Abortion, TOP and Miscarriage Flashcards
What, by definition, is a miscarriage?
How common are they?
- 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
What is a THREATENED MISCARRIAGE?
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)
What is a MISSED MISCARRIAGE?
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)
What are the 2 types of miscarriage with a OPEN OS ?
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
What is a complete misscarriage?
Complete misscarriage
- PV bleeding
- OS CLOSED (it is complete)
- No products
What are some risk factors for miscarriage?
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
How should a threatened miscarriage be managed?
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
How can miscarriage be medically managed?
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
How can miscarriage be surgically managed?
What gestations?
- Manual vacuum aspiration local anaesthetic (<14 weeks)
- Dilation and evacuation (electrical vacuum evacuation general anaesthetic) (from 14 weeks)
To summarise, what misscarrages have open/closed cervical os?
CLOSED OS
- missed miscarriage (already happened)
- complete miscarriage (already happened)
- threatened (BEST)
OPEN OS
- inevetable (will happen)
- incomplete
What is the 1st line investigation for PV bleeding in pregnancy?
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
In PV bleeding with +ve greg test. What are the options if you can see the pregnancy on TV/TA USS?
TV/TA USS shows a pregnancy
- if os open=innevitable
- if os closed=threatened
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?
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)
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?
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)
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)
How do we decide which form of MEDICAL termination is require d depending on gestational age?
<10weeks = EARLY MEDICAL ABORTION
10+ weeks=LATE ABORTION
When can an early medical abortion be offered and what does it involve?
What do you do if not worked initially?
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)
When can a late medical abortion be offered and what does it involve?
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
Is late medical abortion done in outpatients or admitted?
Late medical abortion is an overnight stay (increased risks and repeated misoprostol doses)
What are some risks/complications of TOP?
Varying time to complete procedure Sometimes they fail RPOC Haemorrhage Pain Rupture of uterus Psychological problems Infection
Explain the 2 forms of surgical abortion
What gestations can you do this?
What anaesthetic is used for each?
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
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 contraception advice should you give women after TOP? (surgical and medical)
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
How might an ectopic pregnancy present? (symptoms and signs)
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)
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?
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)
What are your three treatment options for a woman with ectopic pregnancy?
Expectant management (repeated 48hrly hCG shows fall)
Medical management
Surgical management
What is medical management of an ectopic?
When is this indicated? (think of bhcg)
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
When might medical management of ectopic be suitable?
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)
When might a surgical management of ectopic be more suitable?
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
What is the surgical management of an ectopic?
What about if they are heamodynamically unstable?
Laparoscopy with salpingectomy/ostomy
Heamodynamically unstable patients: LaperoTOMY with salpingectomy after resuscitation
What should also be offered following surgical management of an ectopic?
Anti-D (if woman is Rh-)
What is expectant managment?
When would you do this? (include what level of bhcg)
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
Incomplete vs complete miscarriage?
Incomplete miscarriage:
- Partially expelled products
- Open Os
Complete miscarriage:
- Complete pass of products of contraception
- Closed Os
When do you give Anti D?
Non sensitised women who are Rh -ve and…
<12 weeks (medical or surgical evacuation)
>12 weeks with bleeding
What type of drug are mifepristone and and misoprostol?
Mifepristone: antiprogesterone (sensitises uterus to prostaglandins
Misoprostol: prostaglandin analogue (uterine contractions)
What prophylactic antibiotics are given in surgical abortion
Prophylactic abs for surgical TOP
- metronidazole at time +doxycyline 7 days starting on day of TOP
- metronidazole at time+azithromycin on the day
Side effects of methotrexate?
Methotrexate side effects
- Conjunctivitis
- Stomatitis
- GI upset
if hCG 66%+ in 48 hours what do you think it is and what are next steps
- Likely IUP
- Re scan in 10-14 days
if hCG <66% in 48 hours what do you think it is and what are next steps?
- Possible ectopic or failing pregnancy unknown location
- Serial hCG and TVUSS until diagnosis made or until hCG <15IU
What are some causes of recurrent misscarriage?And how do you screen for them?
- 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
What is a molar pregnancy
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)
What is investigations of molar pregnancy?
Molar pregnancy
- USS: intrauterine vesicles (looks like grapes/snowstorm)
- They will also have REALLY HIGH B-HCG (side effects like hyperemesis, thyrotoxicosis, pre eclampsia)
Management of molar pregnancy?
Molar pregnancy
-Surgical evacuation (dilatation and suction) with serial B-hCG follow up
(to check for persistent gestational trophoblastic disease)
What is a complication of molar pregnancy?
Treatment for this comp?
Persistent gestational trophoblastic disease/choriocarcinoma
- persistantly raised bhcg after miscarriage
- mets common (lungs)
- both treated with CHEMO-good responce
What is a stillbirth?
Fetal death beyond 24 weeks
What causes a stillbirth?
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
What infections can be associated with stillbirth?
Chlamydia, GBS, Haemophilus, E.coli, toxoplasmosis, Rubella, cytomegalovirus
How will a stillbirth usually present initially?
What investigation MUST be done?
- RFM
- Reduced growth on scans is a risk factor
- Absent fetal heart beat on scan - full real time USS MUST BE DONE
What are your differentials for bleeding in 1st, 2nd 3rd trimester?
1st: ectopic, miscarriage
2nd: placental abruption
3rd: Placental previa
What happens to platelets and APPT in antiphospholipid syndrome?
Antiphospholipid syndrome=thrombosis and miscarriages
Weirdly you also get:
- APPT goes up
- Thrombocytopenia
