Disorders of early pregnancy Flashcards
when is a heartbeat established with an early pregnancy
22 days
what is defined as a spontaneous miscarriage
fetus delivers or dies <24 weeks old
when does spontaneous miscarriage normally occur
<12 weeks
what is the cause of >60% of spontaneous miscarriages?
isolated chromosomal defects
how does a spontaneous miscarriage usually present
bleeding
pain
during a suspected spontaneous miscarriage, how does bHCG levels help inform diagnosis
in a viable pregnancy bHCG levels increase by >65%, whereas in a non-viable pregnancy they decrease >50%
anywhere inbetween suggests an ectopic
molar pregnancy will show >100,000 IU (dramatically raised)
what should happen if someone presents with spontaneous miscarriage symptoms + fever
swabs + Abx
what is useful in a spontaneous miscarriage of a non-viable foetus
IM ergometrine as it prevents bleeding by contracting the uterus
when should rhesus -ve women be given anti D in the context of a spontaneous miscarriage
if there has been bleeding >12 weeks or if medical/surgical treatment has been performed
what are the types of spontaneous miscarriage
threatened miscarriage inevitable miscarriage complete miscarriage incomplete miscarriage septic miscarriage missed miscarriage
what are features of threatened miscarriage
there is bleeding but the foetus is alive
cervical os is closed
uterus is of the expected size
what % of threatened miscarriages go on to miscarry
25%
what are the features of an inevitable miscarriage
heavy bleeding
foetus may still be alive
cervical os is open
what are the features of an incomplete miscarriage
some foetal parts have already passed
os is open
what are the features of a complete miscarriage
all foetal parts have been passed
bleeding has diminished
uterus is no longer enlarged
cervical os closed
what are features of septic miscarriage
contents of the uterus causing endometritis
offensive vaginal discharge
tender uterus
not necessarily feverish
what features make you think a septic miscarriage has caused a pelvic infection
peritonism
abdominal pain
what are the features of a missed miscarriage
foetus died in utero with no symptoms
not noticed until bleeding/USS
uterus smaller than expected
os is closed
how should you manage a non-viable intrauterine pregnancy
expectant management: watch and wait
medical management: vaginal/oral misoprostol
surgical: evacuation of retained products of conception , essentially vacuuming the non-viable pregnancy out under GA
what are complications of surgical management of a non-viable intrauterine pregnancy (ERPC)
Excessive vaginal bleeding may occur with expectant or medical management – may require surgical intervention (10-40%)
Infection (3%) - similar across all managements
Surgical management may remove some endometrium causing Asherman’s syndrome (excessive scarring in the uterus causing adhesions/the walls to stick to each other)
Surgical management may also perforate the uterus (<1%)
what are the success rates for incomplete miscarriages for each intervention
> 80% - expectant
>95% - surgical
what are the success rates for missed miscarriages for each intervention
expectant - 30-70%
medical - 40-90%
surgical - 95%
what qualifies as recurrent miscarriage
3 successive miscarriages
whats the prevalence of recurrent miscarriage
1%
is someone has had 3 successive miscarriages what is the risk of miscarriage for the 4th pregnancy
40%
what are causes of recurrent miscarriages
Antiphospholipid antibodies
Parental chromosomal defects
Anatomical defects
Infection
Hormonal Issues (PCOS, thyroid)
Obesity
Smoking
Excess Caffeine
Older maternal age
why does antiphospholipid syndrome cause miscarriages and what tends to be the treatment
thrombosis in uteroplacental circulation
asprin + LMWH
What are the statutory grounds for abortion in England
There is a risk to the physical or mental health of the woman if the pregnancy was continued
There is a risk of death to the pregnant women
The foetus is <24 weeks
Substantial risk of severe mental/physical abnormalities causing a handicap
when should rhesus -ve women receive anti-D in reference to planned abortions
within 72 hours
what gestation should surgical abortions be used
7-14 weeks gestation
how is a surgical abortion carried out
cervix is prepared with topical misoprostol and antibiotic prophylaxis is given
vacuum is used to evacuate foetus
what gestation should medical abortions be used at
<7 weeks, 12-24 weeks, but can be used whenever
how is a medical abortion carried out
mifeprostone + prostaglandin 36-48 hours later
what method for medical abortions tends to be used >22weeks gestation if there is a foetal abnormality present
feticide via injection of KCL into the foetal heart/umbilical vein
what are the complications of a surgical abortion
Haemorrhage - 1 in 1000
Infection – 10% (reduced by prophylactic antibiotics)
Uterine perforation
Cervical trauma
Failure (<5% surgical/medical require further intervention – <1% risk of total failure)
Preterm delivery
Associated with multiple surgical terminations
Unsafe abortion
whats the definition of an ectopic pregnancy
foetus implants outside the uterine cavity
where are the majority of ectopic pregnancies
fallopian tube
what is the major worry with ectopic pregnancy
rupture of the fallopian tubes, massive blood loss and death
what are some risk factors for ectopic pregnancy
assisted conception pelvic surgery PID previous ectopics smoking
how does an ectopic pregnancy present
Lower abdominal pain, starts colicky but becomes constant
Vaginal bleeding
Shoulder tip pain/syncopal episodes (intraperitoneal bleeding)
Amenorrhoea for 4-10 weeks previously
Rebound tenderness (peritonitis)
Cervical excitation (extremely painful cervix on bimanual examination)
Adexum tenderness
Uterus is smaller than expected
Cervical os closed
how should you investigate any ?ectopic pregnancy
Pregnancy test
USS – may not detect ectopic but absence of intrauterine pregnancy + +ve pregnancy test = high suspicion
Quantitative serum bHCG –
> 1000 IU/ml = viable intrauterine pregnancy
> 63% rise in 48 hours = early viable intrauterne pregnancy
Outside of these parameters suggests ectopic/non-viable pregnancy
Laparoscopy
what is the overall management for ectopic pregnancy
for all: IV access, cross match, anti-D if Rh-
medical: single dose of methotrexate
surgical: salpingostomy/salpingectomy
when is surgical management appropriate in ectopic pregnancy
Woman in severe pain
Adnexal mass >35mm
Visible foetal heart activity
BHCG >5000 IU/ml
when is medical management appropriate in ectopic pregnancy
Patient able to attend follow up
Has no significant pain
Adnexal mass <35mm
No foetal heart activity
No co-existing intrauterine pregnancy
what is correlated with success rate with medical management of an ectopic pregnancy
bHCG level
how often is a follow up dose required for medical management of ectopic pregnancy
15%
how often is surgical mangagement required in medical management of ectopic pregnancy
10%
what are complications of hyperemesis gravidarum
metabolic disturbance
malnutrition
dehydration
what gestational period is hyperemesis gravidarum mostly active for
first 14 weeks
what patient population is hyperemesis gravidarum more common in
multiparous women
what are predisposing conditions for hyperemesis gravidarum
UTI
molar pregnancy
multiple pregnancy
what is the treatment for hyperemesis gravidarum
IV hydration
Antiemetics (cyclizine 1st line)
Thiamine given (B12) to prevent neurologial complications
Steroids used in severe cases
