miscarriage, TOP, ectopic etc Flashcards
threatened miscarriage
- PAINLESS vaginal bleeding occuring before 24wks - typically 6-9wks
- bleeding less than menstruation
- Os is OPEN
missed (delayed) miscarriage
- gestational sac containing dead fetus before 20 weeks without symptoms of expulsion
- light bleeding/discharge
- symptoms of pregnancy disappear
- PAINLESS
- Os is CLOSED
inevitable miscarriage
heavy bleeding with clots + PAIN
Os is OPEN
incomplete miscarriage
not all products of conception have been expelled
- PAIN + bleeding
- Os is OPEN
risk factors for miscarriage
- women >35
- hx of previous miscarriages
- previous cervical cone biopsy
- smoking, alcohol, obesity
- diabetes, thyroid disorders
management of miscarriage
expectant
- 7-14days, wait to complete spontaneously
- if unsuccessful - medical or surgical
medical
- depends on type - missed/incomplete miscarriage
- give analgesia, antiemetics
- preg test after 3 weeks
surgical
- vacuum aspiration or mx in theatre
medical management of missed and incomplete miscarriage
missed
- oral mifepristone
- 48hrs later misoprostol (unless gestational sac has already passed)
- if no bleeding within 48hrs of miso - contact hospital
incomplete
- single dose of misoprostol
*give antiemetics + analgesia
*pregnancy test at 3 wks
definition of recurrent miscarriage
3 or more consecutive spotaneous abortions
in 1% of women
causes of recurrent miscarriages
- antiphopholipid syndrome
- endocrine - poorly controlled diabetes/thyroid
- PCOS
- uterine abnormality - uterine septum
- parental chromosomal abnormalities
-smoking
termination of pregnancy fetus age limit
24wks
termination of pregnancy approval
2 registered medical practioners must sign legal doc
- in emergency only 1 needed
only a registered medical practioner can perform an abortion, which must be in a NHS hospital or licensed premise
termination of pregnancy and rhesus D
anti-D prophylaxis should be given to women who are rhesus D negative and are having an abortion after 10+0 weeks’ gestation
medical options for TOP
mifepristone (anti-progestogen)
misoprostol 48hrs later - to stimulate contractions
- can be done at home depending on gestation
- takes hour/days
pregnancy test at 2 weeks to confirm end
- detect level of hCG - termed multi-level preg test (not just pos/neg)
surgical options for TOP
vacuum aspiration (MVA)
dilation and evacuation (D&E)
- cervical priming with misoprostol +/- mifepristone before
- intrauterine contraceptive can be inserted immediately after
choice of procedure for TOP
offered medical or surgical choice
- after 9 wks medical less common - seeing products + less successful
- <10wks - medical usally done at home
typical ectopic pregnancy presentation
female with hx of 6-8wks amenorrhoea who present with lower abdo pain + later develops vaginal bleeding
ectopic presentation
- lower abdo pain - constant, due to tubal spasm
- vag bleeding - may be brown
- recent amenorrhoea (if longer 10wks - could be inevitable abortion)
- shoulder tip pain! - peritoneal bleeding can refer, pain on defation
O/E
- abdo tenderness
- cervical excitation (motion tenderness)
risk factors for ectopic preg
anything slowing ovums passage to uterus
- damage to tubes - PID, surgery
- previous ectopic
- endometriosis
- IUCD
- POP
- IVF
ectopic investigation
pos pregnancy test
Ix of choice = transvaginal US
determinign management of ectopic
based on size, rupture status, pain, visible heartbeat, hCG levels
size >35mm, ruptured, pain, visible heartbeat, hCG >5000 = surgical
hCG <1000 + small/asymptommatic - expectant mx
hCG <1500 + small/symptommatic - medical mx
management of ectopic
expectant - monitor for 48hrs, if hCG rise/symptomatic - intervention required
medical = methotrexate (only give if patient willing to attend follow up)
surgical -
- salpingectomy - no other RF for infertility
- salpingotomy - with RF for infertility (eg contralateral tube damage)
–> 1 in 5 require further mx - methotrexate/salpingectomy
where do ectopics most commonly occur
97% tubal - most in ampulla
– most dangerous if in isthmus (section between ampulla + uterus)
3% in ovary, cervix or peritoneum
complete hydatidiform mole presentation + investigations
vaginal bleeding - 1st/2nd tri
exaggerated sx of preg - hyperemesis
uterus larger than expected for gestational age
abnormally high hCG
US = “snow storm” appearance of mixed echogenicity
complete hydatidiform mole
Benign tumour of trophoblastic material
Occurs when an empty egg is fertilized by a single sperm that then duplicates its own DNA, hence the all 46 chromosomes are of paternal origin
considered pre-cancerous -> 2-3% go on to develop choriocarcinoma
partial hydatidiform mole
a normal haploid egg may be fertilized by two sperms, or by one sperm with duplication of the paternal chromosomes
Therefore the DNA is both maternal and paternal in origin. Usually triploid - e.g. 69 XXX or 69 XXY
->Fetal parts may be seen
