpes, varicella-zoster, malaria

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7
Q

threatened miscarriage

  • description
  • history
  • cervix
  • u/s findings
A
  • Possibility of miscarriage (but still can salvage)
  • Bleeding, pain
  • Closed
  • Intrauterine gestation sac (IUGS), yolk sac (YS), foetal pole (FP), foetal heart (FH) present
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8
Q

inevitable miscarriage

  • description
  • history
  • cervix
  • u/s findings
A
  • Pregnancy still intact and miscarriage not started yet but will happen
  • Bleeding, pain
  • open
  • Intrauterine gestation sac (IUGS), yolk sac (YS), foetal pole (FP), foetal heart (FH) present
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9
Q

incomplete miscarriage

  • description
  • history
  • cervix
  • u/s findings
A
  • In the process of being passed out (some tissues inside and some outside)
  • Bleeding, pain
  • May see products of conception
  • IUGS, YS, FP, FH may not be obvious as products of conception are passed out
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10
Q

complete miscarriage

  • description
  • history
  • cervix
  • u/s findings
A
  • Completely passed out
  • Bleeding, pain (may be resolved)
  • Closed
  • No IUGS seen
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11
Q

missed miscarriage

  • description
  • history
  • cervix
  • u/s findings
A
  • Foetus stops growing (dies) but the body does not detect → hormones continue to be produced
  • Bleeding, pain (often asymptomatic)
  • Closed
  • IUGS with FP and crown rump length (CRL) > 7mm and no FH or
    Empty IUGS (no baby in IUGS) > 25mm
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12
Q

septic miscarriage

  • description
  • history
  • cervix
  • u/s findings
A
  • Infection (may occur after incomplete miscarriage/other forms)
  • Bleeding, pain, fever, signs of sepsis
  • Open (may see infected products of conception)
  • IUGS, YS, FP, FH may/may not be seen
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13
Q

What is the management for miscarriage?

A

Expectant: Offered for 7 – 14 days and watch for signs of infection (e.g. fever, chills, malaise, foul-smelling discharge, prolonged bleeding, cramping)
- Medical: Prostaglandins
- Surgical: For heavy bleeding or any unstable patient → vacuum aspiration of products of conception under general anaesthesia
• Risk of uterine perforation (1 in 200), bleeding, infections

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14
Q

where can ectopic pregnancies occur?

A
  • Tubal: Accounts for 98% of ectopic pregnancies; occurring when the fertilised embryo implants itself along the Fallopian tubes (usually the ampulla)
  • Interstitial: Accounts for 1 – 2% of ectopic pregnancies; occurring in the part of the Fallopian tube located in the uterine wall (myometrium) → different from cornual pregnancies in the endometrial cavity at the cornua (horns)
  • Cornual: Occurs at the uterine cornua (horns) but still in the uterine cavity (pregnancy is typically still viable but with high risk of miscarriage)
  • ovarian
  • heterotopic: Simultaneous intrauterine (normal) and ectopic pregnancies
  • abdominal
  • scar ectopic: Implantation within the fibrous tissue from previous C-section delivery
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15
Q

What are the risk factors for ectopic pregnancy?

A
  1. Previous ectopic pregnancy (10% risk of recurrence)
  2. Previous sterilisation or tubal surgery
  3. Previous tubal infection (Chlamydia) or pelvic adhesions
  4. IUCD (intrauterine contraceptive device) in situ
  5. Smoking
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16
Q

What is the clinical presentation of ectopic pregnancy?

A

Classic triad of amenorrhoea, pain, vaginal bleeding:
• Pain: sign of haemoperitoneum (secondary to tubal rupture)
• Vaginal bleeding: may be failing pregnancy (falling progesterone levels from corpus luteum induces withdrawal bleed

17
Q

on physical examination with a patient with ectopic pregnancy, what are the findings?

  • vital signs
  • abdominal palpation
  • speculum exam
  • vaginal exam
A
  • Vital signs: tachycardia, hypotension (ongoing blood loss)
  • Abdominal palpation: ensure abdomen is soft and check for rebound tenderness and guarding (bleeding into abdomen causes irritation)
  • Speculum exam: check for per vaginal bleeding
  • Vaginal exam: check for cervical excitation (pain on palpation of cervix → sign of rupture/inflammation of tubes → bleeding into peritoneum)
18
Q

what are the investigations needed for ectopic pregnancy?

A
  • Serum β-hCG trending (may present with low or slow-rising hCG level) → not diagnostic (must do ultrasound + physical exam)
  • Ultrasound: confirm the location of pregnancy
19
Q

how is a patient with ectopic pregnancy managed?

A
  • expectant: Wait to see if spontaneous trophoblastic regression occurs
  • medical: Methotrexate (folic acid antagonist which interferes with DNA synthesis) → about 80% of appropriately selected unruptured non-live ectopic pregnancies will respond to methotrexate
  • surgical: Laparoscopic salpingectomy/salpingotomy
20
Q

PUL is characterised by a ________________ but no evidence of __________________ → does not exclude it:
• DDx: early intrauterine pregnancy (which cannot be seen on ultrasound), ectopic pregnancy, complete miscarriage (dangerous to assume unless ectopic pregnancy definitely ruled out → life-threatening)
• Management: close surveillance with _______ and _________ (until location of pregnancy is ascertained)

Clinical hx: assess for presence of _______________
clinical signs: vital signs and abdo exam

A

positive urine pregnancy test (elevated hCG)’

intrauterine/extrauterine pregnancy;

serum β-hCG trending and ultrasound pelvis;

risk factors for ectopic pregnancy

21
Q

what is malignant gestational trophoblastic diseases (GTD)?

A

Gestational trophoblastic neoplasia (GTN) → includes invasive mole, choriocarcinoma, placental-site trophoblastic tumour

22
Q

what is benign gestational trophoblastic diseases (GTD)?

A 
Hydatidiform mole (molar pregnancy) → abnormal pregnancy with varying degrees of trophoblastic proliferation:
• Characterised by an absent/abnormal foetus (“snowstorm” appearance on ultrasound scan)
23
Q

Complete hydatidiform moles (CHM) have ____________ (“cluster of grapes” appearance) with absent foetus:
• Monospermic fertilisation: haploid sperm fertilises empty ovum (without maternal haploid chromosomes) → sperm duplicates DNA → 46XX (moles with a 46YY karyotype have never been observed; likely due to their non-viability) • Dispermic fertilisation (rare): 2 haploid sperms fertilise empty ovum → 46XX/46XY

A

swollen chorionic villi

24
Q

Partial hydatidiform moles are mostly _______________ due to the fertilisation of 1 ovum by 2 sperm (each carrying their own haploid set of chromosomes):
• Abnormal triploid foetus is present (but non-viable and cannot survive)

A

triploid (69XXX)

25
Q

how do patients with hydratiform moles present?

A

with vaginal bleeding, large uterus (50%), ovarian theca lutein cysts (50%), hyperemesis gravidarum (25%) and hyperthyroidism (rare; <10%):

theca lutein cysts: β-hCG has a similar structure to LH → stimulates luteinisation of the ovarian follicles → formation of lutein cells

hyperemesis gravidum: Abnormally high production of β-hCG → thyrotrophic effects (similar to TSH) → stimulates T3 and T4 production → severe vomiting triggered by high T4 levels

hyperthyroidism: β-hCG has a similar structure to TSH → stimulates thyroid

26
Q

How are patients with hydratidiform moles managed?

A

Hydatidiform moles are surgically evacuated (removed) then followed up with β-hCG levels (until hCG levels are normalised):
• Pregnancy should be avoided for 6 months from the day of β-hCG level normalisation → to avoid misinterpretation of normal pregnancy with persistent GTN

Woman's Health (29 decks)

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