Miscarriage and Ectopic Pregnancy Flashcards
How common is ectopic pregnancy?
Affects 1-2% of pregnancies
Where is the most common place for an ectopic pregnancy to implant?
Fallopian tube
Miscarriage is defined as _________
A loss of a pregnancy before 24 weeks
How common is miscarriage?
~ 20% of pregnancies miscarry
Consider an ectopic pregnancy in all women of reproductive age with _________
Abdominal pain or vaginal bleeding
When is it appropriate to order investigations in the community?
If clinically stable and low suspicion of ectopic pregnancy
What investigations should you order?
Urinary pregnancy test if not already done
Blood tests
Pregnancy ultrasound to determine location and viability of pregnancy if appropriate
What situations should you order a community USS with possible miscarriage/ectopic
Unknown gestation
> 6 weeks by dates (intrauterine pregnancy is only visible on transvaginal ultrasound from approximately 5 to 6 weeks gestation, and when bHCG is greater than 1500 IU/L).
Low suspicion of ectopic, clinically stable, and same day ultrasound is available.
What can cause people to become clinically unstable in suspected miscarriage/ectopic pregnancy?
Cervical shock when POC are in the cervix
Blood loss (may be internal)
Severe pain or sepsis
Ruptured ectopic pregnancy
Management if clinically unstable
Resuscitate as necessary.
Remove any POC from the cervix with sponge forceps.
Arrange transport by ambulance to ED
Insert two large-bore IV lines.
Give analgesia and continue to resuscitate until assistance arrives.
Contact the gynaecology service to let them know the patient is coming:
Send any available products of conception for histology
Management if clinically stable
Symptoms highly suggestive of possible ectopic, request acute gynaecology assessment.
Prescribe anti-D immunoglobulin if rhesus negative and anti-D immunoglobin is indicated
Manage according to scan results
tip top
Management if scan shows viable intrauterine pregnancy
Reassure.
If the patient is experiencing pain, consider alternative causes and manage accordingly.
If there is ongoing vaginal bleeding:
examine the cervix (if not previously done) to exclude cervical causes of bleeding, e.g. cervical cancer, polyps, infection.
check that cervical screening is up to date
Management if scan shows non-viable intrauterine pregnancy
Expectant management in primary care
Active management in secondary care
Management if scan shows intrauterine pregnancy of uncertain viability
Repeat scan in 1 to 2 weeks (depending on radiologist recommendation)
Acknowledge this will be an anxious wait for your patient, but explain that performing a scan earlier may lead to another inconclusive result
Advise the patient that they may develop pain or bleeding while waiting for the scan, and what to do in this circumstance.
If there is no USS evidence of pregnancy despite positive hCG consider…
Complete or incomplete miscarriage
Early intrauterine pregnancy
Extrauterine pregnancy
Management if scan shows pregnancy of unknown location and the patient is clinically well with minimal symptoms
Repeat hCG in 48 hours
Repeat scan in 1 week or if hCG >2000
Expected hCG trends in ongoing intrauterine pregnancies
Ongoing intrauterine pregnancies are usually expected to have a doubling of hCG over 48h up to 6 weeks gestation
Expected hCG trends in pregnancies that are miscarrying
Pregnancies that are miscarrying usually see hCG levels fall by ≥50%
Monitoring of hCG in miscarriage
Continue to monitor weekly until the hCG returns to zero
hCG in ectopic pregnancies
Interpret hCG levels in conjunction with patient symptoms, as hCG levels in some ectopic pregnancies can mimic the expected rise or fall of a continuing pregnancy or a miscarriage.
Management if scan shows retained products of conception - when to refer to gynae
Severe pain
Signs of infection
Heavy bleeding, e.g. soaking a pad in <1 hour
AP diameter of POC >20 mm on scan
USS suggestive of molar pregnancy or other concern
Management if scan shows retained products of conception - If stable with only small amounts of POC (10 to 15 mm)
Reassure and consider expectant management.
Offer prophylactic abx e.g. amoxicillin + clavulanic acid 500/125 mg TDS for one week.
Inform patient: bleeding normally settles and products are usually passed with next period.
Management if suspected molar pregnancy on USS or prev molar pregnancy/gestational trophoblastic disease
Refer gynae
