Complicated Pregnancy (APH, ectopic p. and miscarriage)

Question 1

Define a spontaneous misscarriage/abortion?

Answer 1

Termination/loss of pregnancy <24wks gestation with no evidence of life

Question 2

What type of spontaneous misccariage has occured if a patient presents <24wks with vaginal bleeding and the cervix is dilating?

Answer 2

Inevitable miscarriage

Question 3

Whats the difference between a complete or incomplete abortion?

Answer 3

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

Question 4

How do we confirm if a woman has had a complete abortion?

Answer 4

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

Question 5

Define a septic miscarriage?

Answer 5

When infection ascends into the uterus and throughout the pelvis following a miscarriage. Its most common if it was an incomplete abortion.

Question 6

Define a missed abortion?

Answer 6

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.

Question 7

List all the major causes of a miscarriage you can think of?

Answer 7

• 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

Question 8

What uterine abnormalities could cause a misscarriage?

Answer 8

A congenital abnormality

Fibroids (distortion of cavity)

Question 9

What causes cervical incompetence?

Answer 9

Trauma including past surgical procedures

Question 10

What maternal problems could cause a misscarriage?

Answer 10

• Low progesterone
• Diabetes
• SLE
• Thyroid disease
• Acute infections e.g. appendicitis

Question 11

How would we manage a threatened abortion?

Answer 11

Conservative management, best to try to get the foetus past 24wks so we can deliver and it will survive

Question 12

How would we manage an inevitable abortion?

Answer 12

At this point there’s no point trying to save the foetus. If the bleeding is heavy they may need evacuation of the uterus.

Question 13

How would we manage a missed misscarriage?

Answer 13

Several options:

• Conservative in the hope the uterus will self-evacuate
• Push the uterus with prostaglandins (MIsoprostol)
• Surgical Management of Misscarriage (SMM)

Question 14

How do we manage a septic misscarriage?

Answer 14

Antibiotics and evacuate the uterus of remaining POC

Question 15

Define an Antepartum Haemorrhage?

Answer 15

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.

Question 16

List the major causes of an APH?

Answer 16

• 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)

Question 17

In what women is Placenta Praevia a risk?

Answer 17

Most common in multiparous women, multiple pregnancies and previous C section

Question 18

How are the different types of Placenta Praevia classified?

Answer 18

Graded 1-4:

1. Placenta doesn’t touch internal cervical orifice
2. Placenta reaches internal Os
3. Placenta covers Os
4. Central placenta praevia (directly over Os)

Question 19

How does a case of placenta praevia present?

Answer 19

• 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

Question 20

How do we confirm a case of placenta praevia?

Answer 20

US! Don’t do vaginal exam till you’ve ruled it out with US as it could trigger a bigger bleed

Question 21

How do we manage a Placenta Praevia?

Answer 21

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.

Question 22

Define placental Abruption?

Answer 22

The placenta seperates from the wall early, usually with a retroplacental clot forming

Question 23

What are the types of placental abruption?

Answer 23

• 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

Question 24

How does a Placental Abruption present?

Answer 24

Severe abdo pain

Vaginal bleeding

May increase uterine tone andhave contractions

Question 25

How extra can a Concealed placental abruption present?

Answer 25

Blood can't escape through os so builds up --\> Uterine volume increases --\> Fundal height excessive Couvelaire Uterus

Question 26

What are the risk factors for a placenta abruption?

Answer 26

* Pre-eclampsia/ chronic hypertension * Multiple pregnancy * Polyhydramnios (XS amniotic fluid) * Smoking, increasing age, parity * Previous abruption * Cocaine use

Question 27

Placenta Abruption can be very dangerous, especially if the bleed is concealed. What complications can it trigger? (Think big bleed and clot)

Answer 27

* 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’

Question 28

List some local genital tract lesions that could be the source of APH?

Answer 28

* Cervical polyps * Cervical cancer * Vaginal thrush

Question 29

So how do we manage an APH?

Answer 29

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

Question 30

What is placenta praaevia?

Answer 30

Placenta is attached to the lower segment of the uterine segment

Question 31

What is Couvelaire Uterus?

Answer 31

Bruising in myometrium

Question 32

What is vasa Praevia?

Answer 32

Small rupture to fetal vessels

Question 33

What are the different categories of spontaneous miscarriage?

Answer 33

* Threatened * Inevitable * Incomplete * Complete * Septic * Missed

Question 34

Defined a threated miscarriage?

Answer 34

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

Question 35

What is an ectopic pregnancy?

Answer 35

A pregnancy which is implanted outside of the uterine cavity.

Question 36

What are the risk factors for ectopic pregnancy?

Answer 36

* Pelvic inflammatory disease * Previous tubal surgery * Previous ectopic * Assisted conception

Question 37

Describe the presentation of an ectopic pregnancy

Answer 37

Period of ammenorhoea (with +ve urine pregnancy test) +/\_ Vaginal bleeding +/\_ Pain abdomen +/\_ GI or urinary symptoms

Question 38

How are ectopic pregnancies diagnosed?

Answer 38

* 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

Question 39

How are ectopic pregnancies managed?

Answer 39

* Medical – Methotrexate * Surgical – mostly laparosciopical: Salpingectomy, Salpingotomy for few indications * Conservative

Question 40

How are Post-Partum Haemorrhages (PPH) managed?

Answer 40

* Medical management – oxytocin, ergometrine, carbaprost, tranexemic acid * Balloon tamponade * Surgical – B Lynch suture, ligation of uterine, iliac vessels, hysterectomy