Problems of early pregnancy Flashcards
Define miscarriage
Pregnancy loss at <20wks gestation or loss of foetus/embryo <500g
Risk factors for miscarriage
Hx miscarriage Smoking Alcohol Increasing maternal age BMI <18.5 or >25 Fever
Epidemiology of miscarriage
20% of all pregnancies
Aetiology of miscarriage - foetal factors
Chromosomal abnormalities (50%)
Congenital abnormalities
- genetic e.g. anencephaly
- teratogen exposure
- extrinsic factors
Trauma
- amniocentesis or chorionic villus sampling
- trauma to abdomen
- DV
Aetiology of miscarriage - maternal factors
TORCH infection
- toxoplasmosis
- syphilis, parvovirus, varicella, listeria
- rubella
- CMV
- HSV2
Medical conditions
- hypothyroid
- DM
- PCOS
Hypercoagulable states
Ix for ?miscarriage
B-hcg
Pelvic US
Group and hold (Ab status)
List the different types of miscarriage
Complete Incomplete Inevitable Threatened Missed Septic
What is a threatened miscarriage? And what are the distinguishing features?
Threatened MC = any bleeding/spotting before 20wks. Does not necessarily mean actual MC.
Features:
- No pain
- minimal bleeding
- no POC passed
- no cervical dilation, closed os
Management for threatened miscarriage
Expectant management: symptoms will either resolve or progress to MC. Avoid strenuous activity and stress. Rest Weekly pelvic US Refer to EPC
Features of complete miscarriage
Full expulsion of POC
PV bleeding and pain - usually resolves after passing POC
Cervical dilation, os open or closed.
Management of complete miscarriage
Confirm cervical os has closed
TV US to exclude retained POC
Monitor b-hcg weekly to ensure it’s dropping
Features of incomplete miscarriage
Heavy PV bleeding with clots
Passage of some POC
Abdo pain
Cervical os open
Management of incomplete miscarriage
Expectant vs medical vs surgical management
b-hcg
pelvic US
Features of inevitable miscarriage
Heavy bleeding Abdo pain Cervical dilation, open os Visible or palpable POC not yet passed \+/- foetal cardiac activity
Define inevitable miscarriage
PV bleeding + open os with passage of POC expected to occur imminently
Management of inevitable miscarriage
Expectant or medical or surgical.
What is a missed miscarriage
US diagnosis of a non-viable IUP in the absence of PV bleeding
Features of missed miscarriage
No bleeding (may have spotting) No pain No cervical changes No foetal HR Empty gestational sac Incidental US finding No expulsion of POC
Management of missed miscarriage
Expectant vs medical vs surgical
Features of septic miscarriage
Vaginal bleeding Offensive PV discharge Abdo pain Fever Complication of an inevitable/missed/incomplete miscarriage
Management of septic miscarriage
Broad spectrum IV abx
Surgical D&C
What is involved in expectant management of miscarriage?
- education
- 60% success rate
- 1-2 wks duration
- Sx should resolve as the POC is passed
- more bleeding than a normal period
- return if malodourous d/c, fever, severe abdo pain, N&V - analgesia - NSAIDs, paracetamol
- Review in 1-2 wks (repeat b-hcg)
Explain the process of medical management of miscarriage
- misoprostol PO or PV (prostaglandin analogue for cervical ripening)
- mifepristone PO (blocks progesterone)
- analgesia
- return if worsened Sx
- follow up in 1-2 wks
(70% have complete MC in 3 days)
Explain the surgical management of miscarriage.
When would you opt for surgical management?
- prime cervix 4hrs before surgery with misoprostol.
- D&C
Management choice for: persistent heavy bleeding, sepsis, larger foetal pole, unsuccessful medical Rx.
Education and counselling after a miscarriage
No sex or tampons for 2 wks
Periods will return in 4-8 wks
Can attempt to conceive after 2 normal periods
reassurance that she didn’t cause the MC
risk recurrance after 1 MC is not substantial
Define recurrent miscarriage
> 3 consecutive miscarriages
Risk factors for recurrent miscarriage
Prev miscarriages Uterine anomalies, leiomyomas, adhesions Antiphospholipid syndrome PCOS Poorly controlled DM Hyperprolactinaemia Inc parity
Investigations for recurrent miscarriage
Lupus anticoagulant
Parental chromosomes
Pelvic US
Management of recurrent miscarriage
Progesterone pessaries
Low does aspirin
Early pregnancy surveillance
Describe management of a medical termination of pregnancy
MS 2-step: 1. Mifepristone Two days later... 2. Misoprostol 3. Ibuprofen Plus prn panadeine forte and antiemetics
Follow up: 2 wks after MTOP to confirm termination is complete: - declining b-hcg - hx of passing POC - US Discuss contraception Review STI results
Advantages and disadvantages of MTOP
Advantages:
- safe and effective
- avoids hospital admission
- avoids surgical and anaesthetic risks
Disadvantages:
- takes longer than STOP (2 wks)
- usually more blood loss
- failure rate is 1 in 100, which is higher than in STOP
- more likely to have retained products
Describe the management of a surgical termination of pregnancy (STOP)
Day procedure Anti-D Misoprostol 4 hrs before surgery GA suction and curettage if <14 wks, dilation and evacuation if >14wks. Abx: doxy +/- metronidazole \+/- IUD insertion in theatre
Risks and benefits of STOP
Risks:
- 0.2% failure rate
- retained POC
- infection
- cervical trauma
- uterine perforation
- Asherman’s syndrome (intrauterine adhesions)
- anaesthetic risks
Benefits:
- higher success rate than MTOP
- less bleeding (‘over and done with’)
DDx for bleeding in pregnancy
Pregnancy-related:
- miscarriage: complete, incomplete, inevitable, theatened.
- ectopic pregnancy
- endometrial implantation bleed
- molar pregnancy
Not pregnancy related:
- endometritis
- STI
- cervical polyps
- cervical cancer
If haemodynamically unstable: ruptured ectopic, incomplete miscarriage with cervical shock.
Risk factors for ectopic pregnancy
Previous ectopic Tubal pathology or surgery (strictures, adhesions) PID Prev STI IUD POP
Indications for expectant management of ectopic pregnancy
Hemodynamically stable No evidence of rupture Tubal mass <3cm No free fluid in pelvis b-hcg <5000 Pain free woman can access follow up
Outline the components of expectant management of ectopic pregnancy
Monitor Sx Refer to EPC serial b-hcg every 2 days US avoid conception until sonographic resolution advise of red flags
Indications for medical management of ectopic pregnancy
hemodynamically stable no evidence of rupture normal FBC, no signs of active bleeding reliable with treatment and follow up b-hcg <5000 mass size <3cm no FHR
What is involved in medical management of ectopic pregnancy
- Methotrexate IM or IV (absorption and resolution of pregnancy)
- Admit to hospital for the 1st few days (the risk of rupture will inc for a few days after MTX as the mass swells before resolving)
- serial b-hcg until -ve
- US in 1 wk
- avoid conception for 4 months (MTX is teratogenic)
- avoid NSAIDS (BM suppression)
What is the success rate of medical management of ectopic pregnancy
90%
Indications for surgical management of ectopic pregnancy
Signs of rupture, peritonism or unstable.
any b-hcg level
persistent excessive bleeding
heterotopic pregnancy
contraindication to medical or expectant management
Management of ruptured ectopic
If stable –> laparoscopy
If unstable –> laparotomy
DDx for pain in early pregnancy
ectopic pregnancy
miscarriage
UTI
Non-pregnancy related (appendicitis, cholelithiasis)
Aetiology of nausea and vomiting in pregnancy
Primary (most common): attributed to pregnancy and rising b-hcg levels.
Secondary:
- inc ICP
- thyrotoxicosis, DKA, hyperglycaemia
- iron supplements, abx
- appendicitis, cholecystitis, bowel obstruction, PUD, pancreatitis
- UTI, pyelo
- Pregnancy specific: HELLP syndrome, acute fatty liver of pregnancy
Aetiology of hyperemesis gravidarum
Molar pregnancy
Multiple pregnancy
Hyperthyroidism
Complications of hyperemesis gravidarum
Maternal complications: Dehydration Ketosis and ketonuria Mallory weiss tear Wernicke's encephalopathy Malnutrition and weight loss Hyponatremia Thrombosis (inc blood viscosity)
Foetal complications:
SGA
Foetal death
Ix for hyperemesis gravidarum
Urinalysis - ketonuria b-hcg TSH UEC LFTs FBC BSL US - molar pregnancy or multiple pregnancy
Management of hyperemesis gravidarum
Mild: pyridoxine or ginger powder, PO fluids, small frequent meals
Moderate:
- metoclopramide or ondansetron
- H2 anatagonist
- IV fluids
Severe:
- admit to hospital
- ondansetron, metoclopramide and prednisone
- switch H2 anatgonist for a PPI
- IV fluids
- electrolyte replacement
- IV thiamine
- VTE prophylaxis
Management of gestational trophoblastic disease
Suction evacuation
Anti-D
COCP for 6/12
Refer to QTC (Queensland Trophoblastic Centre) - they will organise serial b-hcgs.
Diagnosis of GTD
Pelvic US: grape-like vesicles or snow storm appearance
b-hcg super high
hyperthyroidism
