Early Pregnancy Complications (Miscarriage, Ectopic and Molar) Flashcards
What causes ectopic pregnancy?
1) conditions that hamper the transport of a fertilised oocyte to the uterine cavity
2) conditions that predispose the embryo to premature implantation.
e.g. PID, previous surgery, endometriosis, IUcD, POP, sub-fertility, IVF, smoking. Pregnancy after tubal ligation 9x more likely to be ectopic.
Pelvic infection can increase risk by distorting fallopian tube anatomy.
How do embroys in the fallopian tubes get to the uterus?
requires regulated complex interaction between the tubal epithelium, tubal fluid, and tubal contents.
This generates a mechanical force made of tubal peristalsis, ciliary motion, and tubal fluid flow, to drive the embryo towards the uterine cavity.
This is subject to dysfunction at many different points that can ultimately manifest as ectopic pregnancy.
What are key features in your history and exam that would point to Ectopic pregnancy?
History:
Abdo pain - lower, general or unilateral
ammenorhoea 6-8 weeks
vaginal bleeding
referred shoulder tip pain (haemoperioteum irritate diapghram)
urge to defecate (blood pooling in cul-de-sac)
diarrhoea / vomitting
collapse
Examination:
general: orthostatic hypotension / haem instability
Abdominal tenderness / peritonism (acute e.g. guarding warning sign of rupture)
adnexal tenderness or mass
blood in vaginal vault (in absence of rupture)
cervical motion tenderness
What are some RF for ectopic pregnancy
Previous ectopic pregnancy
previous tubal sterilisation surgery
IUD (only increased risk if pregnancy happens with IUD in place)
Genital infections
chronic salpingitis
salpingitis isthmica nodosa (nodular scarring of fallopian tubes)
infertility
multiple sexual partners (increases risk of PID)
smokig
What are some RF for ectopic pregnancy
Previous ectopic pregnancy
previous tubal sterilisation surgery
IUD (only increased risk if pregnancy happens with IUD in place)
Genital infections
chronic salpingitis
salpingitis isthmica nodosa (nodular scarring of fallopian tubes)
infertility
multiple sexual partners (increases risk of PID)
smokig
What investigations for ectopic pregnancy?
Bedside:
- FBC
- Group & Save
- IF UNSTABLE: cross match 6 units of blood, 2 large bore cannula, give IV fluids, senior help.
- urine/serum pregnancy test hCG
- serum progesterone to identify failing pregnancy
Imaging:
- DIAGNOSTIC: high resolution transvaginal ultrasound (TVUS) (to confirm location of pregnancy) ‘bagel sign’ = empty gestational sac
-Transabdominal ultrasound - no uterine pregnancy
Consider:
- serial serum human chorionic gonadotrophin (hCG) (if TVUS does not confirm intrauterine pregnancy)
How would you manage a pt with ruptured tubal ectopic pregnancy who is haemodynamically stable?
1st line:
Surgery - laparoscopy with either salpingostomy or salpingectomy, depending on the status of the contralateral tube and the desire for future fertility
consider:
- post surgical methotrexate IM ( If serum chorionic gonadotrophin levels do not return to undetectable after surgery)
- anti-D immunoglobulin for all rhesus-negative women undergoing surgery for ectopic pregnancy
How would you manage a pt with ruptured tubal ectopic pregnancy who is haemodynamically stable? BMJ BP
1st line:
Surgery - laparoscopy with either salpingostomy (open tube but don’t remove tube) or salpingectomy, depending on the status of the contralateral tube and the desire for future fertility
consider:
- post surgical methotrexate IM ( If serum chorionic gonadotrophin levels do not return to undetectable after surgery)
- anti-D immunoglobulin for all rhesus-negative women undergoing surgery for ectopic pregnancy
How would you manage a pt with ruptured tubal ectopic pregnancy who is haemodynamically UNstable? BMJ BP
1st line:
- Fluid resus (isotonic solution and blood products to avoid iscahemic injury and multi-organ damage)
Surgery:
- Laparotomy
Consider: anti-D immunoglobulin for all rhesus-negative women undergoing surgery for ectopic pregnancy, but not for those treated medically
How would you manage a pt with tubal ectopic pregnancy? (clinically stable with a non-ruptured ectopic pregnancy)
laparoscopic surgery and medical management are both reasonable- decision guided by initial investigations and discussion with the woman
1st line :
Pharm: Methotrexate
Surgery: laparotomy
Consider:
post surgery methotrexate and anti-D immunoglobulin
What is the follow up post treatment of an ectopic pregnancy? (To ensure treatment has worked)
medical or surgical) women are reviewed weekly and serial human chorionic gonadotrophin (hCG) levels should be taken until the levels are <10 IU/L (<10 mIU/mL).
What are complications from the treatment of ectopic pregnancy?
Methotrexate adverse effects: e.g.g hepatotoxicity , nephrotoxicity, myelosuppression (pancytopenia), and pulmonary toxicity.
persistent trophoblast
damage to organs / vessels post surgery
recurrent ectopic pregnancy
Where do ectopic pregnancies occur?
97% tubal mostly in ampulla
25 % narrow isthmus (presents early, + risk of rupture)
3% - implant on ovary, cervix, Caesarean section scar or peritoneum
“Always think of an ectopic pregnancy in a sexually active woman with…..”
“Always think of an ectopic pregnancy in a sexually active woman with….ABDO PAIN, BLEEDING, FAINTING, DIARRHOEA OR VOMITTING .”
How long should a woman be on contraception for post treatment with methotrexate?
3 months
What is a molar pregnancy?
A hydatidiform mole is a type of tumour that grows like a pregnancy inside the uterus- a molar pregnancy.
- Tumours made of proliferating chorionic villi which have swollen and degenerated. Derived from chorion , it makes lots of hCG leading to ++ pregnancy symptoms and strongly +ve pregnancy tests.
There are two types of molar pregnancy: a complete mole and a partial mole.
BMJ:
Definition
Hydatidiform moles are chromosomally abnormal pregnancies that have the potential to become malignant (gestational trophoblastic neoplasia). Gestational trophoblastic disease includes tumours of fetal tissues, including hydatidiform moles, arising from placental trophoblasts. Syncytiotrophoblasts secrete human chorionic gonadotrophin (hCG) and, therefore, this hormonal product is used as a tumour marker for the disease.
What is a complete mole?
Benign tumour of trophoblastic material. Occurs when an empty egg ( no maternal DNA except mitochondrial DNA) is fertilized by a single sperm that then duplicates its own DNA, hence the all 46 chromosomes are of paternal origin
What is a partial mole?
A partial mole occurs when two sperm cells fertilise a normal ovum (containing genetic material) at the same time. The new cell now has three sets of chromosomes (it is a haploid cell). The cell divides and multiplies into a tumour called a partial mole. In a partial mole, some fetal material may form.
dr tom
who is likely to have a molar pregnancy?
- more common at extremes of childbearing age (<20 or >35)
- after a previous mole / GTD
- Asian women
Does a molar pregnancy resemble a normal pregnancy?
Yes
Molar pregnancy behaves like a normal pregnancy. Periods will stop and the hormonal changes of pregnancy will occur.
What symptoms / signs can indicate a molar pregnancy rather than a normal pregnancy?
More severe morning sickness
1st trimester pre-eclampsia
Vaginal bleeding
Increased enlargement of the uterus
Abnormally high hCG
Thyrotoxicosis (hCG can mimic TSH and stimulate the thyroid to produce excess T3 and T4)
How would you
1) image
2) diagnose
a molar pregnancy?
Image:
- Ultrasound of the pelvis - “snowstorm appearance” of the pregnancy
- CXR - pulmonary nodules for metastatic disease or pulmonary oedema due to high-output cardiac failure from anaemia or hyperthyroidism
Diagnose:
- Provisional diagnosis = ultrasound, confirmed with histology of the mole after evacuation
How do you manage a molar pregnancy?
Refer pts to gestational trophoblastic disease centre of management and FU
Management:
- evacuation of the uterus by gentle suction from easily perforated uterus
- histology to confirm diagnosis
- Give anti-D if rheuses -ve
What monitoring should a pt with a molar pregnancy have?
Monitor hCG levels until they return to normal at a specialist centre.
Should return to normal in 6 months.
If they drop rapidly to normal, oral contraceptives can be used after 6 months
A pt is treated for a molar pregnancy with evacuation of the uterus.
At 6 months her hCG levels are still HIGH - what could this indicate?
either:
- Mole was invasive (penetrated myometrium) -> can metastasise to lung, vagina, brain, liver and skin
- Or has given rise to a choriocarcinoma (10%)
Both of the above are treated with systemic chemotherapy
A woman with a molar pregnancy has developed hyperthryoidism (due to the high levels of hCG resembling TSH). Her management is agreed to be an evacuation of the molar tissue.
Why do you need to make the anaesthetist aware of this before you begin the evacuation?
Tell the anaethetist as thyrotoxic storm can occur at evacuation
What are the 1st lab investigations you would order when treating a woman with a molar pregnancy? What are you looking for?
- Serum beta hCGH - abnormally elevated for gestational age (>100,00 IU/L
- FBC - anaemia from persistent vaginal bleeding
- Serum PT, PTT (may be prolonged) = greater risk of serious bleeding during evacuation with a risk of DIC
- serum metabolic panel - normal liver / renal if need chemo drugs
- TSH - as cross reactivity of beta hCG and TSH
- Blood type + antibody screen - so blood available incase of haemorrhage
What are your differentials for a molar pregnancy? BMJ BP for details
Spontaneous abortion
multiple gestation
pelvic tumour
Define miscarriage
Miscarriage is an involuntary, spontaneous loss of a pregnancy before 24 completed weeks
After these differing cut-offs, the loss would be defined as a stillbirth.
Miscarriage is associated with unprovoked vaginal bleeding with or without suprapubic pain.
How common is miscarriage?
When do most occur?
15-20% pregnancies miscarry
around 80% of these are in first trimester
How can we divide the causes of miscarriage?
Embryonic factors
Maternal factors
Multifactorial
How can we divide the causes of miscarriage?
Embryonic factors
Maternal factors
Multifactorial
What are some embroyonic factors leading to miscarriage?
- primary embroyonic diseases, disorder, damage
- 80% of first trimester miscarriages are chromosomally abnormal
- embryonic malformations especially central nervous system are often spontaenously miscarried pregnancies
What are some maternal factors that can lead to miscarriage?
- many second trimester miscarriages (13-22 weeks) due to genital tract dysfunction e.g. ascending infection or systemic illness
- maternal exposure to toxic agents, chemotherapy, immunological disease, trans-placental infections
asymptomatic bacterial vaginosis - Antiphospholipud syndrome - first and second trimester recurrent miscarriage
- cervical incompetence, insufficiency (e..g following invasive foetal diagnostic procedures) or weakness
- previous premature deliveries of pregnancies
- severe rhesus isoimmunisation
What are some maternal factors that can lead to miscarriage?
- many second trimester miscarriages (13-22 weeks) due to genital tract dysfunction e.g. ascending infection or systemic illness
- maternal exposure to toxic agents, chemotherapy, immunological disease, trans-placental infections
asymptomatic bacterial vaginosis - Antiphospholipud syndrome - first and second trimester recurrent miscarriage
- cervical incompetence, insufficiency (e..g following invasive foetal diagnostic procedures) or weakness
- previous premature deliveries of pregnancies
- severe rhesus isoimmunisation
How are miscarriages classified? think headings to describe different types
Threatened miscarriage
Inevitable miscarriage
Incomplete miscarriage
Complete miscarriage
Missed miscarriage
Recurrent miscarriage
What is a threatened miscarriage?
(using pass med, BMJ BP, Ox handbook)
- unprovoked painless / painful vaginal bleeding occurring before 24 weeks (often 6 - 9 weeks)
- Mild symptoms - the bleeding is often less than menstruation
- cervical os is closed
- Pregnancy may continue
What is an inevitable miscarriage?
(using pass med, BMJ BP, Ox handbook)
- Severe symptoms - heavy bleeding with clots and pain
- cervical os is open
- clinical features indicate the process of physiological expulsion from the uterine cavity (pregnancy will not continue and will proceed to incomplete or complete miscarriage
What is an incomplete miscarriage?
(using pass med, BMJ BP, Ox handbook)
-early pregnancy tissue is partially expelled
- pain and vaginal bleeding
- cervical os is open
Ox handbook: if profuse bleeding consider ergometrine 0.5 mg IM. Surgical management of miscarriage if lots of retained product on US or ++pain ++ bleeding
What is a complete miscarriage: miscarriage?
(using pass med, BMJ BP, Ox handbook)
a miscarriage in which early pregnancy tissue is completely expelled
What is a missed miscarriage?
(using pass med, BMJ BP, Ox handbook)
-early embryonic/foetal demise
- foetus dies or never properly develops but remains in uterus
- may be no clinical features / women recall transient brownish vaginal discharge
- cervical os is closed
Diagnose:
- US : foetal pole <7mm w/o foteal heart activity
- US: gestational sac diameter >25mm w/o feal pole or yolk sac
- arrange re-scan in 10-14 days
What are the 3 types of management for miscarriage recommended by NICE
Expectant management
Medical management
Surgical management
What is involved in expectant management of miscarriage?
- ‘Waiting for a spontaneous miscarriage’
-Waiting for 7-14 days for the miscarriage to complete spontaneously - If unsuccessful then medical or surgical management
- rescan in 2 weeks to ensure complete if no significant bleeding
When is expectant management not appropriate? I.e. situations where medical or surgical management is needed?
- increased risk of haemorrhage
- late first trimester
- coagulopathies / unable to have a blood transfusion
- previous adverse and/or traumatic experience associated with pregnancy (for example, stillbirth, miscarriage or antepartum haemorrhage)
- evidence of infection
What is involved in medical management of miscarriage ?
- ‘Using tablets to expedite the miscarriage’
- Vaginal / oral misoprostol
Prostaglandin analogue, (binds to myometrial cells to cause strong myometrial contractions leading to the expulsion of tissue) - Contact doctor if bleeding hasn’t started in 24 hours.
- Give antiemetics and pain relief
What is involved in surgical management of miscarriage?
- Undergoing a surgical procedure under local or general anaesthetic’
- vacuum aspiration (suction curettage) under local anaesthetic as an outpatient
- surgical management in theatre
under general anaesthetic.
- surgical management in theatre
What are key RF for miscarriage you will ask for in history ?
older parental age, uterine malformation, bacterial vaginosis, and thrombophilias, trauma
What are some symptoms a patient might report suffering from miscarriage?
vaginal bleeding with or w/o clots
suprapubic pain
low back pain
recent post-coital bleed
if a woman in early pregnancy comes to you reporting PV bleeding, what are the important things you should be asking / considering to manage this
- Is she haemodynamically stable? (may be blood loss / products of conception in cervical canal)
- has pain and bleeding been worse?
- Have products of conception been seen (mistake for clots)
- Is uterine size appropriate for her dates?
- Is she bleeding from cervical lesion or from uterus?
- the need to use anti-D immunoglobulin if she Rh-ve
What investigations to order for miscarriage?
Bloods:
- serum beta hCG titres (falling titres = failing pregnancy e.g drop >50% in 48 hours)
- serum Progesterone (low titres - non viable)
- FBC - low Hb if + blood loss
- Rhesus blood group - ve in mum?
- Lupus anitcoagulant (antiphospholipid syndrome)
- Pelvic US to look for structural abnormalities / PCOS
- bacterial swab - bacterial vaginosis (cause of 2nd trimester miscarriage)
Imaging
- Trans vaginal US - confirm viability of pregnancy
Differencials for miscarriage?
Ectopic pregnancy - do Trans vag US
Hyadidiform mole - Trans vag US ‘snowstorm’
cystitis - urine microscopy and culture
pregnancy co-existing with bleeding cervical polyp / large ectropian - US
What is recurrent miscarriage?
loss of 3 or more consecutive pregnancies before 24 weeks gestation with the same biological father
1% of women
What are possible causes of recurrent miscarriage?
- Endocrine (but -well controlled e.g thyroid DM does not increase risk, nor does PCOS)
- Infection - bacterial vaginosis 2nd trimester loss
- Parental chromosome abnormality
- Uterine abnormality
- Antiphospholipid syndrome - lupus anticoagulant, phospholipid and anticardiolipin AB - give asprin when +ve preganncy test and enoxoparin when see foetal heart on US e.g. 5 weeks
- Thrombophilia
- Alloimmune causes
After a miscarriage.. thinking of how to speak to parents, foetal products, subsequent pregnancies
- Miscarriage is bereavement - give parents space to grieve, ask why it happened and if will re-occur
- offer follow up
- Foetal products incinerated unless mother wishes to bury herself - give in in an opaque container
- most early losses are due to abnormal foetal development or aneuploidy, 10% maternal illness e.g. pyrexia
- most subsequent pregnancies are normal (although increased risk)
- The miscarriage association website can provide extra support
What are the 3 ways to manage ectopic pregnancy? (thinking logically in terms of types of intervention if you were to present to a senior)
Expectant
Medical
Surgical
What are the criteria for expectant management of an ectopic pregnancy?
What are the criteria for medical management of an ectopic pregnancy?
What is the criteria for surgical management of an ectopic pregnancy?
