Early Pregnancy Complications. Flashcards by Gamuchirai Mugwagwa

Define Miscarriage?

A pregnancy loss before 28weeks,age of viability in Malawi, or with a fetus less than 1000g.
-Expulsion of a conception before a period of foetal viability (which in Malawi is less than 28 weeks but in other setting less than 22weeks)

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What are the general signs and symptoms of a miscarriage ?( 3each)

Symptoms: Abdominal pain(Mild or severe),cramping, bleeding,
Signs:partial expulsion of products of conception,closed/dilated cervix, pv bleeding

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How do you classify spontaneous miscarriages?

Threatened miscarriage
Inevitable miscarriage
Incomplete miscarriage
Complete miscarriage
Missed miscarriage
Septic miscarriage

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What are the fetal risk Factors for a miscarriage?

-Chromosomal Abnormalities (Trisomies 13,16,18, 21 and 22)
-Infections

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What are the maternal risk factors for a miscarriage?(8)

Maternal systemic infection – UTI, Malaria, TORCH
Maternal age > 35 years
Trauma
Abnormalities of the uterus (fibroids)
Immunological disorders e.g. SLE
Endocrine disorders e.g. Diabetes
Psychological factors – stress
Previous miscarriage

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What is a threatening miscarriage?

This is where there is a threat of miscarriage that occurs characterized by vaginal bledding,with minimal or no abdominal pain but with a viable fetus.The pregnancy may contine.

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What are the signs and symptoms of a Threatening Miscarriage?

Minimal bleeding
Minimal/no abdominal pain
Closed cervix
Uterine size =GA
Viable fetus

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What investigations are done in T. miscarriage?

Ultrasound for viability
Grouping and save

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What is the management of threatened abortion?

No specific treatment (self-limiting treatment)
Avoid heavy lifting/work
Pelvic rest/avoid coitus

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What is an inevitable miscarriage?

Pregnancy may still be viable but will eventually proceed to incomplete or complete abortion. Pregnancy will not continue .

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What are the signs and symptoms of an inevitable miscarriage?

Heavy bleeding but no passage of POCs
Abdominal pains/cramping
Open cervix
Uterine size=GA

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Investigations for an inevitable miscarriage?

Blood sample for Hb, Grouping and save
Check vital signs: if signs of infection or induced miscarriage, treat with DCN 100 mg orally BD X 7days plus Metronidazole 800 mg stat

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What management is done in Inevitable miscarriage?

Three management options:
Expectant management (in hospital) for up to 2 days
Medical management
For <13weeks: misoprostol 400 mcg SL or 600 mcg orally
For >13weeks can consider misoprostol 400 mcg PV/SL every 3hrs x 5 doses
3. Surgical Management (still give misoprostol for cervical ripening and dilatation)
MVA preferred if <9 weeks GA, D & C if MVA not available
Bereavement counseling
Syphilis testing, offer HIV testing
Iron supplement if needed
FP: can start immediately

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What is an incomplete miscarriage ?

This is when the POCs are partially expelled?

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What are the signs and symptoms of incomplete miscarriage?

Heavy bleeding with passage of products of conception.
Abdominal pain/cramping
Open cervix
Uterine size<GA

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What are the investigations for an incomplete miscarriage?

Blood samples for Hb, grouping and save/cross match as needed

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What is the management of Incomplete miscarriage?

Same as inevitable miscarriage unless pt is in shock
If in shock, resuscitate with IV fluids and/or blood transfusion proceed with surgical management

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What is a complete miscarriage?

POCs are completed exelled

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What are the investigations done for a complete miscarriage

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Group and Save
Hb as needed
Ultrasound scan to confirm empty uterus(no gestational sac)

What is a missed miscarriage?

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Pregnancy is no longer viable but no POCs have been expelled

What are the signs and symptoms of a missed miscarriage?

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No history of bleeding
No abdominal pains
Closed cervix
Loss of pregnancy symptoms (Nausea /vomiting, breast engorgement etc

What are the investigations done for a missed miscarriage?

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Blood for Hb, grouping and save
Ultrasound to confirm non-viability

What is the ultrasound findings for non-viability in a missed miscarriage?

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Crown Lump Length of greater than or equal to 7mm with no cardiac activity.
Mean sac diameter of greater than or equal to 25mm without embryo.

What is the treatment for a missed miscarriage?

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Three management options:
Expectant management in the hospital up to 2wks
Medical management
For <12 wks: Misoprostol 800mcg PV or 600mcg SL, may be repeated every 3hrs, up to 2 additional doses
For 12-24 wks, Misoprostol 400 mcg PV every 6hrs until uterine contractions are fully establshed
For 24-28 wks, Misoprostol 200mcg PV every 4 hrs until uterine contractions are fully established
3. Surgical Management: (Still give misoprostol to for cervical ripening before surgical intervention)
1st TM: MVA preferred, if not available D& C
Consider cervical ripening with Misoprostol 400mcg PV or SL 2-3hrs prior to procedure
2nd TM: dilation and evacuation
Bereavement counseling
Syphilis and HIV testing
Iron supplementation if needed
FP can start immediately
DCN 400mg STAT, Metronidazole 400mg STAT

What is septic miscarriage?

Any of the above with clinical infection of the uterus and its contents

What are the signs and symptoms of a septic miscarriage?

T ≥ 38°C Maternal PR > 100 bpm Purulent vaginal discharge/POCs Pelvic pain/tenderness

What investigations are done for septic miscarriage?

FBC Grouping & save/crossmatch Bedside clotting time

Management of a septic miscarriage?

Resuscitation: IV fluids +/- blood transfusion Monitor Vital Signs and urine output Benzyl Penicillin 2 MU IV Q6H, Gentamycin 320mg IV OD, Metronidazole 500mg IV Q8H Switch to DCN 100mg BD plus Metronidazole 400mg TDS X 7 days when able to take oral drugs Evacuation by experienced doctor to avoid perforation

What is an Ectopic Pregnancy?

Implantation of a fertilized egg outside of uterus?

What are the most common sites for implantation?

-Tubal (Ampullary, isthmic ,interstitial) -Fimbrial -Ovarian -Cervical Scar -C/scar -Intraligamentous or Abdominal

What are the risk factors for Ectopic Pregnancy?(9)

History of prior ectopic pregnancy History of tubal surgeries History of pelvic inflammatory disease Smoking Infertility Prior abdominal surgeries Failure of contraceptive method Fundal fibroid Age 35-45 years

What is the diagnosis for Ectopic Pregnancy?

History: Classic triad of; abdominal pain, amenorrhea and vaginal bleeding Examination: +/- tenderness, +/- adnexal mass, +/- shock if ruptured Investigations: Vital signs, urine pregnancy test, transvaginal ultrasound, blood samples for X-match

What is the classic triad for ectopic pregnancy

abdominal pain, amenorrhea and vaginal bleeding

What is the management of Ectopic Pregnancy?

Obtain IV access with 2 large bore cannulae Take blood samples for FBC, grouping and X-match If in shock then resuscitate with IV fluids RL/NS and transfuse blood If not in shock and If ruptured then perform emergency laparotomy with possible blood transfusion If not ruptured then consider urgent laparoscopy or laparotomy Send tissue to pathologist for histology confirm and consider D&C if appropriate If patient stable, medical management can be considered at the central hospital under consultant supervision Follow-up: Counsel patient about FP options and risk of future ectopic pregnancy

What is the Prerequistes for the medical management?

The woman should be stable, motivated and compliant to follow ups Beta- hCG < 3000 IU/L Absent cardiac activity Size of gestational sac < 4cm The drug of choice is Methotrexate

What is the drug of choice used in management of ectopic pregnancy?

Methotrexate

Prerequisites for surgical method?

Failed medical management Any contraindication to use of methotrexate Completed family

How is the methotrexate monitored?

-A Single dose of Methotrexate is given intramuscularly, and serum levels of beta- HCG are checked on day 4 and day 7. - A further dose may be given if HCG levels have failed to fall by more than 15% between day 4 and day 7. - A maximum of 3 doses can be given -if it fails, then surgrey

What is a molar a pregnancy?

-A molar pregnancy is the result of a genetic error during the fertilization process that leads to the growth of abnormal tissue within the uterus. -Called a hydatidiform mole.

What are the risk factors of a molar pregnancy?

Previous history of molar pregnancy Extreme age: -Elderly patients with high parity -Teenagers Ethnicity: Asians, Hispanics, American Indians

What are the types of molar pregnancy?

Complete Mole Partial Mole

What is a complete mole?

A complete mole is caused by a single sperm combining with an egg which has lost its DNA The genotype is typically 46XX due to subsequent mitosis of fertilizing sperm but can also be 46XY

What is a partial mole?

Partial mole occurs when an egg is fertilized by 2 sperms or, by sperm which replicates itself yielding the genotype of 69 XXY or 92 XXXY

What are the clinical findings of a molar pregnancy

Nausea and vomiting Painless vaginal bleeding bleeding Confirmed pregnancy Uterine size and date discrepancy Lack of fetal heart beat Hypertension Proteinuria Characteristic “snowstorm” appearance and absence of fetal parts on ultrasound scan High hCG levels for gestational age

What is the management of a Molar pregnancy?

REFER

Discuss Malignant. Gestational Trophoblastic Disease.

Early Pregnancy Complications. Flashcards

(46 cards)