Ectopic/Miscarriage Flashcards
Ectopic pregnancy is
Implantation of a fertilized ovum outside the uterus results in an ectopic pregnancy
Ectopic pregnancy - A typical history is
a female with a history of 6-8 weeks amenorrhoea who presents with lower abdominal pain and later develops vaginal bleeding
Ectopic pregnancy describe lower abdominal pain
due to tubal spasm
typically the first symptom
pain is usually constant and may be unilateral.
Ectopic pregnancy describe vaginal bleeding
usually less than a normal period
may be dark brown in colour
Ectopic pregnancy describe history of recent amenorrhoea
typically 6-8 weeks from the start of last period if longer (e.g. 10 wks) this suggest another causes e.g. inevitable abortion
Ectopic pregnancy peritoneal bleeding can cause
peritoneal bleeding can cause shoulder tip pain and pain on defecation / urination
Ectopic pregnancy can cause symptoms of pregnancy such as breast tenderness
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Ectopic pregnancy Examination findings
abdominal tenderness cervical excitation (also known as cervical motion tenderness) adnexal mass: NICE advise NOT to examine for an adnexal mass due to an increased risk of rupturing the pregnancy. A pelvic examination to check for cervical excitation is however recommended
diagnosis of an ectopic pregnancy
In the case of pregnancy of unknown location, serum bHCG levels >1,500 points toward a diagnosis of an ectopic pregnancy
Ectopic pregnancy Epidemiology
Epidemiology
incidence = c. 0.5% of all pregnancies
Ectopic pregnancy Risk factors
Risk factors (anything slowing the ovum’s passage to the uterus)
damage to tubes (pelvic inflammatory disease, surgery)
previous ectopic
endometriosis
IUCD
progesterone only pill
IVF (3% of pregnancies are ectopic)
Ectopic pregnancy ix
A pregnancy test will be positive.
The investigation of choice for ectopic pregnancy is a transvaginal ultrasound.
Ectopic pregnancy:
Women who are stable are typically investigated and managed in an early pregnancy assessment unit. If a woman is unstable then she should be referred to the emergency department.
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There are 3 ways to manage ectopic pregnancies:
Expectant management Medical management Surgical management
ectopic pregnancies Surgical management
Size >35mm Can be ruptured Pain Visible fetal heartbeat serum B-hCG >1,500IU/L
ectopic pregnancy which mx options compatible with another intrauterine pregnancy
Expectant management Surgical management
ectopic pregnancy Surgical management can involve
salpingectomy or salpingotomy
ectopic pregnancy Size <35mm & unruptured options mx
Expectant management Medical management
Serum bhcg and mx for ectopic pregnancy
Expectant management serum B-hCG <1,000IU/L Medical management serum B-hCG <1,500IU/L Surgical management serum B-hCG >1,500IU/L
Expectant management and mx for ectopic pregnancy
Size <35mm Unruptured Asymptomatic No fetal heartbeat serum B-hCG <1,000IU/L Compatible if another intrauterine pregnancy
Expectant management involves for ectopic pregnancy
closely monitoring the patient over 48 hours and if B-hCG levels rise again or symptoms manifest intervention is performed.
Medical management and mx for ectopic pregnancy
Size <35mm Unruptured No significant pain No fetal heartbeat serum B-hCG <1,500IU/L Not suitable if intrauterine pregnancy
ectopic pregnancy Medical management
involves giving the patient methotrexate and can only be done if the patient is willing to attend follow up.
Ectopic pregnancy: pathophysiology
97% are tubal, with most in ampulla
more dangerous if in isthmus
3% in ovary, cervix or peritoneum
trophoblast invades the tubal wall, producing bleeding which may dislodge the embryo
Ectopic pregnancy: Natural history
most common are absorption and tubal abortion
tubal abortion
tubal absorption: if the tube does not rupture, the blood and embryo may be shed or converted into a tubal mole and absorbed
tubal rupture
Threatened miscarriage
painless vaginal bleeding occurring before 24 weeks, but typically occurs at 6 - 9 weeks
the bleeding is often less than menstruation
cervical os is closed
complicates up to 25% of all pregnancies
Missed (delayed) miscarriage
a gestational sac which contains a dead fetus before 20 weeks without the symptoms of expulsion
mother may have light vaginal bleeding / discharge and the symptoms of pregnancy which disappear. Pain is not usually a feature
cervical os is closed
when the gestational sac is > 25 mm and no embryonic/fetal part can be seen it is sometimes described as a ‘blighted ovum’ or ‘anembryonic pregnancy’
Inevitable miscarriage
heavy bleeding with clots and pain
cervical os is open
Incomplete miscarriage
not all products of conception have been expelled
pain and vaginal bleeding
cervical os is open
Miscarriage: epidemiology
15-20% of diagnosed pregnancies will miscarry in early pregnancies
non-development of the blastocyst within 14 days occurs in up to 50% of conceptions
recurrent spontaneous miscarriage affects 1% of women
An abortion is
the expulsion of the products of conception before 24 weeks. The term miscarriage is used often to avoid any misunderstandings
Miscarriage Expectant management
‘Waiting for a spontaneous miscarriage’
First-line and involves waiting for 7-14 days for the miscarriage to complete spontaneously
If expectant management is unsuccessful then medical or surgical management may be offered
Miscarriage Some situations are better managed with medically or surgically. NICE list the following:
increased risk of haemorrhage
she is in the late first trimester
if she has coagulopathies or is 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
Miscarriage Medical management:
‘Using tablets to expedite the miscarriage’
Vaginal misoprostol
The addition of oral mifepristone is not currently recommended by NICE in contrast to US guidelines
Advise them to contact the doctor if the bleeding hasn’t started in 24 hours.
Should be given with antiemetics and pain relief
Miscarriage Vaginal misoprostol works by
Prostaglandin analogue, binds to myometrial cells to cause strong myometrial contractions leading to the expulsion of tissue
Miscarriage Surgical management
‘Undergoing a surgical procedure under local or general anaesthetic’
The two main options are vacuum aspiration (suction curettage) or surgical management in theatre
Vacuum aspiration is done under local anaesthetic as an outpatient
Recurrent miscarriage is defined as
3 or more consecutive spontaneous abortions. It occurs in around 1% of women
Recurrent miscarriage Causes
antiphospholipid syndrome endocrine disorders: poorly controlled diabetes mellitus/thyroid disorders. Polycystic ovarian syndrome uterine abnormality: e.g. uterine septum parental chromosomal abnormalities smoking
1967 Abortion Act
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 the 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 a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped.
Paperwork abortion
two registered medical practitioners must sign a legal document (in an emergency only one is needed)
only a registered medical practitioner can perform an abortion, which must be in a NHS hospital or licensed premise
The method used to terminate pregnancy depend upon gestation less than 9 weeks
mifepristone (an anti-progestogen, often referred to as RU486) followed 48 hours later by prostaglandins to stimulate uterine contractions
The method used to terminate pregnancy depend upon gestation less than 13 weeks
surgical dilation and suction of uterine contents
The method used to terminate pregnancy depend upon gestation more than 15 weeks:
surgical dilation and evacuation of uterine contents or late medical abortion (induces ‘mini-labour’)
