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m4 obgyn > Bleeding in early pregnancy: Miscarriage > Flashcards

Bleeding in early pregnancy: Miscarriage Flashcards

1
Q

Bleeding in early pregnancy

A
  • 30% of mothers p/w bleeding in early pregnancy
  • Women in reproductive age group with abnormal vaginal bleeding: Think of pregnancy!!!
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2
Q

Causes of bleeding in 1st trimester

A
  1. Intrauterine pregnancies
    - Blighted ovum
    - Threatened miscarriage
    - Inevitable miscarriage
    - Incomplete miscarriage
    - Complete miscarriage
    - Missed miscarriage
    - Trophoblastic miscarriage: molar pregnancy, partial mole
  2. Ectopic pregnancies
  3. Non-pregnancy causes
    - Cervical polyp, cancer, ectropion
    - Infection
    - Implantation bleeding
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3
Q

What causes miscarriage?

A

Fetal causes
- Chromosomal anomalies account for 80% of spontaneous miscarriages due to aberrations in maternal gametogenesis
- Trisomy 13, 18, 21, Turner’s
- Infections: TORCHes

Maternal causes
- Poorly controlled DM / thyroid disease
- SLE / APS
- Renal disease
- Excessive alcohol/caffeine
- Uterine abnormality

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4
Q

Patient pregnancy test positive with BLEEDING and NO PAIN differentials

A
  1. Threatened miscarriage
  2. Missed miscarriage
  3. Inevitable miscarriage
  4. Molar pregnancy (next chapter)
  5. Ectopic pregnancy (next chapter)
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5
Q

Features of threatened miscarriage

A

Small amount of vaginal bleeding
+/- Abdominal pain
Pregnancy symptoms present

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6
Q

Pelvic examination of threatened miscarriage

A

Cervical os CLOSED
Uterus size expected to date

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7
Q

Ultrasound findings of threatened miscarriage

A

Fetus with CRL corresponding to dates
Fetal heart present

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8
Q

Management of threatened miscarriage

A

Ultrasound to check viability of intrauterine pregnancy:
- Fetus with CRL corresponding to dates
- Fetal heart present
Reassure, bed rest
Investigate blood group +/- Anti-D
Oral/IV progesterone (to stabilise)
Repeat scan in 1-2 weeks to determine is fetus is alive

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9
Q

Features of missed miscarriage

A

Fetus fails to develop and dies in utero:
Vaginal bleeding - Nil or staining
NIL abdominal pain
NIL pregnancy symptoms

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10
Q

Pelvic examination of missed miscarriage

A

Cervical os CLOSED
Uterus size smaller than expected

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11
Q

Ultrasound findings of missed miscarriage

A
  • Non-viable Intrauterine fetus
  • CRL > 7mm but NO fetal heart
  • Gestational sac > 2.5cm but NO fetal pole
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12
Q

Management of missed miscarriage

A

Ultrasound to check viability of intrauterine pregnancy
- Non-viable Intrauterine fetus
- CRL > 7mm but NO fetal heart
- Gestational sac > 2.5cm but NO fetal pole
Investigate blood group +/- Anti-D
Misoprostol (vaginal or oral) or cervagerm pessaries
Evacuation of uterus

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13
Q

Features of inevitable miscarriage

A

Large amount of vaginal bleed
Can lead to:
- Spontaneous complete miscarriage OR
- Incomplete miscarriage OR
- Viable pregnancy (rare since os open)

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14
Q

Pelvic examination of inevitable miscarriage

A

Cervical os OPEN
*regardless of state and viability of fetus

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15
Q

Ultrasound findings of inevitable miscarriage

A

Fetus with CRL corresponding to dates
Fetal heart present

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16
Q

Management of inevitable miscarriage

A

Ultrasound to check for viability
Misoprostol (prostaglandin) to hasten miscarriage
Send products of conception for histology -> partial mole

17
Q

Patient pregnancy test positive with bleeding, cramps, passage of blood and possibility some tissue differentials

A
  1. Incomplete miscarriage
  2. Complete miscarriage
  3. Septic miscarriage
  4. Ectopic pregnancy
18
Q

Features of incomplete miscarriage

A

Large amount of vaginal bleed
Abdominal pain
Vasovagal syncope (if POC @ cervical os)
Other sx - dizziness, hypotensive, tachycardic, pale

19
Q

Pelvic examination of incomplete miscarriage

A

Cervical os OPEN
POC seen at cervical os, genital tract
Uterus smaller than expected size

20
Q

Ultrasound finding of incomplete miscarriage

A

Thick endometrium suggestive of retained products of conception

21
Q

Management of incomplete miscarriage

A

Haemodynamically unstable patient:
Secure ABCs
Remove POC from cervical os using sponge forceps
Blood tests - FBC, GXM
Investigate blood group +/- Anti-D
Evacuation of uterus
- Use uterotonic agents during surgery
If infected POC: Abx cover

22
Q

Features of complete miscarriage

A

Small amount of vaginal bleed
+/- abdominal pain
(bleeding and cramps decrease)
NIL pregnancy symptoms

23
Q

Pelvic examination of complete miscarriage

A

Cervical os CLOSE
Uterus is smaller than expected

24
Q

Ultrasound findings of complete miscarriage

A

Empty uterine cavity
Thin endometrium
No adnexal masses

25
Q

Management of complete miscarriage

A

Ultrasound to check for viability
No treatment required
Follow up in 1-2 weeks to ensure bleeding has stopped

26
Q

Features of septic miscarriage

A

Vaginal bleeding
Abdominal pain
Prior instrumentation of uterus
Fever

27
Q

Pelvic examination of septic miscarriage

A

Cervix os OPEN
Purulent vaginal discharge
Cervical motion tenderness
Uterus smaller than expected
Adnexal tenderness

28
Q

Ultrasound findings of septic miscarriage

A

Non-viable intrauterine pregnancy
Thick endometrium suggestive of retained products of conception

29
Q

Management of septic miscarriage

A

Ultrasound to check for viability
Investigate blood group +/- Anti-D
IV Abx
Evacuation of uterus

30
Q

Differentials for CLOSED cervical os

A

Threatened miscarriage
Missed miscarriage
Complete miscarriage

31
Q

Differentials for OPEN cervical os

A

Inevitable miscarriage
Incomplete miscarriage
Septic miscarriage

32
Q

Differentials for uterus of expected size

A

Threatened miscarriage
Inevitable miscarriage

33
Q

Differentials for uterus smaller than expected size

A

Missing miscarriage
Incomplete miscarriage
Complete miscarriage
Septic miscarriage

34
Q

Implantation bleeding

A
  • Occurs in 1st trimester during implantation
  • When the fertilized egg embeds to the uterine lining, light bleeding/ spotting can occur
  • Cannot differentiate it from threatened miscarriage
  • Diagnosis of exclusion

m4 obgyn (37 decks)

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