Lecture 8: Early pregnancy care: Abortion, Miscarriage, Ectopic Flashcards
What are 3 different ways to estimate the expected due date (EDB)
- Naegele rule: 7 + (1st day of last menstrual period) and - 3 months
- Online pregnancy wheel
these methods are based on 28 day cycle, so variations in follicular phase +/- 14 days need to be taken into account - Once embryo visible at 6wks, Crown rump length should be used to calculate EDD +/- 4 days of accuracy
What are the different ways to confirm a pregnancy and its location (intra-uterine or ectopic)
- BhCG via urine dipstick - usually positive by day 32-35 and confirmed with serum BhCG
- Transabdo USS helps to see the gestational sac: first US evidence of pregnancy by 5 wks. +/- fetal heart heard around 5.5 weeks
Location
- USS of Yolk sac (transabdo or vaginal) confirms IUP around 5.5 weeks
What are ways the gestational age (age measured from LMP) of fetus can be found
- Counting back from the expected date of delivery
- Bimanual exam: between 4-12 weeks of gest, the size of uterus increases by 1cm/wk
- Mean gestational sac diameter on USS compared to listed values
- Crown rump Length of fetus: most reliable: at 6wks mean measurement of length from crown to rump within certain flexion of the fetus
What are other things that USS can help find apart from things to do with dating the baby
Location, number of fetuses, fetal heart
What is the prevalence and causes of Miscarriage - is this the same causes as recurrent miscarriage?
25% of pregnancies end in clinical miscarriage. This is mostly before 14 wks but can be up to 20wks
This is due to
- chromosomal abnormalities, congenital anomalies, maternal conditions and unexplained.
Maternal age is a risk factor
Not the same causality and pathology for recurrent miscarriage
How is miscarriage diagnosed and what is the general care
- Clinical diagnosis: falling BhCG, centralised cramping pain which crescendos until it settles, some bleeding
- USS diagnosis: for asymptomatic missed miscarriage
Care is counselling for grief, patient resources, follow up with health professional, early pregnancy assessment services available for early pregnancy complications
1 or 2 is normal
What is the definition of ectopic pregnancy, what is the mechanism and risk factors
Gestation that implants outside of the uterine cavity - mostly in fallopian tube
Mechanism: obstruction to tube transport mechanisms, abnormality of ovum, conception late in cycle, transmigration to the other tube
Risk factors: previous ectopic (10x) or pelvic infection (STI), endometriosis, previous pelvic surgery - c section, IUCD in situ
What is the presentation of ectopic- how does this progress if undiagnosed and how would it be diagnosed and treated
- firstly
- amenorrhea with vaginal spotting or bleeding
- one sided pelvic pain
- abdominal exam elicits tenderness/peritonism
- pelvic exam: CMT, adnexal tenderness or mass
- pregnancy symptoms - if progressed: fallopian tube rupture= shock
- rupture of artery- haemorrhage into pelvic cavity
- fine for couple of hours due to compensatory mechanisms but then sudden collapse
Diagnosis is using serum bHCG, pelvic USS if signs of shock, index of suspicion
Treatment is surgical removal of the fallopian tube or low dose of methotrexate which causes pregnancy to regress and resorb
What law is abortion under. who can have abortion
20% of women have abortions. It is free if eligible for funded healthcare.
Under the Abortion legislation act 2020,
Abortion is a health service, a qualified health practitioner may provide abortion services (medical or surgical options) to a woman who is not more than 20wks pregnant.
Patient needs give informed consent. It is good if they have a support person but not compulsory.
After this there are some legal restrictions and patients need to be self or referred to local abortion services
What is the first thing patients book in early pregnancy care and why is it good?
Book with a Lead maternity carer (midwife) - publicly funded.
Better outcomes for those booked <14 wks bc of prompt routine history, exam, investigations, preg risk assessment, lifestyle modifying advice
What things are asked at the first booking with lead maternity carer
to assess modifiable/non modifiable risk factors for pregnancy
History:
- Previous obs and gyn history
- Medications, smoking, alcohol, drugs
- Screen for mental health, domestic violence
- LMP to date pregnancy, recent hormonal contraception
What things are investigated/measured at the
first booking with lead maternity carer to assess modifiable/non modifiable risk factors for pregnancy
and why
- Hb for anaemia
- Group and hold: blood group and antibody status
- HbA1C: type 2 diabetes
- syphillis, rubella, HIV, hep B
- Urine culture: UTIs can lead to sepsis easily in pregnancy
- Vulvo-vaginal self swab for chlamydia
- Down syndrome and other nationally screened conditions
- Maternal BMI and BP
What is lifestyle advice given in the 1st trimester
- Folate and iodine supplementation
- Immunisation against flu, whooping cough, covid 19 (?)
- Minimise gestational weight gain (green prescription)
- Become smokefree by 16 wks is good
- Alcohol, drugs, medications can already do damage but still stop
- Consider if need for low dose aspirin
