Revision Flashcards
types of spontaneous abortion
Threatened miscarriage - painless vaginal bleeding typically around 6-9 weeks
Missed (delayed) miscarriage - light vaginal bleeding and symptoms of pregnancy disappear
Inevitable miscarriage - complete or incomplete depending or whether all fetal and placental tissue has been expelled.
Incomplete miscarriage - heavy bleeding and crampy, lower abdo pain.
Complete miscarriage - little bleeding
Threatened miscarriage
painless vaginal bleeding typically around 6-9 weeks
Presentation
• Painless vaginal Bleeding occurring <24 weeks
o Typically: weeks 6-9
• Bleeding often less than menstruation
• Closed cervix (cervical os)
• Complicates 25% all pregnancies
• Unclear if it will progress to miscarriage or settle down
USS
• Intrauterine gestation sac + foetal pole
• ± area of bleeding adjacent to gestation sac subchorionic haematoma
Missed (delayed) miscarriage
Missed (delayed) miscarriage - light vaginal bleeding and symptoms of pregnancy disappear
Presentation
• Asymptomatic
• Some pain & bleeding – light vaginal bleeding/ discharge and symptoms of pregnancy disappear
• Cervix closed
• Gestational sac contains dead fetus <20 weeks without the symptoms of explusion
• Pregnancy has failed
o Foetus never developed or Foetus stopped growing at an early gestation or No foetal heart
USS
• When gestational sac >25 mm and no embryonic/ fetal part can be seen = aka blighted ovum or anembryonic pregnancy
• If there is no foetal heartbeat
o Is it a very early pregnancy? or Has the foetus died/never developed? or Are her dates correct?
•
Can call it a miscarriage when:
o Foetal pole >7mm + no heartbeat
o Gestation sac >35mm + no foetal pole
o –>Rescan at 7 days shows no growth
Inevitable miscarriage
- complete or incomplete depending or whether all fetal and placental tissue has been expelled.
Presentation • Heavy bleeding with clots and pain • Open cervical os USS: • Irregular gestation sac + foetal pole • Foetus usually has no heartbeat
Incomplete miscarriage
- heavy bleeding and crampy, lower abdo pain.
Presentation
• Bleeding and pain
• Cervix may be open
• Products may be retained – not all products of conception have been expelled
USS:
• Retained products visible
• Heterogenous tissue, may see gestation sac
Complete miscarriage
- little bleeding
Presentation • Pain and bleeding usually stopped • History of passing products (may have a photo) • Cervix closed USS: • Empty uterus, thin endometrium Was the pregnancy ever there? • Look for ectopic • Follow up with HCG until pregnancy test negative
reasons for miscarriage
- Non-development of the blastocyst within 14 days occurs in up to 50% of conceptions
- Up to 40% of all conceptions
- Recurrent spontaneous miscarriage affects 1% of women
miscarriage management options
1st line = expectant, rescan in 14 days
if risk haemorrhage/ previous traumatic experience/ infection –> medical or surgical
medical = misoprostol (oral or PV) = prostaglandin E2 analogue
surgical = MVA (manual vacuum aspiration = suction currettage under LA) or ERCP (evacuation retained products of conception)
ectopic preganncy rrisk factors
2/3 have no RFs
All other risk factors are micro/macroscopic tube damage --> slow ovum passage to uterus o IVF (3%) o Previous chlamydia or PID o Endometriosis o Pelvic or tubal surgery o Previous ectopic (recurrence risk 10-20%) o IUCD in situ o Smoking o POP
ectopic pregnancy history
History
• 6-8 weeks amenorrhoea who presents with lower abdominal pain and later develops vaginal bleeding
• lower abdominal pain
o due to tubal spasm
o typically the first symptom
o pain is usually constant and may be unilateral.
• vaginal bleeding
o usually less than a normal period
o may be dark brown in colour
• history of recent amenorrhoea
o typically 6-8 weeks from the start of last period
o if longer (e.g. 10 wks) this suggest another causes e.g. inevitable abortion
• peritoneal bleeding can cause shoulder tip pain and pain on defecation / urination
• dizziness, fainting or syncope may be seen
• symptoms of pregnancy such as breast tenderness may also be reported
ectopic Examination findings
- abdominal tenderness
- cervical excitation (aka cervical motion tenderness)
- adnexal mass: NICE advise NOT to examine for an adnexal mass due to an increased risk of rupturing the pregnancy. A pelvic examination to check for cervical excitation is however recommended
why can ectopics be deathly
- Fallopian tube is supplied by ovarian artery (direct branch of aorta)
- lot of bleeding –> collapse
define Pregnancy of Unknown Location
Pregnancy of Unknown Location
Definition
• Positive pregnancy test with no pregnancy seen inside or outside uterus
• Cannot exclude ectopic pregnancy
• serum bHCG levels >1,500 points toward a diagnosis of an ectopic pregnancy
