Miscarraige and Ectopic Pregnancy Flashcards
How is miscarriage defined?
PV Bleeding before 24 weeks gestation
Threatened Miscarriage
Cervical os is closed, foetal heartbeat on USS and uterus at expected size for gestation
25-50% of these women will go on to miscarry
Inevitable miscarriage
Cervical os is open and membranes are bulging/pregnancy tissues coming out
Foetal heartbeat on US
Incomplete miscarriage
Products of conception have been partially expelled but some are retained
Complete miscarriage
all products of conception have been expelled
Missed miscarriage
Foetus is dead but retained-os is closed
Investigation
Haemodynamically unstable then send to A&E and resuscitate
Haemodynamically stable then send to Early Pregnancy Assessment Unit.
Do speculum to see if os is open
USS to establish if there are retained products or foetal heartbeat
FBC, coagulation profile and rhesus group
Causes of empty uterus: ectopic, complete miscarriage, pregnancy too early to see
Management of miscarriage
Expectant (conservative): Allow miscarriage to progress naturally. Should be complete within around 2 weeks and urine test should follow at around 21 days
Medical: Misoprostol, urine test at 21 days
Surgical management: Evacuation of retained products of conception
Products of conception should be sent to lab for analysis
What is recurrent miscarriage
Recurrent miscarriage is where a patient has 3 or more consecutive miscarriages.
Causes of recurrent miscarriage
- Genetic abnormalities, usually chromosomal e.g. parental balanced Robertsonian or reciprocal translocation
- Antiphospholipid syndrome
- Uterine structural abnormalities
- Inherited thrombophilia states
Investigations of recurrent miscarriage
- Antiphospholipid and ß2-glycoprotein antibodies
- Factor V Leiden, prothrombin/protein S/protein C mutation
- USS of the uterus
- Karyotyping of the woman and her partner
What is a molar pregnancy?
Molar pregnancy occurs where there is more paternal genetic material in the embryo than maternal. There are two forms
- Partial molar is where there is a triploidy i.e. the egg was simultaneously fertilised by two sperm
- Full molar is where there is diploidy i.e. an empty ovum was fertilised by two sperm
Consequences of molar pregnancy
The excess paternal genetic material results in increased proliferation of the trophoblasts of the placenta. This leads to the following features
- A larger uterus than gestational dates (due to large placenta size)
- PV bleeding
- High ß-hCG levels leading to hyper-emesis
It usually presents as miscarriage with USS showing a ‘bunch of grapes’ appearance to the placenta, this must be managed surgically.
Where molar pregnancy is identified there must be follow-up to exclude the development of choriocarcinoma
- Advise the patient not to become pregnant for 6 months
- Measure serum ß-hCG levels at 56 days, this should be at nadir. If ß-hCG is still detectable, treat the patient with methotrexate
Pregnancy of Unknown Location
If the uterus is empty on scanning in a patient presenting with PV bleeding this could indicate an ongoing pregnancy <6 weeks, ectopic pregnancy, or complete miscarriage
Serial serum hCG measurement (48 hours apart) should be undertaken
- >63% increase indications ongoing pregnancy
- >50% decrease indicates complete miscarriage
- <50% decrease to <63% increase requires further assessment to exclude ectopic pregnancy
What is an ectopic pregnancy
Ectopic pregnancy by definition is pregnancy outside of the uterus
- The ampullary and isthmic portions of the Fallopian tubes are the commonest sites
- Rarer sites include cervical, fimbrial, ovarian, and peritoneal
