Gynae - early pregnancy Flashcards
what is a threatened miscarriage?
Symptoms - There is bleeding but
tvus - the fetus is still alive, IUP
abdo exam - the uterus is the size expected from the
dates and
speculum - the cervical os is closed (Fig. 14.3a). Only 25% will go on to miscarry.
what is an inevitable miscarriage ?
Inevitable miscarriage refers to the presence of an open internal os in the presence of bleeding in the first trimester of pregnancy.
speculum - the presence of an open internal os in the presence
sx - of bleeding in the first trimester of pregnancy.
Bleeding is usually heavier. Miscarriage is about to occur.
tvus - the fetus may still be alive, or products non-viable but still in utero
what is a complete miscarriage?
TVUS - All fetal tissue has been passed. epmty uterus
Symptoms - initial Bleeding and passage of fetal products (clots)
eventually - bleeding has diminished,
Abdo palpation- the uterus is no longer enlarged
cervix - the cervical os is closed.
what is a septic miscarriage?
The contents of the uterus are infected, causing endometritis.
Vaginal loss is usually offensive, the uterus is tender, but a fever can be absent.
If pelvic infection occurs there is abdominal pain and
peritonism.
What is a missed miscarriage?
tvus - The fetus has not developed or died
in utero: no heart beat, empty gestational sac
sx - but this is not recognized until bleeding occurs
or ultrasound is done
abdo exam - The uterus is smaller than
expected from the dates and
speculum - the os is closed
what causes miscarriage ?
1 off miscarriage - 60 % due to chromosomal abnormalities - specifically UNBALANCED translocation
Recurrent miscarriage - antiphospholipid syndrome ….etc
in whiich miscarriage may you not get bleeding?
missed miscarriage - usually incidental find
how would you investigate a miscarriage?
History
Examination : for uterine size (abdo palpation?), cerviical os opening (speculum)
Refer to EPAU - ultrasound
Why is the LMP and cyclee regularity important in early pregancy?
on tvus non-viable pregnancies can be confused with
a very early pregnancy, especially where the date of the
last menstrual period is uncertain or periods irregular.
define PUL?
When a woman has a + urine pregnancy test
But on TVUS
the uterine cavity is empty and no abnormal adnexal masses or fluid (blood) can be visualised
in case of PUL how can we predict a VIUP?
hCG levels in the blood normally increase
by >63/66% in 48 hours with a viable intrauterine pregnancy
in case of PUL how can we predict a EP?
In 48 hours if riise of hcg is less than 63/66% this is suggestive of ectopic pregnancy.
hcgs often risee into 1000’s - not technically a criteria
in case of PUL how can we predict a Failed PUL?
In 48 hours if riise of hcg is more than 13% drop in Hcg b
how do you ivx a PUL?
Haemodynamically stable + no pain:
- Expectant management (serial hcg’s at 0&48hrs)
Haemodynamically stable + pain:
- Serum hCG
- Consiider laparoscopy
Haemodynamically unstable + pain:
- laparascopy or laparotomy
when hcg ratios are calculated, what is the follow up based on the risks?
Low risk: Failed PUL
- repeat UPT in 2 weeks
Low risk: Viable IUP
- repeat TVUS 7 days
High risk: Ectopic
- Repeat hCG and/or TVUS in 48hrs
which events in eearly pregnancy can warrant admission?
Suspected ectopic pregnancy - if symptomatic (mortaility is from haemorrhage)
Septic miscarriage
Heavy bleeding in miscarriage
in the management of miscarriage, when is Anti-D given?
Anti-D is given to women who are rhesus negative
if the miscarriage is treated surgically or medically
or if there is bleeding after 12 weeks’ gestation.
how is an ectopic preegnancy confirmed ?
laparoscopy
define recurrent miscarriage?
Recurrent miscarriage is when three or more miscarriages occur in succession;
1% of couples are affected.
If a woman is known to have recurrent miscarriages, how will you manage future pregnancy?
- Need clear management plan for US monitoring
- Managed as high risk; need hiigh risk monitoring
- Treatment for the cause eg aspirin + lmwh if APL antibodies
(obvi hopefully tests have been done to identify cause
after last miscarriage)
what is antiphospholipid syndrome?
what effect does it have on pregnancy?
Is an autoimmune, hypercoagulable state caused by antiphospholipid antibodies.
APS provokes blood clots (thrombosis) in both arteries and veins ->
miscarriage, stillbirth, preterm delivery, and severe preeclampsia.
what is the diagnostic criteria for APL syndrome?
The diagnostic criteria require one clinical event (i.e. thrombosis or pregnancy complication)
and two positive blood test results spaced at least three months apart that detect :
lupus anticoagulant,
anti-apolipoprotein antibodies, or
anti-cardiolipin antibodies.
if some1 has Antiphospholipid antibodies / APLS, how arethey treated?
Managed as high risk; need hiigh risk monitoring
aspirin + low dose lmwh
list the causes of recurrent miscarriage? how are they identiified?
APL antibodies
- early and late
Chromosomal defects
- karyotype fetal miscarriage tissue - UB translocation ->
karyotype parents
- early miscarriage
Uterine abnormalities
- US followed by MRI orr hysterosalpingorgram
- late miscarriage >16 wks
Infection
- early and late
Hormonal:
- thyroid autoantibodies
Others:
Obesity, smoking and excess caffeine intake
have been implicated and should all be addressed.
if parents are found to have chromosomal defects, how do we manage this?
Refer to clinical geneticist for advice and support
Prenatal diagnosis using chorionic villus sampling (CVS) or amniocentesis is offered.
The use of donor oocytes or sperm (all donors are routinely karyotyped) or preimplantation genetic diagnosis (PGD) of IVF embryos
what is a late miscarriage ?
fetal loss after 16weeks gestation
