• Miscarriage
• Ectopic pregnancy
• Gestational trophoblastic disease
• Hyperemesis gravidarum
• 'Anxiety state'
• Summary

• Threatened: Bleeding from the uterus prior to 24 weeks with the cervix not dilated and the foetus alive
• Inevitable: Bleeding from the uterus prior to 24 weeks with pain and dilatation of the cervix
• Incomplete: Part of the conceptus has been expelled but there is continuing bleeding due to tissues retained
• Complete: The whole conceptus has been expelled
• Recurrent: 3 or more consecutive miscarriages
• Silent: Pregnancy failure is identified before expulsion of foetal/placental tissues

• LMP and menstrual history: first date of last period (not last date), real flow not expected flow, bleeding may be mistaken for MP (ask amount of flow - same as previously?); Hx: cyclical, long period, amenorrhoea
• Pregnancy test: v easy for women to obtain from chemist
• Vaginal bleeding
• Abdominal pain
• Passage of tissue mass: difficult to differentiate from blood clot + tissue mass
• Planned/ wanted?

• Introitus: blood stained?
• Vagina: blood? Tissue mass?
• Cervix: tissue mass, vulsellum mark (abortion, previous manipulation), os open/closed (cervical os = internal os)
• Uterus - size (smaller in silent miscarriage)
• Fornix

• Hb - also note MCV: thalassaemia
• Rh factor: if -ve, may need to immunise Pt
• Pelvic sonogram: confirm Dx
• Tissue mass for histology: decidua, chorionic villi, foetal parts

• Transvaginal vs. transabdominal: transvaginal - can use probe of high freq. - better resolution - finer details (therefore, different interpretation)
• Gestational sac vs. pseudosac: US can only tell sac-like structure; ectopic pregnancy there is present of decidua which appears like a sac
• Silent miscarriage if sac diameter >20 mm with no evidence of embryo or yolk sac: if sac diameter less than 20 mm and can't see anything, can be very early intrauterine gestation (repeat scan in 1w time), if still nothing - probably silent miscarriage
• CRL >6 mm with no evidence of cardiac pulsation: [crown-rump length]; if less than 5mm and cannot see foetal heartbeat - repeat in on 1w (if still cannot see, silent miscarriage)
• Incomplete miscarriage - thick irregular echoes in the midline of the uterine cavity
• Complete miscarriage - well defined regular endometrial line
• Echoes inside intrauterine cavity can be blood clots - therefore need clinical picture
• Beware of ectopic pregnancy

• Peripheral blood karyotyping in both partners
• Karyotyping of all foetal products
• Pelvic ultrasound to assess ovarian morphology and uterine cavity
• Screening tests for antiphospholipid antibodies

Can kill Pt

• In shock
• Abdominal pain with amenorrhoea; syncope (typical), shoulder pain - 1/4 of women have no amenorrhoea (mistake bleeding for period)
• Abdominal tenderness with varying degree of peritonism; cervical excitation (pain on gentle movement of cervix due to bleeding into peritoneal cavity)
• Clinical diagnosis can only be made in half of the patients (need Ix before you can make Dx of ectopic pregnancy)

• Previous ectopic pregnancy
• Tubal damage from infection/surgery
• History of infertility
• Assisted reproduction techniques
• Increased age
• Smoking

• Hb, Rh, type and screen - may need blood transfusion
• A negative pregnancy test effectively rule out ectopic pregnancy
• Pelvic ultrasound examination
• HCG assay
• Diagnostic laparoscopy
• Others

• Fast: prep for operation
• Intravenous line of wide gauge (16 gauge)
• Close observation

• Rule out ectopic pregnancy if intrauterine sac seen (with exception)
• May be 'normal' in up 1/4
• Live embryo within a gestational sac in adnexa is diagnostic
• 1:30,000 pregnancy both intra and extra-uterine (heterotopic)
• Except IVF: higher chance of heterotopic pregnancy

• Poorly defined tubal ring: Fallopian tube distended, see a ring instead of nothing
• Complex adnexal mass: can also be corpus luteum
• Varying amount of fluid in the Pouch of Douglas (blood)

• Concept of discriminatory zone: if HCG above a certain level, and you cannot see intrauterine sac -> ectopic pregnancy or silent miscarriage
• Repeat assay in 48 hours: change in HCG - should double in 48hr (therefore, if no significant increase in HCG in 48h = abnormal pregnancy)
• Cannot differentiate between abnormal pregnancy outcomes

+ve pregnancy test -> stand-by USG

1. Intrauterine pregnancy -> antenatal care
2. Extrauterine pregnancy, noncystic adnexal mass -> laparoscopy

Standby USG - no ectopic pregnancy, non noncystic adnexal mass -> HCG

Repeat HCG in 2d

• Surgical treatment is the preferred approach
• Laparoscopic approach is superior
• Salpingectomy is to be preferred to salpingotomy when the contralateral tube is healthy
• Salpingotomy is reasonable when there is only one tube
• In selected cases methotrexate is an effective alternative
• Non-sensitised Rh negative women should receive anti-D Ig
• Patient in shock or surgeon with inadequate experience, traditional laparotomy is to be preferred

• Coexistence of an intrauterine and extrauterine gestation
• Classical incidence 1 in 30000
• 1-3% following assisted reproduction technique

• Streamline the management of women with early pregnancy bleeding or pain
• Reduce the need for admission
• Need appointment system, appropriate setting, transvaginal ultrasound examination, access to laboratory facilities(for Rh antibody and HCG)

• Similar to that of threatened miscarriage
• Size of uterus may be larger than date
• Exaggerated pregnancy symptoms (raised HCG level - vomiting, HT)
• Early onset preeclampsia

• Ultrasound examination - 'snowstorm' appearance
• Lutein cysts of ovary

• HCG
• CXR: no spread to lungs
• Suction evacuation: rare, worry about spread of molar tissue through BV
• Monitoring of HCG level after evacuation

Patients with intractable vomiting and disturbed nutrition such as alteration of electrolyte balance, loss of weight of 5% or more, ketosis, and acetonuria, with ultimate neurological disturbances, liver damage, retinal haemorrhage, and retinal damage

Patients with excessive vomiting resulting in admission to hospital

Other causes of vomiting

• Multiple pregnancy
• Gestational trophoblastic disease
• Hyperthyroidism
• Upper gastrointestinal tract disorder
• Hepatitis
• Other infection

• CBP, RFT, LFT, thyroid function [Complete blood picture; Renal function test; Liver function test]
• MSU for routine, microscopy and culture
• Pelvic ultrasound
• Others

• Mallory-Weiss oesophageal tear
• Mendelson syndrome: aspiration
• Neurological disturbances e.g. Wernicke's encephalopathy, peripheral neuropathy
• ARDS (Adult Respiratory Distress Syndrome): aspiration of vomitus into lungs - can be residual deficit; baby can die due to hypoxia

• Fast
• IV fluid and electrolyte replacement
• Multivitamins replacement: encephalopathy
• Intake and output chart, daily body weight monitoring

• Dry diet
• Small frequent meals
• Fairly dry and high in easily digested carbohydrates
• Liquids are taken between the meals
• Antiemetics

• Initially oral fluid intake
• Followed by small carbohydrate meals
• Total avoidance of fatty foods

• Avoiding offensive foods and odours
• Eating frequent small meals
• Low protein, low fat, high carbohydrate
• Avoid iron supplements
• Encouraged to take whichever foods appeal when hungry

• FDA category C - no adequate and well controlled studies in pregnant women
• 25 mg nocte or bd

Miscarriage is the preferred term as compared to spontaneous abortion

• Clinical differentiation for the different types of miscarriage
• Importance of pelvic sonography in the diagnosis
• Best treatment is evolving: includes suction evacuation, but not exclusively
• Ectopic pregnancy is an important differential diagnosis: even for GP's
• Use of algorithm in early diagnosis
• Laparoscopic salpingectomy is the gold standard of treatment
• Role of Early Pregnancy Assessment Service
• Gestational trophoblastic disease is an important differential diagnosis of threatened miscarriage (eg. Young woman with stroke, CXR shows cannon-ball appearance, choriocarcinoma from GTD)
• Hyperemesis gravidarum can be life threatening and it is important to exclude other specific diagnoses