Obs - Early pregnancy complications Flashcards
What is the most common location for ectopic pregnancies?
Ampulla of fallopian tube
Suggest risk factors for ectopic pregnancy.
PMH:
- previous ectopic pregnancy
- PID (adhesions)
- endometriosis (adhesions)
Iatrogenic:
- pelvic surgery
- embryo transfer in IVF
Failure of contraception:
- IUD or IUS
- progesterone oral contraceptive or implant (fallopian tube ciliary dysmotility)
- tubal ligation or occlusion
Describe the typical presentation of an unruptured ectopic pregnancy.
May be asymptomatic (picked up on USS: empty uterus with donut-shaped adnexal mass) or can present with:
- vague unilateral pelvic pain
- small amount of brown PV bleeding
- +/- diarrhoea + vomiting
- occasionally have cervical excitation + adnexal tenderness or adnexal mass on examination
Describe the typical presentation of a ruptured ectopic pregnancy.
Symptoms
- acute severe abdo/pelvic pain
- shoulder tip pain
- dizziness and collapse
Signs
- peritonism
- haemodynamic instability
- fullness in pouch of Douglas on examination
A 26 yo woman presents with vague unilateral abdominal pain + brown PV bleeding. An ectopic pregnancy is suspected. How would you assess her?
- pregnancy test (urine B-hCG)
- if +ve perform pelvic USS to determine presence/absence of uterine/ectopic pregnancy
- if pregnancy cannot be identified on USS (=pregnancy of unknown location), measure serum B-hCG.
- if >1,500 iU = ectopic pregnancy until proven otherwise, perform diagnostic laparoscopy
- if <1,500 iU and patient is stable, take further blood test 48hrs later
- in viable pregnancy: B-hCG expected to double every 48hrs
- in miscarriage: hCG expected to halve every 48hrs
- if outside these limits, ectopic pregnancy cannot be excluded so perform diagnostic laparoscopy
Name 3 options for the Mx of ectopic pregnancy. When would each be indicated?
- Expectant management - offer to women who are:
- clinically stable + pain free
- have tubal ectopic pregnancy measuring <35mm with no visible heartbeat on TVUS
- serum hCG level 1,000-1,500 IU/L
- are able to return for f/u - IM methotrexate - offer to women who:
- have no significant pain
- have an unruptured tubal ectopic pregnancy with an adnexal mass >35mm with no visible heartbeat
- serum hCG level 1,500-5,000 IU/L
- able to return for follow-up - Laparoscopic salpingectomy or salpingotomy (if need to preserve fertility) - offer as 1st line to women who are unable to return for f/u or who have any of the following:
- significant pain
- adnexal mass 35mm or more
- foetal heartbeat visible on USS
- serum hCG 5,000 IU/L or more
What are the advantages and disadvantages of IM methotrexate in the Mx of ectopic pregnancy?
Advantages:
- avoids risks of surgery/GA
- pt can be at home after injection
Disadvantages:
- potential s/e of methotrexate:
- abdo. pain
- myelosuppression
- renal dysfunction
- hepatitis
- teratogenic: pts need to use contraception for 3-6mths after use
- risk of Tx failure requiring surgical Mx
What are the advantages and disadvantages of surgery in the Mx of ectopic pregnancy?
Advantages:
- high success rate
- reassurance about when definitive Tx provided
Disadvantages
- GA risks
- risk of damage to bowels/ureters
- risk of DVT/PE, haemorrhage or infection
- risk of Tx failure (salpingotomy)
- risk of future ectopic in salvaged tube (salpingotomy)
What are the advantages and disadvantages of conservative Mx in the Mx of ectopic pregnancy?
Advantages:
- avoids risks of medication and surgery
- can be done at home
Disadvantages:
- risk of rupture
- failure or complications requiring surgical or medical Mx (25%)
What is the definition of a miscarriage?
loss of a pregnancy before 24 wks gestation
Describe the different types of miscarriage
- threatened: uterine bleeding without cervical dilation or passage of foetal tissue
- inevitable: uterine bleeding with cervical dilation but without passage of foetal tissue
- incomplete: partial passage of foetal tissue through partially dilated cervix
- complete: spontaneous passage of all foetal tissue (cervix may be open or closed)
- missed: intrauterine foetal demise without passage of tissue (closed cervix)
Suggest risk factors for miscarriage.
- maternal age >30-35 (increased risk of chromosomal abnormalities)
- previous miscarriage
- obesity
- maternal or paternal chromosomal abnormalities
- smoking
- uterine anomalies or previous uterine surgeries
- anti-phospholipid syndrome
- coagulopathies
Describe the typical presentation of a miscarriage
Many found incidentally on USS but can also present with:
- vaginal bleeding (+/- passage of POC)
- suprapubic cramping pain
- abdo. tenderness and/or distension
- may see open cervical os, bleeding or POC on speculum
- +/- signs/symptoms of haemodynamic instability if significant bleeding
How would you investigate a woman presenting with suspected miscarriage?
- urine B-hCG
- if +ve, perform TVUS
- if intrauterine pregnancy confirmed:
- look for foetal cardiac activity: if present = viable preg.
- if not present and foetal pole is visible measure CRL: if <7mm repeat scan in 7+ days; if >7mm seek 2nd opinion on viability
- if not present and foetal pole is not visible measure mean gestational sac diameter: if <25mm repeat scan in 7+ days; if >25mm seek 2nd opinion on viability
Perform other Ix as appropriate e.g. FBC, group + save, triple swab + CRP if pyrexial
What are the options for Mx of miscarriage?
- Use expectant management for 7-14 days as 1st line unless there is increased risk of haemorrhage (e.g. late 1st trimester), prev. adverse preg. outcome, evidence of infection or not acceptable to woman.
- Offer medical management if above not acceptable to woman.
- Surgical management is definitely indicated if haemodynamically unstable, infected tissue or gestational trophoblastic disease:
- manual vacuum aspiration with local anaesthetic if <12 wks
- evacuation of retained products of conception under GA
Offer anti-D prophylaxis for all rhesus -ve women undergoing surgical Tx and women undergoing medical Tx if >12/40.
