Anatomy and early pregnancy problems Flashcards

Question

What is the Management miscarriage ?

Answer 1

always provide written and verbal explanations - Initial management • Admission necessary if: ectopic pregnancy suspected, septic miscarriage or heavy bleeding  Resuscitation occasionally required if sig. haemorrhage: ABCDE, IV access: HCG, Rh, FBC, X-match • USS to exclude ectopic + indicate foetal viability • Products of conception in cervical os (cause pain, bleeding, vasovagal shock)  remove via speculum using polyp forceps • IM ergometrine – reduces bleeding by contracting the uterus, only if foetus is non-viable • If fever swabs for bacterial culture + IV broad-spectrum Abx (co-amoxiclav) for septic abortion • Rh anti-D Ig 250 units IM given to women who are Rh –ve if miscarriage treated surgically/medically, or if bleeding after 12wks’ gestation  Reduces risk of isoimmunisation and rhesus disease in future pregnancies • Gynae referral threatened abortion pts may be allowed home after USS + gynae review - Viable intrauterine pregnancy (threatened miscarriage) OR complete miscarriage: no Rx necessary - Non-viable intrauterine pregnancy: expectant, medical or surgical Rx • Expectant – can be continued as long as the woman is willing and there are no signs of infection  Usually recommended to naturally wait for 14 days before discussing further options (usually successful within 2-6wks)  This involves allowing the body to complete the miscarriage “naturally”  Chosen by few women as course unpredictable and can take weeks to complete but avoids hospital admission and use of all drugs  If not bled yet (14 days) or getting worse offer second USS and move onto medical management • Medical – involves the use of PO/SL/PV prostaglandins (e.g. misoprostol) + mifepristone (oral antiprogesterone – taken first)  To induce uterine contractions and expel remaining POC  Can take place in hospital or at home  Can be complicated by heavy bleeding and moderate abdominal pain  There is a 5% incidence of retained products/failure of treatment • Surgical – ERPC (evacuation of retained products of contraception) under GA using vacuum aspiration  Suitable if woman prefers it, heavy bleeding, signs of infection or expectant/medical management fails (under antibiotic cover)  Tissue examined histologically to exclude molar pregnancy  Complications include intrauterine infection (3%), damage to the cervix, haemorrhage and retained products (5%)  NOT offered after 12wks – baby too big - Counselling • Tell pt. miscarriage was not the result of anything they did/did not do and could not have been prevented • Reassurance as to high chance of successful future pregnancies • Inform of benefits of pre-conceptual folic acid and other general health measures for successful pregnancy (e.g. smoking advice) • Referral to support group

Answer 2

- Vaginal bleeding with expectant/medical management can be heavy and painful • Risk of needing surgical evacuation - Infection – similar for all 3 managements • If becomes systemic endotoxic shock, hypotension, AKI, ARDS and DIC - Asherman’s syndrome or perforate uterus if surgical evacuation partially removes endometrium - Long-term conception rates do not differ between the 3

Answer 3

Miscarriage is common. Recurrent miscarriage requires further investigation and even more emotional support + counselling, and a clearly defined pregnancy plan in terms of USS monitoring (esp. late pregnancy – ‘high risk’ monitoring).

Answer 4

implantation of the fertilised ovum outside the body of the uterus. 95% are tubal ectopic but can implant in cervix or cornu of the uterus which can be very serious. Rarer sites of implantation include the ovary and the peritoneal cavity – a so-called abdominal pregnancy which in rare cases have gone to term.

Answer 5

10 deaths in the 2006-08 maternal mortality report due to failed recognition

Answer 6

usually due to damage to fallopian tube and/or cilia • *Pain typically 6-7 weeks gestation; can be sharp, dull and/or crampy and mimic appendicitis (esp. on lower right side) • ▪Bleeding usually >6 weeks after last menstrual period • Usually both pain + PV bleeding, but one can occur without the other

Answer 7

* Pregnancy test (urine HCG) – for all women of reproductive age presenting with abdominal pain, bleeding or collapse regardless of the specialty they present to a negative test confidently excludes an ectopic pregnancy * USS – transvaginal: to confirm an intra-uterine pregnancy (very rarely confirms an ectopic pregnancy, i.e. see a gestation sac outside the uterus). If the uterus is empty and the pregnancy test positive the differential diagnosis is: * A very early pregnancy, too early to see on scan * A complete miscarriage * Ectopic pregnancy * Other ultrasound findings suggestive of an ectopic pregnancy include free peritoneal fluid (in pouch of Douglas), a thickened endometrium, and an adnexal mass adjacent to the ovary. Also intrauterine pseudosac, tubal ring. * Ovarian cysts are common in early pregnancy (corpus luteum) and are not suggestive of an ectopic unless complex * Serum β-HCG (>1000 IU = ectopic) if uterus is empty – if <1000 IU, monitored to differentiate from a miscarriage or an early pregnancy. Levels will rise rapidly in a normal pregnancy (by >66% in 48hrs), fall rapidly in a miscarriage but rise slowly and plateau/decline in an ectopic pregnancy * Caution required, as heterotopic pregnancy can still occur, esp. if assisted pregnancy * Other bloods: FBC, U&E, blood sugar, G&S, Rh status * Laparoscopy – definitive diagnosis but is invasive – only advised if doubt exists about the diagnosis

Answer 8

``` PID/salpingitis – esp. chlamydia Results in scarring Endometriosis Previous ectopic pregnancy Sterilisation/infertility Reversal of sterilisation Use of IUD Tubal surgery (ligation) Intrauterine surgery (D&C) Smoking Exposure to DES Advanced maternal age Lower S/E status ```

Answer 9

Symptoms • Abdominal/pelvic pain* • Scenty, dark vaginal bleeding▪ • Collapse and shoulder tip pain suggest intraperitoneal blood loss (due to tubal rupture - v. dangerous!!!!) • Diarrhoea/vomiting • May see Sx of pregnancy – N&V, urination, fatigue, breast tenderness • Amenorrhoea of 4-10wks is usual, but the pt. may be unaware that she is pregnant and interpret a PV bleed as a period Signs • Abdominal (+ rebound) tenderness • Cervical excitation due to stretching of inflamed tissues • Unilateral adnexal tenderness (Adnexal mass very very rarely palpated in conscious patient) • Small uterus for gestation date • Cervical os closed • Tachycardia if blood loss, hypotension and collapse in extremis

Answer 10

* Where Sx are present admit pt * Oxygen * NBM * IV access – resuscitate initially with crystalloids * FBC and cross-match 6 units of blood * Check Rh status and give anti-D Ig 250 units IM if –ve * Refer urgently to gynae (may deteriorate quickly) * Acute presentation * Alert theatre + anaesthetics team if haemodynamically unstable (sig. haemorrhage) = resuscitation + surgery (laparoscopic preferred if experienced, but usually laparotomy = salpingectomy of affected tube) * Subacute presentation * Surgery (laparoscopic preferred if haemodynamically stable)  salpingostomy (removing ectopic) or salpingectomy * Required in: * Tubal rupture * Mass >3.5cm diameter * Free fluid >50ml * Foetal heart beat on USS * Salpingostomy = 10% risk of persistence of ectopic (detected by failure of serum hCG to fall on follow-up), requiring repeat surgery, and risk of repeat ectopic (as damaged tube remains). However, if contralateral tube is damaged, may allow for future conception whereas salpingectomy requires IVF (if normal, similar rates bt. both procedures) * Medical – methotrexate if ectopic unruptured with no cardiac activity, and hCG <3000IU/ml * Given IM. Takes 4-6 weeks to completely resolve (may require second dose) and 10% ultimately require surgery. Recommended for cervical and cornual ectopics in particular * Conservative – not generally recommended unless the hCG levels are already very low and falling, ectopic is small and unruptured, or location of pregnancy not clear Complications and Prognosis - Women treated with salpingostomy, medical or conservative management must have serial hCG measurements until <20IU/mL to confirm ectopic resolution - Support, esp. to women who ‘lost baby’ through a life-threatening condition and have undergone surgery + have reduced fertility = support groups - 70% have successful subsequent pregnancy; 10% have recurrence of ectopic (higher if tubal damage)

Answer 11

Also known as Gestational Trophoblastic disease – group of conditions in which tumours grow inside a woman's uterus More common at extremes of reproductive age and in Asians • Different types/stages of moles: o Hydatidiform mole (localised and non-invasive)  Complete Mole – where a sperm fertilizes an empty egg and divides by mitosis (diploid 46XX), producing a proliferation of trophoblastic tissue (swollen chorionic villi) that is entirely paternal in nature (no foetus develops)  Partial Mole – where 2 sperm fertilise one egg (triploid) variable evidence of foetus (if present, abnormal and can’t survive and develop into baby) o Malignant (i.e. persistent gestational trophoblastic disease = gestational trophoblastic neoplasia)  Invasive mole – invasion of proliferation within uterus  Choriocarcinoma – metastasis of tissue  Placenta-site trophoblastic tumour (rare)

Answer 12

Examination – uterus often large. Early pre-eclampsia and hyperthyroidism may occur History – vaginal bleeding usual and may be heavy (esp. first 3mths; may contain small, grape-like lumps); severe vomiting (hyperemesis) - However, often no signs that pregnancy is molar (these signs fairly common in pregnancy) spotted during routine ultrasound scan at 8-14 weeks or during further tests carried out after a miscarriage

Answer 13

Investigations – ultrasound shows ‘snowstorm’ appearance of swollen villi with complete moles, but diagnosis can only be confirmed histologically. Serum hCG levels may be very high

Answer 14

Treatment (register with supraregional centre to guide management and follow-up) • Suction curettage (ERPC) – usually done under GA + diagnosis confirmed histologically o Bleeding often heavy o Afterwards, serial blood hCG levels taken – if persisting/rising consider malignancy o Pregnancy and COCP avoided until hCG levels normal as may increase need for chemotherapy • Can also use medication (if too large to suck out) or hysterectomy (if done having children) • If malignant may need chemo (highly malignant, but v. chemosensitive) o ‘Low-risk’ methotrexate with folic acid o ‘High-risk’ combination chemo

Answer 15

- Recurrence (1/60) after every future pregnancy, further hCG samples taken to exclude recurrence - GTN (invasive mole/choriocarcinoma) follows 15% of complete moles and 0.5% of partial moles • Can also follow miscarriage/normal pregnancy usually presents as persistent PV bleeding; diagnosis made by:  Persistently elevated/rising hCG levels  Persistent vaginal bleeding  Evidence of blood-borne metastasis (commonly to lungs) • 5-yr survival with chemo approaches 100%

Anatomy and early pregnancy problems Flashcards

(39 cards)