Implantation and early pregnancy Flashcards
What hormone does the corpus luteum produce?
The corpus luteum produces progesterone (remember: pro- (for) -gest- (getation) -erone (hormone) i.e. the hormone for the gestation)
What prevents the corpus luteum from atrophying when there is aconception?
The implanted blastocyst produces hCG which prevents the corpus luteum from disintegrating.
After around 8 weeks, the placenta takes over progesterone production and the corpus luteum atrophies.
At what stage can a TVUSS detect a foetal heart beat?
The foetal heart beat can be detected from 5.5 weeks, but in some cases might be later.
How do you define miscarriage?
A miscarriage is a pregnancy that ends spontaneously before 24 weeks.
What is the most common sign or miscarriage?
Vaginal bleeding and abdominal pain.
How common are miscarriages?
Miscarriages occurs in 10-20% of clinical pregnancies.
The risk decreases with gestational age (1:5 in the first 3 months).
Age is an improtant risk factor:
- age 30 the risk is 1:5
- age 40 the risk is 1:2
Medical problems such as diabetes, and lifestyle factors such as smoking, obesity and EtOH consumption all also increase the risk of miscarriage.
How can miscarraiges be classified?
Miscarriages can be classified based on clinical presentation and investigational findings.
Thretened miscarriage:
- Intrauterin pregnancy with FH
- Vaginal bleeding + abdo pain
- Os closed
Inevitable miscarriage:
- Intrauterine pregnancy, no FH
- Vaginal bleeding + abdo pain
- Os open
Incomplete miscarriage:
- Retaine products of conception
- Vaginal bleeding + abdo pain
- Os open, products of conspetion located in Os
Complete miscarriage:
- Uterus empty (do hCG to exclude ectopic)
- Pain and bleedin, resolved
- Os closed
Missed miscarriage:
- Intrauterine pregnancy, no FH
- No symptoms
What is the underlying aetiology behind miscarriages?
- Chromosomal abnormalities
- Medical/endocrine disorders
- Uterine abnormalities
- Infections
- Drugs/chemicals
What investigations would you consider in a women that is at risk of, or has already miscarried?
- Take an ABC approach and ensure that the patient is haemodynamically stable as well as basic observations (?temp). Also important to perform an abdomino-pelvic examination and a urine pregnancy test. Other investigations include:
- Transabdominal/TVUSS - a single ultrasound scan can diagnose a miscarriage if indicated.
- Haemoglobin and ‘Group and Save’ (or cross-match if the patient is severely compromised.
- Rhesus status
How do you manage a woman that is miscarrying in secondary-care services?
In threatened miscarriage, there is a high chance of the pregnancy continuing. Reassure the woman and advise her to abstain from sex and strenous exercise and relax at home. Safety net her that in case bleeding starts again she needs to com in.
Expectant: (50% successful)
- For inevitable, incomplete and missed miscarriage
- Wait for pain and bleeding to resolve
- Advise to take pregnancy test again after 3 weeks; no need for follow up scan
- Safety-net that if bleeding starts again/becomes heavy they need to attend again
Medical Management: (85% successful)
- For inevitable, incomplete and missed miscarriage
- Increaseingly done in outpatient setting, so that women can miscarry at home
- Administration of single dose of vaginal misoprostol (prostaglandin analogue)
- Side effect includes Vomiting and diarrhoea -> Give antiemetics + analgesia
- No need for follow up scan
- Again, safety net
Surgical management: (95% successful)
- For inevitable, incomplete and missed miscarriage
- Usually recommended if there is persistent excessive bleeding or haemodynamic instbility
- Usually manual vacuum aspiration under local or general anaesthetic or dilation and curretage
- Can give misoprostol to ripen cervix beforehand
All women should be offered counselling to address the emotional distress of miscarrying.
How do you manage a woman who is miscarrying in primary care services?
If a woman presents with bleeding or any other symptoms suggestive of an early pregnancy complication:
- Take ABC approach and arrange immediate ambulance transfer if the patient has signs of haemodynamic instability, or if there is significant concern about the degree of bleeding or pain.
- If immediate hospital transfer is not indicated, confirm pregnancy with urine pregnancy test.
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Check for signs of ectopic pregnancy if the patient has symptoms of ectopic pregnancy.
- If the patient has abdominal pain or tenderness, pelvic tenderness or cervical motion tenderness: refer the patient to an early pregnancy assessment unit (EPAU).
- If there are no signs of an ectopic pregnancy, and the patient is 6 or more weeks pregnant or of uncertain gestation: refer the patient to an early pregnancy assessment unit (EPAU).
- If there are no signs of an ectopic pregnancy, and the patient is less than 6 weeks pregnancy and is bleeding without pain, consider expectant management. Advise the patient to perform a urine pregnancy test 7-10 days after, and to return if still positive. If still positive, refer to EPAU.
What are the complications of evacuation of retained products of conception after miscarriage (i.e. surgical management) and how common are they?
When describing risk the RCOG recommends certain terminology to be used (see image).
Bleeding:
- Common for up to 2 weeks
- Uncommon (0-3/1000) is heavy bleeding that requires transfusion
Infection:
- Localised pelvic infection
- Common (40/1000)
Retained placental/foetal tissue
- Common (40/1000)
- Might lead to repeat surgery requried (3-18/1000)
Perforation
- Uncommon (1:1000)
- mostly small and clinically insignificant
- Rarely requires transformation to laparoscopy
What happens to the foetal tissue that is removed in evacuation of retained products of conception after miscarriage?
Some tissue is sent for lab diagnosis to exclude ectopic pregnancy and molar pregnancy.
After this, the hospital can offer cremation or in some cases can hand the tissue back so that the couple can have a burial and there is a book or rememberance at most hospitals.
The couple can choose if they want to receive a call when the foetus is cremated.
What do you need to warn women after miscarraige about?
There might be heavy bleeding for 1-2 weeks post miscarraige, which might be browin in colour.
Use sanitary pads and NOT tampons (as they increase the risk of infection).
Safety net that if there is prolonged bleeding, smelly vaginal discharge, fever or abdominal pain the woman needs to come back for a check up.
This is the case for all managment options of abortions.
What is defined as recurrent miscarriage?
How common is this?
The loss of ≥3 consecutive pregnancies.
Around 1% of couples are affected.
Note that even if the woman had just 1 miscarriage, her changes of keeping her subsequent pregnancy are slightly reduced.
What is the most common location for ecotpic pregnancies?
>98% of ectopic pregnancies happen within the Fallopian tubes (where the Ampulla is the most common place, 80%). Isthmus (12%) fimbrial end (5%) are also possible.
Isthumus is a dangerous type of ectopic pregnancy, as rupture is more likely.
Non-tubal ectopics are rare, but include cervical and ovarian.
