Obstetrics - Disorders of early pregnancy Flashcards
Ectopic pregnancy sites
Tubal ampulla - Most common
Tubal isthmus - Most dangerous
ACID = Ampulla Common Isthmus Dangerous
Ovary
Cervix
Peritoneum
Ectopic pregnancy aetiology
Anything slowing ovum passage to uterus - PIPES
Previous ectopic IVF POCP Endometriosis Surgery
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
Ectopic pregnancy investigations
Pregnancy test
b-hCG > 1500 = ECTOPIC
USS
Laparoscopy
Serial serum hCG
Rise > 66% / 48 hours = IUP
Falling / rising slowly = ECTOPIC
Ectopic pregnancy expectant management
Indications
- < 30mm
- Asymptomatic
- Non-rupture
- hCG < 200
- No heartbeat
Serial serum hCG until repeated fall
Ectopic pregnancy medical management
Indications
- < 35mm
- Asymptomatic
- Non-rupture
- hCG < 1500
- No heartbeat
Monitor serum hCG
IM METHOTREXATE
Ectopic pregnancy surgical management
Indications
- > 35mm
- Symptomatic
- Rupture
- hCG > 1500
- Visible heartbeat
Salpingo-oophorECTOMY
Salpingo-oophorOTOMY
Miscarriage definition
Loss of pregnancy < 24 weeks
Miscarriage aetiology
Chromosomal abnormality - Most common
Infection - LATE
Previous miscarriage
DM
Thyroid disease
RFs
- Smoking
- Obesity
- Alcohol
- Maternal age ^
Recurrent miscarriages aetiology
Anti-phospholipid syndrome - Most common
Bleeding disorder
Autoimmune disease
Infection
Smoking
Types of miscarriage
Threatened Inevitable Delayed / missed Incomplete Complete
Threatened miscarriage
Foetus alive
Painless PV bleed
Cervical os CLOSED
Inevitable miscarriage
Foetus alive - But will become complete
Painful bleed
Cervical os OPEN
Delayed / missed miscarriage
Foetus dead
Empty gestational sac
Cervical os CLOSED
Incomplete miscarriage
Foetus dead
Painful PV bleed - Passage of products
Cervical os OPEN
Large uterus
Complete miscarriage
Foetus dead
Large bleed - Passage of products
Cervical os CLOSED
Small uterus
Miscarriages with os open
Inevitable
Incomplete
Miscarriages with os closed
Threatened
Delayed / missed
Complete
Miscarriage investigations
Examine cervical os
hCG
USS
FBC
Cross match
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
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
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
- Placenta encroaches os
- Placenta slightly overlies os
Major
- Majority of placenta overlies os
- 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
- ROM
- Painless PV bleed
- 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
