Miscarriage and Ectopic pregnancy

Question 1

Miscarriage

Answer 1

Spontaneous termination of pregnancy before 24 weeks (pre-viability)
After this it is IUD or stillbirth

Question 2

Ectopic Pregnancy

Answer 2

Pregnancy implanted outside the endometrial cavity

Usually in the Fallopian tube (95%)

Question 3

PUL

Answer 3

Pregnancy of unknown Location

Question 4

Landmarks in Pregnancy

Answer 4

2 weeks from LMP –> ovulation
3 weeks from LMP –>Implantation
3.5 weeks from LMP –>Beta HCG >25iu/l
4.5 weeks from LMP –>BhCG>1000iu/l + gestational sac

Question 5

Risk of Miscarriage by maternal age

Answer 5

16-20–> 15% 31-35–> 17%
21-25–> 11% 35-40–> 30%
26-30–> 12% 41-45–> 60%

Question 6

Chromosomal abnormalities leading to miscarriage

Answer 6

% of misscarriages due to karyotype abnormalities
Autosomal trisomy (16,21 or 22) --> 59%
XO --> 15%
Triploidy --> 9%
Tetraploidy --> 5%
Structural --> 12%

Question 7

Threatened Misscarriage

Answer 7

A state of fetal distress characterized by mild bleeding and little to no pain
The Os will be closed
This can spontaneously resolve or progress to full miscarriage

Question 8

Missed abortion/delayed miscarriage

Answer 8

Fetus is dead by retained
May be loss of early pregnancy symptoms
Will be a history of threatened miscarriage and persistant brown discharge

Question 9

Blighted ovum

Answer 9

Embyro fails or ceases to develop

Question 10

Inevitable Miscarriage

Answer 10

Usually presents with heavy bleeding and clots,
The os is open and the pregnancy will not continue
will progress to either complete or incomplete miscarriage –> placenta is seperating from the womb and in the process of being expelled

Question 11

Incomplete Miscarriage

Answer 11

The products of conception are partially retained and may indicated an unrecognised missed miscarriage–> os is open

Question 12

Complete Miscarriage

Answer 12

A miscarriage where there is full expulsion of the products of conception and no extraction is necessary

Question 13

Causes of Vaginal Bleeding in Pregnancy

Answer 13

44% viable—> 86% continued to term, 14% other
33% embryonic Demise
18% Miscarriage/empty uterus
5% ectopic

Question 14

CRL

Answer 14

Crown Rump length in fetal monitoring

Question 15

At risk of miscarriage signs

Answer 15

Small gestational sac diameter in proportion to CRL
Olgiohydramnios
Fetal bradycardia (<90)
Discrepency between scan and menstral dates of more than 10 days

Question 16

Treatment of Miscarriage

Answer 16

Surgical–>ERPC, give anti-D if R neg. 5% risk of retained products, 5% risk of PID, Prostaglandin (+-mifepristone) = 50-99%
Expectant–> no treatment but follow up to ensure becomes complete

Question 17

Second Trimester Miscarriages

Answer 17

Only 2% of pregnancies

present with abdo pain, bleeding or liquor leak PV

Question 18

Causes of 2nd tirmester miscarriages

Answer 18

Abnormal karyotype
Cervical incompetence
Infection (maternal or ascending)
Placental thrombosis
SROM
Uterine abnormalities or fibroids
iatrogenic (post invasive procedure, amnio or CVS)

Question 19

Recurrent Miscarriage

Answer 19

3 or more with the same partner

Occurs in 1% of couples (greater than expected by chance)

Question 20

Causes of Recurrent Miscarriage

Answer 20

PCOS –. no treatment
APS –> treat with aspirin and herparin if FH
Congential uterine abnormality or cervical incompetence (consider surgery or cervical stitching)
A balanced or Robertsonian chromosomal translocation

Question 21

Causes of Ectopic pregnancy

Answer 21

Tubal occlusion or dysfunction
Assisted conception, IUCD, EC or OCP
PID, endometriosis or previous ectopic
Previous pelvic surgery or sterilisation

Question 22

Incidence of Ectopic pregnancy

Answer 22

1 in 87 in uk (approx) but 1 in 35 in jamaica
The incidence is increasing but the mortality is greatly decreasing, so there is a net decrease in deaths and hospitalisations

Question 23

Clinical features of Ectopic pregnancy

Answer 23

Usually occurs at 5-8 weeks gestation with period like bleeding or spotting (prolonged period with lateralised pain)
Generalised or shoulder tip pain indicates intraperitoneal bleeding

Question 24

Ectopic pregnancy on examination

Answer 24

Abdominal pregnancy there is tenderness and may be guarding on one side
Uterus will be small for dates with adnexal tenderness and cervical excitation
Pregnancy test positive in 99.9% of cases

Question 25

Transvaginal USS

Answer 25

Sensitivity of 87-99%, Similar specificity
A gestational sac seen seperate from the uterus and ovaries –> doppler will show low resistance flow
Trophoblast is echogenic unless degenerating

Question 26

Differential for Ectopic

Answer 26

Corpus luteum cyst (sliding sign if adhesions)
Haematosalpinx
Tubal epithelial hyperplasia
Pyosalpinx
Static loop of bowel
Blood clot

Question 27

Treatment of Ectopics

Answer 27

Open or laparoscopic surgical removal (salpingotomy or salpingectomy)
More commonly people are going for conservative/medical management
Majority are treated laparoscopically surgically

Question 28

Indications for surgical treatment of Ectopics

Answer 28

Cardiovascular compromise,
Severe pain
Large amounts of intraperitoneal bleeding
High BhCG or FH or patients choice

Question 29

Medical management of ectopic pregnancy

Answer 29

Methotrexate or combinations of other drugs

Must be closely monitored and treatment is expectant

Question 30

Non-tubal ectopics

Answer 30

5% of ectopics
80% ampullary
very rarely abdominal, ovarian or cervical
ovarian EPs must be distinguished from the corpus luteum

Question 31

Scar Ectopic pregnancies

Answer 31

Most commonly caesarian scars

Lead to abdominal invasion and risk of placenta etecreta