Benign Gynaecology (See Cancer Care for Gynae Oncology) Flashcards
What can present with a whirlpool sign on pelvic USS?
Ovarian torsion!
When would you see cervical excitation?
PID
Ectopic pregnancy
What is cervical excitation also known as?
Cervical motion tenderness or The chandelier sign
What is cervical excitaton?
Significant pain or manipulation of the cervix
How many times can you repeat a smear test if the sample is inadequate?
3 times!!
Refer for colposcopy after a third inadequate smear
Continuous dribbling incontinence after labour ?
especially in areas with limited obstetric services
Vesicovaginal fistula
Describe the screening routine for cervical cancer in the UK
First invitation aged 25
3 yearly smear tests 25-50
5 yearly smear tests 50-65
Differentials for lower abdo pain in a young woman?
GYNAE- Ectopic pregnancy PID Ovarian torsion Endometriosis
BOWEL-
Acute appendicitis
IBS / IBD
BLADDER-
UTI
What is dysmenorrheoa and list some differentials
Painful periods (+/- Nausea + Vomiting)
May be primary (pain without pathology) or secondary (pain with pathology)
Differentials:
- Fibroids
- Endometriosis
- Adenomyosis
- PID
- Pelvic adhesions
What is adenomyosis
Endometrial tissue which grows into the myometrium
What is oligomenorrhoea and list some differentials
Irregular periods (>35 days between periods)
Differentials:
- PCOS
- Contraceptives
- Prolactinoma
- Stress
- Extreme weight loss
- Thyroid disease
What is amenorrhoea and list some causes
Absence of menstruation in a woman of reproductive age
Primary: failure to start menstruating …
- Late puberty
- Structural defect (imperforate hymen, absent uterus, absent or short vagina)
- Genetic defect (Turner’s syndrome, androgen insensitivity syndrome)
- Anorexia nervosa / extreme stress (hypothalamus doesn’t produce GnRH)
Secondary: periods stop for > 6 months (not due to pregnancy)
- Stress
- Extreme exercise
- Hyperprolactinaemia
- PCOS
- Ovarian failure (premature menopause)
- Asherman’s syndrome (adhesions form in uterus)
- Sheehan’s syndrome (Pituitary Necrosis)
What is menorrhagia and list some causes
Heavy menstrual bleeding impacting a patient’s quality of life (>80 ml or menses lasting >7 days)
Causes:
- Dysfunctional Uterine Bleeding
- Fibroids
- Polyps
- Endometrial adenocarcinoma
- Coagulation disorder
- Infection
- IUD
What other symptoms might a patient with menorrhagia complain of?
Signs of anaemia
Tiredness, pallor, headache, SOB, tinnitus etc
What is dysfunctional uterine bleeding?
Heavy and irregular bleeding in the absence of a pelvic pathology - thought to be related to hormone dysfunction
Ix dysfunctional uterine bleeding
Bedside tests:
- Pregnancy test
- STI swabs (vulvovaginal, endocervical and high vaginal)
Bloods - FSH, LH, Oestrogen, Progesterone, testosterone, prolactin, TFTs, clotting, FBC)
Imaging - TV USS
Hysteroscopy +/- endometrial biopsy (rule out other causes of menorrhagia)
Mx of dysfunctional uterine bleeding / menorrhagia
Medical Mx:
- Mirena IUS (releases levonorgestrel locally to cause atrophy of endometrium)
- Tranexamic acid (anti-fibrinolytic)
- Mefenamic acid (NSAID: inhibits prostaglandins)
- COCP
- IM Progesterone
Surgery:
- Endometrial ablation
- Myomectomy (if family incomplete)
- Hysterectomy
What are the 3 types of oestrogen
Estradiol
Estrone
Estriol
Where are oestrogen and progesterone (& inhibin) secreted from?
Oestrogen & Inhibin released from granulosa cells (under influence of FSH)
Androgens released from theca cells (under influence of LH)
Progesterone is released from the corpus luteum (follicle which has leutinised after ovulation due to the LH surge)
What is endometriosis?
Presence of endometriotic tissue outside of the uterus (uterosacral ligaments, peritoneum, ovaries, bladder and rarely the colon)
How may endometriosis present
PAIN:
- Cyclical (endometrial tissue responds to menstrual cycle)
- Constant (adhesions secondary to chronic inflammation)
- Deep dyspareunia (uterosacral ligaments involved)
- Dysuria (bladder involvement)
- Dyschezia (pain on defecation)
Subfertility
Asymptomatic (many cases are now being detected due to development of laparoscopic surgery)
What will endometriosis feel like on a bimanual examination?
Fixed, retroverted uterus !
may also feel adenxal mass or tenderness
What is the gold standard investigation for endometriosis
Laparoscopy and biopsy!!
May also do:
- MRI pelvis to assess extent in severe disease
- Pelvic USS (may not visualise endometriomas though)
How is endometriosis treated?
Medical:
- NSAIDs (Mefenamic acid)
- COCP
- Mirena IUS
- GnRH analogues
- Danazol (synthetic modified testosterone )
Surgical:
- Laparoscopy for excision / ablation
- Hysterectomy (last resort)
What phenomenon is sometimes seen after removing endometriotic lesions in mild - moderate endometriosis ?
Spontaneous pregnancy rates increase
What is a common complication / sequela of endometriosis?
Chronic pelvic pain
- Refer to endometriosis specialist for input from specialist nurse and chronic pain team
Who does endometriosis affect ?
Women of reproductive age (oestrogen driven)
- increased risk if nulliparious, early menarche, late menopause or FMH
What are fibroids also known as ?
Leiomyomas
What are fibroids ?
Benign tumours arising from the myometrium (benign smooth muscle tumour)
What are the 4 types of fibroids
Intramural (in uterine wall)
Subserosal (under visceral peritoneum)
Submucosal
Pedunculated (on a stalk)
How may uterine fibroids present ?
Menorrhagia
Pain (torsion of a pedunculated fibroid or red degeneration)
Pelvic Mass
Subfertility (especially if submucosal, interferes with implantation)
Increased urinary frequency (if pressing on the bladder)
Oedematous legs and varicose veins (if compressing veins)
Who is likely to get fibroids?
Women of reproductive age (oestrogen dependent)
Risk factors: Increasing age More common in Afro-Caribbean women FMH Mutation in fumarate hydratase gene Renal cell carcinomas (rare)
What can cause fibroids to enlarge?
Pregnancy or COCP as fibroids are oestrogen dependent
What is red degeneration ?
Sudden degeneration of a fibroid in pregnancy due to thrombosis of capsular veins of fibroid
Thrombosis -> Venous engorgement -> inflammation and pain -> low grade fever -> degeneration
“ GROW BIG, TENDER AND DIE “
What are womb stones ?
Calcified fibroids
Mx of fibroids
Medical:
- GnRH analogues (goserelin) (shrinks fibroids prior to surgery)
- Ullipristil acetate (shrinks fibroids prior to surgery)
Surgical:
- Some submucosal fibroids can be resected trans-cervically
- Myomectomy (if haven’t completed family)
- Hysterectomy
- Uterine artery embolisation (neuroses uterus)
What is PCOS
Polycystic Ovarian Syndrome
What are the diagnostic criteria for PCOS ?
Rotterdam criteria- must have 2 of…
- Polycystic ovaries on USS
- Oligoovulation or anovulation / oligomenorrhoea
- Clinical or biochemical hyperandrogenism
What do polycystic ovaries look like on USS ?
String of pearls
What is PCOS associated with ?
Metabolic syndrome (dyslipidaemia, insulin resistance, obesity and hypertension)
- This is important as part of the management of PCOS is yearly screening for T2DM and CVS disease
What is the pathophysiology of PCOS
Unknown -
Thought that increased insulin drives production of LH -> continuously high LH = no ovulation / no LH surge -> cyst forms and irregular periods
High levels of LH = high levels of androgen production, too much that some aren’t converted to oestrogen = hyperandrogenism
Signs / Symptoms of PCOS
Oligomenorrhoea Hirsutism Weight gain Male pattern baldness Acne Subfertility Acanthosis nigracans (hyperinsulinaemia)
Investigating PCOS ?
Bloods- FSH, LH, Prolactin, Androgens, TFTs and cortisol
TVS (USS)
Imaging -> if excessively high testosterone, may want to look for an androgen secreting tumour
Mx of PCOS
Lifestyle modifications -
- lose weight
- stop smoking
- shaving / waxing for hirsutism
Medical/ Surgical
- metformin (thought to improve insulin sensitivity)
- clomifene citrate (induces ovulation as it is an oestrogen receptor antagonist)
- COCP (reduces risk of unopposed oestrogen on the endometrium and helps regulate bleeding)
- Cyproterone for hirsutism
- Ovarian drilling
Preventive:
- Screen for T2DM, GDM and CVS disease yearly (and when pregnant)
- Higher risk of endometrial hyperplasia and carcinoma (due to actions of unopposed oestrogen)
What is pre-menstrual syndrome (PMS) ?
Distressing physical, psychological or behavioural symptoms occurring in the absence of organic or psychiatric disease
- In the luteal phase of menstruation and showing significant improvement by the end of menses
How is PMS diagnosed
Symptom diary over 2 consecutive cycles
What symptoms are associated with PMS?
Mood swings Irritability Depression Bloating Headache Breast tenderness / mastalgia Increased appetite
Mx of PMS
Lifestyle modifications:
- Weight loss
- Increase exercise
- Improve diet
- Stop smoking
CBT (first line!!)
Medical:
- Vit B6
- COCP
- Fluoxetine (low dose or in luteal phase, if moderate disease may give high dose or continuously)
- Estradiol patches and Progesterone (PO or Mirena IUS)
- GnRH analogues (and bone protection)
Surgical:
- TAH and BSO
** 5% women report severe symptoms which cause a major disruption to their lives
What happens during the follicular phase of the ovarian cycle (menstruation) ?
DAY 1 - 14
A follicle matures ready to release an oocyte. FSH and LH are released as inhibin and oestrogen levels are low. This causes a rise in oestrogen and inhibin.
As inhibin levels rise, FSH drops which means only one follicle survives (the rest become polar bodies).
Oestrogen continues to rise and when levels are high this causes positive feedback on the HPG axis and there is an LH surge
LH surge drives ovulation (day 14)
What happens during the luteal phase of the ovarian cycle (menstruation) ?
DAY 14 - 28
Granulosa cells express LH receptors and the follicle is leutinised.
The corpus luteum secretes oestrogen and progesterone to maintain conditions for fertilisation. This causes negative feedback on the HPG axis (as oestrogen and progesterone now present) and FSH and LH levels drop.
If there is no fertilisation (no bHCG production) the corpus luteum regresses spontaneously. This leads to menses as there is a reduction in oestrogen and progesterone production.
What happens in the proliferative phase of the endometrial cycle (menstruation)
DAY 1 - 14 (preparation for fertilisation)
Oestrogen (released from granulosa cells) causes thickening of the endometrium, growth of the myometrium and the cervix to produce a thin, alkaline mucus (for sperm passage)
What happens in the secretory phase of the endometrial cycle (menstruation)
DAY 14 - 28 (preparation for implantation)
Progesterone released by the corpus luteum causes the endometrial glands to become convoluted. The myometrium is thickened further. The cervix produces a thick acidic mucus to prevent polyspermy.
What is the normal duration of the menstrual cycle?
21 - 35 days
What is the normal amount of blood lost during menses ?
20 - 80ml
What is the normal duration of menses?
2 - 7 days
What is PID
Pelvic Inflammatory Disease
An acute, ascending infection from the endocervix causing endometritis, salpingitis, tubo-ovarian abscess and sometimes peritonitis
Common organisms in PID
Chlamydia Trachomatis (40-60%) Neisseria Gonorrhoeae (15-18%) Anaerobes (3-5%) Mycoplasma hominis (10-15%)
Causes of PID
STIs
Post-partum
Iatrogenic (IUCD insertion, TOP, hysteroscopy)
Acute appendicitis (infection can descend to the gynae tract)
Risk factors for PID
Young age
Multiple sexual partners
Previous STIs
How may PID present
Lower abdo pain Dysmenorrhoea Deep dyspareunia PV discharge (purulent) Fever IMB or PCB (bleeding)
Protective factors for PID
COCP
Mirena IUS
Barrier contraception
What signs may PID produce on examination ?
Cervical excitation / cervical motion tenderness
Adenexal tenderness
Discharge
** May also have raised ESR or CRP
Ix for PID
Swabs (vulvovaginal, endocervical) / MC + S
Pregnancy test
Urine dip
FBC, cultures, CRP if acutely unwell
TVS if querying a tubo-ovarian abscess
Mx of PID
Eduction and contract tracing
Avoid sexual intercourse until settled
Antibiotics:
- Doxycycline PO 14 days
- Metronidazole PO 14 days
- Ceftriaxone IM STAT / one off dose
What are the potential complications of PID
Ectopic pregnancy Tubo-ovarian abscess Fitz-Hugh-Curtis syndrome (Chlamydia) Recurrent PID / chronic Subfertility due to Fallopian tube blockage
what is fitz-Hugh-Curtis syndrome
Inflammation of the liver capsule with perihepatic adhesions (due to chlamydia infection)
What is chronic PID
Unresolved, unrecognised or inadequately treated infection
Chronic inflammation -> fibrosis -> adhesions between pelvic organs
Fallopian tubes may become distended with pus (pyosalpinx) or fluid (hydrosalpinx)
How is chronic PID management different to acute PID
Abx often not helpful
Focus on chronic pelvic pain mx - Difficult to manage pain
Causes of post coital bleeding
Benign-
- Ectropion
- STIs
Malignant-
- Cervical cancer
- Vaginal cancer (v rare)
What is a cervical ectropion?
The soft columnar cells of the endocervix appear in the ectocervix where there is usually stratified squamous epithelium.
(LOOKS LIKE A RED RING AROUND THE OS ON SPECULUM)
Can be caused by oestrogen moving the transitional zone in puberty (physiological) or can be related to COCP or pregnancy
Mx of cervical ectropion
If asymptomatic does not require management
- Swap to non-hormonal contraception
- Cautery as an outpatient (silver nitrate)
Causes of inter-menstrual bleeding
Physiological:
- Spotting around ovulation
- Pregnancy
Benign:
- STIs (cervicitis)
- cervical ectropion
- fibroids
- endometriosis
- adenomyosis
- breakthrough bleed after starting new contraception (POP, COCP, IUS)
Malignant:
- cervical cancer
- endometrial cancer
- vaginal cancer (rare)
What is Meig’s syndrome
Triad of:
- Ascites
- Benign ovarian tumour (often a fibroma)
- Pleural effusion (often right sided)
** Typically resolves after resection of the tumour
What type of benign ovarian cyst is most likely to tort and why?
Dermoid cyst (largest and most dense, often have long pedicle due to their weight which can tort)
What gives a ‘‘snowstorm appearance’’ on USS
Hydatidiform mole (gestational trophoblastic disease)
What 2 acts are involved in the legality behind TOP
The abortion act of 1967
The human fertilisation and embryology act of 1990
What are the legal clauses for a TOP
A- risk to mothers life if the pregnancy continues
B- termination necessary to prevent permanent grave injury to the mothers mental or physical health
C - continuance risks injury to the mental or physical health of the mother that is greater than if terminated
D - continuance risks injury to the mental or physical health of existing children that is greater than if terminated
E- Substantial risk that if the child was born they would suffer physical or mental abnormalities / be seriously handicapped
How can a TOP be legally consented/agreed?
HSA1 certificate signed by 2 doctors
What should be done prior to a TOP?
- Counselling
- USS (confirm gestation, location and viability of the pregnancy)
- STI screening (+/- prophylactic Abx)
- Contraception advice / discussion
- If rhesus negative give Anti-D
- Blood tests: rhesus and ABO antibodies, FBC, BBV screen, haemoglobinopathy screen (not necessary to cross match all women)
What comprises a medical termination of pregnancy
Mifepristone (anti-progesterone) AND Misoprostol (prostaglandin: stimulates oxytocin release and uterine contraction and ripens/softens and dilates the cervix)
NSAID analgesia
Feticide (intra-cardiac potassium chloride, given if the fetus is >21 weeks + 6 days as must ensure that the fetus is born dead)
Complications of an abortion?
Retained products of conception and potential infection/sepsis
Failure
Haemorrhage
Uterine rupture / perforation
Cervical trauma
Timescales for medical and surgical termination of pregnancy?
Medical abortion can be done <63 days and up to 24 weeks
Surgical abortion can be done at any time however vacuum aspiration can be done up to 14 weeks and dilatation and evacuation can only be done after 14 weeks
What comprises a surgical termination of pregnancy
If up to 14 weeks = vacuum aspiration
If >14 weeks = dilation and evacuation, this requires cervical priming (misoprostol or osmotic dilator)
NSAID analgesia
What is a pelvic organ prolapse?
Passage of pelvic tissue through the pelvic floor and into the introitus of the vagina
What are the types of pelvic organ prolapse ?
Anterior - cystocele/urethrocystocele (bladder/urethra prolapse)
Posterior - rectocele / enterocele (rectum or small bowel)
Middle / Uterine - cervix / uterus / vaginal vault prolapse
How is the severity of a prolapse graded?
1st degree: lowest part of the prolapse extends 1/2 way down to the introitus
2nd degree: lowest part of the prolapse extends to the level of the introitus and through introitus on straining
3rd degree: lowest part of the prolapse through the introitus and out vagina
4th degree: uterus is outside of the vagina (procidentia)
Symptoms of a pelvic organ prolapse
Urinary (if bladder has prolapsed):
- Urgency
- Frequency
- Retention
- Incontinence (especially stress)
- Haematuria
- Recurrent infections
Bowel:
- Constipation
- Incomplete emptying
- May have to push prolapse by pushing posterior vaginal wall to defecate
Back pain
Dyspareunia
Dragging sensation / feeling of a lump coming down
Mx of a pelvic organ prolapse
Conservative:
- lose weight
- pelvic floor exercises
- stop smoking / avoid chronic cough
- Constipation management
- Stop heaving lifting
Medical:
- Topical oestrogen cream
- Pessary (change every 6 months)
Surgical:
- Pelvic floor repair
- Sacrocolpoplexy
- Hysterectomy
- Colpocleisis (last resort, close vagina off if very poor physical health or many failed operations)
What is urinary incontinence?
Involuntary, spontaneous leakage of urine that occurs with either stress or is associated with uncontrollable sense of urgency or both
What are the different types of incontinence and how do they present ?
Stress: leakage of urine when laughing, sneezing, coughing or on exertion. Caused by an increase in intra-abdominal pressure and destrusor pressure exceeds urethral pressure.
Urge: leakage of urine with or followed by urgency
Mixed: mixture of both the above
Overactive Bladder: frequency, nocturia and urgency with or without being incontient (due to detrusor overactivity)
Continuous: continuous leakage of urine (e.g vesicovaginal fistula)
Nocturnal: involuntary loss of urine during sleep
Overflow: leakage of urine from an overdistended bladder
Mx of stress incontinence
Conservative:
- Lose weight
- Pelvic floor exercises
- Stop smoking / reduce chronic cough
- Modify fluid intake
Medical: duloxetine (increases sympathetic activity in Onuf’s nucleus)
Surgical:
- Tension free vaginal taping (CURRENTLY NOT RECOMMENDED)
- Periurethral injection of a bulking agent
- Culposuspension
Mx of an OAB / Urge Incontinence
Conservative:
- Cut down on caffeine and alcohol
- Bladder retraining exercises
- Lose weight
- Modify fluid intake
Medical:
- Anti-cholinergics (Oxybutynin or Mirabegron if older woman)
Surgical:
- Botulinum toxin type A injections
- Cystoplasty
Discuss control of urine storage
Controlled by the sympathetic nervous system:
Pontine continence centre signals to the sympathetic nuclei in the spinal cord.
Signals then sent via the hypogastric nerve stimulate the detrusor muscle to relax (B3 receptors) and the internal urethral sphincter to contract (a1 receptors)
The external urethral sphincter is under voluntary control by the pudendal nerve. It remains contracted due to nAch receptor activation)
As the bladder fills the ruggae flatten and the bladder wall distends to maintain intravesicular pressure < urethral pressure. This is known as receptive relaxation.
Bladder can store around 300-550mls
Discuss micturition control
Under parasympathetic nervous system control:
When the bladder reaches >400ml full, the afferent receptors signal to the pontine micturition centre.
If the pontine micturition centre and cortex voluntarily decide to urinate the pons sends parasympathetic signals to the sacral preganglionic neurons. The pons also inhibits Onuf’s nucleus to reduce sympathetic innervation to the internal urethral sphincter via the hypogastric nerve.
This sends signals via the pelvic nerve which releases Ach to cause detrusor contraction (M3 receptors). The inhibition of the SNS causes the internal sphincter to relax.
Once intravesicular pressure > intraurethral pressure due to detrusor contraction, the external sphincter relaxes via pudendal nerve and you get urination
What are normal urine flow rates in men and women
Men = 20-25 mls/s Women = 25-30mls/s
What can cause urinary incontinence?
- Increase in intra-abdominal pressure (laughing, exertion, coughing)
- Damage to pelvic floor muscles, pudendal and pelvic nerves (childbirth, Genito-urinary surgery)
- UMN lesions (MS, stroke)
- Neurological damage in the cortex / pons (Parkinson’s disease)
- Radiation exposure
- Drugs (ACE inhibitors, diuretics)
What are the normal values for semen analysis?
Volume: >1.5ml Concentration: >15 x 10(6) Motility (total): 40% Motility (progressive): 32% Normal morphology: 4%
List some causes of subfetility
Anovulation (21%) Tubal factors (15-20%) Endometriosis (6-8%) Male factors (25%) Unexplained (28%)
Define primary and secondary subfertility
Primary: failure to conceive despite having >12 months regular UPSI with the female never having conceived before
Secondary: failure to conceive despite having >12 months regular UPSI with the female having conceived before
List some anovulatory causes of subfertility
PCOS Genetics (e.g. 45X) Ovarian failure (premature) Prolactinoma Sheehan's syndrome (anterior pituitary necrosis)
List some tubal factors causing subfertility
PID Endometriosis Asherman's syndrome (adhesions due to repeated D+C) Fibroids Tubal ligation / sterilisation
List some male factors causing subfertility
Absent sperm
Low sperm count
Abnormal sperm
Immotile sperm
Causes: Genetic (47XXY) Previous orchiditis, e.g. Mumps Testicular cancer Anabolic steroid use Alcohol Smoking STIs Varicocele Vasectomy Undescended testes
What % of couples having regular UPSI conceive within 1 year?
84%
How many eggs does a woman have to start with, how many by 30 and how many by 40 y/o
300,000 to start with
12% by 30 y/o
3% by 40 y/o
What Ix would you do for someone presenting with infertility
Height and weight
Day 21 progesterone (marker of ovulation)
Oestrogen, LH, FSH, Testosterone, Prolactin
USS uterus
Hysterosalpingogram (tubal patency using injected contrast)
Laparoscopy and Methylene blue dye (tubal patency gold standard)
Semen analysis
STI screens (male and female)
What is the gold standard investigation for assessing tubal patency?
Laparoscopy with methylene blue dye
What test would you do to check for ovulation ?
Day 21 progesterone (or 6 days prior to cycle ending ??)
What are the mx options for subfetility
Male:
Reduce alcohol and smoking
Take a multivitamin with zinc, vit c and selenium
Recheck sperm analysis in 3/12
Female:
Folic acid
Induce ovulation:
- clomiphene citrate = antioestrogen which increases FSH
- ovarian drilling (to reduce LH, only if PCOS)
- metformin if PCOS
Surgery: unblock tubes (dilation and curretage), adhesionlysis
Assisted conception: IVF (in-vitro fertilisation) ICSI (intracytoplasmic sperm injection) IUI (intrauterine insemination) Sperm donation Egg donation
What is OHSS
OVARIAN HYPERSTIMULATION SYNDROME
Usually occurs 3-7 days after hCG given in IVF or 12-17 days after pregnancy ensured in IVF
It is a systemic disease where vasoactive products are released and causes increased capillary permeability. This causes an increase in fluid leaving the intra-vascular space.
How might OHSS present
N+V
Abdo pain and distension
SOB
DUE TO: Pleural effusion Ascites VTE Renal failure Pulmonary failure
Mx of OHSS
Supportive:
- analgesia
- anti-emetics
- restrict fluids
- LMWH to reduce thrombosis risk
- paracentesis of ascites + albumin replacement
Pathophysiology of endometriosis?
Three theories:
- Retrograde menstruation
- Metaplasia of mesothelial cells
- Impaired immunity means that cells from retrograde menstruation fail to be destroyed by the immune system
Types of miscarriage
Threatened - os is closed, painless bleeding
Missed - os is closed, no symptoms of expulsion and a sac with a dead fetus seen on USS
Complete - os is closed, pain and bleeding with tissue passed, empty intrauterine cavity seen on USS
Inevitable - os is open, painful heavy bleeding with clots
Incomplete - os is open, painful bleeding, some products remain
Management of a miscarriage
3 methods:
EXPECTANT
- Wait 7-14 days for products of conception to pass naturally
MEDICAL
- Misoprostol given vaginally (prostaglandin analogue given to cause myometrial contractions)
- Give analgesia and antiemetics with this
- Wait up to 24h for bleeding to start
SURGICAL
- If medical management fails OR evidence of infection or increased risk of haemorrhage
- Vacuum aspiration under local anaesthetic
- Theatre for evacuation of retained products of conception
When would you opt for surgical management of a miscarriage > medical/expectant management?
Evidence of infection
Increased risk of haemorrhage
How long post-termination will the urinary pregnancy test remain positive
4 weeks
