Abortion, TOP and Miscarriage Flashcards
How common are miscarriages?
Occur in 25% pregnancies but women might not be aware
What, by definition, is a miscarriage?
A loss of pregnancy of 24 weeks or earlier
Sometimes the classification is as early as 20 weeks
After this it is defined as a stillbirth
What is a THREATENED MISCARRIAGE?
PV bleeding, painless with CLOSED CERVICAL OS before 24 weeks with an ongoing pregnancy
What is an INEVITABLE MISCARRIAGE?
PV bleeding with OPEN CERVICAL OS and usually some associated pain
What is a MISSED MISCARRIAGE?
This is when the gestational sac is present but there is no evidence of fetal pole or yolk sac
What are some risk factors for miscarriage?
Increased maternal age Smoking Consuming alcohol Recreational drug use High caffeine intake Obesity Infections and food poisoning Health problems (e.g. cardiac, diabetes, hypertension and hyperthyroid) Medicines e.g. ibuprofen, methotrexate and retinoids Unusual shape of uterus Cervical incompetence
How should a threatened miscarriage be treated?
Expectant management
Tell a woman that if her bleeding gets worse or persists beyond 14 days she should come back - if stops continue with antenatal care
Consider medical management if high haemorrhage risk or if she has had previous traumatic association with pregnancy
How can miscarriage be medically managed?
Vaginal misoprostol 800mcg (can give orally if preferred) - this is for incomplete or missed miscarriage
She will then begin bleeding after 24 hours
Consider analgesics and anti-emetics
Advise them to take a pregnancy test after 3 weeks and return if this is positive
How can miscarriage be surgically managed?
Manual vacuum aspiration under LA
Surgical management under a GA
What is a stillbirth?
Fetal death beyond 24 weeks
What causes stillbirth?
Sometimes they are classed as ‘unexplained’
PLACENTAL PROBLEMS - e.g. abruption or praaevia
MATERNAL PROBLEMS - pre-eclampsia, maternal drugs and alcohol, obstetric cholestasis, diabetes, infection, obese, multiple pregnancy, RHESUS STATUS
FETAL PROBLEMS - Cord prolapse, Genetic physical defect
What infections can be associated with stillbirth?
Chlamydia, GBS, Haemophilus, E.coli, toxoplasmosis, Rubella, cytomegalovirus
How will a stillbirth usually present initially?
RFM
Reduced growth on scans is a risk factor
Absent fetal heart beat on scan - full real time USS MUST BE DONE
What needs to happen before a TOP can occur?
Must confirm woman is under 24 weeks of pregnancy
The termination order must be signed by 2 separate physicians
When can you terminate a pregnancy?
CDE CLAUSE
C- Continuation of the pregnancy would cause greater harm to the woman’s physical or mental health then the termination (94% done with this)
D - Danger. Greater risk to with continuing pregnancy than termination, could be to mother, unborn baby o existing children
E - Significant risk that if it were born it would be born with significant congenital abnormalities
How should an unwanted pregnancy be managed?
Confirm with bHCG tests
Confirm with USS to get an idea of, gestational age, single or multiple, uterine pregnancy (not ectopic) and viability of pregnancy
How should you consider counselling a woman before having a TOP?
Has she weighed up implications and risks?
Discuss continuation of pregnancy and adoption?
BE SYMPATHETIC AND NON-DIRECTIONAL
GIVE TIME
Consider contraceptive plan for the future
What investigations should be ordered before a termination?
BLOODS: Hb, ABO and Rh (Rh- will need anti-D)
Estimation of gestational age (USS or LMP)
Commonly given prophylactic abs (1g azithromycin)
provide verbal and written information
How do we decide which form of termination is require d depending on gestational age?
<9weeks = EARLY MEDICAL ABORTION
9-13weeks = LATE MEDICAL ABORTION
13-24 weeks = MID-TRIMESTER MEDICAL ABORTION
When should an early medical abortion be offered and what does it involve?
<9weeks
EVERYONE is offered 200mg MIFEPRISTONE tablet and then MISOPROSTOL 400mcg PO 36/48 hours later
Sometimes you might need an extra dose of 400mcg misoprostol especially if between 7w and 9w
When can a late medical abortion be offered and what does it involve?
9-13w
MIFEPRISTON 200mg PO followed by 800mcg MISOPROSTOL - up to 4 more doses of 400mcg can be offered until abortion is completed
When can a mid-trimester medical abortion be offered and what does it involve?
13-24w
MIFEPRISTONE 200mg followed by 800mcg VAGINAL MISOPROSTOL
+ an extra mifepristone
What are some risks/complications of TOP?
Varying time to complete procedure Sometimes they fail RPOC Haemorrhage Pain Rupture of uterus Psychological problems Infection
In what forms can an abortion be surgically managed?
Vacuum aspiration up to 14 weeks
Surgical evacuation from 17-15w
Dilation and Evacuation - 15-18w
Surgical evacuation without fetocide - 19-22w
Surgical evacuation with fetocide - 22-24w
What needs to be done before surgical management of abortion?
The cervix needs to be primed
Using MISOPRISTOL 400mcg either given vaginally or sub-lingually about 3 hours before operation
What are some risks/complications with surgical management of TOP?
Failure, trauma, haemorrhage, sepsis, PID, hysterectomy, death, continuing pregnancy, injury to cervix, psychological trauma
What extra procedures might you need to warn a women she might need later while consenting for surgical TOP?
Hysterectomy
Repeat TOP
Blood transfusion
Laparotomy
What are some common complications of all TOPs?
RPOC - advise about persistent bleeding Haemorrhage 1 in 1000 cases Failure - 2.3 per 1000. Return for follow up Perforation Infection (prophylactic abx) Cervical trauma Future fertility - no reduction
What advice should you always consider giving women after TOP?
CONTRACEPTIVE ADVICE
IUD/IUS can be implanted same day as can depot injections the implant and the pill/patch/ring
Pill doesn’t need to be taken for 5 days after
How might an ectopic pregnancy present?
Pain +++ lower abdominal might be lateralised Vaginal bleeding Amenorrhoea (missed periods) Vomiting Nausea Collapse
Woman’s abdomen is likely to be tender on examination and there might be pelvic and/or cervical motion tenderness
If you suspect ectopic pregnancy how should you investigate it?
TVUSS is gold standard
What are your three treatment options for a woman with ectopic pregnancy?
Expectant management
Medical management
Surgical management
When might medical management of ectopic be suitable?
For women with little to no pain With an adnexal mass <35mm and no fetal heart beat Serum hCG <1500U/L Stable No uterine pregnancy
What is medical management of an ectopic?
Methotrexate
When might a surgical management of ectopic be more suitable?
If there is a heart beat
If it is anywhere other than adnexal
If bHCG is >1500 U/L
What is the surgical management of an ectopic?
Salpingostomy or salpingectomy
What should also be offered following surgical management of an ectopic?
Anti-D (if woman is Rh-)
