Obstetrics 1 Flashcards
What is a miscarriage and what are the classifications?
- Miscarriage is a spontaneous termination of pregnancy
- <12 weeks: early
- 12-24 weeks: late
- > 24 weeks: stillbirth
What are the types of miscarriage?
- Missed (no symptoms
- Threatened (bleeding, closed cervix, foetus alive)
- Inevitable (bleeding, open cervix)
- Incomplete (RPOC)
- Complete (no RPOC)
- Anembryonic (sac present but no embryo)
What are the chances of miscarriage occurring at different ages?
- 20-30: 10%
- 30-35: 15%
- 35-40: 25%
- > 40: 50%
How is miscarriage diagnosed?
- Transvaginal US
What is looked for on transvaginal USS in miscarriage?
- Mean sac diameter
- Crown-rump length
- Foetal heartbeat
- Once 1 is present the use of the other diminishes
When to expect each finding on TVUS?
- Mean sac of >25mm should see foetal pole (if empty sac rescan in 1 week, if still empty then an embryonic)
- Crown-rump length of >7mm should see foetal heartbeat (if not then rescan in 1 week, if still can’t be seen then pregnancy not viable)
- Won’t see anything before 6 weeks
How is miscarriage managed before 6 weeks?
- If no pain and complications then expectant management
- Do pregnancy test 10 days later
- If bleeding or pain then investigate
How is miscarriage managed >6 weeks?
- Refer to EPAU for USS
- Expectant
- Medical
- Surgical
Expectant management of miscarriage after 6 weeks?
- First line in healthy women with no complications
- Give 2 weeks
- Retest in 3 weeks
Medical management of miscarriage after 6 weeks?
- Misoprostol (prostaglandin analogue that softens cervix and causes contractions)
- Side effects include bleeding, pain, diarrhoea and vomiting
What is the surgical management of miscarriage after 6 weeks?
- MVA (outpatient procedure done under local; appropriate for pre-10 week and multiparous women)
- EVA (requires general anesthetic)
Incomplete miscarriage and treatment?
- Infection risk from RPOC
- Can be managed medically
- Surgery is MVA and curettage (risk of post-curettage endometritis)
What should miscarriages be investigated?
- 3 consecutive first trimester miscarriages
- Any second trimester miscarriage
What are some causes of miscarriage?
- Idiopathic
- Chromosomal abnormality
- Bleeding disorders (inherited thrombophilias or antiphospholipid syndrome)
- Chorionic histolytic intervillositis
- Uterine abnomalities
- DM, thyroid and SLE
Chromosomal abnormalities and miscarriage?
- 50-60% or miscarriage
- Trisomy most common cause (trisomy 16)
- Turner’s is most common specific abnormality
- Aneuploidy risk increases with age
Antiphospholipid syndrome?
- Primary or secondary to SLE
- APL or anticardiolipin antibodies
- Give LMWH and aspirin in pregnancy
What is the most common inherited thrombophilia and how is it inherited?
- Factor V Leiden (activated protein C resistance)
- Autosomal dominant
Chorionic histiocytic intervillositis?
- Rare but most common in T2
- Histiocyte and macrophage buildup in placenta
- This causes inflammation and poor outcomes
- Diagnosis: placental histology showing mononuclear cell infiltrate
How do you investigate the possible causes of recurrent miscarriage?
- Antibodies (antiphospholipid syndrome)
- Pelvic USS (uterine abnormalities)
- Genetic testing of foetus or parents with consent (chromosomal abnormality, Factor V Leiden)
What 2 acts are relevant to TOP?
- 1967 Abortion Act
- 1990 Human Fertilisation and Embryo Act (reduced legal age from 28 to 24 weeks)
What is the criteria for allowing abortion before 24 weeks?
Continuing must present cause of significant harm to physical or mental health of the mother or unborn child
What is the criteria for abortion after 24 weeks?
- Significant risk to life of woman
- Child likely to be born with severe disability
- Prevent significant harm to woman’s physical or mental health
What are the aspects of pre-abortion care?
- Can be referred by self, GP, or GUM clinic
- Marie stopes is UK charity that offer remote service pre-10 weeks
- Offer counselling
What its the medical management of abortion?
- Mifepristone (anti-progesterone; halts pregnancy)
- Misoprostol 2 days later (prostaglandin analogue that softens cervix and causes contractions)
- Must give anti-D prophylaxis if before week 10
What is the surgical management of abortion?
- Priming with mifepristone, misoprostol, and dilation
- <14 weeks: dilation and suction
- > 14 weeks: dilation and forced evacuation
- Must give anti-D regardless of gestation
Post-abortion?
- Bleeding and cramps for 2 weeks
- Pregnancy test at 3 weeks
- Bleeding, pain, infection, TOP failure and damage to structures are risk
Where are most ectopic pregnancies?
- 97% are tubal
- Most are in the ampulla
- Isthmus is most dangers
What are the risk factors for ectopic pregnancy?
- Previous ectopic, PID, STI or Fallopian tube surgery
- Intrauterine coil
- Smoking
- IVF
- Old age
Presentation of ectopic?
- 6-8 weeks gestation (missed LMP
- Lower abdo pain in IF
- Bleeding
- CMT
- Shoulder tip pain
- Syncope and dizziness from bleeding
Investigation of ectopic pregnancy?
- TVUS will show gestational sac outside of uterus (if can’t be seen this pregnancy of unknown location)
- Ectopic moves independently to ovary (if move together will be corpus luteum)
What is the management of ectopic?
- Expectant
- Medical
- Surgical
What is the medical management of ectopic pregnancy?
- Methotrexate IM buttock
- Can’t get pregnant for 3 months
What are the surgical options for ectopic?
- Salpingectomy (better, removal of whole tube)
- Salpingotomy (less definitive, ⅕ women will need methotrexate;
done if other tube damaged/ removal of tube leaves infertile) - Need anti-D phophylaxis
What criteria must be met for an expectant TOP of ectopic?
- Unruptured
- No pain
- Sac <35mm
- No heartbeat
- HCG <1500
What criteria must be met for medical TOP of ectopic?
- Unruptured
- No pain
- Sac <35mm
- No heartbeat
- HCG <5000
- USS evidence of non-intrauterine pregnancy
What criteria must be met for medical TOP of ectopic?
- If ruptured
- If painful
- > 35mm
- Heartbeat present
- HCG >5000
What is pregnancy of unknown location?
When gestational sac can’t be seen on TVUS
How is pregnancy of unknown location investigated?
- 2 HCG tests 48 hours apart
- Rise of >63% suggests intrauterine pregnancy
- Rise <50% is likely ectopic, admit
- Fall <50% likely miscarriage, recheck in 2 weeks
