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
