Disorders Of Early Pregancy Flashcards
What is an incomplete miscarriage?
Some foetal parts have been passed but the os is usually open
What is a threatened miscarriage?
There is bleeding but the foetus is still alive, the uterus is the size expected from the dates and the os is closed.
Only 25% will go on to miscarry
What is a complete miscarriage?
All foetal tissue has been passed.
Bleeding has diminished, the uterus is no longer enlarged and the cervical os is closed
What is an inevitable miscarriage?
The bleeding is usually heavier
Although the foetus may still be alive, the cervical os is open.
Miscarriage is about to occur
What are the clinical features of miscarriage on history and examination?
History:
Vaginal bleeding - may be clots or tissue
Low abdominal pain
Examination
Uterine size and state of the cervical os should be examined, as these vary with the type of pregnancy
What investigations are indicated in suspected miscarriage?
Speculum examination- for state of cervical opening
Ultrasound scan - confirms location and size of gestational sac
Bloods- FBC and blood group
Serum b-hcg levels may be useful
How is miscarriage managed?
Counsel patient
Give Anti-D to Rhesus negative women
May require mechanical dilatation and curettage of the uterus for the evacuation of retained products of conception if the miscarriage is complete. This is done under anaesthetic
Or misoprostolol
Or spontaneous resolution waited for two weeks
What is the definition of recurrent miscarriage?
When three or more miscarriages occur in succession
This affects 1% of couples
The chance of having a further miscarriage is 40%, but having further investigations is indicated
What investigations are indicated in recurrent miscarriage?
Autoimmune screen, thrombophilia screen
Karyotyping of both parents
Pelvic ultrasound
What are the causes of recurrent miscarriage?
Autoimmune disease Chromosomal defects Poly cystic ovary syndrome Uterine abnormality Infection Obesity, smoking and higher maternal age are implicated
What is he most common cause of miscarriage?
Greater than 60% are due to isolated non-recurring chromosomal abnormalities
How common is spontaneous miscarriage?
15 percent of clinically recognised pregnancies
How common are ectopic pregnancies?
1% of pregnancies
What are the risk factors for ectopic pregnancy?
Maternal age Number of sexual partners Use of IUD PID After pelvic surgery
What are the clinical features of ectopic pregnancy?
Lower abdominal pain - colicky
Dark vaginal bleeding
Syncopal episodes and shoulder tip pain may be a result if intraperitoneal blood loss
On examination:
Tachycardia due to blood loss
Abdominal guarding/rebound tenderness
Cervical excitation
What investigations are indicated in suspected ectopic pregnancy?
Urine hcg (pregnancy test)
FBC and cross match
Ultrasound to detect intrauterine pregnancy- if not present, either ectopic or less than five weeks gestation
Serum hcg - repeat in 48 hours - If there is a change in concentration between 50% decline and 63% rise inclusive over 48 hours, suggestive of ectopic
Consider transvaginal ultrasound if uterus is empty
Consider laparoscopy if repeat hcg is above 600 and absence of intrauterine gestational sac on USS
What is the management of ectopic pregnancy?
Admit if symptomatic
IV access
Give anti d if Rhesus negative
Surgical:
Laparoscopy and remove affected tube (salpingostomy)
Medical:
Single dose methotrexate - if hcg is <3000, patient is clinically stable, ectopic is less than 3cm on ultrasound
May require repeat dose
What is gestational trophoblastic disease, and what are the different types?
Trophoblastic tissue (part of the blastocyst) invades the endometrium and proliferates, secreting hcg
Hydatiform mole: localised and non invasive proliferation
Invasive mole: proliferation has characteristics if malignancy
Choriocarcinoma: invasive mole that has metastasis
Complete mole: entirely paternal, when a sperm fertilises an empty ovum and undergoes mitosis
Partial mole: triploid, derived from two sperms and one egg
What are the clinical features of GTD?
Vaginal bleeding, may be heavy
Severe vomiting
Large uterus
Early pre-eclampsia and hyperthyroidism may occur
How is GTD investigated?
Post excision histology necessary for diagnosis
USS may show uterus with swollen villi
How is GTD managed?
Suction curettage
Serial blood:urine hcg taken for 6-24 months. if persistently high, this is suggestive of malignancy
Up to 29% will develop a persistent trophoblastic tumour
What is the medical management of ectopic pregnancy?
Single dose methotrexate
Indicated if:
Hcg is <3cm on ultrasound
Check hcg on days 4 and 7 post injection - if no 15% drop, give second dose
After methotrexate, avoid pregnancy for three months and abstain from intercourse until pregnancy is finished
When is urgent laparotomy indicated in suspected ectopic?
Haemodynamically unstable, with live, bleeding ectopic
Laparoscopy may be attempted instead but if very Ill, need to stop the bleeding
