Miscarriage + TOP Flashcards
Def threatened miscarriage (4)
Up to 13 weeks (first crimester)
- os closed
- Spotting
- with or without lower abdominal pain
- fetus alive
Presentation of inevitable miscarriage
First trimester: up to 13 weeks
- Os dilated
- increased PV bleed: clots
- lower abdominal pain-tender uterus
- fetus alive
- Products still in uterus
Presentation of incomplete miscarriage (5)
First or second trimester
- Os open with or without POC in os
- passed some products of conception: clots
- uterus smaller than expected for GA, bulky uterus
- lower abdominal pain-tender uterus, pain better after passing products of conception
- ultrasound: retained POC or ET >15mm
May have hypovolaemic shock
US: still retained products conception
Presentation complete miscarriage
Second trimester: 13 - 20 weeks
- os open OR closed
- passed ALL products of conception. Examine foetus and placenta for completeness
- bleeding subsides within 48 hours
- ultrasound: no POC, ET <15mm
Presentation missed miscarriage
Can be first or second trimester. Usually seen on routine examination as no symptoms
- os closed
- no bleeding
- No pain
- Fetus dead
Rx threatened miscarriage
- Conservative /expectant: 60% do not abort.
- Reassurance and follow up
Rx inevitable miscarriage (5)
- Resus if shocked: crystalloids and blood products
- if haemodynamically stable 1st trimester: expectant management, allowed to abort. Then reassess for further rx
- later pregnancy: active management with iv oxytocin + acute pain relief
- medical management options: iv oxytocin (decrease bleeding) , misoprostol
- surgical options: <14 weeks(first trimester) = mva or suction curettage
incomplete miscarriage rx! (5)
- Resus if shocked. Can only intervene when haemodynamically stable, not septic (end organ involvement - kidney, liver, haematological). Do hysterectomy if 2 or more organs involved.
- Remove visible retained products W/ ovum forceps to enable uterus to contract and stop further vaginal blood loss
- expectant or medical management (misoprostol and mifepristone) only if easy access to health facility should bleeding persist as most early miscarriage (<6 weeks amenorrhoea) bleeding subsides in 48 hours
- surgical management preferred to medical
- <14 weeks - MVA or surgical curettage
- > 14 weeks - evacuation
Antibiotics: gentamicin, ampicillin, flagyl
Rx complete miscarriage (3)
- Expectant management
- uterine evacuation not indicated. Observe for possible haemorrhage.
- second trimester: examine foetus and placenta for completeness to make diagnosis. Where indicated, send tissue eg calf muscle for chromosomal analysisand placenta biopsy for histology and Chorioamnionitis
Rx missed miscarriage (2)
- First trimester (<14 weeks): medical management with misoprostol and mifepristone or surgical with primary dilatation cervix and curettage or MVA
- > 14 weeks - medical management followed by uterine evacuation if indicated. Expert can do dilatation and extraction of foetus
Differential vaginal bleeding in early pregnancy? (4)
- Threatened miscarriage
- Implantation bleeding
- anembryonic pregnancy (blighted ovum)
- Ectopic pregnancy
Diagnosis anembryonic pregnancy (blighted ovum) (2)
- Irregular gestational sac without foetus in pregnancy 8 or more weeks gestation , or
- empty gestational sac > 25 mm
Name 4 types miscarriages that can occur in first trimester (up to 13 weeks)
- Threatened
- inevitable
- incomplete
- missed
Name 4 types miscarriages that can occur in second trimester (13 - 20 weeks)
- Incomplete
- complete
- septic
- missed
Diagnosis septic miscarriage?
Miscarriage complicated by fever (38 or more)
Name 4 warning signs for serious underlying septic miscarriage
- Generally: distress, agitation, lethargic, hyperventilate, bed bound
- vitals: weak peripheral pulse > 100, rr > 20, T< 36,5 or > 37,8
- abdomen: tender or signs peritonism
- gynae: excessive bleed, foul smell discharge, vaginal lacerations, gangrenous cervix
Management protocol septic miscarriage? (7)
Determine status and Resuscitate , admit
Hysterectomy indications
- septic shock
- multi organ dysfunction
- necrotic cervix
- pus in abdomen detected by colpopuncture
- uterine perforation
If not meet criteria/decline:
- evacuation of septic uterine contents under ga.
Special investigations for miscarriage? (4)
- Screen for syphilis (rpr)
- Rh factor (give anti-d if Rh negative and second trimester miscarriage)
- cervical cytology
- hb
Name 3 risk factors miscarriage
- AMA
- previous miscarriage
- maternal smoking
Name 8 possible causes early (12 - 14 weeks/ first trimester ) miscarriage
Medical
- sporadic chromosomal abnormalities
- HLA status ( human leukocyte antigen)
- auto-immune diseases
Structural
- corpus luteum defect
- poor placentation
- uterine septum
Other
- Chance occurrence
- environmental factors
Name 6 possible causes late ( 14 - 24 weeks/ second trimester ) miscarriage
- Cervical incompetence!
- congenital abnormality uterus
- submucous myomata
- poor placentation
- infections
- medical diseases: hypothyroid, diabetes
Antibiotics for unsafe abortion? (3)
- Cefuroxime 750 mg 8 hourly iv +
- metronidazole 500 mg 8 hourly iv +/ -
- gentamicin 240 mg daily iv or ertapenem 1 g daily iv
Name 6 contraindications mva
- Gestation > 14 weeks
- extreme patient anxiety
- active pelvic infection
- uterine anomalies
- unsafe top
- unstable pt: P > 100, SBP < 100, hb < 9, temp 37,5
Define recurrent early pregnancy loss
3 or more consecutive losses of pregnancy <14 weeks
Workup for recurrent early pregnancy loss? (6)
- Uterine study pre-pregnancy: sonohysterography, hysterosalpingogram, hysteroscopy or MRI
- maternal antiphospholipid antibodies (2 positive tests > 12 weeks apart)
- paternal karyotype (>2 miscarriages < 10 weeks)
- fasting glucose
- thyroid functions
- genetic evaluation of products of conception
Which law governs termination of pregnancy
Choice of termination of pregnancy act no 92, 1996
According to Choice of termination of pregnancy act no 92, 1996, when may pregnancy be terminated (8)
First 12 weeks
- upon request
12 weeks - 20 weeks (need 1 Dr)
- risk injury to woman physical/mental health
- substantial risk to foetus, would suffer severe physical/mental abnormality
- significantly affect social/ economic circumstances woman
- rape or incest
After 20 weeks (need 2 Drs or Dr + midwife)
- endanger woman’s life
- severe malformation of foetus
- risk injury to foetus
Name 5 indications for surgical evacuation over MVA
- active bleeding
- severe anaemia
- uncontrolled medical conditions
- septic ICA
- Large height of fundus (>14 weeks)
Antibiotics for septic miscarriage?
Clindamycin 900mg tds (anaerobes, strep, staph)
Plus
Gentamicin 5mg/kg IVI dly (gram neg)
With or without
Ampicillin 2g IVI 4HRLY (gram pos)
OR
ampicillin + gentamicin + flagyl 500 IVI tds
