Bleeding in Pregnancy Flashcards
What is the differential diagnosis for bleeding in early pregnancy?
Miscarriage Ectopic pregnancy Molar pregnancy Cervial lesions Unknown
Define miscarriage
Expulsion of the conceptus before week 24
List the different classifications of miscarriage
Threatened Inevitable Complete Incomplete Missed Septic (Recurrent)
What is meant by “threatened miscarriage”?
There is some vaginal bleeding but the cervix remains closed, and the pregnancy is still viable.
What is meant by “inevitable miscarriage?”. How does the presentation differ to that of a threatened miscarriage?
The pregnancy is still viable at this stage, however, the cervix has begun to dilate; this process is irreversible and means that there will be a miscarriage.
Presents with heavier bleeding and abdominal pain.
Describe a “complete miscarriage”
All of the uterine content has been expelled; the cervix is now closed and bleeding has stopped
Describe an “incomplete miscarriage”
Some of the uterine content has been expelled but some tissue remains; e.g. chorionic and/or placental tissue. The cervix is still open.
What risks are associated with an incomplete miscarriage?
Sepsis
Bleeding (could lead to hypovolaemia and shock)
What are the management options for a patient with an incomplete miscarriage?
Uterus must be evacuated;
Medical evacuation: prostaglandins
Surgical evacuation: Manual Vacuum Aspiration (MVA) or Evacuation of Retained Products of Conception (ERPC)
What is meant by a “missed miscarriage”? What would be seen on ultrasound?
The pregnancy is non-viable, but the cervix is still closed and the uterine content has not been expelled.
On USS: an empty gestational sac or foetal pole with no heartbeat.
Describe the management of a patient with a septic miscarriage.
Broad-spectrum antibiotics
Emergency evacuation of the uterus
Monitor for signs of sepsis and septic shock
List the main causes of spontaneous miscarriage
Abnormal conceptus (chromosomal, genetic or structural abnormality)
Uterine abnormality (congenital or due to fibroids)
Cervical incompetence
Maternal (e.g. increasing age, diabetes)
Unknown
What is meant by cervical incompetence?
Cervix begins to dilate before the pregnancy has reached term.
Give four risk factors for ectopic pregnancy
Pelvic inflammatory disease (e.g. due to Chlamydia)
Previous tubal surgery
Previous ectopic pregnancy
Assisted conception
What is an ectopic pregnancy?
The conceptus implants anywhere outside of the uterine cavity
Describe the difference in typical presentations of miscarriage vs ectopic pregnancy
Miscarriage tends to have heavier bleeding whereas in ectopic pregnancy the main symptom tends to be abdominal pain
Describe how B-hCG level can be used to assess whether a patient is likely to have an ectopic pregnancy
Take paired B-hCG samples 48 hours apart:
- normal pregnancy: level will double
- miscarriage: level will fall
- ectopic pregnancy: level will rise slightly
Describe how a patient with an ectopic pregnancy may present
Period of amenorrhoea (may or may not have a positive pregnancy test) May also have: - lower abdominal pain - vaginal bleeding - GI/urinary symptoms
Describe the management options for an ectopic pregnancy
Medical: methotrexate
Surgical: salpingectomy/salpingotomy
Conservative management
What is a molar pregnancy? How does it form?
Large chorionic villi with overgrowth of trophoblast cells.
Forms when two sperm enter and fertilise an empty ovum. (there are other causes but this is most common)
Explain how a molar pregnancy develops
Two sperm enter and fertilise one ovum.
- the conceptus has a normal number of chromosomes but two lots of methylated genes from Dad and none from Mum; there is an imbalace.
Mum’s methylated genes promote early baby growth, whereas Dad’s methylated genes promote trophoblast proliferation (placental growth)
Therefore, in molar pregnancy, trophoblasts overproliferate but no fetus forms.
What is the major (but rare) risk of molar pregnancy
Development of choriocarcinoma
How is a molar pregnancy managed?
If B-hCG returns to normal, no treatment is needed
If B-hCG stays high, treat with methotrexate (to evacuate the uterus)
Describe the differential diagnosis fo bleeding in late pregnancy
Local bleeding (from vulva, vagina or cervix) Blood dyscrasias Placenta previa Placental abruption Placenta accreta Uterine rupture Vasa previa
