Women's Health : Early Pregnancy Flashcards
What is the definition of a miscarriage?
Spontaneous loss of pregnancy before 24 weeks of gestation.
Name some causes of miscarriage.
Chromosomal abnormalities, hormonal factors, thrombophilia/autoimmunity, anatomical factors, infection.
What is the most common cause of miscarriage?
Chromosomal abnormalities, typically autosomal trisomies.
Why can chromosomal abnormalities cause miscarriage?
Chromosomal abnormalities can result in failure of development of embryo within gestational sac.
Name two hormonal factors that can lead to miscarriage.
PCOS, hyperprolactinaemia, diabetes, hyper/hypothyroidism.
What autoimmune condition can induce placental thromboses, leading to placental insufficiency?
Antiphospholipid syndrome, factor V Leiden - induces placental thromboses leading to placental insufficiency.
What type of anatomical factors can lead to miscarriage?
Bicornuate uterus, cervical insufficiency.
Which infections can lead to miscarriage?
Toxoplasmosis, syphilis.
List two risk factors for miscarriage.
Increased maternal age and previous miscarriage.
List some types of miscarriage.
Threatened, incomplete, complete, missed, inevitable.
Define a ‘threatened miscarriage.’
Vaginal bleeding in the first 24 weeks of pregnancy (with viable intrauterine pregnancy).
Define an ‘Incomplete miscarriage.’
Non-viable pregnancy, bleeding begun, products of conception in uterus.
Define a ‘Complete miscarriage.’
All products of conception passed, bleeding has stopped.
Define a ‘Missed miscarriage.’
Non-viable pregnancy on ultrasound (without pain / bleeding).
Mean gestational sac diameter >25mm with no yolk sac or CRL >7mm with no cardiac activity.
Define an ‘Inevitable miscarriage.’
Non-viable pregnancy, bleeding begun, cervical os opened, POCs remain in uterus.
What type of miscarriage involves all products of conception being passed and bleeding stopping?
Complete miscarriage.
Fill in the blank: A missed miscarriage is diagnosed by a mean gestational sac diameter of >___ mm without a yolk sac or CRL >___ mm without cardiac activity.
25 mm; 7 mm.
Presentation of miscarriage
Pelvic pain, vaginal bleeding.
Differentials of bleeding in early pregnancy
The commonest causes of bleeding in early pregnancy are miscarriage, gestational trophoblastic disease, implantation bleeding, ectopic pregnancy, and importantly, bleeding without an identified cause.
How is a miscarriage diagnosed?
Transvaginal ultrasound scan - to identify location, foetal pole and heartbeat.
How is a threatened miscarriage managed if there is no history of previous miscarriage?
Conservative management: Advise returning if bleeding persists after 14 days or becomes heavier.
How is a threatened miscarriage managed if there is a history of previous miscarriage?
Offer vaginal progesterone until 16 weeks of pregnancy completed.
Once the bleeding has stopped, what should the patient (suspecting miscarriage) do?
Take a pregnancy test 3 weeks after the bleeding has stopped.
If the bleeding is ongoing, offer __ ______ _____.
A repeat scan.
First line management of Incomplete/Inevitable Miscarriage
Expectant management (appropriate to 13 weeks gestation): Allow 7-14 days for POCs to pass / bleeding to end.
Second line management of Incomplete/Inevitable Miscarriage
Medical management: mifepristone, followed by misoprostol 48 hours later.
Alternative second line management of Incomplete/Inevitable Miscarriage
Surgical management: Vacuum aspiration under local or dilatation and evacuation under GA.
For Incomplete/Inevitable Miscarriage when should a pregnancy test be taken?
Pregnancy test 3 weeks post-miscarriage.
How is missed miscarriage managed differently to Incomplete/inevitable miscarriage?
Exactly the same except for the second line (medical management) only use misoprostol NOT mifepristone.
Contraindications to expectant management:
- Heavy vaginal bleeding / increased risk of bleeding / increased vulnerability to heavy bleeding (coagulopathy) 2. Previous traumatic experience in pregnancy 3. Evidence of infection.
Mechanism of mifepristone
Antiprogesterone; sensitises myometrium to prostaglandins, induces breakdown of decidua basalis.
Mechanism of misoprostol
Prostaglandin E1 analogue; degrades cervical collagen, stimulates uterine contraction.
The 1967 Abortion Act gives four legal grounds for termination of pregnancy (TOP): what are they?
- Pregnancy before 24 weeks - continuation risks injury to physical / mental health of the pregnant woman / her children. 2. Necessary to prevent grave permanent injury to physical / mental health of the pregnant woman. 3. Continuation of pregnancy involves risk to the life of the pregnant woman. 4. Substantial risk of serious physical / mental disability to the child if it were born.
Medical Abortion Procedure
Up to 9+6 weeks - single dose mifepristone, followed by single dose PO / PV misoprostol 48 hours later. 10+0 to 23+6 weeks - single dose mifepristone, followed by serial misoprostol every 3 hours. Analgesia - NSAIDs, opioids as required.
Surgical Abortion Procedure
Up to 13+6 weeks - cervical priming with misoprostol or mifepristone, followed by vacuum aspiration. 14+0 to 24+0 weeks - cervical priming with mifepristone + misoprostol or osmotic dilator, followed by dilatation and evacuation. Plus - oral doxycycline to prevent infection. Analgesia - NSAIDs, local anaesthetic, conscious sedation.
What are the 2 main options for abortion?
Medical or Surgical.
Both the medical and surgical abortion methods use misoprostol. How do they differ?
Medical - mifepristone plus misoprostol taken 48 hours later. Surgical - misoprostol plus vacuum aspiration / dilatation and evacuation.
Anti-D should be offered to Rhesus-negative women after ___ weeks post-abortion.
10.
What is the medical regimen for abortion up to 9+6 weeks?
Mifepristone, followed by misoprostol (PO or PV) 48 hours later.
What surgical procedure is used for termination between 14+0 and 24+0 weeks?
Dilatation and evacuation with cervical priming using mifepristone + misoprostol or an osmotic dilator.
What antibiotic is administered post-surgical abortion?
Oral doxycycline.
Define ectopic pregnancy
Any pregnancy that implants outside of the endometrial cavity. 97% are implanted in a fallopian tube.
What is the most common implantation site for ectopic pregnancy?
Fallopian tube, specifically the ampulla.
Where does fertilisation of the oocyte happen?
Fertilisation of the oocyte typically takes place in the ampulla of the fallopian tube.
Name two mechanisms that assist the conceptus in reaching the endometrial cavity.
This occurs due to tubal peristalsis alongside ciliary motion and tubal fluid flow.
Any dysfunction in the movement of the conceptus to the endometrial cavity can prevent it from implanting in the correct place. What could cause that dysfunction?
Tubal surgery, salpingitis, PID can prevent the conceptus from implanting in the correct place.
A pregnancy that implants in the fallopian tube can cause what?
A pregnancy that implants in the fallopian tube will grow and eventually lead to rupture and catastrophic bleeding.
Most tubal ectopics implant in the ____.
Ampulla (widest point).
Name one risk factor for ectopic pregnancy.
- Previous ectopic pregnancy 2. Cu-IUD use (although background risk of pregnancy is obviously much lower). 3. Chronic salpingitis (tubal inflammation) 4. PID.
Presentation of ectopic pregnancy
Typically presents at 6-8 weeks after LMP; at this point the conceptus has grown to sufficient size to cause symptoms / signs.
Symptoms of ectopic pregnancy
Lower abdominal pain, amenorrhea, PV bleeding, urge to defecate, shoulder pain.
Signs of ectopic pregnancy
Lower abdominal tenderness / adnexal tenderness, cervical motion tenderness.
Differentials of ectopic pregnancy
Miscarriage, appendicitis and ovarian torsion.
Any female of childbearing age presenting with abdominal pain should be offered a ____ to exclude ectopic pregnancy.
UPT (urine pregnancy test).
The following signs / symptoms occur due to intraperitoneal bleeding and are indicative of rupture
Urge to defecate, shoulder tip pain, cervical motion tenderness.
Investigations for ectopic pregnancy
- Urine pregnancy test 2. Transvaginal ultrasound scan 3. Serial serum beta-hCG if no pregnancy found on USS.
Different types of management for ectopic pregnancy
Expectant, Medical and Surgical.
Expectant Management of ectopic pregnancy
No criteria for surgical intervention can be present - Measure beta-hCG on days 0, 2, 4, and 7; if drop of more than 15% from previous measurement, repeat weekly until beta-hCG is less than 20IU/L. If not, refer for further management.
Medical management of ectopic pregnancy
Oral methotrexate - as long as no surgical criteria are met. Take UPT three weeks later.
Surgical management of ectopic pregnancy
Salpingectomy / salpingotomy.
When is a salpingectomy / salpingotomy indicated for ectopic pregnancy?
Indicated if any of the following features are present: Ruptured ectopic, Significant pain, Heartbeat on USS, >35mm diameter of pregnancy, Serum beta-hCG > 5000IU/L.
What is the first-line surgical intervention for ectopic pregnancy?
Salpingectomy.
When is a salpingotomy offered instead?
Unless there are risk factors for infertility; in which case, salpingotomy (opening of tube for removal of ectopic) is recommended. Salpingotomy is less effective than salpingectomy. Advise UPT 3 weeks post surgery.
What is the definition of a pregnancy of unknown location (PUL)?
Positive UPT with no pregnancy visualized on ultrasound.
What investigation is crucial for diagnosing and managing PUL?
Serial serum beta-hCG measurements. (2 measurements taken 48hrs apart).
What does a >63% increase in beta-hCG over 48 hours indicate?
Likely viable intrauterine pregnancy; offer a scan in 7–14 days.
What does a >50% decrease in beta-hCG over 48 hours suggest?
Likely non-viable pregnancy; advise UPT in 14 days.
Fill in the blank: If the beta-hCG change falls between these parameters, further review is required for ___________.
Ectopic pregnancy.
