Legal < 24 weeks After 24 weeks... 1. Continuing would risk maternal life 2. Prevent grave injury to mother's physical/mental health 3. Would risk mother's life more than termination 4. Risk to current children 5. Child may have severe mental/physical handicap

Obstetrics - Disorders of early pregnancy Flashcards by Jack Hogg

Ectopic pregnancy sites

Tubal ampulla - Most common
Tubal isthmus - Most dangerous

ACID = Ampulla Common Isthmus Dangerous

Ovary
Cervix
Peritoneum

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Ectopic pregnancy aetiology

Anything slowing ovum passage to uterus - PIPES

Previous ectopic 
IVF 
POCP 
Endometriosis 
Surgery

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Ectopic pregnancy presentation

Acute abdo pain in woman of child bearing age
= ECTOPIC UNTIL PROVEN OTHERWISE

Amenorrhoea - 6-8 weeks
Unilateral abdo pain
PV bleed - Dark brown

Cervical excitation
Shoulder tip pain
Vomiting
Rupture - Shock + hypo

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Ectopic pregnancy investigations

Pregnancy test
b-hCG > 1500 = ECTOPIC
USS
Laparoscopy

Serial serum hCG
Rise > 66% / 48 hours = IUP
Falling / rising slowly = ECTOPIC

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Ectopic pregnancy expectant management

Indications

< 30mm
Asymptomatic
Non-rupture
hCG < 200
No heartbeat

Serial serum hCG until repeated fall

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Ectopic pregnancy medical management

Indications

< 35mm
Asymptomatic
Non-rupture
hCG < 1500
No heartbeat

Monitor serum hCG
IM METHOTREXATE

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Ectopic pregnancy surgical management

Indications

> 35mm
Symptomatic
Rupture
hCG > 1500
Visible heartbeat

Salpingo-oophorECTOMY
Salpingo-oophorOTOMY

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Miscarriage definition

Loss of pregnancy < 24 weeks

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Miscarriage aetiology

Chromosomal abnormality - Most common
Infection - LATE

Previous miscarriage
DM
Thyroid disease

RFs

Smoking
Obesity
Alcohol
Maternal age ^

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Recurrent miscarriages aetiology

Anti-phospholipid syndrome - Most common

Bleeding disorder
Autoimmune disease
Infection
Smoking

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Types of miscarriage

Threatened
Inevitable 
Delayed / missed
Incomplete 
Complete

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Threatened miscarriage

Foetus alive

Painless PV bleed
Cervical os CLOSED

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Inevitable miscarriage

Foetus alive - But will become complete

Painful bleed
Cervical os OPEN

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Delayed / missed miscarriage

Foetus dead

Empty gestational sac
Cervical os CLOSED

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Incomplete miscarriage

Foetus dead

Painful PV bleed - Passage of products
Cervical os OPEN

Large uterus

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Complete miscarriage

Foetus dead

Large bleed - Passage of products
Cervical os CLOSED

Small uterus

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Miscarriages with os open

Inevitable

Incomplete

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Miscarriages with os closed

Threatened
Delayed / missed
Complete

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Miscarriage investigations

Examine cervical os
hCG
USS

FBC
Cross match

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Miscarriage management

Rhesus -ve - Give Anti-D
- Sensitising event!

Stop bleeding - SYNTOMETRINE

Expectant - Wait 7-10 days

Medical

Mifepristone
24-48 hours later - Misoprostol

Surgical

Manual suction < 13 weeks
Surgical extraction - ERCP

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Abortion act 1967

Legal < 24 weeks

After 24 weeks…

Continuing would risk maternal life
Prevent grave injury to mother’s physical/mental health
Would risk mother’s life more than termination
Risk to current children
Child may have severe mental/physical handicap

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What to offer before ToP

Counselling
USS - Confirm foetus

Chlamydia screen

Anti-D if Rh -ve

Who can perform an abortion

Signed off by two registered medical practitioners
Performed by a registered medical practitioner
Must be in a NHS hospital or licensed premise

Abortion methods

< 9 weeks

Mifepristone
Prostaglandins - Misoprostol
Follow up scan in 2 weeks

< 13 weeks

Surgical dilatation
Suction / vacuum

> 15 weeks

Surgical dilatation
Evacuation

> 22 weeks
- KCl - Umbilical vein

Abortion complications

``` Haemorrhage Uterine perforation Cervical trauma Retained products Psychological ```

Placenta previa types

Minor 1. Placenta encroaches os 2. Placenta slightly overlies os Major 3. Majority of placenta overlies os 4. Placenta completely overlies os Generally rise away from os during gestation

Placenta previa aetiology

Previous CS Older woman Multiparous Multi-pregnancy

Placenta previa presentation

PAINLESS PV BLEED BRIGHT RED! Uterus not tender Picked up at 20 week USS Baby may be transverse lie or breech

Placenta previa investigations

USS Do not perform PV FBC Cross match

Placenta previa management

Wait and rescan at 34 weeks Then rescan every 2 weeks 38/39 weeks - Planned CS

Placenta previa complications

PPH | Death

Vasa previa definition

Foetal vessels overlie the cervical os

Vasa previa aetiology

Multiple pregnancy Abnormal lie Villamentous insertion

Vasa previa presentation

1. ROM 2. Painless PV bleed 3. Foetal bradycardia

Vasa previa investigations

USS | CTG - Foetal bradycardia

Vasa previa management

Induce at 36 weeks Presenting with ROM - CS!

Vasa previa complications

Foetal exsanguination | Maternal death

Placenta accreta definition

Abnormal invasion of placenta into uterine wall Accreta - Up to myometrium Increta - In the myometrium Precreta - Beyond myometrium

Placenta accreta aetiology

Previous CS Previous accreta Uterine surgery

Placenta accreta presentation

Asymptomatic? | Picked up on USS

Placenta accreta investigations

USS - Swiss cheese - Loss of hypoechoic zone

Placenta accreta management

Planned CS at 36 weeks

Placenta accreta complications

Uterine prolapse Uterine rupture PPH Death

Placenta abruption definition

Placenta separates from endometrium before delivery of foetus

Placenta abruption aetiology

Think - HTN Pre-eclampsia HTN Previous abruption Smoking

Placenta abruption presentation

WOODY UTERUS! - Abdomen is hard and tense on palpation Painful PV bleed - Dark red Foetal distress Shock - Tachycardia

Placenta abruption investigations

USS FBC Cross match

Placenta abruption management

Foetal distress? - Perform CS No foetal distress? > 37 weeks - Induce labour < 37 weeks - Admit and monitor

Placenta abruption complications

PPH Death DIC Renal failure

Antepartum haemorrhage definition

Bleeding from genital tract > 24 weeks pregnancy | - Prior to delivery

Antepartum haemorrhage classification

Minor < 50ml Major = 50-1000ml Massive > 1000ml + Shock

APH differentials

Uterine - Placental abruption - Placenta previa - Vasa previa Cervical - Show - Cancer - Polyps - Ectropion Vaginal - Trauma - Infection

Placenta previa Vasa previa Placenta accrete Placenta abruption MANAGEMENT

PP - Scans @ 34, 36, 38 - CS at 38 VP - Presenting with ROM - CS - Induce @ 36 Accreta - CS @ 36 Abruption - Foetal distress - CS - No foetal distress < 37 weeks - Admit and monitor - No foetal distress > 37 weeks - Induce