Disorders of early pregnancy Flashcards
What is a threatened miscarriage?
There is PV bleeding or pain, but the cervical os is closed (25% will miscarry)
What is an inevitable miscarriage?
Heavy PV bleeding, cervical os is open
What is an incomplete miscarriage?
Heavy bleeding and clots with some foetal tissue passing, however the cervical os is still open and there is still tissue in the uterus
What is a complete miscarriage?
All foetal tissue has passed, cervical os has closed, cessation of bleeding
What is septic miscarriage?
Uterine contents are infected resulting in endometritis. Offensive vaginal loss and uterus is tender
What is a missed miscarriage?
Foetus has died in utero but not recognised till bleeding or ultrasound. Os is closed.
What is the management of miscarriage?
Expectant management for 7-14 days
Offer medical management if bleeding/pain has not subsided by this point:
• Misoprostol (Vaginal progestogen)
• Pain relief and anti-emetics
If medical management fails, can conduct manual vacuum aspiration under local anaesthetic
What is the definition of recurrent miscarriages? What are the risk factors for miscarriage?
Suffering from 3 or more miscarriages
Risk factors: • Maternal age (>35 y/o) • Previous miscarriage • Obesity • Environmental factors (smoking, alcohol)
What are causes of recurrent miscarriages?
Antiphospholipid syndrome
SLE
Genetic disorders
• Typically associated with first trimester losses
Anatomical causes: • Reduced uterine volume • Reduced vascular supply to uterus (Treated with aspirin and LMWH) • Fibroids • Intrauterine adhesions • Incompetent cervix
Endocrine causes:
• Diabetes
• Thyroid dysfunction
• Luteal phase insufficiency
Infections (Toxoplasma, Chlamydia, Trichomonas, Gonorrhoea)
Treat cause
If no cause, supportive care & counselling
What are the methods of termination of pregnancy?
<9 weeks gestation = Mifepristone (Anti-progestogen) followed by Misoprostol (prostaglandin to stimulate contraction) 48 hours later. Though can be used at any point (most effective before 9 weeks
<13 weeks gestation = Surgical dilation and suction of uterine contents
> 15 weeks gestation = Surgical dilation and evacuation of uterine contents or late medical abortion
What are the clinical features of ectopic pregnancy?
Lower abdominal pain (Colicky then constant)
Dark vaginal bleeding
Amenorrhoea for 4-10 weeks (Patient may interpret vaginal bleed as period)
Syncopal episodes and shoulder tip pain suggest intraperitoneal blood loss
On examination there may be cervical excitation (movement of uterus causes pain), tender adnexae (though you should not palpate on bimanual), uterus is small for gestation
What are the investigations for ectopic pregnancy?
Pregnancy test - Always positive
Transvaginal ultrasound - Looks for intrauterine pregnancy, if absent, could be too early (<5 weeks gestation), there could’ve been a complete miscarriage, or there is an ectopic
Quantitative serum HCG - Useful if uterus is empty.
• >1000 IU/mL = Intrauterine pregnancy
• <1000 IU/mL but rising by more than 63% in 2 days = Early intrauterine pregnancy
• <1000 IU/mL but declining/slow rising = Ectopic
What is the immediate management of ectopic pregnancy?
When symptoms present, patient should be admitted, and IV access gained to test Rhesus status (if negative, give anti-D)
If haemodynamically unstable - Resuscitation and surgery (salpingectomy via laparotomy) is required
What is the criteria for expectant management of ectopic pregnancy?
<30 mm size <200 IU/mL serum HCG No symptoms No rupture No foetal heartbeat
Involves watching the patient closely for 48 hours and if HCG starts to rise, then immediately intervene
What is the criteria for medical management of ectopic pregnancy?
<35 mm size <1500 IU/mL serum HCG No pain No rupture No foetal heartbeat
Treatment involves giving methotrexate, but only possible if patient can attend follow-up
