Disorders of early pregnancy 2 Flashcards
What are the statutory grounds for termination of pregnancy in England?
The continuance of pregnancy would involve risk to the life of the pregnancy woman greater than if the pregnancy were terminated
The termination is necessary to prevent grave permanent injury to the physical or mental health of the woman
The pregnancy has not exceeded its 24th week
The pregnancy would involve risk greater than if the pregnancy were terminated, of injury to the physical or mental health of any existing children of the family of the pregnant woman
There is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped
What needs to be given before the management for abortion?
- Rhesus –ve women should receive anti-D within 72hrs of TOP
* Contraception should be discussed at the initial consultation- screened for STIs
What are the surgical methods for abortion?
suction curettage is used between 7 and 12-14 weeks
before 7 weeks failure rates are higher than with medical abortion
>14 weeks, medical methods are usually employed, although surgical abortion by dilation and evacuation is safe and effective
the cervix is ‘prepared’ with preoperative vaginal misoprostol and antibiotic prophylaxis given
What are the medical methods for abortion?
anti-progesterone (mifepristone) plus progstagladin 36-48hrs later is the most effective method of abortion at <7 weeks
can be used at any gestation as an alternative to surgical
it is usual and most effective method for mid-trimester abortion (13-24 weeks)
from 22 weeks, feticide is performed first to prevent live birth using KCl into umbilical vein or foetal heart
such late termination are usually only performed where a foetal abnormally is present
What are the complications of a therapeutic abortion?
o Haemorrahge- 1 in 1000 with greater risk in later gestations
o Infection- up to 10% of cases, reduced by screening and prophylactic antibiotics
o Uterine perforation-1-4 in 1000 surgical abortions
o Cervical trauma- at the time of surgical abortion
o Failure- <5% of surgical and medical abortions required further intervention, <1% fail to end the pregnancy
o Preterm delivery-associated with multiple surgical terminations
o Unsafe abortion- 50% worldwide with 98% of these in developing countries
What is an ectopic pregnancy?
when the embryo implants outsides the uterine cavity
occurs in 1 in 60-100 pregnancies
mortality rate is 16.9/100000 estimated ectopic pregnancies
more common with advanced maternal age and lower socioeconomic class
What occurs with an ectopic pregnancy?
• The thin walled tube is unable to sustain trophoblastic invasion-it bleeds into lumen and may rupture,
when intraperitoneal blood loss can be catastrophic
• Ectopic can be naturally aborted either within the tube or extruded through the fimbrial ends
What are the risk factors for an ectopic?
PID from STI o Assisted conception o Pelvic surgery- particularly tubal o Previous ectopics o Smoking
How does an ectopic pregnancy present?
o Lower abdominal pain- colicky pain, then constant o Light, dark vaginal bleeding o Syncopal episodes and shoulder tip pain- intraperitoneal bleeding o Amenorrhoea for 4-10 weeks previously o Rebound tenderness o Cervical excitation o Adexum tenderness o Uterus is smaller than expected o Cervical os closed
What are the investigations for an ectopic pregnancy?
Pregnancy test (positive) USS- may not visualise ectopic, but will detect lack of intrauterine pregnancy, also free fluid in the adnexae o Quantitative serum hCG- if >1000IU/ml then an intrauterine pregnancy will be visible on transvaginal USS- if the level is lower but rises >63% in 48hrs it is a early viable intrauterine pregnancy, declining or slowing levels suggest an ectopic or non-viable intrauterine pregnancy Laparoscopy- most reliable but very invasive
What is the management for an ectopic pregnancy?
• Where symptoms are present, the patient should be admitted
IV access and blood cross-matched
anti- D is given if the patient is Rhesus –ve
What is the surgical management for an ectopic pregnancy?
appropriate if women in significant pain, adnexal mass >35mm, visible foetal heart activity or a serum hCG level >5000 IU/ml
laparoscopy is standard and preferable to laparotomy because recovery is faster and subsequent fertility rates are equivalent or better
the ectopic is either removed from the tube (salpingostomy) or the whole tube including the ectopic is remove (salpingectomy)
What is the medical management for an ectopic?
appropriate if the patient is able to return for follow-up, has no significant pain, has an adnexal mass <35mm with no foetal heart activity, plus no coexisting intrauterine pregnancy
the lower
the hCG, then the higher the success rate
systemic single-dose methotrexate can be used without recourse to laparoscopy
hCG levels measure to confirm removal, but second dose (15%) or surgery (10%) may be required
What is hyperemesis gravid arum?
nausea and vomiting in early pregnancy are so severe as to cause severe dehydration, weight loss and electrolyte disturbance- occurs in only 1 in 750 women
• Seldom persists beyond 14 weeks and is more common in multiparous women
• Predisposing conditions include urinary infection and multiple or molar pregnancy
• IV rehydration is given- anti-emetics (metoclopramide, cyclizine or ondansetron) and thiamine to prevent neurological complications of vitamin depletion- steroids have been used in severe cases
What is gestational trophoblastic disease?
• Trophoblastic tissue proliferates in a more aggressive way than normal- hCG is usually secreted in excess, proliferation can be localised and non-invasive (hydatidiform mole) and is considered a premalignant condition
