Pregnancy loss Flashcards
What is a molar pregnancy?
when foetus doesn’t form properly in the womb and abnormal cells develop instead of normal foetus. known as hydatidiform mole (complete or incomplete).
Which factors increase the risk of miscarriage?
Age Obesity Antiphospholipid syndrome / SLE Parental chromosomal translocation Poorly controlled diabetes Alcohol, smoking, recreational drug use Uterine anomaly High levels of natural killer cells
Outline the presentation of a miscarriage
Bleeding
Pain
Found at time of routine scan (i.e. missed miscarriage)
Acute collapse - cervical shock, hypotension, tachycardia, bleeding
Sepsis - pyrexia, hypotension, tachycardia, raised respiratory rate, confusion
How are miscarriages managed?
Conservative
Medical management – managed at home or on the ward, dependent on size of pregnancy.
Patients must be counselled: expectations for bleeding and discomfort, potential risk of retained tissue.
Surgical management - including risks
Follow up - support/counselling.
What are recurrent miscarriages and how are they investigated/managed?
3 consecutive pregnancy losses less than 24 weeks.
On third (or later) miscarriage offer karyotyping of tissue from products of conception.
Chromosomal abnormalities - most common: balanced translocation.
Recurrent miscarriage clinic
Blood tests - thrombophilia screen, anti cardiolipin antibodies, lupus anticoagulant. treatment for anti phospholipid syndrome: aspirin and tinzaparin.
Uterine anomalies: ultrasound 3D scan or hysteroscopy/laparoscopy.
What are the risk factors for an ectopic pregnancy?
Previous ectopic pregnancy Tubal damage - previous tubal surgery, history of pelvic infection / PID or endometriosis History of subfertility / IVF Presence of IUCD Use of progesterone only contraception Cystic fibrosis
What is the clinical presentation of an ectopic pregnancy?
Classic presentation: pain and bleeding, positive pregnancy test, empty uterus on USS, options for conservative, medical (methotrexate), or surgical management.
Emergency: collapsed patient, hypotension, tachycardia, acute abdomen, managed with emergency surgery.
Modern: minor symptoms in early pregnancy, may be monitored over 48 hours to confirm diagnosis (using scans and hCG levels), conservative management / medical / elective surgical.
When should an ectopic pregnancy be suspected?
Patient who presents with pelvic pain +/- bleeding + positive pregnancy test and always perform more investigations to rule out ectopic.
In a pregnancy of unknown location (not visible on USS) a sub-optimal rise of hCG (not double in 48-hours)
How may an ectopic pregnancy be diagnosed?
From a visualised ectopic on USS.
At laparoscopy (eg. following previous suspicious investigations).
After the patient has collapsed.
How are ectopic pregnancies treated?
Conservative
Medical – methotrexate injections
Surgical - salpingectomy
What are the causes of in-utero deaths that can lead to a second trimester miscarriage?
Fetal abnormality – structural / chromosomal
Infection
Placental dysfunction, growth restriction
SLE / anti phospholipid syndrome
What are the causes of pre-term labour that can lead to a second trimester miscarriage?
Cervical weakness / incompetence
Uterine abnormality
Infection - inflammatory response causing uterine irritability and contractions
Rupture of membranes - can be due to infection
Bleeding e.g. from placenta = abruption (emergency)
How are second trimester miscarriages examined and what investigations may take place post-loss?
Speculum - cervix, bleeding, swabs. scan / dopplers for fetal heart.
Tissue for karyotyping, postmortem?, screening for infection and APS.
What are the indications for cervical sutures?
Past history of mid-trimester pregnancy loss
Past history of cervical surgery
Known uterine anomaly
Cervical dilatation noted - on speculum examination or TV scan
What are the causes of stillbirth?
Antepartum/ intrapartum bleeding.
Intrauterine growth restriction (eg. caused by maternal medical problems).
Fetal abnormality - structural/ chromosomal.
Placental factors
Infection
Poorly controlled diabetes
