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O&G - MISCARRIAGES & ECTOPICS Dr Meena Nayagam, FY2A LITTLE ABOUT ME Currently in FY2 Interest in O&G Former Manchester grad and was the Revision Coordinator for OGSOC! MNAYAGAM@DOCTORS.ORG.UKCASE 1 You are an FY1 in GAU 32 yr female, currently 14 weeks pregnant G9P3 - has not been investigated previously PV bleeding +++ Potential causes? Next steps?CASE 1, CONTINUED Observations stable - BP 100/90, HR 85 bpm Abdo soft but tender ++ over lower abdomen PV exam - open external and internal cervical os Products of conception visualised Diagnosis?MISCARRIAGE Incredibly common Several risk factors 25% of people who become pregnant will miscarry Nevertheless… Can be traumatic Painful time for patients and their families Think about how you would BBNMISCARRIAGE - CLASSIFICATION First trimester - early; up to 12 weeks Typically due to foetal or placental anomalies Second trimester - late; between 13 to 20 weeks Maternal illness - antiphospholipid syndrome, thyroid disease, uterine malfx Infections - TORCH + STIs, malaria Cervical incompetenceMISCARRIAGE - CLASSIFICATION Threatened - painless vaginal bleeding, healthy pregnancy Inevitable - cervical os open, imminent Incomplete - some POC remains in the uterus Complete - all POC passed into vagina Delayed - nonviable pregnancy, no signs of bleedingMISCARRIAGE - DIAGNOSIS Clinical history = patient may not know they are pregnant!! LMP Onset of symptoms - PV bleeding +/- pain Examination Observations PV - speculum + bimanual Bloods (bHCG) +/- USS depending on gestational ageMISCARRIAGE - MANAGEMENT Expectant - highly variable!! At home, on their on terms vs uncertainty/anxiety F/U in 2 to 3 weeks Medical Misoprostol - causes uterine contractions; can be painful with heavy bleeding Surgical - dilatation and curettage All carry SEsMISCARRIAGE - PREVENTION Counsel on reversible causes Alcohol/smoking/drugs Weight (to a certain extent) Test for underlying conditions Genetic counselling + IVF Cervical cerclage for incompetence - several types!BACK TO CASE 1 USS confirms incomplete miscarriage Patient chooses to have D&C Further testing done due to recurrent miscarriages in the second trimester Dx with cervical incompetence Next year, becomes pregnant again - cerclage inserted, gives birth to healthy baby boy at 36 weeksCASE 2 FY1 in A&E 26 yr female with lower abdominal pain ++ that began yesterday N/V/D, feeling fatigued Accompanied by slight PV bleeding - may be her period BP 90/50, HR 100 Abdo soft but tender +++ over RIFCASE 2 - DIFFERENTIAL DX Gynae Gastro Other • Ectopic!! • Gastroenteritis • UTI • Torsion • Appendicitis • Renal colic • Ruptured cyst • PIDCASE 2, CONTINUED O/E: Abdo - McBurney’s negative, no renal angle tenderness Bimanual exam - cervical excitation, adnexal tenderness in R Urine dip - hematuria + Pregnancy test - positive What is the diagnosis? What are the next steps?ECTOPIC PREGNANCY Implantation of pregnancy outside of the endometrium Most common areas Fallopian tube - ampulla! Ovaries Previous C section scarsECTOPIC PREGNANCY, CONTINUED Risk Factors Previous ectopics PID Certain contraceptive options - IUD/IUS, Depo Assisted reproductionECTOPIC PREGNANCY - DIAGNOSIS Careful history taking!! Symptoms may be mild Always consider in a someone of child-bearing age Observations + examination - abdominal, PV Serial beta hCGs Progesterone is useful for pregnancy viability, nil else USSECTOPIC PREGNANCY - MANAGEMENT Conservative - not preferred Medical Methotrexate - counsel on SEs! Surgical Salpingectomy Patient can still get pregnant! Follow up regardlessBACK TO CASE 2 Haemodynamically unstable - priority is resuscitation until definitive management Taken into theatre - ectopic in R ampulla R salpingectomy performed Recovers well after her operation On retrospect - previous history of PIDSUMMARY Miscarriage Ectopic Very common Always consider!!! First vs second Careful with hCG interpretation Three forms of management MTX or salpingectomy preferred Think about causes Common risk factors - PID, coilHELPFUL SOURCES (WHAT I USED) BMJ Best Practice NICE/CKS Guidelines RCOG Guidelines THANK YOU! ANY QUESTIONS?