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3A Womens health > ectopic pregnancy, miscarriage, > Flashcards

ectopic pregnancy, miscarriage, Flashcards

1
Q

What is an ectopic pregnancy?

A

Ectopic pregnancy is when a pregnancy is implanted outside the uterus

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2
Q

What is the most common site of an ectopic pregnancy?

A

Fallopian tube

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3
Q

Where are some other places an ectopic pregnancy can occur?

A

fallopian tube (cornual region), ovary, cervix or abdomen.

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4
Q

What are the RFs for an ectopic pregnancy?

A

Previous ectopic pregnancy
Previous pelvic inflammatory disease
Previous surgery to the fallopian tubes
Intrauterine devices (coils)
Older age - older than 35
Smoking
Black
History of infertility
IUC
Salpingitis

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5
Q

What is the prevalence of Ectopic pregnancies?

A

In the UK, the incidence is approximately 11 in 1000 pregnancies [NICE, 2021a], with an estimated 12,000 ectopic pregnancies diagnosed each year [HSIB, 2020].
The incidence of ectopic pregnancy reported in women attending early pregnancy units is 2–3

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6
Q

When does an ectopic pregnancy usually occur?

A

6-8 weeks of gestation

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7
Q

Classic features of an ectopic pregnancy?

A
  • Missed period
  • Constant lower abdominal pain in the right or left iliac fossa
  • Vaginal bleeding
  • Lower abdominal or pelvic tenderness
  • Cervical motion tenderness (pain when moving the cervix during a bimanual examination)
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8
Q

What are the signs of an ectopic pregnancy?

A
  • Abdominal tenderness.
  • Pelvic tenderness.
  • Adnexal tenderness.
  • Cervical motion tenderness.
  • Rebound tenderness or peritoneal signs.
  • Pallor.
  • Abdominal distension.
  • Enlarged uterus.
  • Tachycardia (more than 100 beats per minute) or hypotension (less than 100/60 mmHg).
  • Shock or collapse.
  • Orthostatic hypotension.
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9
Q

What are the symptoms of ectopic pregnancy?

A

Abdominal or pelvic pain.
Amenorrhoea or missed period.
Vaginal bleeding (with or without clots).
Breast tenderness.
Gastrointestinal symptoms (such as diarrhoea and/or vomiting).
Dizziness, fainting, or syncope.
Shoulder tip pain.
Urinary symptoms.
Passage of tissue.
Rectal pressure or pain on defecation.

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10
Q

Differential diagnosis for ectopic pregnancies?

A

Miscarriage
Molar pregnancy
Miscarriage
Ruptured ovarian corpus luteal cyst
Urethral bleeding
Haemorrhoids
Cancer of the cervix
UTI
IBS
Pelvic inflammatory disease
Appendicitis
Bowel obstruction

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11
Q

Investigations for ectopic pregnancy?

A

1st line - transvaginal US - gestational sac containing a yolk sac or fetal pole may be seen in fallopian tube

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12
Q

What are the signs called when a mass containing an empty gestational sac is seen?

A

“blob sign”, “bagel sign” or “tubal ring sign”

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13
Q

How would a a mass representing a tubal ectopic pregnancy move?

A

moves separately to the ovary. The mass may look similar to a corpus luteum; however, a corpus luteum will move with the ovary.

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14
Q

What are some other feature that may also indicate an ectopic pregnancy?

A
  • An empty uterus
  • Fluid in the uterus, which may be mistaken as a gestational sac (“pseudogestational sac”)
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15
Q

What is a pregnancy of unknown location?

A

when the woman has a positive pregnancy test and there is no evidence of pregnancy on the ultrasound scan

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16
Q

What can be used to track over time and help monitor a pregnancy of unknown location?

A

Serum human chorionic gonadotropin (hCG)
The serum hGC level repeated at 48 hours to measure change from baseline

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17
Q

What produces hCG in a pregnancy?

A

The developing syncytiotrophoblast

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18
Q

What happens to hCG in an intrauterine pregnancy?

A

A rise of more than 63% after 48 hours is likely to indicate an intrauterine pregnancy

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19
Q

What is needed to confirm an intrauterine pregnancy?

A

A repeat ultrasound scan is required after 1 – 2 weeks to confirm an intrauterine pregnancy. A pregnancy should be visible on an ultrasound scan once the hCG level is above 1500 IU / l.

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20
Q

Link between hCG and ectopic pregnancy?

A

A rise of less than 63% after 48 hours may indicate an ectopic pregnancy. When this happens the patient needs close monitoring and review.

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21
Q

Miscarriage and hCG?

A

A fall of more than 50% is likely to indicate a miscarriage. A urine pregnancy test should be performed after 2 weeks to confirm the miscarriage is complete.

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22
Q

When should you perform a pregnancy test in women?

A
  • Perform a pregnancy test in all women with abdominal or pelvic pain that may be caused by an ectopic pregnancy.
  • Women with pelvic pain or tenderness and a positive pregnancy test need to be referred to an early pregnancy assessment unit (EPAU) or gynaecology service.
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23
Q

What are the 3 options for terminating an ectopic pregnancy?

A

Expectant management (awaiting natural termination)
Medical management (methotrexate)
Surgical management (salpingectomy or salpingotomy)

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24
Q

What are the criteria for expectant management?

A
  • Follow up needs to be possible to ensure successful termination
  • The ectopic needs to be unruptured
  • Adnexal mass < 35mm
  • No visible heartbeat
  • No significant pain
  • HCG level < 1500 IU / l
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25
Q

What do women with expectant management need?

A

need careful follow up with close monitoring of hCG levels, and quick and easy access to services if their condition changes.

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26
Q

What is the criteria for medical management/ methotrexate?

A
  • HCG level must be < 5000 IU / l
  • Confirmed absence of intrauterine pregnancy on ultrasound
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27
Q

Methotrexate and pregnancy

A
  • teratogenic (harmful to pregnancy).
  • given as an intramuscular injection into a buttock. This halts the progress of the pregnancy and results in spontaneous termination.
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28
Q

What are women treated with methotrexate advised?

A

are advised not to get pregnant for 3 months following treatment. This is because the harmful effects of methotrexate on pregnancy can last this long.

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29
Q

What are some common side effects of methotrexate?

A

Vaginal bleeding
Nausea and vomiting
Abdominal pain
Stomatitis (inflammation of the mouth)

30
Q

When doe we have surgical management for ectopic pregnancy?

A

Anyone that does not meet the criteria for expectant or medical management requires surgical management. Most patients with an ectopic pregnancy will require surgical management.

31
Q

What is the first line treatment for a surgical ectopic pregnancy?

A

Laparoscopic salpingectomy
This involves a general anaesthetic and key-hole surgery with removal of the affected fallopian tube, along with the ectopic pregnancy inside the tube.

32
Q

What is second line surgical management for ectopic pregnancy?

A

Laparoscopic salpingotomy may be used in women at increased risk of infertility due to damage to the other tube. The aim is to avoid removing the affected fallopian tube. A cut is made in the fallopian tube, the ectopic pregnancy is removed, and the tube is closed.

33
Q

Which one has an increased risk of failure to remove ectopic pregnancy?

A
  • salpingotomy compared with salpingectomy
  • NICE state up to 1 in 5 women having salpingotomy may need further treatment with methotrexate or salpingectomy.
  • Anti-rhesus D prophylaxis is given to rhesus negative women having surgical management of ectopic pregnancy.
34
Q

What is a miscarriage?

A

Miscarriage is the spontaneous termination of a pregnancy. Early miscarriage is before 12 weeks gestation. Late miscarriage is between 12 and 24 weeks gestation.

35
Q

What are the definitions we have to know about miscarriage?

A
  • Missed miscarriage – the fetus is no longer alive, but no symptoms have occurred
  • Threatened miscarriage – vaginal bleeding with a closed cervix and a fetus that is alive
  • Inevitable miscarriage – vaginal bleeding with an open cervix
  • Incomplete miscarriage – retained products of conception remain in the uterus after the miscarriage
  • Complete miscarriage – a full miscarriage has occurred, and there are no products of conception left in the uterus
  • Anembryonic pregnancy – a gestational sac is present but contains no embryo
36
Q

Prevalence/ epidemiology of miscarriages?

A

Miscarriage is the most common cause of pregnancy loss and one of the most common complications in early pregnancy [Ghosh, 2021].
Early pregnancy loss accounts for over 50,000 hospital admissions in the UK each year [NICE, 2023].
It is estimated that miscarriage occurs in 8–24% of clinically recognized pregnancies
About 25% of women will experience a miscarriage in their lifetime

37
Q

RFs for a miscarriage?

A

Advanced maternal age — advanced maternal age (usually defined as age 35 years or older
Advanced paternal age
Congenital uterine anomalies
Endocrine disorders — maternal endocrine disorders, such as polycystic ovary syndrome (PCOS), diabetes mellitus, and thyroid disease
Vitamin D deficiency
Black
Smoking
Alcohol

38
Q

Investigations for a miscarriage?

A

A transvaginal ultrasound scan is the investigation of choice for diagnosing a miscarriage.

39
Q

What are the 3 key features that a sonographer looks for in an early pregnancy which appear sequentially as the pregnancy develops>

A
  • Mean gestational sac diameter
  • Fetal pole and crown-rump length
  • Fetal heartbeat
40
Q

What happens when a fetal heartbeat is visible?

A

When a fetal heartbeat is visible, the pregnancy is considered viable. A fetal heartbeat is expected once the crown-rump length is 7mm or more.

41
Q

What happens when the crown-rump length is less than or more than 7mm?

A
  • When the crown-rump length is less than 7mm, without a fetal heartbeat, the scan is repeated after at least one week to ensure a heartbeat develops
  • When there is a crown-rump length of 7mm or more, without a fetal heartbeat, the scan is repeated after one week before confirming a non-viable pregnancy.
42
Q

What is a fetal pole?

A
  • A fetal pole is expected once the mean gestational sac diameter is 25mm or more.
  • When there is a mean gestational sac diameter of 25mm or more, without a fetal pole, the scan is repeated after one week before confirming an anembryonic pregnancy.
43
Q

What is the management for a miscarriage for less than 6 weeks gestation?

A

Women with a pregnancy less than 6 weeks’ gestation presenting with bleeding can be managed expectantly provided they have no pain and no other complications or risk factors (e.g. previous ectopic)

  • Expectant management before 6 weeks gestation involves awaiting the miscarriage without investigations or treatment. An ultrasound is unlikely to be helpful this early as the pregnancy will be too small to be seen
  • A repeat urine pregnancy test is performed after 7 – 10 days, and if negative, a miscarriage can be confirmed. When bleeding continues, or pain occurs, referral and further investigation is indicated.
44
Q

What happens to miscarriages with more than 6 weeks gestation?

A

The NICE guidelines (2019) suggest referral to an early pregnancy assessment service (EPAU) for women with a positive pregnancy test (more than 6 weeks’ gestation) and bleeding

The early pregnancy assessment unit will arrange an ultrasound scan. Ultrasound will confirm the location and viability of the pregnancy. It is essential always to consider and exclude an ectopic pregnancy.

45
Q

What are the 3 options for managing a miscarriage?

A

Expectant management (do nothing and await a spontaneous miscarriage)
Medical management (misoprostol)
Surgical management

46
Q

What is expectant management in miscarriage?

A

Expectant management is offered first-line for women without risk factors for heavy bleeding or infection. 1 – 2 weeks are given to allow the miscarriage to occur spontaneously

A repeat urine pregnancy test should be performed three weeks after bleeding and pain settle to confirm the miscarriage is complete

Persistent or worsening bleeding requires further assessment and repeat ultrasound, as this may indicate an incomplete miscarriage and require additional management.

47
Q

What is the medical management for a miscarriage?

A

Misoprostol is a prostaglandin analogue, meaning it binds to prostaglandin receptors and activates them. Prostaglandins soften the cervix and stimulate uterine contractions.

involves using a dose of misoprostol to expedite the process of miscarriage. This can be as a vaginal suppository or an oral dose.

48
Q

What are the key side effects of misoprostol?

A

Heavier bleeding
Pain
Vomiting
Diarrhoea

49
Q

What are the 2 options for surgical management for a miscarriage under general or local anaesthetic?

A

Manual vacuum aspiration under local anaesthetic as an outpatient
Electric vacuum aspiration under general anaesthetic

Prostaglandins (misoprostol) are given before surgical management to soften the cervix.

50
Q

What is the electric vacuum aspiration?

A

Traditional surgical management of miscarriage. It involves a general anaesthetic. The operation is performed through the vagina and cervix without any incisions. The cervix is gradually widened using dilators, and the products of conception are removed through the cervix using an electric-powered vacuum.

51
Q

What is manual vacuum aspiration?

A

involves a local anaesthetic applied to the cervix. A tube attached to a specially designed syringe is inserted through the cervix into the uterus. The person performing the procedure then manually uses the syringe to aspirate contents of the uterus. To consider manual vacuum aspiration, women must find the process acceptable and be below 10 weeks gestation. It is more appropriate for women that have previously given birth

52
Q

What is given to rhesus negative women having surgical management of miscarriage?

A

Anti-rhesus D prophylaxis

53
Q

What is an an incomplete miscarriage?

A

Occurs when retained products of conception (fetal or placental tissue) remain in the uterus after the miscarriage. Retained products create a risk of infection.

54
Q

What are the 2 options for treating an incomplete miscarriage?

A

Medical management (misoprostol)
Surgical management (evacuation of retained products of conception)

55
Q

What is ERPC for miscarriage?

A
  • Evacuation of retained products of conception (ERPC) is a surgical procedure involving a general anaesthetic.
  • The cervix is gradually widened using dilators, and the retained products are manually removed through the cervix using vacuum aspiration and curettage (scraping).
  • A key complication is endometritis (infection of the endometrium) following the procedure.
56
Q

What is a termination of pregnancy?

A

Abortion

57
Q

What are the legal requirements for a TOP?

A

24 weeks

58
Q

An abortion can be performed before 24 weeks if …

A

continuing the pregnancy involves greater risk to the physical or mental health of:
The woman
Existing children of the family

59
Q

An abortion can be performed at any time during the pregnancy if:

A

Continuing the pregnancy is likely to risk the life of the woman
Terminating the pregnancy will prevent “grave permanent injury” to the physical or mental health of the woman
There is “substantial risk” that the child would suffer physical or mental abnormalities making it seriously handicapped

60
Q

The legal requirement for an abortion are:

A

Two registered medical practitioners must sign to agree abortion is indicated
It must be carried out by a registered medical practitioner in an NHS hospital or approved premise

61
Q

How can abortion services be accessed?

A

accessed by self-referral or by GP, GUM or family planning clinic referral. Doctors who object to abortions should pass on to another doctor able to make the referral. Many abortion services are accessed by self-referral, without the involvement of a GP or other doctor to make the referral.

62
Q

What are the 2 types of medical abortion?

A

medical abortion is most appropriate earlier in pregnancy, but can be used at any gestation. It involves two treatments:

Mifepristone (anti-progestogen)
Misoprostol (prostaglandin analogue) 1 – 2 day later

63
Q

What is Mifepristone for a medical abortion?

A

an anti-progestogen medication that blocks the action of progesterone, halting the pregnancy and relaxing the cervix.

64
Q

What is misoprostol for abortion?

A

prostaglandin analogue, meaning it binds to prostaglandin receptors and activates them. Prostaglandins soften the cervix and stimulate uterine contractions. From 10 weeks gestation, additional misoprostol doses (e.g. every 3 hours) are required until expulsion.

Rhesus negative women with a gestational age of 10 weeks or above having a medical TOP should have anti-D prophylaxis.

65
Q

What can a surgical abortion be performed under?

A

Local anaesthetic
Local anaesthetic plus sedation
General anaesthetic

66
Q

Prior to a surgical abortion what is given?

A

medications are used for cervical priming. This involves softening and dilating the cervix with misoprostol, mifepristone or osmotic dilators. Osmotic dilators are devices inserted into the cervix, that gradually expand as they absorb fluid, opening the cervical canal.

67
Q

What are the 2 options for a surgical abortion?

A
  • Cervical dilatation and suction of the contents of the uterus (usually up to 14 weeks)
  • Cervical dilatation and evacuation using forceps (between 14 and 24 weeks)
68
Q

What should rhesus negative women having a surgical TOP have?

A

should have anti-D prophylaxis. The NICE guidelines (2019) say it should be considered in women less than 10 weeks gestation.

69
Q

What is post abortion care?

A

Women may experience vaginal bleeding and abdominal cramps intermittently for up to 2 weeks after the procedure. A urine pregnancy test is performed 3 weeks after the abortion to confirm it is complete. Contraception is discussed and started where appropriate. Support and counselling is offered.

70
Q

Complications of Termination of pregnancy?

A

Bleeding
Pain
Infection
Failure of the abortion (pregnancy continues)
Damage to the cervix, uterus or other structures

3A Womens health (33 decks)

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