Early pregnancy + complications Flashcards
Miscarriage: Definition
UK: Loss of intrauterine pregnancy
WHO: Expulsion of foetus/embryo weighing 500g or less
EARLY: When pregnancy loss occurs before 12 wks gestation.
LATE: pregnancy loss occurs after 12 wks
Stillbirth: If a baby dies at or after 24 weeks of pregnancy
Miscarriage:
- Causes (4)
- Factors (11)
Causes:
- Chromosomal abnormalities
- Fetal malformations
- Placental abnormalities
- Infection
Other factors:
- Multiple pregnancy
- Advanced maternal/paternal age
- Smoking
- Stress
- Previous TOP
- Previous miscarriage
- Alcohol
- Assisted conception
- Chronic illness/thyroid disorders/diabetes
- Uterine malformations/fibroids
- High BMI
In utero: Developmental milestones
Week 0: LMP
Week 2: Conception
Week 4.5-5: Gestational sac appears
Week 6: Embryo appears, cardiac pulsation begins (with a lower limit of 100bmp)
Week 6.5-7: Amniotic membrane appears, cardiac pulsation lower limit = 120bpm
Week 7-8: spine develops
Week 8-8.5: Intrinsic motion of embryo occurs
Miscarriage: Diagnosis
- Crown-rump length of embryo of 7mm or more with NO fetal heart action
- Mean sac diameter of 25mm gestational sac with no yolk sac or embryo
Terminology:
- Threatened miscarriage
- Inevitable miscarriage
- Complete miscarriage
- Incomplete miscarriage
- Delayed miscarriage
- THREATENED miscarriage: pregnancy confirmed, presenting with vaginal bleeding.
- INEVITABLE miscarriage: cervix open on examination - miscarriage likely imminent.
- COMPLETE miscarriage: when all pregnancy tissue has passed from the uterus.
- INCOMPLETE miscarriage: when some pregnancy tissue remains in the uterus.
- DELAYED miscarriage: when the pregnancy has stopped growing or when the foetus has died but there has been no signs of bleeding.
Miscarriage: Clinical assessment - FULL Hx
- LMP
- Date of first pregnancy test
- Vaginal bleeding
- Pain
- Gynae hx
- Obs hx
- Sexual hx
Miscarriage: Clinical assessment - EXAMINATION
- Vital signs
- Inspection/pallor
- Abdominal examination
- Speculum examination
- Digital vaginal examination
Miscarriage: Clinical assessment - INVESTIGATIONS
- Depends on gestation
- FBC/ G+S/ serum hCG
- USS
Miscarriage: Clinical assessment - MANAGEMENT
- Expectant
- Medical
- Surgical
All 3 options have a risk of:
- Infection
- Haemorrhage
- Similar outcomes in future pregnancy
Management of Miscarriage: EXPECTANT
- What happens?
- Advantages
- Disadvantages
What happens: varies a lot - days-weeks before miscarriage begins. Bleeding may go on for several weeks. Follow up in 2-3 weeks. Scan might be offered. Outcome:
- Resolution of miscarriage 60-80%
- Infection 1%
- Haemorrhage 2%
- Retained tissue
Advantages:
- Avoids hospital treatment
- Natural process
Disadvantages:
- Uncertainty
- Coping with pain/bleeding at home
- Seeing pregnancy passing may be distressing
Management of Miscarriage: MEDICAL
- What happens?
What happens:
- Outpatient/inpatient
- Prostaglandin analogues (Misoprostol)
- Leads to uterine contraction + passing of pregnancy tissue
- Can be painful/cause heavy bleeding
- Effective in 80-90% of cases
- Risk of infection/bleeding similar to expectant management
Management of Miscarriage: SURGICAL
- What happens?
- Advantages
- Disadvantages
What happens: Operation to remove pregnancy tissue. Should be performed in patients who have excessive/persistent bleeding or who request surgical management.
Advantages:
- Shorter time to resolve
Disadvantages:
- Infection
- Uterine perforation
- Uterine adhesions
- Retained products of conception
- GA risk
- Hysterectomy
- Cervical tears
- Intra-abdominal trauma
Post-miscarriage counselling: What did I do to cause it?
Nothing. It was not stress at work, carrying heavy shopping, having sex or any other reason women commonly worry about. Sadly miscarriages happen in up to about 40% of pregnancies.
Post-miscarriage counselling: If I had had a scan earlier could you have stopped it happening?
No, we might have found out it was happening sooner, but we could not have stopped it. There is no effective treatment to stop a 1st trimester miscarriage.
Post-miscarriage counselling: How bad will the pain be if I opt for expectant management?
It will be like severe period pain, which comes to a peak when tissue is being passed, then settles down shortly afterwards. Ibuprofen, paracetamol or codeine should help and may be taken. If pain is very bad contact hospital for advice.
Post-miscarriage counselling: What is heavy bleeding?
Soaking more than 3 heavy sanitary pads in under 1hr or passing a clot larger than the palm of your hand. If you bleed heavily you should seek medical attention urgently.
Post-miscarriage counselling: How long will I bleed for?
It should gradually get less and less but may be up to 3 wks after the miscarriage before the bleeding stops completely.
Post-miscarriage counselling: Do I need bed rest afterwards?
No, not necessarily, but obviously it can be physically and emotionally draining so a few days off work may help. You can return to normal activities as soon as you feel ready.
Post-miscarriage counselling: How long will the pregnancy test remain positive?
hCG is excreted by the kidneys and it can take up to 3 wks after a miscarriage for it all to be removed from the blood stream and a pregnancy test to record as -ve.
Post-miscarriage counselling: How long before we can try again?
There is no good evidence that the outcome of the subsequent pregnancy is affected by how soon you conceive after a miscarriage. As long as you have had either a period or a -ve pregnancy test since you miscarried, you can try again as soon as you feel physically and emotionally ready.
