Early Pregnancy - Ectopic and Miscarriage (incl: Recurrent MC GT17) Flashcards
What is the incidence of Ectopic pregnancies?
11/1000 (~1%)
11,000 per year in U.K.
Accounts for 2-3% of all attendances to EPAU
What percentage of Ectopic pregnancies are found located in the ampullary portion of the Fallopian tube?
Ampullary 80%
Isthmic 12% Fimbrial 5% Interstitial 2% Cervical <1% Ovarian < 1% Abdominal <1% Cornual - rarest
What are the intrauterine pregnancy rates for a woman who has had a laparoscopic salpingectomy for a previous Ectopic pregnancy?
What is the chance of her having a repeat Ectopic pregnancy?
IUP rates 55-60%
Repeat Ectopic rates 5% (8% with salpingotomy)
What are the US appearances of a gestational sac?
Round hyperechoic structure with an echogenic rim eccentrically situated within the decidua at or near the fundus from day 28-31
When is the embryonic pole first visualised on US?
Day 35
What are the TVUSS cut offs to diagnose miscarriage?
Above
MSD 25mm with no embryonic pole
CRL 7mm with no FH
What are the USS appearances of ectopic pregnancies?
‘Bagel sign’ - Adnexal mass with hyperechoic ring around the gestational sac
‘Blob sign’ - Homegenous mass seen separate to the ovary
What is the likelihood of a miscarriage due to a karyotypic abnormality in a 30 year old with 2 previous miscarriages?
50%
What are the chances of requiring further treatment following salpingotomy for ectopic pregnancy?
Up to 1:5
What is the risk of persistent trophoblast tissue following salpingotomy for ectopic pregnancy?
4-8 in 100
What are the USS appearances of cervical ectopic pregnancy?
Empty uterus Barrel shaped cervix Gestational sac below internal os Absent sliding sign Blood flow around the sac using Doppler
What are the USS appearances of an interstitial pregnancy?
Empty uterine cavity
POC/sac in interstitial (intramural) part of tube surrounded by <5mm myometrium in all planes, and present ‘interstitial line sign’
What are the criteria for managing an ectopic pregnancy expectantly?
Clinically stable
US diagnosis
HCG <1500, decreasing
What is the prevalence of Caesarean section scar pregnancy?
1 in 2000
What is the rate of persistent trophoblast after salpingotomy?
4-11%
What are the most common adverse effects of methotrexate?
Excessive flatulence and bloating
Transient mild elevation of LFTs
Stomatitis
(Marrow suppression, pulmonary fibrosis, nonspecific pneumonitis, liver cirrhosis, renal failure, gastric ulceration)
What are the criteria for first line management with methotrexate?
- No significant pain
- Unruptured ectopic <35mm with no FH
- bHCG between 1500-5000
- No intrauterine pregnancy on USS
What are the adjunctive methods to control haemorrhage in treatment of cervical ectopic pregnancy?
UAE
Uterine artery ligation
What are the adjunctive methods to control haemorrhage in treatment of Caesarean scar ectopic pregnancy?
Cervical cerclage
Foley catheter insertion
UAE
What is the recommended treatment of cornual pregnancies?
Excision of the rudimentary horn via laparoscopy/laparotomy
What is the recommended treatment of cornual pregnancies?
Definitive surgical treatment to make the diagnosis
Systemic mtx if risk surgery high or post-op for persistent trophoblast tissue/raised b-HCG levels
What is the management of a heterotopic pregnancy?
- Mtx only if the uterine pregnancy is non-viable or if not wishing to continue with pregnancy
- Local injection KCl or hyperosmolar glucose with aspiration sac contents if haemodynamically stable
- Sugical removal ectopic - recommended method
- Expectant management an option in non-viable pregnancy
What are the contraindications to methotrexate?
- Haemodynamic instability
- Presence of intrauterine pregnancy
- Breastfeeding
- Unable to comply with follow up
- Chronic liver disease
- Pre-existing blood dyscrasia
- Active pulmonary disease
- Immunodeficiency
- Peptic ulcer disease
What is misoprostol?
Prostaglandin E1 analogue
What is the NICE recommended dose for misoprostol in missed/incomplete miscarriage?
800mcg single dose missed
600mcg incomplete
What is the 1/2 life of mifepristone?
25-30 hours
What is the mode of action of mifepristone?
Competitive binding of progesterone and glucocorticoid receptors
Decidual necrosis
Increased endogenous prostaglandin production
Increased uterine sensitivity to prostaglandins
Cervical ripening
How is misoprostol carried in blood and what is its 1/2 life?
85% albumin bound
1/2 life 30 mins
What is the RCOG recommended dose for misoprostol in late miscarriage/iufd?
100mcg 6 hourly <26/40
25-50 mcg 4 hourly >=27/40
Max 5 doses
Safe with 1 previous Caesarean section
What % of couple will have recurrent miscarriage?
1%
What % will have a further miscarriage after 3 consecutive?
40%
What constitutes ‘adverse pregnancy outcome’ to define antiphospholipid syndrome?
>= 3 consecutive miscarriages <10/40 >= 1 morphologically normal fetal loss >10/40 >= preterm birth <34/40 2dry to placental disease
How many cases of recurrent miscarriage are due to antiphospholipid syndrome, and what is the live birth rate with no intervention?
15% of RMC
Live birth in 10%
What % of couples with RMC will have a balanced reciprocal/Robertsonian translocation?
2-5%
What % of couples with RMC will be found to have congenital uterine malformations?
1.8-37.6%
Tends to increase if loss is in T2 - ?weak cx
Which thrombophilias have been implicated in second trimester miscarriages?
FVL Factor II (prothrombin) gene mutation Protein S deficiency
What is the recommended treatment in RMC with antiphospholipid syndrome to prevent further miscarriage?
Consider low dose aspirin + LMWH
What % of RMC will have successful subsequent pregnancy with supportive care alone?
75%, but worsens with age
