Case 2 - Early Pregnancy Loss Flashcards
Take a History
Explain to the women what examination and investigations you wish to carry out
Outline a differential diagnosis and treatment plan
-info on OSCE notes
Causes of miscarriage
-LOOK AT the chart she gave us
-chromosomal anomalies (trisomies, monosomy)
-Structural anomalies (NTD)
maternal factors - uterine abnormalities
infection
poorly controlled medical disorders (DM, thyroid)
unexplained
- What are the causes of bleeding during early pregnancy?
Threatened, inevitable, incomplete, complete, missed miscarriage
Ectopic pregnancy
molar pregnancy
- What are the causes of bleeding during early pregnancy?
-normal pregnancy
- Cervical inflammation, common cause of post-coital spotting
- Uterine fibroids
- Polyps
- Cervical or vaginal infection.
- Inherited disorders of haemostasis (e.g. Von Willebrand’s Disease)
- Trauma (nb screen for domestic violence)
Threatened, inevitable, incomplete, complete, missed miscarriage
Ectopic pregnancy
molar pregnancy
When assessing a woman with early pregnancy pain and / or bleeding, what important features of
the history and examination would help you in reaching a differential diagnosis?
-Look at OSCE notes
History Vaginal bleeding Pelvic pain tissue passed pregnancy symptoms
Examination
Internal cervical os open/closed
Uterine size compared with dates
Unilateral adnexal tenderness
- Why is a speculum examination important?
To determine if internal cervix is open or closed
- What investigations will be indicated in different clinical scenarios?
- US - uterine size, presence of products of conception in utero
- BHCG
What is cervical shock?
Cervical Shock: (rare) low BP and HR, ruptured ectopic pregnancy-massive
haemorrhage with weak pulse and tachycardia. Cervical shock occurs when a miscarriage is occurring and a clot or pregnancy tissue gets stuck in transit in the cervix, causing a profound vagal response of hypotension and bradycardia. Treatment is required immediately by doing a speculum and removing the POC from the cervical os)
- What initial steps will you take in assessment and resuscitation of an acutely unwell woman who
presents with pain and/or bleeding in early pregnancy?
- Perform ABC’s with a few modifications for pregnancy
- Obtain IV access
- Give O2
- Continuous monitoring
- Give IV fluids.
- Request urgent bloods including group and hold. Transfuse blood while finding
cause of bleeding and treating it.
- What are the treatment options for management of a miscarriage?
- Conservative - no treatment; 65-80% will pass within 2-6 weeks.
Advantages: considered “natural” – no complications of medical and surgical management.
Disadvantages: woman goes home, is not monitored for bleed or infection. - Medical – give misprostol, 95% of missed miscarriages will complete within a few days.
- Surgical – vacuum aspiration – instant, woman doesn’t go home unmonitored, provides rapid closure.
Risks of surgical intervention (future problems getting pregnant):
Damage to cervix causing cervical incompetence.
Rupture of uterus.
Scarring of uterus.
- What specific points for their ongoing and future care will you discuss with a woman who has an
early pregnancy loss?
Grief and loss after miscarriage is often more extensive and intense than one may expect. Research indicates that many couples who have had a miscarriage experience grief responses similar in duration and intensity to those parents who have lost a new baby. Common emotions couples experience may include fear (particularly as the miscarriage begins), anger and a sense of unfairness, disappointment, guilt and then sadness and grief. Mothers commonly blame themselves and feel guilty about the loss of their baby, even though most miscarriages are not preventable. For these reasons, following a miscarriage all women should have access to support, follow-up and formal counselling when necessary.
Grief Counselling and Support Services
Miscarriage Support Auckland Inc.
Sands New Zealand
SIDS New Zealand 24 hour support line 0800 164 455
SIDS New Zealand
Patients should also be advised that there is no evidence to support a couple
delaying attempts to conceive following a miscarriage. They should be advised of lifestyle risk factors, such as alcohol consumption, smoking and elicit drug use.
- What are the treatment options for management of an ectopic pregnancy?
Grief and loss after miscarriage is often more extensive and intense than one may expect. Research indicates that many couples who have had a miscarriage experience grief responses similar in duration and intensity to those parents who have lost a new baby. Common emotions couples experience may include fear (particularly as the miscarriage begins), anger and a sense of unfairness, disappointment, guilt and then sadness and grief. Mothers commonly blame themselves and feel guilty about the loss of their baby, even though most miscarriages are not preventable. For these reasons, following a miscarriage all women should have access to support, follow-up and formal counselling when necessary.
Grief Counselling and Support Services
Miscarriage Support Auckland Inc.
Sands New Zealand
SIDS New Zealand 24 hour support line 0800 164 455
SIDS New Zealand
Patients should also be advised that there is no evidence to support a couple
delaying attempts to conceive following a miscarriage. They should be advised of lifestyle risk factors, such as alcohol consumption, smoking and elicit drug use.
- What specific points for their ongoing and future care will you discuss with a woman who has had
an ectopic pregnancy?
Advice: In most cases it is recommended that women wait for at least two full menstrual cycles before trying for another pregnancy, to allow time for fallopian tube to recovery. If treated with methotrexate, recommended to wait at least three months. Chances of having a successful pregnancy will depend on the underlying health of your fallopian tubes. In general, 65% of women achieve a successful pregnancy 18 months after having an ectopic pregnancy. IVF can be an option if unable to conceive naturally.
- What is recurrent miscarriage? What is the main treatable cause of recurrent miscarriage?
Definition: loss of three or more consecutive pregnancies. Affects 1% of women. Associated with chromosomal abnormality, congenital uterine abnormality, cervical incompetence, infection, inadequate progesterone secretion in luteal phase, PCOS, auto-immune disease (anti phospholipid syndrome).
- What is a molar pregnancy? What are the principles of management and follow up?
- non-viable fertilised egg implants in the uterus. cell mass grows and develops swollen chorionic villi which resemble a bunch of grapes
- Complete - an egg with no DNA fertlizine by sperm, sperm grows on its own. Partial - egg is fertilized by two sperm. placenta becomes molar growth and has severe defects.
Risk factors - heavy bleeding, on-going gestational trophoblastic disease and rarely choriocarcinoma. Age (risk for complete molar pregnancy steadily increases after age 35), history of molar pregnancy, especially two or more, history of miscarriage, diet low in carotene.
Management: evacuation of uterus by suction curettage (risk of heavy bleeding). Follow up required, preferably at specialist clinic, with serum BhCG measured every 1-2 weeks until non-detectable, then monthly for 6 months. ANTI D for all Rh-negative women.
Advice: Outlook for future pregnancy is good, with repeated molar pregnancy only 1-2%. Avoid pregnancy for full duration of follow up and up to 1 year, contraception should be used. Persistant disease/evidence of cancer- consider chemotherapy.
