Complicated Pregnancy (APH, ectopic p. and miscarriage) Flashcards
Define a spontaneous misscarriage/abortion?
Termination/loss of pregnancy <24wks gestation with no evidence of life
What type of spontaneous misccariage has occured if a patient presents <24wks with vaginal bleeding and the cervix is dilating?
Inevitable miscarriage
Whats the difference between a complete or incomplete abortion?
Complete: all the products of conception have been expelled, the cervix closed and bleeding stopped.
Incomplete: the POC are still partly inside, cervix open and bleeding ongoing
How do we confirm if a woman has had a complete abortion?
We need to either see the POC and confirm them to be that.
Or have a previous scan that confirms there was a viable pregnancy before
Define a septic miscarriage?
When infection ascends into the uterus and throughout the pelvis following a miscarriage. Its most common if it was an incomplete abortion.
Define a missed abortion?
When the foetus has died but the uterus hasn’t attempted to expel the POC. It can appear on US like a gestational sac lacking a foetus or a foetal pole without a developed heart.
List all the major causes of a miscarriage you can think of?
- Abnormal conceptus (problems with the foetus, mainly chromosomal)
- Uterine abnormality (problems with the uterus)
- I.e. fibroids
- Cervical Incompetence (problems with cervix)
- Maternal conditions (problems with the mother)
- Increase age, diabetes, hormone imbalance
What uterine abnormalities could cause a misscarriage?
A congenital abnormality
Fibroids (distortion of cavity)
What causes cervical incompetence?
Trauma including past surgical procedures
What maternal problems could cause a misscarriage?
- Low progesterone
- Diabetes
- SLE
- Thyroid disease
- Acute infections e.g. appendicitis
How would we manage a threatened abortion?
Conservative management, best to try to get the foetus past 24wks so we can deliver and it will survive
How would we manage an inevitable abortion?
At this point there’s no point trying to save the foetus. If the bleeding is heavy they may need evacuation of the uterus.
How would we manage a missed misscarriage?
Several options:
- Conservative in the hope the uterus will self-evacuate
- Push the uterus with prostaglandins (MIsoprostol)
- Surgical Management of Misscarriage (SMM)
How do we manage a septic misscarriage?
Antibiotics and evacuate the uterus of remaining POC
Define an Antepartum Haemorrhage?
Bleeding from genital tract >24wks but before delivery
Contrast to a miscarriage which is used for bleeds <24wks, this is because 24wks is when the foetus is considered viable.
List the major causes of an APH?
- Placenta praevia - placenta attached to lower segment of uterus
- Placental abruption - haemorrhage due to premature separation of placenta
- Local lesion of genital tract
- Idiopathic
- Vasa praevia (very rare)
In what women is Placenta Praevia a risk?
Most common in multiparous women, multiple pregnancies and previous C section
How are the different types of Placenta Praevia classified?
Graded 1-4:
- Placenta doesn’t touch internal cervical orifice
- Placenta reaches internal Os
- Placenta covers Os
- Central placenta praevia (directly over Os)
How does a case of placenta praevia present?
- Painless PV bleeding >24wks -
- Malpresentation of uterus
- Soft, non-tender uterus
- Often they present because we spot malpresentation on exam, send for an US and discover placenta praevia as the source of the bad alignment
How do we confirm a case of placenta praevia?
US! Don’t do vaginal exam till you’ve ruled it out with US as it could trigger a bigger bleed
How do we manage a Placenta Praevia?
If possible be conservative e.g. blood transfusions etc to get the baby to term then deliver by C-section (but watch for PPH). Either way you can’t deliver vaginally.
Define placental Abruption?
The placenta seperates from the wall early, usually with a retroplacental clot forming
What are the types of placental abruption?
- Revealed - blood can escape through Os
- Concealed - blood trapped between placenta/uterine wall
- Blood can penetrate uterine wall and uterus appears bruised –> Couvelaire uterus)
- Mixed
How does a Placental Abruption present?
Severe abdo pain
Vaginal bleeding
May increase uterine tone andhave contractions
How extra can a Concealed placental abruption present?
Blood can’t escape through os so builds up –> Uterine volume increases –> Fundal height excessive Couvelaire Uterus
What are the risk factors for a placenta abruption?
- Pre-eclampsia/ chronic hypertension
- Multiple pregnancy
- Polyhydramnios (XS amniotic fluid)
- Smoking, increasing age, parity
- Previous abruption
- Cocaine use
Placenta Abruption can be very dangerous, especially if the bleed is concealed. What complications can it trigger? (Think big bleed and clot)
- Maternal shock, collapse (may be disproportionate to the amount of bleeding seen)
- Fetal death
- Maternal Disseminated Intravascular Coagulation (DIC), renal failure
- Postpartum haemorrhage - ‘couvelaire uterus’
List some local genital tract lesions that could be the source of APH?
- Cervical polyps
- Cervical cancer
- Vaginal thrush
So how do we manage an APH?
It varies based on:
- Amount of bleeding
- Maternal/foetal condition
- Gestation
- Expectant treatment
- Conservative e.g. blood transfusions
- Attempt a vaginal delivery
- Emergency C-sections
What is placenta praaevia?
Placenta is attached to the lower segment of the uterine segment
What is Couvelaire Uterus?
Bruising in myometrium
What is vasa Praevia?
Small rupture to fetal vessels
What are the different categories of spontaneous miscarriage?
- Threatened
- Inevitable
- Incomplete
- Complete
- Septic
- Missed
Defined a threated miscarriage?
Bleeding from gravid uterus before 24 weeks gestation when there is a viable fetus and no evidence of cervical dilatation
- Vaginal bleeding +/- pain
- Viable pregnancy
- Closed cervix
What is an ectopic pregnancy?
A pregnancy which is implanted outside of the uterine cavity.
What are the risk factors for ectopic pregnancy?
- Pelvic inflammatory disease
- Previous tubal surgery
- Previous ectopic
- Assisted conception
Describe the presentation of an ectopic pregnancy
Period of ammenorhoea (with +ve urine pregnancy test)
+/_ Vaginal bleeding
+/_ Pain abdomen
+/_ GI or urinary symptoms
How are ectopic pregnancies diagnosed?
- USS – no intrauterine gestational sac, may see adnexal mass, fluid in Pouch of Douglas
- Serum BHCG levels – may need to serially track levels over 48hr intervals - if a normal early intrauterine pregnancy HCG levels will increase by at least 66%ish
- Serum Progesterone levels – with viable IU pregnancy high levels > 25ng/ml
How are ectopic pregnancies managed?
- Medical – Methotrexate
- Surgical – mostly laparosciopical: Salpingectomy, Salpingotomy for few indications
- Conservative
How are Post-Partum Haemorrhages (PPH) managed?
- Medical management – oxytocin, ergometrine, carbaprost, tranexemic acid
- Balloon tamponade
- Surgical – B Lynch suture, ligation of uterine, iliac vessels, hysterectomy
