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Obs & Gynae > Pregnancy Complications - Miscarriage / Ectopic / Molar > Flashcards

Pregnancy Complications - Miscarriage / Ectopic / Molar Flashcards

1
Q

What is miscarriage and what is recurrent

A

Termination of pregnancy before 24 weeks gestation

Recurrent if >3 miscarriages

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2
Q

What are most common causes of bleeding <12 weeks

A 
Miscarriage (7-13 weeks)
Ectopic - earlier
Molar 
Cervical lesions 
No cause
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3
Q

What do you do if pain or vaginal bleeding in pregnancy

A

Admit to assessment unit

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4
Q

What are categories of causes of miscarriage

A 
Abnormal conception = most common
Uterine abnormality
Cervical incompetence
Hormonal 
Maternal
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5
Q

What is abnormal conception

A

Chromosomal
- Trisomy / translocations etc.
Genetic
Surgical

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6
Q

Uterine abnormalities

A 
Congenital - bisetpum
Fibroids
Utreine surgery
Endometriosis  
PCOS
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7
Q

What can cause cervical incompetence

A

Primary = can’t hold

Secondary after dilatation or cone biopsy

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8
Q

Hormonal imbalances

A

Low progesterone in threatened
Thyroid abnormalities
Anti-phospholipid

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9
Q

What are maternal causes

A 
Age 
Previous miscarriage
Chronic - DM / SLE
Smoking
Alcohol
Drugs
Obesity
Underweight
Endocrine
Infections
VTE 
Invasive tests
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10
Q

What is a threatened miscarriage?

A 
Bleeding from uterus <24 weeks 
No cervical dilatation 
Viable fetus 
Little pain 
Minimal bleeding / less period 
Conservative Rx - usually fine
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11
Q

What is an inevitable miscarriage

A 
Bleeding <24 weeks 
Heavier 
Cervix has begin to dilate
Periodic painful contractions 
Will go on to miscarry
POC present in uterus on USS 
Irreversible
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12
Q

Incomplete miscarriage

A

Partial expulsion of POC
Os open
Heavy vaginal bleeding and pain
Risk of ascending infection

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13
Q

Complete miscarriage

A

Complete expulsion of POC
Cervix has closed and bleeding and pain has stopped
No gestational sac
Previous hx of bleeding and pain

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14
Q

Septic Miscarriage

A

Spread of infection into uterus / pelvis after incomplete
Febrile tender abdomen
Pain
Vaginal bleeding and offensive discharge
Septicaemia / DIC / shock

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15
Q

Missed miscarriage

A 
No symptoms
Light bleeding or discharge 
Cervix closed 
Fetus died but no attempt to expel 
Non viable pregnancy present in uterus 
Fetal pole with no heart seen 
No clear foetus in sac on USS
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16
Q

How is miscarriage Dx

A

USS to look for viable pregnancy

  • no gestational sac
  • no foetal pole / clear fetes in sac
  • no HR

Speculum to look to see if os open or closed
Blood and urine culture in septic

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17
Q

What is diagnostic on USS

A

Absence foetal heart - not heard till 14 week
Crown rump >7
Sac >25

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18
Q

What else should you do in miscarriage / bleed

A 
Pregnancy test + bHCG 
Pelvic and abdo exam 
- Excitation suggest ectopic 
Speculum to look for local lesions / is os open or closed 
Blood and urine culture in septic
Endocervical swab 
X-match 
Rhesus if >12 weeks
Anti-emetic and analgesia
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19
Q

What is suggestive of an ectopic

A

bHCG >1500

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20
Q

How do you treat threatened

A

Conservative
Fine if viable pregnancy seen on USS
Advice bleeding may continue but pregnancy fine
Come back if bleeding or pain worsens

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21
Q

How do you treat inevitable miscarriage

A

Conservative as contractions will expel
Surgical evacuation if heavy bleeding / haemodynamic unstable
Analgesia
Anti-D

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22
Q

What do you do for incomplete miscarriage

A

Evacuate
Misprostol vaginal pessary = encourage contraction
Advise to come back if no bleeding within 24 hours
Give with anti-emetic and pain relef

If fails
MVA under LA
ERPC under GA

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23
Q

What do you do for missed miscarriage

A

Wait for products to naturally expel
Or Vaginal prostaglandin - misoprostol
OR surgical as above

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24
Q

When is medical / surgical management preferred

A 
Haemorrhage risk as risk of DIC
Infection 
Previous adverse
Haemodynamic unstable 
Patient choice
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25
What do you do in septic
Broad spectrum Ax Rapid fluid resus Evacuate fetus Co-amoxiclav - cover E.coli and strep
26
What are general measures
Physiological support Anti-emetic Analgesia If >12 weeks and Rhesus -ve = Anti D
27
Complications of miscarriage
Haemodynamic instability = evacuate Low BP / tachy / fever = suggest septic Small risk of DIC
28
If early beed what do you ask
``` Amount passed Bigger or smaller than a period Clots / tissue Normal cycle Sx of ectopic If bleeding still present Previous bleeding Previous miscarriage ```
29
What is an ectopic pregnancy
Pregnancy implanted outside the uterine cavity
30
What is common site of ectopic and where is most dangerous
``` Ampulla = most common Isthmus = most dangerous ```
31
When should you consider ectopic
All patients with acute abdomen / PV bleed even if not sexually activity DO pregnancy test and bHCG
32
When does ectopic present
6/7 weeks early than miscarriage | Rarely over 8 weeks
33
What are the symptoms of ectopic
Period of amenorrhoea + +ve pregnancy test = suspect Lower abdominal pain = main feature Radiates to shoulder tip if peritoneal bleed Vaginal bleed = main feature miscarriage Cervical excitation GI or urinary if pressing on bladder / bowel
34
What are vague symptoms of ectopic
Tachycardia Right iliac fossa pain Guarding Cervical excitation
35
What are symptoms of rupture
``` Haemodynamic unstable Peritonitis Pallor Tachycardia Hypotension Guarding and rebound ```
36
What are RF for ectopic
``` PID Previous tubal surgery Previous ectopic Assisted conception - IVF Intrauterine contraception - IUD / POP Endometriosis ```
37
How do you Dx ectopic
USS = no gestational sac BhCG don't rise as normal pregnancy (would decrease miscarriage) Lower progestogen levels
38
What is ectopic till proven otherwise
bHCG >1500
39
What else might USS show
Adnexal mass | Fluid in Pouch of Douglas
40
What must you never do
Examine for adnexal mass as risk of rupture | Can still do pelvic exam to look for excitation
41
If going for medical management what do you do
Monitor bHCG and levels should decrease
42
When can you use methotrexate to manage
``` No significant pain Unruptured bHCG <1500 No intrauterine pregnancy on USS No heat beat Mass <35 mm Willing to attend follow up ```
43
What is surgical management
Salpingectomy to remove tube if rupture or close or medical CI Sapingotomy - but risk of ectopic due to damage wall
44
What must you do after Rx
Contraception 3 months after methotrexate
45
Can you observe
NO if confirmed must terminate
46
What must you also give
ANti-D
47
What should you do incase of rupture
X match IV cannula Resus Emergency laparotomy
48
DDX of ectopic
``` Ovarian torsion Appendicits PID MIscarriage Renal calque Ovarian cyst COnstipation Endometriosis Ovulation pain ```
49
What is molar pregnancy
Non-viable fertilised egg implants in uterus 2 sperm fertilise an empty ovum with no genetic material All 46 chromosomes = paternal
50
What are the symptoms of molar compared to normal
``` +ve pregnnacy Bleeding Large for date uterus Abnormally high b-HCG More severe morning sickness Hypertension / hyperthyroid as HCG mimics TSH - Vomiting / dry skin / fatigue ```
51
How do you Dx
USS - placental tissue / messy Follapain tubes normal Remove endometrial tissue and send to pathology to confirm Dx
52
What does histology show
Enlarged abnormal chorionic villi | Abundant trophoblast
53
How do you manage molar
If bHCG returns to normal = no Rx Methotrexate if high Suction curettage of fetus and send to histology Measure bHC to ensure return to normal Surveillance for malignancy transformation
54
What should you avoid
Pregnancy 12 months
55
What can molar cause
Malignant choriocarcinoma
56
What are Dx of abdominal pain in pregnancy
``` Labour Miscarriage Ectopic PET HELLP Abruption Uterine rupture Fibroid Uterine torsion Ovarian tumour Pyelonephritis Appendicits UTI = 1 in 25 Cholecystitis Pancreatitis Gastroenteritis Cardiac ```
57
How does uterine torsion present
Abdo pain Shock Tense uterus Retention
58
How does cholecystitis present
Same as not pregnancy | Increased risk due to biliary stasis and increased cholesterol in bile
59
How does appendicitis present
Pain changes depending on gestation Leucocytosis High mortality
60
How do you Dx torsion
Laparoscopy
61
How do you Dx cholecystitis
USS confirm stone | Laparotomy if cannot exclude appendicitis
62
What do you do for back / chest or epigastric pain
Full investigation for cardiac cause
63
How do you treat appendicitis
Deliver by LSCS Perforation much more likely Beware of sepsis
64
How do you investigate abdominal pain
``` Pregnancy test USS MSSU Swabs FBC, U+E, CRP, clotting Pelvic and abdo exam to look for peritonitis ```
65
What are causes of recurrent miscarriage
``` Idiopathic - particularly if older Anti-phospholipid Other thrombophilia Uterine abnormality Genetic factors in parents Chronic disease Chronic histocytic intervillositis ```
66
How do you investigate
Anti-phospholipid Ab / lupus / anti-cardolipin Pelvic USS Genetic tests on parents - Cytogeneic chromosomal analysis to look for translocations
67
If 1st trimester bleed
Ectopic Miscarriage Molar
68
If 2nd triemster
Miscarriage Molar Placental abruption
69
If 3rd trimester
Bloody show Abruption Placenta praaevia Vasa praevia

Obs & Gynae (23 decks)

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