Complications in the first 20 weeks Flashcards
What is a miscarriage?
Pregnancy loss that occurs before 20 weeks
Abortion
Both spontaneous and elective - before 20 weeks
Recurrent miscarriages
3 or more consecutive before 20 weeks
Causes of miscarriage
aneuploidy (missing/extra chromosones)
maternal conditions (viral infections, unstable diabetes)
uterine and cervical (weak cervix, fibroids, congenital abnormality of the uterus)
drug abuse (smoking, DV)
balanced translocation from partner (genetic)
obesity, leptin, stress, caffeine
age
Types of miscarriage
threatened (some bleeding)
inevitable
complete (products of conception expelled)
incomplete (products of conception partially expelled)
anembryonic (fetus dies or fails to develop but placental tissue continues to function)
missed (fetus dies but cervix closed)
How to diagnose
physical exam
labs
USS
obs
Management
rest
reassurance
surgical
medical
Care options
expectant
medical
surgical
Expectant
wait and see
effective
Medical
comprehensive history taking
confirm dates
USS for viability
speculum
informed consent
operative under GA
oral misoprostal 1200 ug divided by 4 doses over 24 hrs
combination of misoprostol and mifepristone is approved for medical termination of early intrauterine pregnancy in Australia and New Zealand. Mifepristone is administered as a single 200mg oral dose, followed by an oral dose of 800μg misoprostol 36–48 hours later.
Surgical
comprehensive history taking
confirm dates
USS for viability
speculum
informed consent
operative under GA
misoprostol 400ug S/L 2 hr prior to surgery
gemeprost PV 1mg
I.V Syntocinon reduce blood loss and to decrease the risk of uterine perforation by causing the uterus to contract and thicken.
Vacuum aspiration is preferred over sharp curettage in cases of incomplete miscarriage. Routine use of a metal curette after suction curettage is not required.
Incidental causes
Cervical carcinoma (1 in 6000 births). The most frequently diagnosed cancer in pregnancy. Is treatable if detected early. 80% of cases detected in pregnancy are diagnosed in the first or second trimester. Hence need for cervical smears. CIN is the precursor to invasive cancer of the cervix.
* Cervical pathology - ectropion/erosion, polyps.
* Varicosities of the cervix, vagina or vulva.
* Diagnostic error e.g. bleeding from the urinary tract or haemorrhoids.
* General maternal conditions – infections
* ‘Weakened’ cervix
Gestational trophoblastic disease (molar pregnancy)
term covering both the benign hydatidiform mole and choriocarcinoma which is malignant.
is the gross malformation of the trophoblast in which the chorionic villi are abnormal, they proliferate and become avascular.
how does molar pregnancy present?
villi up to 3cm in length = complete or partial moles
10 weeks by dark brown vaginal bleeding - may pass vesicular tissue
molar pregnancy - aetiology
age <20 and >40
environment
poor nutrition
previous 1:100 chance in subsequent
molar pregnancy incidence
rare
asian women 2.0 per 1000 pregnancies
caucasian 0.57-1.1 per 1000
can lead to cancer
diagnosis molar pregnancy
A positive sign of hydatidiform mole is vesicular shapes on U/S creating a ‘snowstorm’ appearance and elevated serum ßhCG levels.
Complete molar pregnancy
develops from abnormal fertilisation and abnormal development of the placental tissue.
Arises from an ‘empty egg’ which has lost its maternal genetic material. It shows total hydatidiform change with no evidence of an embryo or normal placental tissue. Proliferation of the trophoblast cells is marked. Complete moles are more likely to develop malignant change of the trophoblast cells = choriocarcinoma
Partial molar pregnancy
is associated with a fetus even if the only evidence is traces of a microscopic fetal circulation. The karyotype is abnormal and has duplicate paternal genetic material. Most common is triploidy 69XXX or XXY instead of 46 and is the result of fertilisation by more than one sperm. Partial moles are less likely to develop malignant change
signs and symptoms of molar pregnancy
bleedings
hyperemesis
uterine enlargement
absent FHR
early onset preeclampsia
signs of hyperthyroidism
Management
remove all trophoblast tissue
Women are advised to avoid hormonal family planning methods and use barrier contraception until ßhCG levels are within normal limits and not to conceive until levels have been normal for 6 months .
* Persistent ßhCG elevation = presence of choriocarcinoma and requires tertiary centre referral.
* Serial serum quantitative ßhCG every 1-2 weeks until 3 consecutive tests show normal levels, after which ßhCG levels should be determined at 3 month intervals for 6 months after the spontaneous return to normal
F/U every 8 weeks for twelve months with urine pregnancy tests due to the risk of persistent trophoblastic disease or choriocarcinoma (10% of cases)
* Treatment with chemotherapy in cases of myometrial invasion or evidence of trophoblastic metastases to the brain, liver or lungs.
* The need for chemotherapy following a complete mole is 15% and after a partial mole 0.5%
risks before evacuation (molar)
- haemorrhage
- trophoblastic invasion and perforation of the myometrium
- dissemination of possibly malignant cells
- Risks during evacuation:
- haemorrhage
- perforation by instruments
- dissemination of possibly malignant cells
- emergency hysterectomy
Ectopic pregnancy
pregnancy in which implantation and the products of conception develop outside the uterine cavity
the fallopian tube is 95% of cases
1-2% of pregnancies
Mortality 10-15% deaths related to haemorrhage
Ectopic (location)
Fertilisation is in the ampulla of the tube, the dilated end, furthest away from the uterus. The ampulla is also the most common site of ectopic implantation (90%) followed by the isthmus. Interstitial implantation is rare but dangerous because it ends in rupture of the uterine muscle with severe haemorrhage