Miscarriage and early pregnancy Flashcards
Causes of bleeding in early pregnancy
Miscarriage
Molar pregnancy
Ectopic
Polyps
Vaginitis
Trauma
Cervical ectropion
Woman comes in with bleeding in early pregnancy what is management
If has
- abdo pain/tenderness
- pelvic pain or tenderness
- cervical motion tendernss
REFER immediately to early pregnany unit
Over 6 weeks pregnant then REFER
Under 6 weeks with no RFx for ectopic, pain or tenderness then repeat pregnancy test in a week and return if postive, negative or bleeding continues
What investigations will be done in early pregnancy unit for suspected miscarriage
Transvaginal USS
If it can’t be located can consider
- more TVUSS
- serial bHCG
- laparascopy if suspect ectopic
What do if location of a pregnancy can’t be found but suspect ectopic
Laparoscopy
What is first line for miscarriage
Expectant management UNLESS
- has infection
- coagulopathy or won’t have transfusion
- end of first trimester
- previous traumatic experience with a pregnancy
What is it when have vaginal bleeding early in pregnancy but fetal heart beat found
Threatened miscarriage
What does expectant management of miscarriage involve
Analgesia
Safety net about when to return
- if bleeding stops then do a pregnancy test in 3 weeks and return if positive
- if bleeding worse or persisting after 14 weeks then do a repeat scan and probable medical management
When do medical management of miscarriage
Expectant management not appropriate or 14 days of expectant did not work
What does medical management of miscarriage involve
Oral or vaginal misoprostol
Do pregnancy test in 3 weeks and return if positive
When would consider surgical management of miscarriage
Medical management did not expel products of conception
Option after expectant management did not work
What does surgical option for miscarriage involve
Either manual vacuum aspiration under LA
Surgical under GA
Given anti-d IG if rhesus negative unless complete or threatened miscarriage
What is difference between early and late miscarriage
Early- before 13 weeks
Late- 13-24 weeks
What are the different types of miscarriage
Complete- all products of conception have been expelled
Incomplete- bleeding has begiu but products of conception still there
Missed- when baby has died and evident in uterus with closed OS
Threatened- bleeding has begun but is still a viable pregnancy
Inevitable- heavy bleeding and clots with an open cervical os
What defines recurrent miscarriage
3 consecutive before 24 weeks gestation
How to follow-up someone who has had miscarriage
Can have sex when symptoms stop
Assess if want to get pregnant
- can get pregnant in 6 weeks
- if doesnt want to then offer contraception
Assess psychological side
Check anti-d IG was given
When offer referral for investigations for recurrent miscarriage
3 miscarriages before 10 weeks gestation
1 miscarriage after 10 weeks
What investigations are done for recurrent miscarriages
Anti-phospholipid antibodies
TVUSS to assess for structural problems
Genetic testing of both partners
Investigate foetal tissue if possible
If someone has known anti-phospholipid how treat during pregnancy
Low dose aspirin and LMWH as soon as becomes pregnant
How does misoprostol work
Prostaglandin analogue which causes contraction of myometrium
What happens to cervical os in different types
Complete- closed
Threatened- closed
Incomplete- open
Missed- closed
Inevtiable- open
What is hyperemesis gravidarum
Describes severe symptoms of nausea and vomiting of pregnancy
Rfx for nausea and vomiting of pregnancy
Multiple pregnancies
Trophoblastic disease
Nulliparity
Obesity
Fhx
How is nausea and vomiting of pregnancy diagnosed
If onset in first trimester of pregnancy and other causes of N&V excluded
What differs hyperemsis gravidarum from NVP
Severe vomting associated with all of
- dehydration
- electrolye imbalances
- 5% weight loss from pre pregnancy weight
How is severity of nausea and vomiting of pregnancy diagnosed
Pregnancy unique quantification of emesis
When does hyperemesis gravidarum typically come on and what is progression
Starts between 4-7th week
Peaks at 9th and finishes by 20th
What differentials should be excluded for NVP
Peptic ulcers
Hepatitis
Pancreatitis
Genitourinary conditions
Metabolic
Neuro
Drug induced
What should be done if severe abdo pain and vomiting or epigastric pain in pregnancy
Amylase levels
USS
OGD maybe
H pylori antibodies
Management of NVP in community
Assess if need for admission
If not able to tolerate oral fluids or anti-emetics then refer to ambulatory care
First line anti-emetics- H1 antihistamines or phenothiazines
Second line anti-emetics- ondensatron or metoclopramide
Recommend ginger and oral hydration
First line anti-emetics for NVP
Anti-histamines- cyclizine or promethazine
Phenothiazines- propchlorperazine or chlorpromazine
Second line anti-emetics for NVP
Ondensatron
Metoclopramide (do not use for over 5 days)
Problems of phenothiazines and metoclopramide as NVP
Extrapyramidal SEs in which case cessate immediately
Problem with ondensatron for NVP
In first trimester associated with cleft palate
Complications for NVP
Dehydration
Electrolye imbalances
Weight loss
Wernickes
AKI
Oesophagitis
Mallory-weiss tear
Very few risks to baby unless dont catch up weight in which case can get LBW
When admit for NVP/HG
Not able to keep down liquids
Continued N&V leading to weight loss over 5% or ketonuria despite oral anti-emetics
Confirmed or suspected comorbidity like not being able to tolerate abx
What fluids are used for HG
Saline with potassium chloride
What are options once admit for HG
Fluids- saline with KCl
Parenteral feeding- dextrose and thiamine supplements
Anti-emetics deliverd subcut or rectal
Do USS if haven’t had dating scan to rule out gestational trophoblastic disease
LMWH for VTE risk
Causes of miscarriage
Foetal chromosomal abnormalities- most common
Poorly controlled DM, thyroid disease, uterine abnormalities
Smoking
Drugs
Causes of recurrent miscarriages
APL- most common
Poorly controlled DM, PCOS, thyroid problems
Uterine abnormalities
Parental chromsomal abnormalities
Smoking
Factors associated with miscarriages
Alcohol
Obesity
Maternal age
Drug use
Caffeine
Uncontrolled health conditions
Uterine or cervical incompetence
What are the different types of gestational trophoblastic disease
Complete hydatidiform mole
Partial hydatidiform mole
Choriocarcinoma
What is pathophysiology of a complete hydatidiform mole
Where an empty egg is fertilised by a sperm which then duplicates its genetic material forming 46 chromosomes
All genetic material belongs to father
What is pathophysiology of partial hydatidform mole
Occurs when normal egg fertilised by 2 sperm or 1 which then duplicates forming 69XXX or 69XXY
Difference between complete and partial hydatidiform mole
Complete- 46 chromosomes all paternal
Partial- 69 chromosomes where 2/3 paternal
Complete no fetal parts seen unlike in partial
Difference on USS between complete and partial hydatidiform mole
Complete you get snowstorm apperance where lots of hydropic villi so get central hyperechoic mass with interspersed cystic areas
What is snowstorm appearance on USS associated with
Complete hydatidiform mole
How can molar pregnancy present or be suspected
Very high bHCG
Bleeding in first 2 trimesters
Uterus very large for date
Exaggerated symptoms of pregnancy like NVP
HTN and hyperthyroidism present
What conditions are associated with molar pregnancy during the pregnancy
HTN
Hyperthyroid
Hyperemesis gravidarum
How does molar pregnancy cause HTN
bHCG can mimic TSH
How are molar pregnancies diagnosed
On histology
When is histological examination of pregnancy tissue in miscariage indicated
Post medical or surgical removal of miscarriage where no fetal parts were identified
What are theca lutein cysts
Cysts in ovaries caused by excess bHCG from molar pregnancy and twins
What is management of molar pregnancy
Referral to specialist centre
Suction curettage unless partial molar where fetal tissue too large
Anti-D prophylaxis
What is gestational trophoblastic neoplasia
When after failure to treat molar pregnancy fully it may remain and invade tissue. Can also be caused by live birth or non-molar miscarriage
When should GTN be suspected
Persistent bleeding after any pregnancy event- perform beta hcg 8 weeks after
2 medical treatments for miscarriage have not worked
bHCG not stabilising
Management of GTN
Refer to GTD center
Chemotherapy
What can GTN progress to
Choriocarcinoma
Epithelioid trophoblastic tumour
Placental trophoblastic tumour
How are choriocarcinoma, epithelioid trophoblastic tumour and placental trophoblastic tumour all managed
At GTD centre
If localised- hysterectomy
If spread and metastatic then intense chemo
How long after molar pregnancy should women wait to get pregnancy
1 year
When can women have hormonal contraception following molar pregnancy
As soon as bHCG normalised
What suspect if beta HCG not normalising after molar or any pregnancy
GTD or failure to remove it
What is management of surgical abortion before 14 weeks
Sublingual misoprostol 1 hour before or oral misoprostol 3 hours before
Surgical suction
3 days doxycycline
If after 10 weeks anti-rhesus
LMWH post operation for 7 days
What is surgical management of abortion after 14-19 weeks
Can give osmotic dilators or oral/ vaginal misoprostol
Surgical evacuation
3 days doxyclycine
Anti-D if rhesus negative
LMWH post op
Extra management of abortion to consider
Anti-rhesus if post 10 weeks and rhesus neg
LMWH for 7 days and before if at high risk
Mental health
If surgical give doxycycline for 3 days
What is medical management of abortion
Before 10 weeks
-mifepristone and then 2 days later vaginal misoprostol at HOME
After 10 weeks
- mifepristone and then 2 days later vaginal misoprostol IN CLINIC
What is mifepristone
Anti-progestogen
What is advice surrounding abortion without evidence of intra-uterine pregnancy
Safety net about risks of ectopic so follow-up
What do if abortion at 23+6 weeks
Give feticide followed by surgical management
What is a feticide
Feticide is the injection of digoxin or potassium chloride into the fetus, or an injection of digoxin into the amniotic cavity, to stop the fetal heart before an abortion
What do if do not want medication for NVP
Ginger
Accupuncture at P6 on wrist
Why do USS if admitted with HG
If have not had dating scan needed to rule out GTD
How do threatened miscarriages present
Cycical abdo pain
Some brown discharge
How does septic miscarriage present
Increasing pain
Fever
Bleeding
What causes septic miscarriage
Typically it getting stuck in the cervical OS
Management of septic miscarriage
Surgical evacuation
Why do you get cysts in molar pregnancy
Excess HCG forms multiple theca lutein cysts
What chemo is choriocarcinoma particularly responsive to
Methotrexate
Antibodies in anti-phospholipid syndrome
Lupus anti-coagulant
Anti-cardiolipin
Anti-beta 2 microglobulin
How is anti-phospholipid syndrome diagnosed
1 of lupus anticoagulant, anti-cardiolipin or anti-beta 2 microglobulin picked up twicw in blood 12 weeks apart
Presentation of antiphospholipid syndrome
Venous or arterial thrombosis
Pregnancy problems
Nephropathy
Thrombocytopenia
A 16-year-old girl attends accident and emergency complaining of mild vaginal spotting. Her serum beta hCG is 4016mIU/mL. She is complaining of severe left iliac fossa pain and stabbing sensations in her shoulder tip. Next investigation
TVUSS not laparoscopy
Woman with twin pregnancy has really bad abdominal pain
Ruptured theca lutein cyst
Prolonged bleeding in early pregnancy with bilaterally enlarged ovaries
Molar pregnancy with theca lutein cysts
What is seen on ERCP of hydidatiorm mole
genetically abnormal placenta
mixture of large and small villi with scalloped outlines
trophoblastic hyperplasia
What is it when foetus alive but cervical OS open
Inevitable miscarriage
How are inevitable and incomplete miscarriage differentiated
Both have an open cervical OS
In incomplete they will have passed some foetal tissue but some will remain
At what bHCG are intrauterine pregnancies normally seen
1000
With which abortion method is the bleeding worse
Medical
What happens if give mifepristone and misoprostol at the same time
More likely to fail
Bleeding will be delayed
What are the sections of abortion act
2 doctors in good faith agree
A- continuing would risk life of pregnant woman
B- necessary to prevent grave risk to life of mother
C- pregnancy not exceeded 24 weeks and continuance would involve risk of injury to physical or mental health of mother
D- not exceedd 24 weeks and would involve risk to mental/physical health of existing children
E- born handicapped
What abortion section most commonly used
Section C
Differentiating missed from complete
In complete the uterus is empty but in missed the foetus is still in the uterus without a HB and a lack of significant bleeding
What do if no intrauterine or tubal pregnancy found at dating scan
Take 2 bHCGs 48 hours apart and safety
If proper rise then do TVUSS in 7-14 days
If decrease then explain miscarriage and do pregnancy test in 14 days
How to calculate EDD
First day of LMP
Add 1 year - 3 months+7 days
GI symptoms, spotting and cervical motion tenderness. Ectopic pregnancy or PID?
Ectopic pregnancy as bowel symptoms are consistent with ectopic
Surgical management of abortion after 19+0 weeks
Mifepristone 200mg and osmotic dilators day before
Surgical evacuation
Doxycycline for 3 days
LMWH 7 days
Anti-D if negative
What is the gestational sac
Fluid surrounding the embryonic tissue
What is a blighted ovum
A gestational sac without embryonal tissue inside
How manage termination if unknown location
If any signs of ectopic then must do beta HcG measurements 48 hours apart and then USS to confirm
If no signs then can proceed however must safety net about ectopic
Bleeding post termination differentials
Most likely- post abortion bleeding very normal especially medical
Rule out- retained products of conception and PID
Management of bleeding post termination bleeding
If well do bloods to check if inflammatory response
If unwell A-E and TVUSS to look for retained products of conception
