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GOSH > Abortion, TOP and Miscarriage > Flashcards

Abortion, TOP and Miscarriage Flashcards

1
Q

What, by definition, is a miscarriage?

How common are they?

A
  • 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

*Occur in 25% pregnancies but women might not be aware

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2
Q

What is a THREATENED MISCARRIAGE?

A

Threatened miscarriage

  • PV bleeding
  • Painless (may have mild cramps)
  • CLOSED CERVICAL OS before 24 weeks with an ongoing pregnancy -this is a good sign :)
  • Viable products of conception (most women will have baby as normal but 1 in 7 will have complications)
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3
Q

What is a MISSED MISCARRIAGE?

A

Missed miscarriage

  • This is when the gestational sac is present but no fetal heart
  • Patient presents for routine scanning and it has miscarriaged-no heavy or painful bleeding
  • CERVICAL OS CLOSED (because it has already happened)
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4
Q

What are the 2 types of miscarriage with a OPEN OS ?

A

Inevitable

  • PV Bleeding
  • Pain
  • OPEN CERVICAL OS-they have not passed yet but they will :(

Incomplete

  • PV bleeding
  • OPEN CERVICAL OS-not all passed yet
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5
Q

What is a complete misscarriage?

A

Complete misscarriage

  • PV bleeding
  • OS CLOSED (it is complete)
  • No products
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6
Q

What are some risk factors for miscarriage?

A

Risk factors for miscarriage

MATERNAL

  • older age
  • smoking/alcohol/drugs/high caffeine
  • Obesity
  • Health problems (cardiac, GM, HTN, hyperthyroid)
  • Meds (ibuprofen, methoterexate, retinoids)
  • Cervical incompetence
  • Infections/food poisoning

PLACENTAL
-unusual shape

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7
Q

How should a threatened miscarriage be managed?

A

Expectant management of threatened miscarriage

  • Tell a woman that if her bleeding gets worse or persists beyond 14 days she should come back - if stops continue with antenatal care
  • Anti D if >12 weeks or heavy bleeding or pain
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8
Q

How can miscarriage be medically managed?

A

Vaginal misoprostol (prostaglandin analogue) (can give orally if preferred) - this is for incomplete or missed miscarriage (think of that patient)

  • 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
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9
Q

How can miscarriage be surgically managed?

What gestations?

A
  • Manual vacuum aspiration local anaesthetic (<14 weeks)

- Dilation and evacuation (electrical vacuum evacuation general anaesthetic) (from 14 weeks)

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10
Q

To summarise, what misscarrages have open/closed cervical os?

A

CLOSED OS

  • missed miscarriage (already happened)
  • complete miscarriage (already happened)
  • threatened (BEST)

OPEN OS

  • inevetable (will happen)
  • incomplete
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11
Q

What is the 1st line investigation for PV bleeding in pregnancy?

A

1st line: pregnancy test (check are they pregnant)
if they are then:
2nd line: TV/TA USS to see if you can see the pregnancy

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12
Q

In PV bleeding with +ve greg test. What are the options if you can see the pregnancy on TV/TA USS?

A

TV/TA USS shows a pregnancy

  • if os open=innevitable
  • if os closed=threatened
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13
Q

In PV bleeding with +ve greg test. What are the options if you CANT see the pregnancy on TV/TA USS?

How could you tell these differentials apart using bhcg?

A

TV/TA USS does not show a pregnancy

  • misscarriage (declining bhcg)
  • ectopic (suboptimal rise in bhcg <66%)
  • viable but too early to see (bhcg should double every 48 hours)
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14
Q

What needs to happen before a TOP can occur?

A
  • Must confirm woman is under 24 weeks of pregnancy

- The termination order must be signed by 2 separate physicians

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15
Q

When can you terminate a pregnancy?

A

TOP indications

No time limit

  • Continuing pregnancy would cause risk to life of mother (greater than if pregnancy stopped)
  • Termination is necessary to prevent grave permanent damage to mental/physical health of mother
  • If there is substantial risk that child would be born with physical/mental abnormalities

<24 weeks

  • Continuation of the pregnancy would involve risk of harming mothers mental/physical health (greater than if pregnancy stopped)
  • Continuation of the pregnancy would involve risk of harming other children/family members mental/physical health (greater than if pregnancy stopped)
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16
Q

How should an unwanted pregnancy be managed?

A
  • 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
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17
Q

How should you consider counselling a woman before having a TOP?

A

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

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18
Q

What investigations should be ordered before a TERMINATION?

A
  • BLOODS: Hb, ABO and Rh (Rh- will need anti-D)

- Estimation of gestational age (USS or LMP)

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19
Q

How do we decide which form of MEDICAL termination is require d depending on gestational age?

A

<10weeks = EARLY MEDICAL ABORTION

10+ weeks=LATE ABORTION

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20
Q

When can an early medical abortion be offered and what does it involve?

What do you do if not worked initially?

A

EARLY MEDICAL ABORTION
<10weeks (less than ten weeks)
-200mg MIFEPRISTONE
-then 24-48 hours later give 800mg MISOPROSTOL (vaginal, buccal or sublingual)
-If the abortion has not occurred after 4 HOURS then give another does of MISOPROSTAL (400mg)

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21
Q

When can a late medical abortion be offered and what does it involve?

A

LATE MEDICAL ABORTION (from 10 weeks)

  • 200mg MIFEPRISTON
  • followed by 800mcg MISOPROSTOL
  • up to 4 more doses of MISOPROSTOL 400mcg can be offered until abortion is completed
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22
Q

Is late medical abortion done in outpatients or admitted?

A

Late medical abortion is an overnight stay (increased risks and repeated misoprostol doses)

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23
Q

What are some risks/complications of TOP?

A 
Varying time to complete procedure 
Sometimes they fail 
RPOC 
Haemorrhage 
Pain 
Rupture of uterus 
Psychological problems 
Infection
24
Q

Explain the 2 forms of surgical abortion

What gestations can you do this?

What anaesthetic is used for each?

A

MANUAL VACUMM ASPIRATION
<14 weeks
-If less than 7 weeks examine aspirate and confirm its a complete abortion
-local anaesthetic or conscious sedation (fentanyl + midazolam)

DILATION AND EVACUATION (electronic vacuum aspiration)
-
-from 14 weeks (up to 23+6 weeks)
-preceded by cervical preparation 
-USS guided
-General anaesthetic
25
Q

What needs to be done before SURGICAL management of abortion?

A
  • The cervix needs to be primed

- Using MISOPRISTOL 400mcg either given vaginally or sub-lingually about 3 hours before operation

26
Q

What are some risks/complications with surgical management of TOP?

A

Failure, trauma, haemorrhage, sepsis, PID, hysterectomy, death, continuing pregnancy, injury to cervix, psychological trauma

27
Q

What extra procedures might you need to warn a women she might need later while consenting for surgical TOP?

A

Hysterectomy
Repeat TOP
Blood transfusion
Laparotomy

28
Q

What are some common complications of all TOPs?

A 
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
29
Q

What contraception advice should you give women after TOP? (surgical and medical)

A

CONTRACEPTIVE ADVICE following surgical TOP

  • 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

WITH MEDICAL YOU HAVE TO CONFIRM IT IS COMPLETE

30
Q

How might an ectopic pregnancy present? (symptoms and signs)

A

Ectopic pregnancy (98% are tubal)
Symptoms
-Often asymptomatic
-Amenorrhoea (missed periods)
-Pain +++ (unilateral, lower abdominal might be vague)
-Vaginal bleeding (often small and brown)
-Shoulder tip pain (diagphramatic irritation-heamoperitoneum)
-Nausea and vomiting
-Dizzyness
-Collapse (if ruptured)

Signs

  • Tenderness
  • Signs of peritonism (intra abdo blood if rupture)
31
Q

If you suspect ectopic pregnancy how should you investigate it? (1st 2nd 3rd line and what would you see)

What is gold standard/when is it used?

A 
1st line: Pregnancy test (+ve) 
2nd line: TVUSS
  -extra adnexal mass 
  -free fluid pouch of douglas 
  -no evidence of IU pregnancy 
3rd line: Serum b-hcg and repeat after 48 hours (suboptimal rise <66% although not diagnostic)

*Laparoscopy is gold standard but should only be for when TVUSS cant pick up

(also serum progesterone <20mmol/L suggests that pregnancy is failing)

32
Q

What are your three treatment options for a woman with ectopic pregnancy?

A

Expectant management (repeated 48hrly hCG shows fall)
Medical management
Surgical management

33
Q

What is medical management of an ectopic?

When is this indicated? (think of bhcg)

A

Medical managment of ectopic

  • IM single dose Methotrexate (with contraception following because its teratogenic)
  • re-test hCG at 4 and 7 days (if fall <15% give another dose)

Indications

34
Q

When might medical management of ectopic be suitable?

A

Medical managment ectopic

  • Clinically stable and no significant pain
  • Small adnexal mass (<35mm)
  • Serum hCG <1500
  • Unruptured (No heamoperitonium on TVUSS)
  • Viable pregnancy excluded-no FHB (tetarogenic)
  • WILL attend follow up (need to re-check bhcg)
35
Q

When might a surgical management of ectopic be more suitable?

A

Surgical managment ectopic

  • Significant pain/heamodynamically unstable
  • If there is a heart beat/viable pregnancy
  • If it is anywhere other than adnexal
  • Mass>35mm
  • If bHCG is >1500 U/L
36
Q

What is the surgical management of an ectopic?

What about if they are heamodynamically unstable?

A

Laparoscopy with salpingectomy/ostomy

Heamodynamically unstable patients: LaperoTOMY with salpingectomy after resuscitation

37
Q

What should also be offered following surgical management of an ectopic?

A

Anti-D (if woman is Rh-)

38
Q

What is expectant managment?

When would you do this? (include what level of bhcg)

A

Expectant managent of ectopic
-This is where you do serial bhcg until you see a FALL

Expectant managment (have to meet all criteria)

  • Asymptomatic
  • Small adnexal mass (<35mm)
  • Serum hCG <1500
  • Unruptured (No heamoperitonium on TVUSS)
  • Unable to return for follow up
39
Q

Incomplete vs complete miscarriage?

A

Incomplete miscarriage:

  • Partially expelled products
  • Open Os

Complete miscarriage:

  • Complete pass of products of contraception
  • Closed Os
40
Q

When do you give Anti D?

A

Non sensitised women who are Rh -ve and…
<12 weeks (medical or surgical evacuation)
>12 weeks with bleeding

41
Q

What type of drug are mifepristone and and misoprostol?

A

Mifepristone: antiprogesterone (sensitises uterus to prostaglandins
Misoprostol: prostaglandin analogue (uterine contractions)

42
Q

What prophylactic antibiotics are given in surgical abortion

A

Prophylactic abs for surgical TOP

  • metronidazole at time +doxycyline 7 days starting on day of TOP
  • metronidazole at time+azithromycin on the day
43
Q

Side effects of methotrexate?

A

Methotrexate side effects

  • Conjunctivitis
  • Stomatitis
  • GI upset
44
Q

if hCG 66%+ in 48 hours what do you think it is and what are next steps

A
  • Likely IUP

- Re scan in 10-14 days

45
Q

if hCG <66% in 48 hours what do you think it is and what are next steps?

A
  • Possible ectopic or failing pregnancy unknown location

- Serial hCG and TVUSS until diagnosis made or until hCG <15IU

46
Q

What are some causes of recurrent misscarriage?And how do you screen for them?

A
  • Anti phosphlipid syndrome (most important treatable cause)>aCL/IgM/IgG
  • Genetic (robertsonian translocation)>karyotyping
  • Fetal chromosome abnormalities
  • Fibroids>pelvic USS
  • Uterine anatomy (bicornuate uterus)
  • Thrombophilic>screening
  • Cervical weakness
47
Q

What is a molar pregnancy

A

Molar pregnancy
-Non viable pregnancy (hydatidiform mole)
-Either 2 sperm and 1 egg (overgrowth of placenta)
OR 1 sperm and no egg (all placenta, no fetus)

48
Q

What is investigations of molar pregnancy?

A

Molar pregnancy

  • USS: intrauterine vesicles (looks like grapes/snowstorm)
  • They will also have REALLY HIGH B-HCG (side effects like hyperemesis, thyrotoxicosis, pre eclampsia)
49
Q

Management of molar pregnancy?

A

Molar pregnancy
-Surgical evacuation (dilatation and suction) with serial B-hCG follow up
(to check for persistent gestational trophoblastic disease)

50
Q

What is a complication of molar pregnancy?

Treatment for this comp?

A

Persistent gestational trophoblastic disease/choriocarcinoma

  • persistantly raised bhcg after miscarriage
  • mets common (lungs)
  • both treated with CHEMO-good responce
51
Q

What is a stillbirth?

A

Fetal death beyond 24 weeks

52
Q

What causes a stillbirth?

A 
Sometimes they are classed as 'unexplained'
MATERNAL 
-pre-eclampsia/diabetes 
-maternal drugs/smoking/alcohol 
-obstetric cholestasis/other infection 
-obesity 
-RHESES STATUS

PLACENTAL
-abruption or praaevia

FETAL
-Cord prolapse, Genetic physical defect

53
Q

What infections can be associated with stillbirth?

A

Chlamydia, GBS, Haemophilus, E.coli, toxoplasmosis, Rubella, cytomegalovirus

54
Q

How will a stillbirth usually present initially?

What investigation MUST be done?

A
  • RFM
  • Reduced growth on scans is a risk factor
  • Absent fetal heart beat on scan - full real time USS MUST BE DONE
55
Q

What are your differentials for bleeding in 1st, 2nd 3rd trimester?

A

1st: ectopic, miscarriage
2nd: placental abruption
3rd: Placental previa

56
Q

What happens to platelets and APPT in antiphospholipid syndrome?

A

Antiphospholipid syndrome=thrombosis and miscarriages

Weirdly you also get:

  • APPT goes up
  • Thrombocytopenia

GOSH (29 decks)

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