Gynae: early pregnancy bleeding (miscarriage and ectopics) and ToP Flashcards
A 25 year old lady comes into A&E with bleeding. She is 8 weeks pregnant. What should you ask about when exploring HxPC?
•How many weeks pregnant are you?
o Ectopics usually symptomatic by 10 weeks o Miscarriage is most common before 15 weeks; after 24 weeks it is classified as “stillbirth”
•Can you tell me more about what happened?
•Bleeding – amount? What was it like? Offensive discharge? •Pain? – NB major differential = ectopic
•Has everything been normal so far in this pregnancy?
o Hyperemesis? (in molar pregnancy)
o No illnesses?
o No trauma?
o Normal scans? (if after 10-14 weeks).
o Foetal movements? (Normal = 13-25 weeks)
•Have you felt foetal movements today?
What other Sx should you ask about?
- Discharge?
- Pelvic pain, fever?
- Syncope, shoulder tip pain, anuria, collapse?
What background Hx is relevant to this case?
- Past gynaecological history – previous operations, STIs, pelvic disease, abnormal smears
- Past obstetric history – previous ectopics, miscarriages? •FHx: clotting/PEs/DVTs/thrombophilias
- DHx (including contraception – coil?), SHx (smoking, drinking)
Outline the physiology of early pregnancy (fertilisation to placental formation
- Egg fertilised in fallopian tube and becomes zygote
- Day 3-4: formation of morula (each cell is totipotent)
- Day 5: 1st differentiation makes inner (epiblast and hypoblast) and outer (syncytiotrophoblast and cytotrophoblast) layers and get formation of blastocyst
- Day 5-6: implantation – trophoblast interacts with endometrium (which controls invasion)
- By end of week 2: conceptus has implanted, embryo has 2 cavities (amniotic and yolk) and is suspended by stalk.
- HCG is produced by syncytiotrophoblast and supports secretory function of corpus luteum. Found in maternal blood 7-12 days after conceptions and tests positive in urine after 2 weeks.
- Heartbeat starts 4-5 weeks, visible on US at 6 wks
- Placenta formed at 12 weeks
What is your differential for this lady?
Miscarriage, ectopic, molar pregnancy
What are the different types of spontaneous miscarriage?
- Threatened- bleeding by foetus still alive, os closed, uterus right size for dates. Only 25% miscarry. Light PV bleeding and no pain
- Inevitable- Heavier bleeding with clots and pain. Although fetus may still be alive, cervical os is open, about to miscarry.
- Complete- All fetal tissue passed, cervical os closed, uterus no longer enlarged, bleeding diminished
- Septic- Contents of uterus infected giving endometritis. Offensive vaginal loss, fever can be absent. May be abdo pain and peritonism.
- Missed- A gestational sac which contains a dead fetus before 20 weeks without the symptoms of expulsion - fetus not developed, or has died, but it isn’t recognised until bleeding occurs/ USS. Uterus is small for dates and os is closed.
What Ix would you like to order?
- Pregnancy test with quantitative beta-HCG. Blood hCG- increases 66% in 48hrs with a viable pregnancy (differentiate from an ectopic)
- An urgent TVUS to assess foetal viability and also confirm the presence of an intrauterine pregnancy.
- FBC, G and S.
How would you manage this lady if she was having a miscarriage?
Management depends on stability of patient - If patient is unstable, admit and monitor in hospital
•Conservative: send patient home and book TVUS in 2/52 to rescan and identify retained PoC o Woman must have 24h access to gynae service
o Advantages: avoids risks of surgery/medication and pt can be at home
o Disadvantages: pain and bleeding can be unpredictable/v distressing, takes longer, may be unsuccessful
•Medication: misoprostol (prostaglandin)
o Advantages: avoids surgery and can potentially be done as outpatient
o Disadvantages: pain/bleeding may be distressing, drug S/Es (cramping) and may still need SERPC
•Surgery: use of suction curette to empty uterus under GA
o Advantages: planned procedure, day case, patient is asleep
o Disadvantages: perforation, damage to cervix, Asherman’s (scar tissue forms inside of uterus/cervix), anaesthetic risk
Suggest three drugs you could prescribe for post-SERPC analgesia
Paracetamol: 1g PO every 4hours, max 4g/day
Co-codeamol: 8/500 or 16/1000 PO route max 64/4000mg/day
NSAIDs: 400mg PO, max 4 doses/day
How would you investigate a couple with recurrent miscarriages?
- Autoimmune disease such as the antiphospholipid syndrome= thrombosis in uteroplacental circulation, (Screen woman for antiphospholipid abs [need 2+ve tests at least 3 months apart for either lupus anticoagulant or anticardiolipin Abs] – if positive treat with 150mg aspirin and LMWH)
- Thrombophilia: factor V Leiden, Fact II gene mutation and protein S deficiency - LMWH
- Chromosomal defects-refer to clinical geneticist, offer prenatal diagnosis (CVS/ amniocentesis)
- Anatomical uterine abnormalities
- Cervical incompetence (late miscarriage, more preterm labour): may need cerclage
- Infection (preterm labour and late miscarriage)
Obesity, PCOS, smoking and higher maternal age also confer a risk.
Investigations include autoimmune and thrombophilia screen, karyotyping of both parents and of products of conception, and pelvic USS.
What are Sx/history findings of an ectopic pregnancy?
- Lower abdo pain: usually 1st Sx, pain is usually constant and may be unilateral – due to tubal spasm
- PV bleed: usually less than normal period – may be dark brown in colour
- Hx of recent amenorrhea: typically 6-8 weeks from start LMP
- Peritoneal bleeding can cause should tip pain and pain on defecation/urination
What are examinations and Ix findings in an ectopic pregnancy?
- Abdo tenderness
- Cervical excitation
- Adnexal mass: NICE advice NOT to examine for adnexal mass due to increased risk of rupturing the pregnancy – should only do a pelvic exam to check for cervical excitation • USS showing an empty uterine cavity.
- Quantitative hCG is high and rising by less than 66% in 48h. (If it is low but rising this suggests an intrauterine pregnancy which is too early to visualise on USS (<5 weeks.)
- Urine for preg +ve test.
How would you manage this lady if you suspected an ectopic pregnancy?
An acute presentation is an obstetric emergency
- ABCs, large-bore IV cannula, bloods (FBC, coagulation and G+S).
- Conservative/Expectant management can be used if the ectopic is small (<35mm), no heartbeat and un-ruptured and the bHCG is declining
- Medical management: If small and un-ruptured with no cardiac activity, bHCG<1500, no pain single-dose methotrexate can be used but patient must be willing to return for f/u
- Surgical management: laparoscopic salpingostomy (where there is risk of infertility) or salpingectomy if ectopic is larger than 35mm, there is a heartbeat present, there is severe pain, if bHCG >1500 or if patient is unstable.
*Rhesus-negative women should be given anti-D. Patient support
**Misoprostol and mifepristone are not used in the management of ectopic pregnancy.
What is a molar pregnancy, and how would you investigate and manage it?
- Implantation of an abnormal blastocyst – results in excess hCG. Blastocyst may be incomplete (46XX, usually due to one sperm fertilising an empty ovum and undergoing mitosis) – means there is no foetal tissue and just proliferation of swollen chorionic villi.
- There is a significant risk of malignant transformation to an invasive mole (local) or choriocarcinoma (mets).
- Ix: Characteristic ‘snowstorm’ appearance on US, confirm histologically
- Mx: curettage, with monitoring of hCG to detect incomplete removal, or carcinogenesis. Chemotherapy is very successful even in disseminated disease (~100% cure)
Outline the key points on the current law on abortion
- Two registered medical practitioners must sign a legal document (in emergency only 1 needed)
- Only a registered medical practitioner can perform an abortion, which must be in a NHS hospital/licensed premise
- Upper limit is 24 weeks gestation
