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3A Womens health > Miscarriage, Ectopic > Flashcards

Miscarriage, Ectopic Flashcards

1
Q

What is the definition of a miscarriage?

A

● Spontaneous loss of pregnancy before 24 weeks of gestation (NICE CKS).

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2
Q

What is the pathophysiology and aetiology of miscarriage?

A

Pathophysiology and Aetiology:
● Chromosomal abnormality (commonest) - typically autosomal trisomies.
○ Can result in failure of development of embryo within gestational sac.
● Hormonal factors:
○ PCOS, hyperprolactinaemia, diabetes, hyper/hypothyroidism
● Thrombophilia / autoimmunity:
○ Antiphospholipid syndrome, factor V Leiden - induces placental thromboses
leading to placental insufficiency.
● Anatomical factors:
○ Bicornuate uterus, cervical insufficiency
● Infection:
○ Toxoplasmosis, syphilis

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3
Q

What are the risk factors for a miscarriage?

A

● Increased maternal age
● Previous miscarriage

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4
Q

What are the different types of miscarriage?

A

● Threatened: vaginal bleeding in the first 24 weeks of pregnancy (with viable intrauterine
pregnancy).
● Incomplete: non-viable pregnancy, bleeding begun, products of conception in uterus.
● Complete: all products of conception passed, bleeding has stopped.
● Missed: non-viable pregnancy on ultrasound (without pain / bleeding).
○ Mean gestational sac diameter >25mm with no yolk sac or
○ CRL >7mm with no cardiac activity
● Inevitable: non-viable pregnancy, bleeding begun, cervical os opened, POCs remain in
uterus.

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5
Q

How can a miscarriage present?

A

● Pelvic pain
● Vaginal bleeding

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6
Q

What are some differentials for for a miscarriage?

A

gestational
trophoblastic disease, implantation bleeding, ectopic pregnancy, and importantly,
bleeding without an identified cause.

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7
Q

What is first line investigation for a miscarriage?

A

○ Transvaginal ultrasound scan - to identify location, foetal pole and heartbeat.

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8
Q

How do we manage a threatened miscarriage?

A

○ Manage conservatively: if no history of previous miscarriage, advise to return if
bleeding persists after 14 days / becomes heavier. If there is a history of previous
miscarriage, offer vaginal progesterone until 16 weeks of pregnancy completed.
○ Advise to take a pregnancy test 3 weeks after bleeding has stopped.
○ If bleeding is ongoing, offer a repeat scan.

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9
Q

How do we manage and incomplete/inevitable miscarriage?

A

○ First Line - expectant management (appropriate to 13 weeks gestation):
■ Allow 7-14 days for POCs to pass / bleeding to end.
○ Second Line - medical management:
■ mifepristone, followed by misoprostol 48 hours later.
○ Alternative Second Line - surgical management:
■ Vacuum aspiration under local or dilatation and evacuation under GA
○ Plus: pregnancy test 3 weeks post-miscarriage

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10
Q

How do we manage a missed miscarriage?

A

○ As above, but use misoprostol only for medical management.

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11
Q

What are some contraindications to expectant management?

A
  1. Heavy vaginal bleeding / increased risk of bleeding / increased vulnerability to heavy bleeding
    (coagulopathy)
  2. Previous traumatic experience in pregnancy
  3. Evidence of infection
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12
Q

What is the mechanism of mifepristone?

A
  • Antiprogesterone; sensitises myometrium to prostaglandins, induces breakdown of decidua basalis
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13
Q

What is the mechanism of misoprostol?

A
  • Prostaglandin E1 analogue; degrades cervical collagen, stimulates uterine contraction
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14
Q

According to the 1967 Abortion act which four legal grounds give acceptance for a termination of pregnancy?

A
  1. Pregnancy before 24 weeks - continuation risks injury to physical / mental health of the
    pregnant woman / her children.
  2. Necessary to prevent grave permanent injury to physical / mental health of the pregnant
    woman.
  3. Continuation of pregnancy involves risk to the life of the pregnant woman.
  4. Substantial risk of serious physical / mental disability to the child if it were born.
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15
Q

What is the medical way of abortion?

A

○ Up to 9+6 weeks - single dose mifepristone, followed by single dose PO / PV
misoprostol 48 hours later
○ 10+0 to 23+6 weeks - single dose mifepristone, followed by serial misoprostol
every 3 hours.
○ Analgesia - NSAIDs, opioids as required.

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16
Q

What is the surgical way of abortion?

A

○ Up to 13+6 weeks - cervical priming with misoprostol or mifepristone, followed by
vacuum aspiration.
○ 14+0 to 24+0 weeks - cervical priming with mifepristone + misoprostol or osmotic
dilator, followed by dilatation and evacuation.
○ Plus - oral doxycycline to prevent infection.
○ Analgesia - NSAIDs, local anaesthetic, conscious sedation.

17
Q

Summary of medical and surgical abortion

A

○ Medical - mifepristone plus misoprostol taken 48 hours later
○ Surgical - misoprostol plus vacuum aspiration / dilatation and evacuation.

18
Q

Because abortion is a sensitising event, what should be offered?

A

Anti-D should be offered after 10+0 weeks to women
who are Rhesus negative.

19
Q

What is the definition of an ectopic pregnancy?

A

● Any pregnancy that implants outside of the endometrial cavity. 97% are implanted in a
fallopian tube.

20
Q

Pathophysiology and aetiology of ectopic pregnancy?

A

● Fertilisation of the oocyte typically takes place in the ampulla of the fallopian tube; the
conceptus must then travel into the endometrial cavity.
○ This occurs due to tubal peristalsis alongside ciliary motion and tubal fluid flow.
○ Any dysfunction in the above due to e.g. tubal surgery, salpingitis, PID can
prevent the conceptus from implanting in the correct place.
● A pregnancy that implants in the fallopian tube will grow and eventually lead to rupture
and catastrophic bleeding.
● Most tubal ectopics implant in the ampulla (widest point).

21
Q

What are the risk factors for an ectopic pregnancy?

A
  1. Previous ectopic pregnancy
  2. Cu-IUD use (although background risk of pregnancy is obviously much lower).
  3. Chronic salpingitis (tubal inflammation)
  4. PID
22
Q

What is the presentation of ectopic pregnancy?

A

● Typically presents at 6-8 weeks after LMP; at this point the conceptus has grown to
sufficient size to cause symptoms / signs.

23
Q

What are the signs of an ectopic pregnancy?

A

lower abdominal tenderness / adnexal tenderness, cervical motion tenderness.

24
Q

What are the symptoms of an ectopic pregnancy?

A

lower abdominal pain, amenorrhea, PV bleeding, urge to defecate, shoulder
pain.

25
Q

What are the differentials of a ectopic pregnancy?

A

miscarriage, appendicitis and ovarian torsion.

26
Q

What should any female of childbearing age presenting with abdominal pain should be offered to exclude ectopic pregnancy>

A

UPT

27
Q

Why do the signs and symptoms in ectopic pregnancy occur and what are the indicative of?

A

Intraperitoneal bleeding
urge to
defecate, shoulder tip pain, cervical motion tenderness.

28
Q

What are the investigations for an ectopic pregnancy?

A
  1. Urine pregnancy test
  2. Transvaginal ultrasound scan
  3. Serial serum beta-hCG if no pregnancy found on USS
29
Q

What is the expectant and medical management for ectopic pregnancy?

A

● Expectant: must meet certain criteria, and close monitoring required (see text box).
● Medical: oral methotrexate - as long as no surgical criteria are met. Take UPT three
weeks later

30
Q

What is the surgical management for an ectopic pregnancy?

A

Surgical: salpingectomy / salpingotomy; indicated if any of the following features are
present:
○ Ruptured ectopic
○ Significant pain
○ Heartbeat on USS
○ >35mm diameter of pregnancy
○ Serum beta-hCG > 5000IU/L

31
Q

What is the expectant management of an ectopic pregnancy?

A
  • No criteria for surgical intervention can be present
  • Measure beta-hCG on days 0, 2, 4, and 7; if drop of more than 15% from previous measurement, repeat
    weekly until beta-hCG is less than 20IU/L. If not, refer for further management.
32
Q

How do we choose the surgery for an ectopic pregnancy?

A

Salpingectomy (removal of affected tube) is first line unless there are risk factors for infertility; in which case,
salpingotomy (opening of tube for removal of ectopic) is recommended. Salpingotomy is less effective than
salpingectomy. Advise UPT 3 weeks post surgery.

33
Q

What do we do when there is a pregnancy of unknown location?

A
  • Diagnosed when UPT is positive but no pregnancy can be visualised on ultrasound scanning.
  • In this circumstance, the pregnant woman must be closely monitored as there is still a chance of ectopic.
  • Diagnosis and management are guided by serial beta-hCG measurements:
  • 2 measurements taken 48 hours apart
  • If second measurement is >63% greater than first: likely viable intrauterine pregnancy; offer a
    scan 7-14 days later
  • If second measurement is >50% less than first: likely non-viable pregnancy; advise UPT 14
    days later
  • If the second measurement falls between these parameters: further review required for ?ectopic.
    `

3A Womens health (33 decks)

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