Early Pregnancy Problems Flashcards
Menstruation definition
It involves sloughing off the endometrirum each month if a pregnancy fails to develop over a period of days, bleeding and subsequent repair so that the uterus is then receptve to an implanting embryo in the next cycle
EDD
Expected date of delivery - 280 days (40 weeks) from 1st day of last menstrual period
Represents number of weeks of pregnancy, used in clinical practice
Miscarriage definition
Any pregnancy loss before 24 weeks gestation
Still birth
Any fetus born dead at or after 24 weeks gestation
Live birth
A fetus which shows signs of life after delivery at any gestation
recurrent miscarriage
3 or more consectuive miscarriages
Clinical presentation of miscarriage
In the presence of a positive pregnancy test
- vaginal bleeding - brown spotting or heavy +/- tissue
- asymptomatic
- pelvic pain or discomfort
What investigations would you do of women presenting with pain or bleeding in early pregnancy
- Clincal examination
- haemodynamically stable
- assess pain and bleeding
- removal of POC
- ultrasound scan - TV or TA
- examination of POC
- serum HCG tracking +/- serum progesterone
- Assess FBC and blood group
Assessing an ultrasound scan for a viable intrauterine pregnancy
- offer women a TV scan to identify the location of the pregnancy and whether there is a fetal pole and heart beat
- no fetal heart activity, >7 mm CRL on TV scan
- empty sac when gestatonal sac diameter >25mm on TV scan
- retained tissue - in incomplete miscarriage
- empty uterus
- complete passage of tissue (complte miscarriage)
- pregnancy too early to visualise on scan
- ectopic pregnancy
- confirmatory scan required in many cases (7 days later(
Serum BHCG tracking of a women presenting in ealy pregnancy with pain or bleeding
HCG levels double every 48 to 73 hours at the start of pregnancy and can be detected in the blood 3 weeks from the LMP
take at least 2 measurements 48 hours apart to determine miscarriage
- increases >66% - suggests viable intrauterine pregnancy
- <66% increase or <15% decrease - suggests ectopic pregnancy
- >15 % decrease - suggests failing PUL
When to given Anti- D?
Anti- D is required if a mother Rh negative if:
- <12 weeks vaginal bleed and severe pain
- <12 weeks medical or surgical management
- and potentially sensitising event >12 weeks
Management of Miscarriage
- Expectant management
- 65% sucess
- intesive follow up and review every 7-14 days
- medical management
- misoprostol (oral or vaginal, dose depeding on gestation)
- 70% success
- surgical
- requires cervical priming (usually misoprostol)
- electric vacum aspiration under GA as daycase
- Manual vaccum aspiration under local anaesthetic as outpatient
- both >98% success rate
When to consider management options other than expectant?
- the woman is at increased risk of haemorrhage
- previous adverse or traumatic experience
- at risk from effects of haemorrhage (coagulopathy)
- there is evidence of infection
Potential causes of miscarriage
- unexplained- over 50% have no identifiable cause
- maternal age - age 30-20%. age 42 50% risk
- fetal chromosome abnormality
- immunological - autoimmine (lupus or antiphospholipid antibodies)
- endocrine - PCOS, poorly controlled thyroid disease or diabetes
- uterine abnormalities - bicornuate/ septate/ fibroids
- infection - pyrexia and loss, specific infections (CMV)
- environment - cigarette smoking, alcohol consumotion
- cervical weakness - consider with mid-trimester loss
recurrent miscarriage managment
- Dependent on cause
- aspirin and LMWH for antiohospholipid antibody syndrome
- other treatments not proven
- supportive care for early pregnancy services mainstay of management (unclear mechanism)
- 60-75% of women with 3 consecutive early pregnancy loss and no apparent cause will have a successful pregnancy with their next attempt
Two types of GTD
