Early pregnancy complications: miscarriage, ectopic and molar pregnancy Flashcards
(38 cards)
What is a miscarriage?
Any pregnancy loss before 28 weeks gestation, the age of viability in Malawi, or with a fetus <1000 g.
Give 5 risk factors for a miscarriage.
- 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
- Chromosomal abnormalities e.g. Trisomy
Name the 6 types of miscarriages.
- Threatened miscarriage
- Inevitable miscarriage
- Incomplete miscarriage
- Complete miscarriage
- Missed miscarriage
- Septic miscarriage
What is a threatened miscarriage and what are the signs and symptoms?
Pregnancy still has a live fetus and may continue.
Signs and symptoms
Minimal bleeding
Minimal/no abdominal pain
Closed cervix
Uterine size =GA
Live fetus
How do you investigate for a threatened miscarriage?
Ultrasound for viability
Grouping and save
How do you manage for a threatened miscarriage?
No specific treatment (self-limiting treatment)
Avoid heavy lifting/work
Pelvic rest/avoid coitus
What is an inevitable miscarriage and what are the signs and symptoms?
Pregnancy may still have a live fetus but will inevitably proceed to incomplete or complete abortion
Signs and symptoms
Heavy bleeding but no passage of POCs
Abdominal pains/cramping
Open cervix
Uterine size=GA
Investigations for inevitable miscarriage.
Take blood sample for Hb, Grouping & Save
Check vital signs
If infection or induced miscarriage suspected:
Doxycycline 100 mg orally BD for 7 days
Metronidazole 800 mg stat
Management for inevitable miscarriage.
- Expectant (hospital, ≤2 days)
- Medical
<13w: Misoprostol 400 mcg SL / 600 mcg PO
13w: 400 mcg PV/SL q3h × 5 - Surgical
Misoprostol for cervix
MVA (<9w) or D&C
Bereavement support, syphilis/HIV test, iron, immediate FP
What is an incomplete miscarriage and what are the signs and symptoms?
POCs are partially expelled
Signs and symptoms
Heavy bleeding
Abdominal pain/ cramping
Open cervix
Uterine size=GA
How do you manage incomplete abortion?
Same as inevitable miscarriage
What is a complete miscarriage and what are the signs and symptoms?
POCs are completely expelled
Signs and symptoms
Minimal bleeding
History of passage of POCs
Minimal abdominal pain
Closed cervix
Small uterus
Management of complete miscarriage.
- no evacuation needed
- bereavement counselling
- VDRL & HIV testing
- iron supplement if needed
- FP can start if passage of POCs with 2 past weeks
What is a missed miscarriage and what are the signs and symptoms?
Pregnancy is no longer viable but no POCs have been expelled
Signs and symptoms
No history of bleeding
No abdominal pains
Closed cervix
Loss of pregnancy symptoms (Nausea /vomiting, breast engorgement etc)
How do you manage a missed miscarriage?
Medical:
<12w: Misoprostol 800 mcg PV / 600 mcg SL, repeat q3h ×2
12–24w: 400 mcg PV q6h
24–28w: 200 mcg PV q4h
Surgical:
1st TM: MVA preferred, D&C if unavailable
Cervical ripening: Misoprostol 400 mcg PV/SL 2–3h before
2nd TM: Dilation & evacuation
What is a septic miscarriage and what are the signs and symptoms?
Any of the above with clinical infection of the uterus and its contents
Signs and symptoms
Temp ≥38°C
Maternal PR>100bpm
Purulent vaginal discharge
Pelvic pain/tenderness
How is a septic miscarriage managed?
- 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
Define ectopic pregnancy.
Ectopic pregnancy is a pregnancy that occurs outside of the uterus.
Where do most ectopic pregnancies implant?
Ampulla of the fallopian tube
Give 6 risk factors for ectopic pregnancy.
- 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 classic triad for ectopic pregnancy?
Abdominal pain, amenorrhea and vaginal bleeding
List 4 investigations that would be important in an ectopic pregnancy.
Urine pregnancy test, transvaginal ultrasound, blood samples for X-match
How do you manage an ectopic pregnancy if unstable?
2 large-bore IV lines, take FBC, group & crossmatch
If in shock: Resuscitate with IV fluids (RL/NS), transfuse blood
If ruptured: Emergency laparotomy ± transfusion
If unruptured: Urgent laparoscopy/laparotomy
Send tissue for histology ± D&C if indicated
How do you manage an ectopic pregnancy if stable?
Indications: Stable, no rupture/bleeding, normal FBC
Drug: Methotrexate (1st choice)
Follow-up: FP counseling, warn of future ectopic risk
