Early Pregnancy Pathologies Flashcards
1
Q
What is an Ectopic Pregnancy?
A
Implantation of fertilized ovum outside the uterus. Occurs in 0.5% of all pregnancies.
- 97% are tubal with most in ampulla.
- More dangerous in isthmus
- 3% in ovary, cervix, uterus, peritoneum and heterotopic. Trophoblast invades the tubal wall producing bleeding which may dislodge the embryo
2
Q
How does an Ectopic Pregnancy present as an emergency?
A
- Present as emergency with evidence of rupture or impending rupture.
- Open tubular rupture may have
- Sudden onset of abdominal pain and circulatory collapse.
- Referral to emergency department if unstable
3
Q
How does an Ectopic Pregnancy naturally progress?
A
Can develop into 3 thing:
- Tubal Abortion
- Tubal Absorption: if tube does not rupture, blood and embryo may be shed or converted into tubal mole and absorbed
- Tubal Rupture
4
Q
What are risk factors for an Ectopic Pregnancy?
A
- Damage to tubes (PID, Salpingitis, Surgery)
- Previous ectopic
- IVF
- Previous Endometriosis
- IUCD, Progesterone only pill
5
Q
What are symptoms and signs of an Ectopic Pregnancy?
A
Symptoms
- Low abdominal pain
- Due to tubal spasm
- Pain is usually constant and may be unilateral
- Vaginal bleeding
- Less than normal period usually
- May be dark brown in colour
- History of recent amenorrhoea
- Typically, 6-8 weeks from start of last period. If longer, this suggests another cause such as inevitable abortion
- Peritoneal bleeding – can causes shoulder tip pain and pain on defecation/urination
- GI symptoms – Nausea, diarrhoea and vomiting
- Dizziness, fainting or syncope may be seen
- Breast tenderness
6
Q
What are features of an Ectopic pregnancy on examination?
A
- Abdominal tenderness and adnexal tenderness
- Cervical excitation (also known as cervical motion tenderness)
- Adnexal mass (should be examined for due to risk of rupture)
7
Q
What are investigations used for Ectopic pregnancy?
A
- Pregnancy test positive
- Serum bHCG levels >1500 points toward diagnosis of an ectopic pregnancy
- In a normal pregnancy the b-HCG levels would double every 48 hours however in an ectopic pregnancy the b-HCG levels would be lower and rise more slowly (less than 66% rise)
- Transvaginal Ultrasound showing no intrauterine pregnancy. May show intra-abdominal free fluid however.
8
Q
How is an Ectopic pregnancy managed?
A
- Emergency management: Laparoscopy or laparotomy if haemodynamically unstable. Salpingectomy is usually performed.
- Expectant management: Close monitoring of patient over 48 hours an if B-hCG levels rise again or symptoms manifest intervention is performed. 24-hour access to gynae services
- Medical Management: Give patient methotrexate and can only be done if patient is willing to attend follow-up. There is a longer resolution. 1 in 10 may rupture. Must avoid pregnancy for at least 3 months
- Surgical Management: Involves salpingectomy or salpingotomy
9
Q
How is medical termination of pregnancy conducted?
A
<64 days:
- Mifepristone orally
- Misoprostol 24-48 hours later given by the vagina, buccal or sublingual route
64 to 13 week and 6 days:
- Mifepristone orally
- Misoprostol given by buccal, vaginal or sublingual route 24-48 hours after followed by misoprostol every 3 hours until abortion occurs at the hospital. If Mifepristone isn’t available, the regimen with misoprostol can still be used
14 weeks and above:
- Undertaken in medical facility.
- Mifepristone orally
- Misoprostol given vaginally 12-48 hours after followed by misoprostol every 3 hours until abortion occurs at the hospital. If after 24 hours the abortion does not occur, mifepristone can be repeated 3 hours after last dose of misoprostol and 12 hours later, misoprostol may be recommended
10
Q
How is Surgical Termination of pregnancy conducted?
A
Below 14 weeks: Either manual or electric vacuum aspiration
- No lower limit of gestation for surgical abortion but below 7 weeks, risk of failure is higher.
- Cervical preparation advised to minimise cervical trauma
- Uterus emptied using suction canula (and forceps if required) only during vacuum aspiration
- Sharp curettage should not be performed
- Use of oxytocin or ergometrine not recommended for prophylaxis against bleeding
14 weeks and after
- Surgical abortion performed by trained providers using vacuum aspiration using large bore cannula or dilatation and evacuation.
11
Q
What advice needs to be given in regard to Post-Abortion care?
A
- How much bleeding to expect in the next few days and week?
- How to recognise potential complications, including signs of ongoing pregnancy?
- When they can resume normal activities (including sexual intercourse)?
- How and where to seek help if required?
- Women who want to try to conceive again should be advised to wait until after at least one normal menstrual period longer if chronic health problem
- Administer Anti-D if possible
- Receive contraception information and given the contraceptive method of choice if required. If not available, need to refer to receive this
12
Q
What are complications of Termination of Pregnancy?
A
- Surgical and medical methods carry small risk of failure to end pregnancy
- Need for further intervention to complete produced i.e. surgical intervention following mediation abortion or re-evacuation follow surgical abortion
- Haemorrhage requiring transfusion
13
Q
What are specific surgical and medical complications of TOP?
A
Medical Complications
- Uterine rupture in associated with second trimester medical
Surgical Complications
- Uterine perforation
- Cervical trauma
- Further treatment (blood transfusion, laparoscopy, laparotomy or hysterectomy) may be required
- Upper genital tract infection of varying degrees of severity
14
Q
What are the laws regarding abortion in the UK?
A
1967 Abortion Act
- In 1990 the act was amended, reducing the upper limit from 28 weeks’ gestation to 24 weeks (HFEA act). These limits do not apply in cases where it is necessary to save the life of the woman, there is evidence of extreme foetal abnormality, or there is risk of serious physical or mental injury to the woman
15
Q
What are the specific details in the UK abortion law?
A
A person shall not be guilty of an offence under the law relating to abortion when a pregnancy is terminated by a registered medical practitioner if two registered medical practitioners are of the opinion, formed in good faith
- That the pregnancy has not exceeded its 24th week and that the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman or any existing children of her family; or
- That the termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman; or
- That continuance of the pregnancy would involve risk to the life of the pregnant woman, greater than if the pregnancy were terminated; or
- That there is substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped.
