Early pregnancy Flashcards
What is an ectopic pregnancy?
pregnancy implanted outside the uterus, most common site is a fallopian tube. can also implant in the entrance to the fallopian tube (cornual region), ovary, cervix or abdomen.
risk factors for ectopic pregnancy
Previous ectopic pregnancy Previous pelvic inflammatory disease Previous surgery to the fallopian tubes Intrauterine devices (coils) Older age Smoking
presentation of ectopic pregnancy
6-8 weeks gestation low threshold missed period constant lower abdominal pain in r/l iliac fossa vaginal bleeding lower abdominal or pelvic tenderness cervical motion tenderness
dizzy/syncope (blood loss)
shoulder tip pain (peritonitis)
investigation for ectopic prengnacy
beta HCG
transvaginal ultrasound to diagnose miscarriage
- gestational sac containing yolk sac / fetal pole
- non specific mas
- empty gestatoinal sac ‘blob sign’ ‘bagel sign’ ‘tubal ring sign’
features indicating ectopic pregnancy:
Features that may also indicate an ectopic pregnancy are:
An empty uterus
Fluid in the uterus, which may be mistaken as a gestational sac (“pseudogestational sac”)
PUL
pregnancy of unknown location
+ve pregnancy test
no evidence of pregnancy on ultrasound
cannot exclude ectopic pregnancy
- track HCG (repeat after 48hrs)
- intrauterine pregnancy HCG will double every 48hrs (not in miscarriage or ectopic pregnancy)
rise of more than 63% after 48hr= intrauterine pregnancy. repeat ultrasound in 1-2 weeks to confirm.
pregnancy should be visible on USS once HCG is >15000 IU/L
rise of <63% in 48hr could indicate ectopic pregnancy= close monitor and review
fall of more than 50%= miscarriage. perform urine pregnancy test 2 weeks to confirm.
management of ectopic pregnancy
- pregnancy test in all women with abdominal or pelvic pain
- refer to early pregnancy assessment unit (EPAU) or gynaecological service
- all ectopic pregnancies need to be terminated
Expectant management (awaiting natural termination) Medical management (methotrexate) Surgical management (salpingectomy or salpingotomy)
expectant management for ectopic pregnancy
Follow up needs to be possible to ensure successful termination The ectopic needs to be unruptured Adnexal mass < 35mm No visible heartbeat No significant pain HCG level < 1500 IU / l
*same for criteria of methotrexate, plus HCG levels must be <5000IU/l and confirmed absence of intrauterine pregnancy on ultrasound
ectopic pregnancy- methotrexate
methotrexate is highly teratogenic (harmful to pregnancy)
IM into buttock to halt progress of pregnancy and result in spontaneous termination
do not get pregnant for 3 months following treatment
Common side effects of methotrexate include:
Vaginal bleeding
Nausea and vomiting
Abdominal pain
Stomatitis (inflammation of the mouth)
surgical management for ectopic pregnancy
if do not meet criteria for expectant / medical management.
management. This include those with:
Pain
Adnexal mass > 35mm
Visible heartbeat
HCG levels > 5000 IU ;
two options:
1. Laparoscopic salpingectomy
1st line in ectopic pregnancy. GA and key hole surgery with removal of the affected fallopain tube
- Laparoscopic salpingotomy
women at increased risk of infertility due to damage with the other tube. (avoid affecting the fallopian tube)
anti rhesus D prohpylaxis given to rhesus negtive women having surgical mx of ectopic pregnancy.
ovarian torsion
ovary twists in relation to the surrounding connective tissue, fallopian tube and blood supply (adnexa)
usually due to an ovarian mass larger than 5cm, such as a cyst or a tumour
more likely to occur with benign tumours. It is also more likely to occur during pregnancy.
n also happen with normal ovaries in younger girls before menarche (the first period), when girls have longer infundibulopelvic ligaments that can twist more easily.
twisting adnexa- ovarian ischaemia- necrosis. emergency
presentation of ovarian torsion
sudden onset of severe unilateral pelvic pain. constant, progressively worse, nausea and vomiting.
can be mild and prolonged. can twist intermittently (comes and goes)
O/E localised tenderness, palpable mass in pelvis.
investigation to diagnose ovarian torsion
- transvaginal ultrasound (initial investigation of choice.)
2 trans abdominal if TUV unable.
whirlpool sign, free fluid in pelvis, oedema of ovary
- doppler studies show lack of blood flow
management of ovarian torsion
emergency admission under gynaecology for urgent investigation and management
laparoscopic surgery to detorsion or remove ovary (oophorectomy)
complications of ovarian torsion
loss of function of ovary if delay
other ovary usually compensates- fertility not effected.
necrosis - infection - abssess - sepsis
rupture- peritonitis- adhesions
miscarriage definitions:
- missed miscarriage
- threatened miscarriage
- inevitable miscarriage
- incomplete miscarriage
- complete miscarriage
- anembryonic pregnancy.
Missed miscarriage – the fetus is no longer alive, but no symptoms have occurred
Threatened miscarriage – vaginal bleeding with a closed cervix and a fetus that is alive
Inevitable miscarriage – vaginal bleeding with an open cervix
Incomplete miscarriage – retained products of conception remain in the uterus after the miscarriage
Complete miscarriage – a full miscarriage has occurred, and there are no products of conception left in the uterus
Anembryonic pregnancy – a gestational sac is present but contains no embryo
