Gynae Protocol Flashcards
Miscarriage management
Expectant
Medical
Surgical
Expectant management miscarriage
- wait and watch for 7-14 days for the expulsion to occur naturally
Consider other management if
- woman has coagulopathy or no blood transfusion available
- history of still birth, missed miscarriage
- risk of haemorrhage (late 1st tri)
- risk of infection
- less than 6weeks of preg with bleeding but no pain, advise for preg test after 7 days
Medical management miscarriage
Misoprostol (cytotec)
1tab is 200mg
- Missed- 800mg pv 2doses 6hrs apart
- incomplete 600mg oral 1dose
- induced (13-22wks)- 400 mg pv 3hrly
- IUD
200 if 13- 17 wks pv 6hrly
100 if 18- 26 wks pv 6hrly
25-50 if more than 26wk pv 4hrly - induction of Labour 25mg pv or 50mg orally 4hrly
-pph prophylaxis- 800mg perrectal
-pph treatment- 1000mg perrectal
-cervical ripening- 400mg pv 3hrs before op
Reduce dose if c-sec scar present
Surgical management miscarriage
1- MVA AND DNE
2- Surgical uterine evacuation for excessive vaginal bleeding, hemodynamic instability, evidence of infected retained tissue and suspected gestational trophoblastic disease
3- misoprostol 3hr before
4- send products of conception for histo path
5- 1gram azithromycin I/v or oral + metronidazole 500mg iv before procedure
6- grief councelling
Labs for miscarriage
1 cbc
2 tvs (pelvis)
3 blood group rh factor (give 250iu antiD if more than 12 weeks and -ve)
4 coagulation profile
5 hepBsag and hep C
6 seria BhcG weekly until negative
Recurrent miscarriage history
3 or more miscarriages. 1% incidence
History
- prev miscarriage history number and age
- hx of prev cervical surgery
- history of painless cervical dilatation
- was fetal heartbeat confirmed at the time of miscarriage
- congenital uterine malformations
-APLA
- thyroid disorders
- thrombophelia
- vaginal Infections
- PCOS
MCC of recurrent miscarriages
6-8 wks chromosomal abnormalities
8-12 IUD APLA thrombocytopenia
12-24 cervical weakness, (anatomical defects) vag infections, uterine abnormalities
Labs for recurrent miscarriages
1- cbc
2- blood group th factor
3- tvs
4- anti phospholipid antibodies
5- rubella serology ig
6- HVS for c/s
7- day 2 LH FSH
8- laparoscopy hysteroscopy
9- screaming for APLA, factor 5 Leiden deff, thrombophilia, protein S
10- paternal peripheral karyotyping for both parents
11- histo path of products of conception of 3rd miscarriage.
Management for recurrent miscarriages
1 reassurance and councelling
2 folic acid 400ug 3 months before conception
3 low dose aspirin and LMWH for APLA and thrombophilia
4 clinical geneticist for karyotypical abnormalities
5 cervical cerclage offered for cervical incompetence
60-70 percent chance after 3
45 percent chance after 6
Ectopic pregnancy
It is defined as an implantation of a fetus outside the normal uterine cavity
11.1/1000 pregnancies)
Fallopian tubes 95%, Ovaries 3%, and Peritoneal cavity 1%
RISK FACTORS:
Previous ectopic pregnancy
Pelvic infections especially chlamydia infection (40%)
Pelvic inflammatory disease
Previous tubal surgery
Subfertility
Use of assisted reproductive techniques
Ectopic cp
Unruptured ectopic —- lower abdominal pain, mild vaginal bleeding, May be asymptomatic
Ruptured ectopic— severe lower abdominal pain, shoulder tip pain, epigastric pain or shock Common
Symptoms:
abdominal or pelvic pain
amenorrhoea or missed period
vaginal bleeding with or without clots
More common signs:
pelvictenderness
adnexaltenderness
abdominaltenderness
Labs for ectopic
1 cbc
2 rbs
3 serial bhcg
4 tvs
5 urine dr
6 hep c Hbsag
Ectopic ultrasound for fallopian tube
1- Adenexal mass moving separate from ovary with gestational sac containing a yolk sac - sliding sign
2- adnexal mass moving separately form ovary with empty gestational sac - bagal sign
3- empty uterus
4- collection of fluid in uterine cavity
Expectant management for ectopic done in?
1- are able to return for follow up
2- bhcg less than 1000IU/L
3- adnexal mass less than 4cm
4- tubal ectopic less than 35mm w no heartbeat
5- haemodynamically stable pt
6- less than 100ml free fluid in pelvis
Expectant management in ectopic
hCG should be 50% less after 7 days
1- 2x weekly serial bHcG, then at 2,4,7 days. Reduce by 15%, then do weekly till less than 20IU/L
2- TVS weekly - adnexal mass reduction w/I 7 days
3- council for compliance
4- council for ectopic
If values don’t decrease seek consultation
Medical management for ectopic
Methotrexate - an anticancer anti folate agent.
Do LFT RFT CBC before
Single IM inj calculated from patients, body surface area as 50mg/m2. ( mostly will be between 75 mg and 90 mg or 1mg/kg.)
Criteria
1- bhcg less than 3000IU (can be 1500-5000)
2- mass less than 4cm
3- no contraindication for metho
4- unruptured ectopic
5- no fetal heartbeat
6- heamodynamically stable
7- pt compliance for follow up
IN/CI for medical m in ectopic
INDICATION
Cornual pregnancy,
Persistent trophoblastic disease
Patient with one fallopian tube and fertility is desired
Patients who refuses surgery or in whom risk of surgery is too high
Cervical Ectopic pregnancy.
CONTRAINDICATION:
Chronic liver, renal and haematological disorder
Active infection
Breast feeding
Immunodeficiency
Surgical management for ectopic
If Serum βhCG is >3000IU/L
Patient is symptomatic
1- Salpingotomy
Removal of conceptus with conservation of tubes done in women with diseased contra lateral tube and fertility desired.
In women with history of fertility reducing factor e.g.
Previous Ectopic pregnancy
Contra lateral tubal damage
Previous abdominal surgery
Previous (PID).
2- Salpingectomy
Removal of tube in the presence of healthy contra lateral tube can be done by two methods;
- laptoscopic
Haemodynamically stable patient
No h/o previous surgeries
Unruptured ectopic
Adnexal mass<4cm
- laprotomic
Haemodynamically unstable
Ruptured ectopic
Previous surgeries
Expertise for laparoscopy is not available
Investigations for molar pregnancy
1- cbc
2- Blood group rh factor
3- Bhcg
4- TVS
5- Thyroid profile
6- Urea creatinine electrolytes
7- Chest X-ray
Treatment of molar pregnancy
- Suction curettage
- Anti-D prophylaxis in Rh negative mother
- Use of Oxytocin infusion prior the evacuation is not recommended.
- Follow up with serial beta HCG
- Provide written information about the condition.
Follow up molar pregnancy
Complete mole-
BhcG tested (if reducing)
- weekly for first 4 weeks (28)
- fortnightly for next 4 weeks (56)
- monthly till 6 months complete
If HCG has not reverted to normal within 56 days then follow-up will be for 6 months from normalization of the HCG level.
Partial mole- normal hcg on 2 samples 4weeks apart then stop
Notify for future pregnancy
Retake bhcg 6-8 weeks after next pregnancy
Pregnancy after molar
No chemo- can after 6 months of bhcg being Norma
W chemo- after 1 year of treatment
Barrier method until Normal hcg levels
COCP after hcg levels are normal
NO iucd - risk of uterine perforation
HMB history and exam
History-
Cycle, passage of clots, dysmenorrhea
Post coital bleeding, inter menstrual bleeding.
Signs and symptoms of thyroid, bruising and drug intake of anticoagulants.
Comorbidity and quality of life
Exam-
GPE- anemia bruising patechiae goiter
PA- mass
P/S- polyp fibroid cyst
P/V- uterine size and adnexa
Labs for HMB
1- CBC
2- TVS
3- THYROID FT
4- Coagulation profile
5- Endometrial sampling (biopsy)
6- Hysteroscopy if u/s indecisive
Pipelle or DNC
Indications for a biopsy include
I. Persistent intermenstrual bleeding
II. Women aged 45 and over
III. Treatment failure or ineffective treatment
