miscarriage, TOP, ectopic etc Flashcards
threatened miscarriage
- PAINLESS vaginal bleeding occuring before 24wks - typically 6-9wks
- bleeding less than menstruation
- Os is OPEN
missed (delayed) miscarriage
- gestational sac containing dead fetus before 20 weeks without symptoms of expulsion
- light bleeding/discharge
- symptoms of pregnancy disappear
- PAINLESS
- Os is CLOSED
inevitable miscarriage
heavy bleeding with clots + PAIN
Os is OPEN
incomplete miscarriage
not all products of conception have been expelled
- PAIN + bleeding
- Os is OPEN
risk factors for miscarriage
- women >35
- hx of previous miscarriages
- previous cervical cone biopsy
- smoking, alcohol, obesity
- diabetes, thyroid disorders
management of miscarriage
expectant
- 7-14days, wait to complete spontaneously
- if unsuccessful - medical or surgical
medical
- depends on type - missed/incomplete miscarriage
- give analgesia, antiemetics
- preg test after 3 weeks
surgical
- vacuum aspiration or mx in theatre
medical management of missed and incomplete miscarriage
missed
- oral mifepristone
- 48hrs later misoprostol (unless gestational sac has already passed)
- if no bleeding within 48hrs of miso - contact hospital
incomplete
- single dose of misoprostol
*give antiemetics + analgesia
*pregnancy test at 3 wks
definition of recurrent miscarriage
3 or more consecutive spotaneous abortions
in 1% of women
causes of recurrent miscarriages
- antiphopholipid syndrome
- endocrine - poorly controlled diabetes/thyroid
- PCOS
- uterine abnormality - uterine septum
- parental chromosomal abnormalities
-smoking
termination of pregnancy fetus age limit
24wks
termination of pregnancy approval
2 registered medical practioners must sign legal doc
- in emergency only 1 needed
only a registered medical practioner can perform an abortion, which must be in a NHS hospital or licensed premise
termination of pregnancy and rhesus D
anti-D prophylaxis should be given to women who are rhesus D negative and are having an abortion after 10+0 weeks’ gestation
medical options for TOP
mifepristone (anti-progestogen)
misoprostol 48hrs later - to stimulate contractions
- can be done at home depending on gestation
- takes hour/days
pregnancy test at 2 weeks to confirm end
- detect level of hCG - termed multi-level preg test (not just pos/neg)
surgical options for TOP
vacuum aspiration (MVA)
dilation and evacuation (D&E)
- cervical priming with misoprostol +/- mifepristone before
- intrauterine contraceptive can be inserted immediately after
choice of procedure for TOP
offered medical or surgical choice
- after 9 wks medical less common - seeing products + less successful
- <10wks - medical usally done at home
typical ectopic pregnancy presentation
female with hx of 6-8wks amenorrhoea who present with lower abdo pain + later develops vaginal bleeding
ectopic presentation
- lower abdo pain - constant, due to tubal spasm
- vag bleeding - may be brown
- recent amenorrhoea (if longer 10wks - could be inevitable abortion)
- shoulder tip pain! - peritoneal bleeding can refer, pain on defation
O/E
- abdo tenderness
- cervical excitation (motion tenderness)
risk factors for ectopic preg
anything slowing ovums passage to uterus
- damage to tubes - PID, surgery
- previous ectopic
- endometriosis
- IUCD
- POP
- IVF
ectopic investigation
pos pregnancy test
Ix of choice = transvaginal US
determinign management of ectopic
based on size, rupture status, pain, visible heartbeat, hCG levels
size >35mm, ruptured, pain, visible heartbeat, hCG >5000 = surgical
hCG <1000 + small/asymptommatic - expectant mx
hCG <1500 + small/symptommatic - medical mx
management of ectopic
expectant - monitor for 48hrs, if hCG rise/symptomatic - intervention required
medical = methotrexate (only give if patient willing to attend follow up)
surgical -
- salpingectomy - no other RF for infertility
- salpingotomy - with RF for infertility (eg contralateral tube damage)
–> 1 in 5 require further mx - methotrexate/salpingectomy
where do ectopics most commonly occur
97% tubal - most in ampulla
– most dangerous if in isthmus (section between ampulla + uterus)
3% in ovary, cervix or peritoneum
complete hydatidiform mole presentation + investigations
vaginal bleeding - 1st/2nd tri
exaggerated sx of preg - hyperemesis
uterus larger than expected for gestational age
abnormally high hCG
US = “snow storm” appearance of mixed echogenicity
complete hydatidiform mole
Benign tumour of trophoblastic material
Occurs when an empty egg is fertilized by a single sperm that then duplicates its own DNA, hence the all 46 chromosomes are of paternal origin
considered pre-cancerous -> 2-3% go on to develop choriocarcinoma
