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MRCOG PART 2 SBAs and EMQs

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early pregnancy loss

early pregnancy loss Posted by vijaya L.
A 30 year old woman presents with vaginal bleeding and abdominal pain. Ultrasound scan shows a viable 8 week pregnancy in one horn of a bicornuate uterus. Justify your management.

I would first enquire about the amount and duration of bleeding and severity of the pain. Threatened miscarriage is associated with mild abdominal bleeding, viable pregnancy and minimal or no pain, where as pain is usually a sign of inevitable miscarriage. And severe bleeding requires immediate evacuation of the uterus in spite of the presence of viable pregnancy.
I would also enquire about her obstetric history, as age and previous miscarriage are important predictors of the outcome.
The other features I would look for in the history are personal or family history of diabetes mellitus, connective tissue disease, thrombophilia and thyroid endocrinopathy, as these are recognized factors associated with higher incidence of pregnancy losses.
A complete physical and pelvic examination performed. Tachycardia, hypotension and pallor are signs suggestive of significant blood loss. Cervix is closed in threatened abortion where as it is partially dilated in inevitable miscarriage.
Blood grouping typing, FBC, HB, blood sugar would be done. Anti D prophylaxis is usually not required for threatened or spontaneous complete miscarriage before 12 weeks, but required in case surgical termination becomes necessary.
Ultrasound report would be looked for further details like irregularity of the sac and presence of subchorionic hemorrhage which when present are indicative of bad prognosis. Bicornuate uterus is not a known cause of early pregnancy loss, but most of the uterine anomalies are associated with cervical incompetence, which would indicate the need for close monitoring of the pregnancy.
Majority of the time a viable pregnancy continues normally without any treatment. So she should be reassured and can be recommended to be in the hospital till the bleeding and pain subsides, else she can also be reviewed at the early pregnancy unit.
There is no evidence for advising either bed rest, progesterone or HCG in the management of early pregnancy loss.
She should be given a review appointment after 2 weeks and repeat ultrasound examination confirms the viability and normal progress of the pregnancy, this especially necessary when subchorionic hemorrhage was noticed.
Early pregnancy bleeding has also been advocated as marker for suboptimal outcome in the pregnancy in the form of IUGR and Preterm labour.
In the event that the pregnancy becomes missed she should be offered bereavement counseling to deal with the grief and discussed about the conservative management or evacuation.
If she chooses conservative management, more than 50 percent of the time she would expel spontaneously and the side effects of medical termination and surgical morbidity of cervical dilatation and infection can be avoided.
If evacuation is chosen then medical termination with mifepristone and misoprostol is offered in the absence of contraindications like liver and kidney disease. It is effective in about 95% of the time.
When surgical termination is done swabs should be taken from the cervix and vagina or universal prophylaxis with metronidazole provided. Cervical dilatation can be made less traumatic with prior application of misoprostol .
She should be given appointment 2 weeks later to discuss about the contraception and to plan future pregnancy.
Corrective surgery for bicornuate uterus is not indicated because it has not shown to improve the pregnancy outcome and it is associated with infertility and rupture uterus.

Posted by Rani M.
Kindly check my answer also
Q: A 20year woman with vaginal bleeding and abdominal pain.On ultrasound there is viable pregnancy in one horn of a cornuate uterus. Justify your management.

The pregnancy outcome in this case will depend upon the size of the horn which may vary from rudimentary horn to a well developed horn of a bicornuate uterus.There is an increased risk of spontaneous miscarriage, rupture of a rudimentary horn, preterm labour, abnormal lie or presentation of fetus, retained placenta and consequently higher rate of operative interventions.
If patient is bleeding heavily, her vitals are checked, blood is sent for complete blood counts, blood grouping and atleast 2 units of blood is cross matched. Resuscitaion may be required if she is in shock.
A history is taken regarding her previous pregnancies and their outcome.If there is history of first trimester abortions, other causes of miscarriage should also be looked for.
Per speculum examination is done to look for any abnormalities of cervix and to assess amount of bleeding.
As bicornuate uterus is an abnormality of mullerian duct fusion there may be associated renal anamolies, so an abdominal ultrasound is done to look for kidneys and renal tract anamolies.
She is admitted to the hospital for observation aspain and bleeding may be early sign of rupture of horn Though it occurs usually at about 14 weeks, so if pain and bleeding subsides , she can be discharged and managed at home with instructions to report early in case of any pain or vaginal bleeding.If pain persists laproscopy may be required.
If she has spontaneous miscarriage, evacuation should be done by an experienced gyneclogist for complete evacuation of both horns is required...
Preterm labour in these patients is usually due to restricted intrauterine space and due to cervical incompetence. therfore cervical cerclage should not be done unless there is history suggestive of cervical incompetence. Infact cerclage in itself may increase the risk of infection, premature rupture of membranes and preterm labour
.If pregnancy continues,abnormal presentation such as breech & transverse lie and placenta praevia is more common. E.C.V. may not be successful and cesarean will be a more appropiate choice.Woman is counselled accordingly antenatally & appropiate information leaflets are provided
If presentation is cephalic there is no contraindication for vaginal delivery. though there is risk of retention of placenta and manual removal of placenta may be required.
Index of suspician for above adverse events is kept high and closer follow up is done with regular ultrasound scans.
Posted by SWATI M.
This woman would be anxious and needs psychological support .She should be explained that the pregnancy is viable and also risks due to threatened miscarriage.The discussion should also involve explaination of bicornuate uterus and it?s implication on reproductive outcome.
Amount of blood loss taken into consideration for further management and to predict outcome along with history of previous pregnancy outcome .Severity of abdominal pain is noted .Clinical examination includes, vitals signs to assess blood loss,abdominal and pelvic examination performed .Investigations such as haemoglobin estimation,Rhesus blood group performed.
Woman should be counselled that outcome is good and most pregnancies continue in threatened miscarriage if they have minimal blood loss and pain.For the treatment of threatened miscarriage bed rest,use of progesterone or HCG do not improve the outcome.She should be given Rhesus immunoglobulins if rhesus negative,non sensitized and have severe abdominal pain or significant bleeding to prevent sensitization.She should be informed of increased risk of miscarriage with repeated bleeding,increased risk of fetal growth restriction.She should also be explained the diagnosis of bicornuate uterus and may have potential on reproductive outcome .She may deliver at term or have preterm delivery.There is increased risk of malpresentation and need for caesarean section with bicornuate uterus.
If she has minimal symptoms and no significant blood loss she can be sent home with written account of symptoms of complication and contact details in emergency.
She should be given follow up appointment after 1-2 weeks for repeat ultrasound scan to ensure the fetal condition.
Further antenatal care should be preferably consultant led with regular ultrasound growth scans .Noting presentation by clinical examination and if in doubt by ultrasound particularly near term is important as malpresentations are common .Route of delivery depends on presentation and caesarean sections are reserved for obstretric indication only.
Role of reconstructive surgery is uncertain for repeated pregnancy losses due to bicornuate uterus.Problem of infertility and increased risk of uterine rupture in subsequent pregnancy should be taken into account.