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Women's Health > Early Pregnancy and Complications > Flashcards

Early Pregnancy and Complications Flashcards

1
Q

What is the sign for an inevitable miscarriage?

A

If a patient comes in with vaginal bleeding and speculum exam shows an open cervix then this is leading to an inevitable miscarriage - the foetus will eventually bleed out through the cervix.

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2
Q

What do you do for a vaginal bleeding examination?

A
  • A-E assessment (Group and Save)
  • Check obs, signs of pallor, temp, CRT (to assess quantity of blood loss)
  • Abdo exam to exclude signs of peritonism (think ectopic)
  • Speculum exam to exclude open cervix (diagnosis of inevitable miscarriage) and to assess quantity of blood loss
  • Digital exam to assess cervix (whether cervical excitation is present) and adnexal tenderness
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3
Q

What needs to be investigated for in a woman of childbearing age with abdominal tenderness?

A

Ectopic until proven otherwise, but need to exclude other causes like haemorrhagic luteal cyst or non-gynae causes like appendicitis.

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4
Q

What is the definition of a miscarriage?

A
  • UK - loss of intrauterine pregnancy <24 weeks gestation
  • WHO - expulsion of foetus/embryo weighing 500g or less
  • Early miscarriage: when pregnancy loss occurs before 12 weeks gestation
  • Late miscarriage: when pregnancy loss occurs between 12-24 weeks
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5
Q

What are causes of miscarriage?

A
  • Multiple pregnancy
  • Advanced maternal/paternal age
  • Smoking
  • Stress
  • Previous miscarriage
  • Alcohol
  • Assisted conception
  • Chronic illness e.g. diabetes, thyroid
  • High BMI
  • Previous TOP
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6
Q

How is a miscarriage diagnosed?

A
  • Crown-Rump length of embryo 7mm or more with NO foetal heart action (or could be heart is too small to see, need to wait and re-scan after 7 days)
  • Mean sac diameter of 25mm gestational sac with no yolk sac or embryo
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7
Q

What does a clinical assessment of a miscarriage involve?

A
  • LMP
  • Date of first pregnancy test
  • Vaginal bleeding - severity (A-E if unwell) - check for clots (can be pregnancy tissue from miscarriage)
  • Pain - referred pain/shoulder tip pain/rectal pain - typically, colicky pelvic pain (central lower abdo - usually iliac fossa), can get diarrhoea/rectal pain due to bleeding in pouch of Douglas, irritating rectum
  • Shoulder tip pain - due to diaphragmatic irritation from blood (C3-5 nerves innervate diaphragm)
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8
Q

What examination needs to be done for miscarriage?

A
  • Vital signs (haemodynamic shock)
  • Inspection/pallor (anaemia)
  • Abdominal exam
  • Speculum exam (visualise cervix)
  • Digital vaginal exam (assess pelvic tenderness/cervical excitation)
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9
Q

What investigations need to be done for miscarriage?

A
  • Depends on gestation timeframe and symptoms
  • FBC, Group and Save (in case transfusion needed), serum hCG (gestation <7 weeks)
  • USS (>7 weeks)
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10
Q

What is the management for a miscarriage?

A
  • Assess hx - are they symptomatic?
  • Expectant management - wait it out
  • Medical - give prostaglandin to start miscarriage process (home or in hospital)
  • Surgical - remove pregnancy tissue from uterus (more likely to need surgery if patient feeling very unwell as it indicates tissue may have become infected and may spread to surrounding pelvic tissue, become septic etc.)
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11
Q

What are the risks of miscarriage management?

A
  • Infection (1%)
  • Haemorrhage (2%) - 1/100 lose enough blood to need blood transfusion
  • Similar outcomes in future pregnancy rates/pregnancy outcomes
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12
Q

What does expectant management of a miscarriage involve?

A
  • May pass pregnancy at home/sac may be reabsorbed without much bleeding
  • Miscarriage/bleeding can take up to 6 weeks to complete
  • Follow-up in 2-3 weeks (USS to check for retained tissue)
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13
Q

What does medical management of a miscarriage involve?

A
  • Misoprostol leads to uterine contraction and passing of pregnancy tissue
  • Can be painful/heavy bleeding
  • Effective in 80-90% of cases
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14
Q

What does surgical management of a miscarriage involve?

A
  • Shorter time to resolution

- Disadvantages: uterine perforation, uterine adhesions, retained products, GA risk

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15
Q

What is the classic presentation of an ectopic pregnancy?

A

Woman of reproductive age, with colicky abdominal pain and vaginal bleeding. It is a potentially life-threatening condition as it can cause catastrophic bleeding, patients may present in a state of collapse&raquo_space; resuscitation.

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16
Q

Where are common places for an ectopic pregnancy?

A
  • 5% fimbrial
  • 80% ampullary
  • 12% isthmus
  • Can also occur in uterine horn ‘cornu’, ovaries, uterus, abdominal (rare, likely very severe bleeding) and in caesarean scar (gap in myometrium)
17
Q

What are risk factors for an ectopic pregnancy?

A
  • Anything that damages the fallopian tubes or affects mobility of the cilia
  • Previous pelvic inflammatory disease e.g. chlamydia
  • Smoking (affects ability of the egg to move through uterus)
  • Prior tubal surgery (can damage fallopian tubes)
  • Hx of infertility
  • Assisted reproductive techniques e.g. IUD - increases risk of ectopic
18
Q

What are symptoms of an ectopic pregnancy?

A
  • Suspect ectopic in ALL women of reproductive age until proven otherwise
  • May be asymptomatic
  • Pain (mild to severe) - stretching of fallopain tube, rupture, bleeding irritating peritoneum
  • Shoulder tip pain - bleeding in abdomen irritate diaphragm - referred pain
  • Rectal pain (bleeding behind uterus irritates rectum)
  • Diarrhoea
  • Vaginal bleeding or none at all
19
Q

How does an ectopic pregnancy present?

A
  • Usually presents between 5-7 weeks - around this gestation trophoblastic tissue grows to the size where the fallopian tube is stretched
  • Can present with sudden collapse (may be tachycardic)
  • Dizziness/fainting/syncope episodes
20
Q

What examination should be done in ectopic pregnancy?

A
  • Obs - may be normal or show signs of hypovolaemic shock
  • Abdomen may be tender/signs of peritonism
  • Cervical excitation/adnexal tenderness may be present - uterus moving causes pain
21
Q

What investigations should be done for ectopic pregnancy?

A
  • USS - usefulness depends on gestation, may show signs of intrauterine pregnancy from 5wks, signs of intraperitoneal haemorrhage (free fluid > blood), may see ectopic pregnancy (absence doesn’t exclude)
  • Serum HCG - peaks at around 8wks, if it doesn’t show up it could be too early in pregnancy or woman may have miscarried earlier
  • Progesterone - cannot diagnose
22
Q

What does serum-HCG show in pregnancy?

A
  • Serum HCG levels increase >53% every 48hrs in on-going pregnancies
  • Serum HCG level falls in failing pregnancies (21-35%)
  • Ectopics - 15-20% behave like intrauterine pregnancies, 10% behave like failing pregnancies
  • Most ectopic pregnancies will probably either show a slow decline/rise in HCG (so nothing extreme), however if rise in HCG is declining/slow then suspect ectopic
  • You would expect an intrauterine pregnancy once HCG reaches 1000iu/ml. If HCG lower than this then may represent very early pregnancy or a pregnancy that is failing.
23
Q

How does progesterone indicate tissue viability?

A
  • <20 nmol/l - likely failing pregnancies
  • > 25nmol/l - likely predict viable pregnancies
  • > 60nmol/l - strongly associated with viable pregnancies
24
Q

What is the surgical management for an ectopic pregnancy?

A

Indications: patient is clinically unstable or signs of internal bleeding, hCG >5000iU, US mass >3.5cm, failed medical treatment, patient choice

  • Laparoscopic salpingectomy: keyhole to remove fallopian tube (recurrence is 10%)
  • Laparoscopic salpingotomy: removing ectopic tissue itself but leave fallopian tube (this leaves behind damaged fallopian tube) - 15% of ectopic in damaged tube
  • Laparotomy: ideal for unstable patient (e.g. collapsed) as abdomen can be accessed quickly to stop bleeding
  • Patient will beed an injection of Anti-D25oiu if they are Rhesus negative
25
Q

What is the medical management for an ectopic pregnancy?

A
  • Methotrexate (folate antagonist) - stops cell proliferation of pregnancy tissue
  • Indicated when: minimal symptoms, patient stable, US mass <3.5cm
  • Static/rising hCG but low levels (hCG <3000IU ideally but up to 5000IU)
  • Follow-up for 2 months to monitor progress as 5% chance ectopic could still rupture
  • Will need to delay pregnancy for 3 months after
26
Q

When would you do conservative management of an ectopic?

A
  • Minimal symptoms
  • Patient stable
  • Low/falling HCG
  • Pregnancy of Unknown Location (PUL)
  • US mass <4cm
  • Good patient compliance
27
Q

What happens if you see a foetal heart beat on an ectopic?

A

Presence of a heart means ectopic is quite big so could rupture. Need to stop foetal heart before giving further treatment. Ideally HCG should be <3000 to treat medically. If it’s between 3000-5000, consider surgery, if >5000 then definitely surgery.

28
Q

What is the future management after an ectopic pregnancy?

A
  • Risk of recurrence is approx 10%

- Recommend USS at 7 weeks during next pregnancy to ensure it’s intrauterine

29
Q

What needs to be discussed about contraception after treatment of ectopic?

A
  • Do they want another pregnancy?
  • If not, what do they want to do about contraception?
  • If they do want to try again they will have to wait several months

Women's Health (19 decks)

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