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Gynaecology > Miscarriage + TOP > Flashcards

Miscarriage + TOP Flashcards

1
Q

Def threatened miscarriage (4)

A

Up to 13 weeks (first crimester)

  • os closed
  • Spotting
  • with or without lower abdominal pain
  • fetus alive
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2
Q

Presentation of inevitable miscarriage

A

First trimester: up to 13 weeks

  • Os dilated
  • increased PV bleed: clots
  • lower abdominal pain-tender uterus
  • fetus alive
  • Products still in uterus
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3
Q

Presentation of incomplete miscarriage (5)

A

First or second trimester

  • Os open with or without POC in os
  • passed some products of conception: clots
  • uterus smaller than expected for GA, bulky uterus
  • lower abdominal pain-tender uterus, pain better after passing products of conception
  • ultrasound: retained POC or ET >15mm

May have hypovolaemic shock

US: still retained products conception

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4
Q

Presentation complete miscarriage

A

Second trimester: 13 - 20 weeks

  • os open OR closed
  • passed ALL products of conception. Examine foetus and placenta for completeness
  • bleeding subsides within 48 hours
  • ultrasound: no POC, ET <15mm
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5
Q

Presentation missed miscarriage

A

Can be first or second trimester. Usually seen on routine examination as no symptoms

  • os closed
  • no bleeding
  • No pain
  • Fetus dead
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6
Q

Rx threatened miscarriage

A
  • Conservative /expectant: 60% do not abort.
  • Reassurance and follow up
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7
Q

Rx inevitable miscarriage (5)

A
  • Resus if shocked: crystalloids and blood products
  • if haemodynamically stable 1st trimester: expectant management, allowed to abort. Then reassess for further rx
  • later pregnancy: active management with iv oxytocin + acute pain relief
  • medical management options: iv oxytocin (decrease bleeding) , misoprostol
  • surgical options: <14 weeks(first trimester) = mva or suction curettage
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8
Q

incomplete miscarriage rx! (5)

A
  • Resus if shocked. Can only intervene when haemodynamically stable, not septic (end organ involvement - kidney, liver, haematological). Do hysterectomy if 2 or more organs involved.
  • Remove visible retained products W/ ovum forceps to enable uterus to contract and stop further vaginal blood loss
  • expectant or medical management (misoprostol and mifepristone) only if easy access to health facility should bleeding persist as most early miscarriage (<6 weeks amenorrhoea) bleeding subsides in 48 hours
  • surgical management preferred to medical
  • <14 weeks - MVA or surgical curettage
  • > 14 weeks - evacuation

Antibiotics: gentamicin, ampicillin, flagyl

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9
Q

Rx complete miscarriage (3)

A
  • Expectant management
  • uterine evacuation not indicated. Observe for possible haemorrhage.
  • second trimester: examine foetus and placenta for completeness to make diagnosis. Where indicated, send tissue eg calf muscle for chromosomal analysisand placenta biopsy for histology and Chorioamnionitis
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10
Q

Rx missed miscarriage (2)

A
  • First trimester (<14 weeks): medical management with misoprostol and mifepristone or surgical with primary dilatation cervix and curettage or MVA
  • > 14 weeks - medical management followed by uterine evacuation if indicated. Expert can do dilatation and extraction of foetus
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11
Q

Differential vaginal bleeding in early pregnancy? (4)

A
  • Threatened miscarriage
  • Implantation bleeding
  • anembryonic pregnancy (blighted ovum)
  • Ectopic pregnancy
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12
Q

Diagnosis anembryonic pregnancy (blighted ovum) (2)

A
  • Irregular gestational sac without foetus in pregnancy 8 or more weeks gestation , or
  • empty gestational sac > 25 mm
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13
Q

Name 4 types miscarriages that can occur in first trimester (up to 13 weeks)

A
  • Threatened
  • inevitable
  • incomplete
  • missed
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14
Q

Name 4 types miscarriages that can occur in second trimester (13 - 20 weeks)

A
  • Incomplete
  • complete
  • septic
  • missed
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15
Q

Diagnosis septic miscarriage?

A

Miscarriage complicated by fever (38 or more)

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16
Q

Name 4 warning signs for serious underlying septic miscarriage

A
  • Generally: distress, agitation, lethargic, hyperventilate, bed bound
  • vitals: weak peripheral pulse > 100, rr > 20, T< 36,5 or > 37,8
  • abdomen: tender or signs peritonism
  • gynae: excessive bleed, foul smell discharge, vaginal lacerations, gangrenous cervix
17
Q

Management protocol septic miscarriage? (7)

A

Determine status and Resuscitate , admit

Hysterectomy indications
- septic shock
- multi organ dysfunction
- necrotic cervix
- pus in abdomen detected by colpopuncture
- uterine perforation

If not meet criteria/decline:
- evacuation of septic uterine contents under ga.

18
Q

Special investigations for miscarriage? (4)

A
  • Screen for syphilis (rpr)
  • Rh factor (give anti-d if Rh negative and second trimester miscarriage)
  • cervical cytology
  • hb
19
Q

Name 3 risk factors miscarriage

A
  • AMA
  • previous miscarriage
  • maternal smoking
20
Q

Name 8 possible causes early (12 - 14 weeks/ first trimester ) miscarriage

A

Medical

  • sporadic chromosomal abnormalities
  • HLA status ( human leukocyte antigen)
  • auto-immune diseases

Structural

  • corpus luteum defect
  • poor placentation
  • uterine septum

Other

  • Chance occurrence
  • environmental factors
21
Q

Name 6 possible causes late ( 14 - 24 weeks/ second trimester ) miscarriage

A
  • Cervical incompetence!
  • congenital abnormality uterus
  • submucous myomata
  • poor placentation
  • infections
  • medical diseases: hypothyroid, diabetes
22
Q

Antibiotics for unsafe abortion? (3)

A
  • Cefuroxime 750 mg 8 hourly iv +
  • metronidazole 500 mg 8 hourly iv +/ -
  • gentamicin 240 mg daily iv or ertapenem 1 g daily iv
23
Q

Name 6 contraindications mva

A
  • Gestation > 14 weeks
  • extreme patient anxiety
  • active pelvic infection
  • uterine anomalies
  • unsafe top
  • unstable pt: P > 100, SBP < 100, hb < 9, temp 37,5
24
Q

Define recurrent early pregnancy loss

A

3 or more consecutive losses of pregnancy <14 weeks

25
Q

Workup for recurrent early pregnancy loss? (6)

A
  • Uterine study pre-pregnancy: sonohysterography, hysterosalpingogram, hysteroscopy or MRI
  • maternal antiphospholipid antibodies (2 positive tests > 12 weeks apart)
  • paternal karyotype (>2 miscarriages < 10 weeks)
  • fasting glucose
  • thyroid functions
  • genetic evaluation of products of conception
26
Q

Which law governs termination of pregnancy

A

Choice of termination of pregnancy act no 92, 1996

27
Q

According to Choice of termination of pregnancy act no 92, 1996, when may pregnancy be terminated (8)

A

First 12 weeks

  • upon request

12 weeks - 20 weeks (need 1 Dr)

  • risk injury to woman physical/mental health
  • substantial risk to foetus, would suffer severe physical/mental abnormality
  • significantly affect social/ economic circumstances woman
  • rape or incest

After 20 weeks (need 2 Drs or Dr + midwife)

  • endanger woman’s life
  • severe malformation of foetus
  • risk injury to foetus
28
Q

Name 5 indications for surgical evacuation over MVA

A
  • active bleeding
  • severe anaemia
  • uncontrolled medical conditions
  • septic ICA
  • Large height of fundus (>14 weeks)
29
Q

Antibiotics for septic miscarriage?

A

Clindamycin 900mg tds (anaerobes, strep, staph)
Plus
Gentamicin 5mg/kg IVI dly (gram neg)
With or without
Ampicillin 2g IVI 4HRLY (gram pos)

OR

ampicillin + gentamicin + flagyl 500 IVI tds

Gynaecology (40 decks)

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