Non viable pregnancy Flashcards
Ectopic pregancy - definition
Implantation of a fertilized ovum outside the uterus results in an ectopic pregnancy
Ectopic pregancy - Clinical features
- Constant lower abdominal pain - may be unilateral
- Vaginal bleeding - may be dark in colour
- History of Amenorrhea <6-8 weeks (recent)
- Shoulder tip pain
- Dizziness, fainting syncope
Ectopic pregancy - Clinical signs
- Abdominal tenderness - may have adenexal mass
- Cervical excitation : cervical motion tenderness on pelvic examination
Ectopic pregancy - Risk factors
- anything slowing the ovum’s passage to the uterus*
1. Damage to fallopian tubes : pelvic inflammatory disease, surgery
2. previous ectopic
3. endometriosis
4. IUCD
5. progesterone only pill
6. IVF (3% of pregnancies are ectopic)
Ectopic pregancy - Investigation
- Positive pregnancy test and HCG level
- Gold standard : Transvaginal Ultrasound
Ectopic pregancy - Expectant management criteria
- HCG < 1000
- Size < 35cm
- Unruptured + Asymptomatic + No heart beat
Mx : Close monitoring for 48 hours
⦁ If further HCG rise or symptoms develop } for intervention
Ectopic pregancy - Medical management criteria
- HCG < 1500
- Size < 35cm
- Unruptured + mild pain + No fetal heart beat
Mx : Methotrexate with f/u
Ectopic pregancy - Surgical management criteria
- HCG >5000
- Size >35cm
- May be ruptured + Pain + Visible heart beat
Mx :
⦁ Saplingectomy - surgical removal of fallopian tube if no other issues with infertility
⦁ Saplingotomy - Contents are removed via an opening in the fallopian tube
- Indic if ; other risk factors for infertility, helps to preserve both fallopian tubes
Miscarriage : Definition
Loss of pregnancy < 20 weeks of gestation
Miscarriage : Risk factors
- Prior miscarriage
- Advanced maternal age
- Chromosomal abnormalities
- Structural uterine abnormalities : cervical insufficiency, fibroids
- Maternal infection : Mumps, Bacterial vaginosis
- Maternal comorbidities - T2DM, Obesity, Hypothyroidism
- Smoking/Substance abuse
Miscarriage : Threatened miscarriage features
- Painless vaginal bleeding < 24 weeks
- Cervical os : Closed
- US : Viable foetus
Misacarriage : Missed/Delayed miscarriage
Definition : Dead foetus within gestational sac before < 20 weeks without symptoms of expulsion
- Painless vaginal bleeding
- Pregnancy symptoms have resolved
- Cervical os : closed
- US : Gestational sac > 25 mm and no fetal parts can be seen/ empty sac
- Missed miscarriage - empty gestation sac without foetal pole seen on Ultrasound
- Complete miscarriage - all products of consumptions including gestational sac would be passed - nothing in the uterus
Misacarriage : Inevitable miscarriage
- Pain and heavy bleeding with clots
- Cervical os : open
If not all products of conception have been expelled this is - ‘Incomplete Miscarriage’
Misacarriage : Complications
- Infection : septic abortion
- DIC : retained products of conception in missed abortions can release chemical mediators and cause coagulopathy
Misacarriage : Most common cause
Chromosomal abnormalities
> 3 miscarriages - refer for further investigations
Miscarriage : Investigations
- TV US < 9 weeks
- Transabdominal US > 9 weeks gestation
Misacarriage : First line management
- 7-14 days of monitoring without intervention for spontaenous miscarriage and ejection of foetal contents
- If unsucessful - consider medical /surgical management
Misacarriage : Indication for medical/surgical management
- Increased risk of haemorrhage
⦁ Late in first trimester
⦁ Coagulopathies - Evidence of infection
Misacarriage : Medical management
- Vaginal Misoprostol
Prostaglandin analogue, binds to myometrial cells to cause strong myometrial contractions leading to the expulsion of tissue
Misacarriage : Surgical management
- Vacum aspiration : under local anaesthetic in OP
- Surgical curettage : in theatre
Mifepristone : MOA
Blocks the effects of progesterone - making both cervix and uterine vessels dilate, causing uterine contraction
Termination of pregnancy : Upper limit
24 weeks of gestation
Termination of pregnancy : Medical management
Indication : 0 - 10 weeks of pregnancy
1. Mifepristone : block the effects of progesterone
48 hours later
2. Misoprostol : cause uterine contraction and ejection of fetal contents
3. HCG pregnancy test in 2 weeks time
Termination of pregnancy : Surgical management
Done under local anaesthesia
1. Vaccum aspiration
2. Dilatation and Evacuation
Termination of pregnancy : Time line
Medical abortion
< 9 weeks
Late medical abortion 9-20 weeks
Vacuum aspiration : 7-15 weeks
Dilation and evacuation > 15 weeks