Early Pregnancy Complications - Ectopic Pregnancy/Miscarriage/Molar Pregnancy

Question 1

Early pregnancy complications?

Answer 1

1. Miscarriage
2. Ectopic pregnancy
3. Molar pregnancy

Question 2

What is a miscarriage?

Answer 2

Expulsion of a conception before a period of fetal viability, which is a gestational age of less than 28 weeks for Malawi and up to 22 weeks in other settings.

Question 3

Risk of miscarriage?

Answer 3

15 to 20% of pregnancies end in miscarriage.

Question 3

Risk factors for miscarriage?

Answer 3

1. Maternal infection – UTI, Malaria, TORCH
2. Maternal age > 35 years
3. Trauma
4. Abnormalities of the uterus (fibroids, septations)
5. Immunological disorders e.g. SLE, APS
6. Endocrine disorders e.g. Diabetes, PCOS
7. Psychological factors - stress

Question 4

Types of miscarriages?

Answer 4

1. Complete miscarriage
2. Incomplete miscarriage
3. Threatened miscarriage
4. Inevitable miscarriage
5. Missed miscarriage
   *Induced miscarriage
   *Septic miscarriage
   *Recurrent miscarriage

Question 5

Features of complete miscarriage?

Answer 5

bleeding and complete passage of products of conception
cervix: open or closed depending on stage of abortion
US: empty uterus

Question 6

Incomplete misccariage?

Answer 6

heavy bleeding which includes passage of some products of conception
cervix: dilated
US: retained tissues

Question 7

Threatened miscarriage?

Answer 7

• slight vaginal bleeding
• abdominal pain may be present
• intact membranes
  cervix: closed
  USS: visible intrauterine pregnancy detected
  > reversible

Question 8

Missed miscarriage?

Answer 8

often asymptomatic
cervix: closed
USS: nonviable pregnancy - retained products with no fetal cardiac activity or empty gestational sac

Question 9

Recurrent miscarriage?

Answer 9

history of >=3 spontaneous abortions (may be m=missed, inevitable, incomplete, complete)
cervix: depends on type
USS: empty uterus, uterine anomalies may be evident

Question 10

Inevitable miscarriage?

Answer 10

vaginal bleeding and abdominal pain present
membranes may/may not be ruptured
cervix: dilated
USS: pregnancy may be viable or nonviable at time of presentation

Question 11

Management of miscarriages?

Answer 11

1. expectant
2. medical
3. surgical
   Note: The MIST trial (miscarriage treatment trial) and subsequent Cochrane reviews (2006, 2010) have concluded that there is no superior method of management and have recommended that the woman’s preferences are taken into account when planning care; treatment should therefore be patient guided, based on an informed decisions

Question 12

Expectant management of miscarriages?

Answer 12

• Expectant management employs awaiting the natural course of events, for the products to pass spontaneously.
• Expectant management aims to avoid surgery, may result in prolonged follow-up with a risk of heavier bleeding and failed treatment

Question 13

Medical management of miscarriages?

Answer 13

• Medical management involves combinations of oral or vaginal prostaglandins to induce the completion of miscarriage.
• Medical management aims to avoid surgery, may be uncomfortable with heavier bleeding and risk of later surgery

Question 14

Surgical management of miscarriages?

Answer 14

• Surgical management involves an operation, usually vacuum aspiration, to remove any remaining products of pregnancy
• Surgical management allows early completion of treatment with the risk of surgical and anaesthetic complications

Question 15

Recurrent miscariage?

Answer 15

• Defined as three or more consecutive miscarriages
• Affects 1% of couples
• For the majority of patients all investigations are normal

Question 16

1st trimester miscarriage?

Answer 16

A minority of patients with 1st trimester miscarriages will have antiphospholipid syndrome which can be treated with heparin and aspirin to improve the chance of an ongoing pregnancy

Question 17

2nd trimester miscarriage?

Answer 17

Second trimester miscarriages caused by cervical incompetence can be managed surgically by performing a cervical cerclage

Question 18

Septic misscarriage?

Answer 18

miscarriage with clinical infection of the uterus and its contents

Question 19

Features of septic miscarriage?

Answer 19

1. T > 38
2. maternal PR > 100bpm
3. purulent vaginal discharge/POCs
4. pelvic pain/tenderness

Question 20

Management for septic miscarriage?

Answer 20

1. resuscitation: IV fluids +/- blood transfusion
2. antibiotics
3. evacuation

Question 21

Alloimmunization in miscarriage?

Answer 21

give anti-D 250 IU IM x 1 if:
1. mother rhesus negative
2. sensitized

Question 22

Who should not receive misoprostol in miscarriage management?

Answer 22

1. any woman with prior scar and gestational age >28 weeks
2. 2 prior scars and classical incision

Question 23

What is an ectopic pregnancy?

Answer 23

an embryo that implants outside the uterine cavity

Question 24

Common sites for ectopic pregnancy?

Answer 24

1. Fallopian tube - ampulla = 70% - fimbria = 10% - isthmus = 11% - interstitial = 3% 2. Ovary - 3% 3. Cervix <1% 4. C/Section scar - 2% 5. Abdominal cavity - 1%

Question 25

Risk factors of ectopic pregnancy?

Answer 25

1. Previous ectopic pregnancy - 1 prev. ectopic = 10% - 2 or more prev. ectopic = >25% 2. Previous tubal surgery 3. Previous pelvic surgery 4. History of PID 5. Ovulation induction 6. Abnormal uterine structure (fibroids or abnormal anatomy)

Question 26

Clinical features of ectopic pregnancy?

Answer 26

1. Abdominal pain 2. Vaginal bleeding 3. Shoulder pain 4. Dizziness 5. Palpitations 6. Signs and symptoms of hypovolemic shock 7. Uterus not palpable, tender and guarding

Question 27

Investigations in ectopic pregnancy?

Answer 27

1. Pregnancy test 2. FBC 3. Gp and Xmatch 4. USS (TV vs Abdominal) 5. Diagnostic laparoscopy

Question 28

Acute management of ectopic pregnancy?

Answer 28

In an acute emergency due to a bleeding ectopic 1. resuscitation with IV fluids + blood transfusion 2. urgent laparotomy is required as a lifesaving procedure - salpingectomy

Question 29

Management if ectopic has not ruptured?

Answer 29

Scheduled laparoscopic surgery or by medical management with methotrexate - Laparoscopic surgery may be initially diagnostic to confirm the ectopic pregnancy as the cause of pain and then therapeutic by salpingectomy or salpingotomy as definitive treatment

Question 30

Conservative management of ectopic pregnancy?

Answer 30

Conservative management is also an option with resolving trophoblast - the trend is for the hCG level to fall

Question 31

Indication for salpingotomy in ectopic pregnancy?

Answer 31

Salpingotomy is only recommended during surgical treatment if there is a concern that the contralateral tube is non-functional

Question 32

Salpingectomy vs salpingotomy?

Answer 32

salpingectomy - removal of the fallopian tube salpingotomy - incision made in fallopian tube o remove the ectopic

Question 33

Salpingectomy?

Answer 33

- complete surgical removal of one or both fallopian tubes - used to treat ectopic pregnancy, tubal disease or as a preventative measure for ovarian cancer - removes the risk of future ectopic pregnancy in the removed tube - can reduce chances of spontaneous conception in women who desire to have children

Question 34

Salpingotomy?

Answer 34

- incision made in the fallopian tube to remove the pregnancy but the tube itself is not removed - used to treat tubal ectopic pregnancies - preserved both fallopian tubes improving fertility prospects - carries risk of persistent trophoblast (incomplete removal of pregnancy tissue) - higher risk of future ectopic pregnancies in the same tube