Bleeding in early pregnancy Flashcards
What is the most common reason for bleeding in early pregnancy
Spontaneous miscarriage
Define spontaneous miscarriage
Expulsion or removal of the products of conception prior to 24 weeks gestation
How common is a miscariage
10-15 percent of pregnancies
45-55 percent if using B-HCG
Name other reasons for bleeding in early pregnancy
ectopic pregnancy
Hydratiform mole
lower genital tract causes
What are the ‘types’ of miscarriage
Threatened Inevitable Incomplete Complete Septic
Define threatened
Not painful Not profuse bleeding Cervix closed Uterus= gestational age Fetal heart present
Define incomplete
Lower abdo pain Heavy vaginal bleeding with clots Shock +ve Tenderness Cervix open Products of conception may be present in cervix Fetal heart not present
define complete
Similar to incomplete history but followed by cessation of bleeding.
Uterus smaller than gestational age
Cervix closed
Fetal heart not present
define septic miscarriage
INfection following a miscarriage
define inevitable
similar to incomplete but not as far along in the process
What are the possible factors which can lead to a miscarriage
Abnormal conceptus - chromosomal abnormalities
Uterine abnormalities - bicornuate uterus, septae, marked ante/retrofexion, fibroids, incompetent cervix
Acquired disease - infection, malaria, influenza, hypertension, diabetes, thyroid
Toxins - durgs, smokig, alchohol, chemotherapy
Immunoogical - antiphospholipid syndrome, lupus
Endocrine- deficient cirpus luteum and progesterone
Trauma- amniocentesis, coitus, surgery
Foreign body - IUS/IUD
Psychological - stress/anxiety
What investigations should be done in a miscarriage
Hb Blood group and Rh group and save Pregnancy test Serium b-hcg - hydratiform mole ECS and blood culture- sepsis Ultrasound
How is a threatened miscarriage treated
Reassure and rest
Avoid coitus
Remove IUCD if present
Aspirin, heparin or prednisolone for APLS after 1st trimester
How is an inevitable miscarriage treated
Allow uterus to evacuate itself
Pain relief
Oxytoxic
Evacuation of uterus if needed
How is an incomplete miscarriage treated
Blood transfusion if shocked Oxytoxic Removal of POC Uterus evacuation Biannual compression
When would miscarriages be defined as ‘recurrent
Miscarriage on 3 or more consecutive occasions
What is the probablitity of a live birth with the nect pregnancy after 3 miscarriages
40-50 percent
What investigations should be done in people with recurrent miscarriages
Karyotyping both parents Glucose tolerance TSH T4 hysteroscopy HSG Laparoscopy Intra venous pyelogram
What is an ectopic pregnancy
Implantation of the conceptus outside the uterine cavity
What is the incidence of an ectopic pregnancy
1 in 300
recurrence rate is 10-15 percent
How many women who have an ectopic pregnancy will be subfertile/infertile
one third
What make it more likely to have an ectopic pregnancy
Chlamydial or gonoccocal salpingitis Previous tubak surgery Endometriosis IUCD previous tubal ligation IVF increased parental age
Clinical features of an ectopic pregnancy
Amenorrhoea
Lower abdo pain
Vaginal bleeding - three most common symptoms
Shoulder tip pain, shock, syncope, abdo guarding, cervical excitation, adnexal tenderness, bulky uterus
Where are the possible sites of an ectopic pregnancy
Isthmal Ampullary Interstitial Ovarian Peritoneal Cervical
What are the dangerous of an ectopic pregnancy
Intraperitoneal bleeding- potentially fatal
Tubal rupture
Tubal abortion
What investigations should be done in suspected ectopic pregancies
Urine b hcg
Serun b hcg
Transvaginal ultrasounf
diagnostic laparoscopy
What is the treatment of an ectopic pregnancy
Laparascopic salpingectomy or salpingotomy
IM methotrexate (or intratubal injection)
Conservative management
Laparotomy if ruptured
What is a hydratiform mole
Developmental anomaly of the trophoblast or placental in which there is a local or general vesicular change in the chorionic villi
What are the clinical features of a hydratiform mole
Amernorrhoea Vaginal bleeding Uterus larger than dates doughy uterus fetal heart negative hyperemesis Pre eclampsia
What types of moles are there
complete and incomplete/partial
complete have ahigher risk of becoming a choriocarcinoma
What is the difference between an complete an partial mole
Complete - one or two sperm fertilise and egg which has lost its DNA
Partial- one or two sperm fertilise an egg with DNA
Where are hydratiform moles more common
SE asia - about 1 in 150 - 1 in 500
In UK incidence is about 1 in 1000-2000
What investigations should be done in suspected hydratifrom moles
Urinary and serum B HCG
Ultrasound
CXR
What is seen on ultrasound in moles
snowstorm appearance
theca lutein ovarian cysts
How is a mole treated
Evacuation of uterus Urinary and serum b hcg and follow up Contraception to avoid pregnancy during follow up Hysterectomy if family complete persistant disease may require chemo
What can cause cervical incompetence
dilatation during top cone biopsy of cervix cervical amputation exposure to DES idiopathic in 25 percent
How can cervical incompetence be treated
Shirodhkar suture or Mcdonald suture
At 14 weeks
risk of ROM and infection
removed at 36 weeks of gestation or early labour - whichever is first
