Early pregnancy compliactions Flashcards
Definition of a threatened miscarriage
Bleeding +/- pain before 24 weeks with a viable pregnancy I.e a fetal HR and a closed cervical os
Definition of inevitable miscarriage
Internal os of cervix is open before 24 weeks
Products of conception have not yet been passed, but it is inevitable that they will
Definition of incomplete miscarriage
Some products of conception have been passed before 24 weeks but some tissue remains in uterus
Cervix open until all POC are passed
Usually 6-14 weeks gestation
Definition of septic miscarriage
Incomplete/inevitable/threatened miscarriage with fever (infected products of conception)
Patient will be septic
Definition of complete miscarriage
All products of conception have been passed before 24 weeks
Cervix was open, now closed
Bleeding and pain settle
Usually <6 or >14 weeks gestation
How to differentiate types of miscarriage
Clinical picture/os open of closed
Or
Ultrasound
Ultrasound classification of miscarriage
Missed miscarriage - no fetal HR
Anembryonic pregnancy - empty gestation sac
Incomplete miscarriage (>20mm mass in uterine cavity)
Complete miscarriage (clinical features more useful than USS)
Differential if US shows empty uterus but positive pregnancy test
Complete miscarriage
Ectopic pregnancy
POC too small to detect with USS
Risk factors for miscarriage
High maternal age Previous miscarriage Antiphospholipid syndrome Smoking Alcohol Folate deficiency e.g methotrexate Consanguinity (higher rate of genetic defects) Ashermans syndrome PID Multiple pregnancy Incompetent cervix Aneuploidy Abdominal trauma
3 options of miscarriage management
Conservative
Medical
Surgical
Describe conservative management of miscarriage
Wait for POC to pass naturally over 2 weeks
Pregnancy test in 3 weeks time
AntiD prophylaxis for Rh-
Advantages of conservative management of miscarriage
Patient can be at home
Avoids risks of surgery/medical
Disadvantages of conservative management of miscarriage
Need 24 hour access to gynae services as bleeding can be unpredictable and excessive
May be unsuccessful
Takes longer therefore longer to get back to work etc
Advantages of medical management of miscarriage
Avoids surgery
Done as outpatient
Disadvantages of medical management of miscarriage
Pain and bleeding
Side effects of drugs
Some need emergency surgery
What is medical management of miscarriage
Give misoprostol (prostaglandin) to stimulate uterine contraction and empty the uterus
Pregnancy test in 3 weeks
AntiD prophylaxis for Rh-
What is surgical management of miscarriage
Using a suction curette to empty the uterus under GA
Bleeding lasts for 1-2 weeks after
AntiD prophylaxis for Rh-
Advantages of surgical management of miscarriage
Successful
Day case
Disadvantages of surgical management of miscarriage
Risks of surgery and anaesthetic
Definition of recurrent miscarriage
Loss of at least 3 consecutive pregnancies with same partner
Risk factors for ectopic pregnancy
Previous ectopic Tubal surgery Tubal pathology PID Endometriosis Pregnancy with copper IUD
Management options of ectopic pregnancy
Expectant
Medical
Surgery
AntiD prophylaxis for Rh-
Need weekly HCG until negative
Criteria for medical management for ectopic pregnancy
<3.5cm HCG<5000 No symptoms No free fluid No rupture Patient willing to return for follow up
Criteria for surgical management for ectopic pregnancy
Clinically unwell
Don’t meet criteria for medical
Patient choice
Criteria for expectant management of ectopic pregnancy
Asymptomatic
No rupture
<3cm
HCG<1500 and decreasing
What is medical and surgical management of ectopic pregnancy
Medical: IM methotrexate (must avoid pregnancy for at least 3 months). One dose usually enough
Surgical: laparoscopic salpingostomy (if only 1 tube) or salpingectomy (both tubes present)
How many medically managed ectopic pregnancies rupture
10%
What are the pre malignant trophoblastic diseases
Hydatidiform mole:
Complete mole - no DNA in egg, fertilised by 1 sperm, sperm duplicates = 46 chromosomes
Partial mole - 1 egg, 2 sperm = 69 chromosomes
What are the malignant trophoblastic diseases
Invasive mole
Choriocarcinoma (complete mole can transform into this)
Symptoms of trophoblastic disease
Asymptomatic - US picks up 50% of time Bleeding Severe N+V Uterus large for date Severe symptoms of pre-eclampsia (very rare)
Diagnosis of trophoblastic disease
US gives high level of suspicion - snowstorm appearance
Histology to confirm diagnosis
Management of trophoblastic disease
Surgical procedure to evacuate retained products of conception
Postal follow up of serum and urine HCG (only 3 national centres) for 6 months - can’t get pregnant during this time
What is hyperemesis gravidarum
1% pregnancies characterised by: Severe hyperemesis Severe dehydration Marked ketosis Weight loss >5% Nutritional deficiency
Pathophysiology of hyperemesis gravidarum
Higher HCG levels e.g twins or molar pregnancy
Diagnosis of hyperemesis gravidarum
Diagnosis of exclusion:
No abdo pain
No infection e.g UTI
No metabolic disorder e.g thyrotoxicosis, Graves’ disease, Addison’s, DKA
Drug side effect
No tumours such as molar pregnancy, choriocarcinoma, teratoma, germ cell tumour, islet cell tumour
Investigation for hyperemesis gravidarum
Urine dipstick for UTI and ketones Haematocrit and U+Es to look for dehydration Amylase to rule out pancreatitis Thyroid function tests USS
Management of hyperemesis gravidarum
Rehydrate - NOT WITH GLUCOSE (precipitates Wernicke’s)
Thiamine replacement IV
Folic acid
Antiemetics - 1st line cyclizine
Ranitidine if evidence of Mallory Weiss tear
Thromboprophylaxis if severe dehydration
PUQE index to classify severity and decide appropriate setting for management
Risks of threatened miscarriage
Prematurity
Low birthweight
Half eventually miscarry
Symptoms of septic miscarriage
Fever
Abdo tenderness
Foul smelling discharge
Raised inflammatory markers
Definition of ectopic pregnancy
Implantation occurring in any location other than the endometrial lining of the uterus
Symptoms of ectopic pregnancy
Lower abdo pain +/- iliac fossa pain
Vaginal spotting
Secondary amenorrhoea
Adnexal mass
If ruptured:
Shoulder pain
Tachycardia
Hypotension
Investigations for ectopic pregnancy
Serial beta-hCG levels don’t rise by double every 48 hours
Progesterone <20
TA or TV ultrasound
Culdocentesis shows blood in pouch of Douglas
Laparoscopy if location not found on TVUS
Normal beta-HCG levels with medical management of ectopic pregnancy
Decrease by at least 15% from day 4-7
Levels may rise from day 1-4
Management of pregnancy of unknown location
Beta HCG 48 hours apart:
If at least doubled - rescan 1 week
If < doubled - monitor for ectopic/laparoscopy
Describe red degeneration of fibroids
Necrosis of fibroids caused by enlarging fetus in first half of pregnancy
Abdo pain
Test for recurrent miscarriage
Karyotyping for mother, father and POC
TVUS - cervical length
Antiphospholipid antibodies -
