Problems with early pregnancy Flashcards
(53 cards)
Early pregnancy pain and PV bleed Hx?
SQITARS
Bleeding - how long, how much (spotting v light v heavy period - how many pads)
Past gynae Hx: LMP, cycle, previous ectopic/miscarriage, planned/unplanned/unwanted pregnancy, previous STIs
PMH, surgery
Drugs Hx: teratogenic drugs, allergies, POP (RF for ectopic)
Social - consanguineous, smoker, alcohol, drugs
Family history – any inheritable diseases?
early pregnancy pain and PV bleed exam?
- General – collapsed, unwell, clinically shocked
- Abdo – distension, scars
- Per speculum – Internal os open? (important if establishing if miscarriage happening) – also quantify amount of bleeding patient is having
- Bimanual exam – uterus enlarged? (DDx: fibroids, adenomyosis)
early pregnancy pain and PV bleed Ix?
- Urine pregnancy test
- USS – Trans-abdo (fine after 8wks gestation) or TV
o By 6weeks – can detect fetal heartbeat
o First sign is gestational sac, 2nd yolk sac, 3rd is fetal pole - If excluding ectopic – serum BHCG
o If >1500 and nothing in uterus increased risk of ectopic
o If BHCG low – repeat in 48hrs (if >63% rise – likely to be IU pregnancy)
If <63% rise – ectopic or non-viable IU pregnancy - G+S – for future transfusion and if require anti-D
Causes of miscarriage?
- Never established in most cases
- Chromosomal abnormalities
- Congenital abnormalities
- Maternal disease: Poorly controlled diabetes, Acute illness / infection, Uterine anomalies, Thrombophilia/Antiphospholipid Syndrome
RFs for miscarriage?
- Advanced maternal age (>/= 40)
- Previous miscarriage
- Smoking
- Alcohol (moderate to heavy) and drug use
o NSAIDs and Aspirin
o Street drugs - Folate deficiency
- Consanguinity
Define threatened miscarriage?
Bleeding and or pain up to 24/40 with a viable ongoing pregnancy. Cervix closed.
Define inevitable miscarriage?
Open cervix but products of conception have not yet passed but inevitably will.
- Features: Heavy bleeding, clots, pain
- TV: Fetus can be viable or non-viable
- Offer conservative/medical/surgical options. Likely to proceed to incomplete/complete miscarriage
Define missed miscarriage?
where the baby has died or not developed, but has not been physically miscarried
- Features: Asymptomatic or hx of threatened miscarriage, on-going discharge, small for dates uterus
- TV: No fetal heart pulsation in a fetus where crown rump length is >7mm
o Crown rump length must be greater than 7mm before you can accurately comment on fetal heart pulsation
- May want to rescan and second person to confirm
Define incomplete miscarriage?
Some POC have been passed, however some tissues and blood clot remain within uterus. Cervix stays open and bleeding and pain usually persist
- TV: Retained POC, with A/P endometrial diameter >15mm AND proof that were was a intrauterine pregnancy previously present
Define complete miscarriage?
All POC been passed. Cervix now closed and Bleeding and pain reducing. Complete sac (Pale – colour of raw chicken) may be identifiable. - TV: No POC seen in uterus, with endometrium that is <15 mm diameter AND previous proof of intrauterine pregnancy - Mx: Anti-D if >12wks Serum hCG to exclude ectopic if any doubt Review if bleeding persists >2wks and consider endometritis or retained products of conception
What does a blighted ovum/anembryonic pregnancy look like on TVUSS?
Failed pregnancy with empty gestation sac i.e. no fetus present
Mx for all types of miscarriage?
If >12 weeks & rhesus negative: Anti-D
Define septic miscarriage?
If POC infected → septic patient. Rare where Termination of pregnancy (TOP) is legal
- fever, rigors, uterine tenderness, bleeding/discharge, pain
- TV: Leucocytosis, raised CRP + can be features of complete or incomplete miscarriage
- Mx: IV antibiotics and fluids
Whats the conservative Mx of miscarriage? CIs? Advs? Disadv? follow up>
Waiting for all POC to pass naturally usually over 2 weeks, but can be longer
o Require access to 24hr gynae service (EPAU)
o CIs: Infection, high risk of haemorrhage ie. Coagulopathy, haemodynamic instability.
o Advantages:
Avoid risks of surgery / medication
Can be at home
o Disadvantages
Pain and bleeding can be unpredictable
Worries re: being at home
Takes longer
May be unsuccessful – still requiring active management
A repeat TVS should be offered at 2wks to ensure complete
miscarriage—can be repeated after another 2wks if a woman wishes to
continue with conservative management.
Whats the medical Mx of miscarriage? Adv disdv? follow up?
o Misoprostol (prostaglandin analogue) to stimulate cervical ripening and myometrial contractions
usually preceded by mifepristone 24-48 hours prior to administration.
o Advantages:
Can be at home if patient desires ( with 24/7 access to gynaecology services)
Avoid anaesthetic and surgical risk.
o Disadvantages:
Pain and bleeding may be unpleasant and/or severe - bleeding may continue for up to 3 wks
s/e of drugs: vomiting/diarrhoea, heavy bleeding and pain during passage of POC
Need for emergency surgical management (SERPC) < 5%
o Follow up pregnancy test 3wks later
DDx for bleeding in early pregnancy?
iscarriage. • E ctopic pregnancy. • G estational trophoblastic disease. • R arely gynaecological lower tract pathology (e.g. Chlamydia, cervical cancer, or a polyp).
Define miscarriage?
expulsion of a pregnancy, embryo, or fetus at a stage of
pregnancy when it is incapable of independent survival - includes all pregnancy losses before 24wks
When to give anti-D prophylaxis in miscarriage?
< 12wks (250IU IM):
• u terine evacuation (medical and surgical)
• e ctopic pregnancies.
• > 12wks: all women with bleeding (250IU IM before 20wks and 500IU
IM after 20wks).
Describe surgical Mx of miscarriage? Complications? Advs, disadvs?
A n ERPC should be performed in patients who have excessive or persistent bleeding or request surgical management.
• Suction curettage should be used.
Complications: infection. • H aemorrhage. • U terine perforation (and rarely intraperitoneal injury). • R etained products of conception. • I ntrauterine adhesions. • C ervical tears. • I ntra-abdominal trauma.
o Return to normal physically 24 hours - Bleeding 1-2 weeks
o Advantages: Planned procedure, closure
o Disadvantages:
Surgical risks: perforation, bowel/bladder damage, damage to cervix, Asherman’s, Cervical weakness
Anaesthetic risks
Ectopic pregnancy symptoms?
o ften asymptomatic, e.g. unsure dates
• a menorrhoea (usually 6–8wks)
• p ain (lower abdominal, often mild and vague, classically unilateral)
• v aginal bleeding (usually small amount, often brown)
• d iarrhoea and vomiting should never be ignored
• d izziness and light-headedness
• s houlder tip pain (diaphragmatic irritation—haemoperitoneum)
• c ollapse (if ruptured).
Ectopic pregnancy signs?
o ften have no specifi c signs
• u terus usually normal size
• c ervical excitation and adnexal tenderness occasionally
• a dnexal mass very rarely
• p eritonism (due to intra-abdominal blood if ectopic ruptured).
ectopic pregnancy Ix?
TVUSS - establish location of pregnancy, adnexal mass presence or free fluid
serum progesterone - to distinguish whether a pregnancy is failing: <20nmol/L is highly suggestive of this, whether ectopic
pregnancy (EP) or intrauterine pregnancy (IUP).
Serum hCG - >1500 - IUP should be seen on TVUSS
repeated 48h later:a rise of ≥ 66% suggests an IUP - a suboptimal rise is suspicious, but not diagnostic of an EP.
Laparoscopy - gold standard
RFs for ectopic pregnancy?
H istory of infertility or assisted conception. • H istory of PID. • E ndometriosis. • P elvic or tubal surgery. • P revious ectopic (recurrence risk 10–20%). • I UCD in situ. • A ssisted conception, especially IVF. • S moking.
When to do medical or expectant Mx for ectopic?
C linically stable.
• A symptomatic or minimal symptoms.
• h CG, initially <3000IU (can be tried >3000IU but less successful).
• E P <3cm and no fetal cardiac activity on TV USS.
• N o haemoperitoneum on TV USS.
• F ully understand symptoms and implications of EP.
• L anguage should not be a barrier to understanding or communicating
the problem to a third party (such as phoning an ambulance).
• L ive in close proximity to the hospital and have support at home.
• Y ou deem the patient will not default on follow-up.
do expectant over medical if falling hCG level
