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Miscarriage is the most common complication in early pregnancy. It occurs in 15% of clinically recognised pregnancies and accounts for 50 000 inpatient hospital admissions each year in the UK. In recent years early pregnancy units have been designed to improve the quality of service in the diagnosis of early pregnancy complications and provide rapid and accessible care.
The prevalence of miscarriage in early pregnancy units varies from 17% to 46%. The management of women with suspected or confirmed miscarriage is the main task for medical professionals with an interest in providing early pregnancy care. The introduction of ultrasound into routine clinical practice has greatly improved the diagnosis and management of early pregnancy complications. However, easier access to dedicated early pregnancy services has also led to an increasing number of women seeking advice at early gestations. The main challenge in the provision of modern early pregnancy care is balancing the need for sympathetic and individualised care of women who have suffered early pregnancy loss with the need to manage a large number of patients on a routine daily basis.
A miscarriage can be defined as a pregnancy failure occurring before the completion of 24 weeks of gestation, which is the current threshold for fetal viability. Miscarriages are classified as early (less than 12 weeks of gestation) or late (from 12 to 24 weeks of gestation).
For the past 50 years, the mainstay of treatment for the management of miscarriage has been surgical management, or the evacuation of retained products of conception. Until recently, up to 88% of women diagnosed with a miscarriage would be offered an evacuation of retained products of conception under general anaesthesia. The rationale for surgical management was based on the assumption that the presence of a non-viable pregnancy within the uterus would increase the risk of infection and haemorrhage. In the past, these complications were more likely to develop from infected retained products of conception following poorly performed illegal abortions but, with the legalisation of abortion in developed countries, the introduction of antibiotics and a general improvement in women's health, these risks have decreased substantially. Over the past decade, there has been less emphasis on urgent surgical management and more on individualised treatment and patient choice between expectant, medical and semi-elective surgical treatment.
Expectant management is chosen by women because of a desire for a natural approach to management. It is becoming an increasingly popular option; in one observational study, 70% of women opted to wait for the pregnancy to resolve spontaneously. The first randomised controlled trial of expectant management compared with surgical management of miscarriage, carried out by Nielsen and Hahlin, showed a 79% success rate for cases of incomplete or inevitable miscarriage when managed expectantly for 3 days, with no increased risk of pelvic infection or excessive bleeding.
Acute gynaecological problems are among the most common reasons for women of reproductive age to seek medical help. Early pregnancy complications account for the majority of gynaecological emergencies. In the UK, emergency gynaecological care used to be provided mainly by junior doctors working in casualty departments. However, it became clear that this model of care was not well suited to meeting the needs and increasing expectations of women. Developments in diagnostic ultrasound, which occurred in parallel, have led to wide acceptance of ultrasound as an essential tool for the assessment of developing pregnancy from a very early stage until delivery. Routine ultrasound scanning to assess fetal health and wellbeing has now been introduced in most developed countries.
To meet demands for more accessible, patient-centred care, early pregnancy assessment units were developed in the UK. This model of care has proved to be very successful and has been adopted by most acute hospitals. Early pregnancy units usually provide an integrated ultrasound scanning service to facilitate diagnostic work-up and to formulate appropriate management plans. Easier access to health professionals with an interest in early pregnancy care and greater availability of ultrasound scanning have resulted in increased attendance at early pregnancy units, with many women wishing to confirm that their pregnancy is normal rather than seeking help for serious medical complications. Improved diagnosis of miscarriage and ectopic pregnancy has prompted the development and implementation of more conservative management strategies.
Acute gynaecological problems are among the most common reasons for women of reproductive age to seek medical help. Emergency outpatient visits now outnumber elective clinical appointments in gynaecology. With a growing number of patients, increasingly complex diagnostic algorithms and a wide range of management options, the participation and training of senior doctors in this field is vital to ensure women receive the best possible treatment. This book provides a thorough overview of acute gynaecology and early pregnancy and has been designed to reflect the syllabus of the RCOG's Advanced Training Skills Module (ATSM) in 'Early pregnancy and emergency gynaecology'. It covers the diagnosis and management of routine clinical problems, such as miscarriage and tubal pregnancy, as well as less frequently seen presentations, such as uncommon forms of ectopic pregnancy and trophoblastic disease. The use of drugs in early pregnancy and management organisational aspects of care are also addressed.
The fallopian tube is the most common location for pregnancies that implant outside the uterine cavity. In the minds of the lay public and many health professionals, tubal implantation is often considered synonymous with ectopic pregnancy. However, there are many other locations within the pelvis and abdominal cavity where a pregnancy could implant and grow. Cases of ectopic pregnancy have been described affecting organs as distant as the liver or omentum. It has been reported that approximately 7% of all ectopic pregnancies are located outside the fallopian tubes. Such pregnancies are often referred to as non-tubal ectopic pregnancies.
In recent years the incidence of ectopic pregnancy has increased owing to many factors such as improved sensitivity of urine pregnancy tests, better ultrasound diagnosis, wide use of assisted reproductive techniques and, possibly, the increased incidence of tubal damage caused by pelvic inflammatory disease. In addition, the increase in the number of surgical procedures involving the uterus, in particular the high rate of caesarean sections, has played an important role in the higher number of both tubal and non-tubal ectopic gestations.
Although non-tubal ectopic pregnancies are relatively rare, they are associated with significantly higher maternal morbidity and mortality rates compared with tubal ectopic pregnancies. This is primarily because of their tendency to remain clinically silent in early gestation and to present with acute, severe symptoms either late in the first trimester or during the second trimester of pregnancy.
The incidence of congenital uterine anomalies in the general population is between 0. 4% and 3. 2%. This chapter describes the principles of ultrasound diagnosis of uterine anomalies and compares the results with other available diagnostic modalities. The gold standard in the diagnosis of congenital uterine anomalies used to be a simultaneous laparotomy/ laparoscopy and hysteroscopy to visualize the serosal surface of the uterus and the endometrial cavity. The real breakthrough in ultrasound assessment of congenital uterine anomalies was the development of three-dimensional transvaginal probes. This technique involves the acquisition and storage of a volume of ultrasound information. Magnetic resonance imaging (MRI) has been shown to be effective for the diagnosis of congenital uterine anomalies with sensitivity and specificity up to 100%. The advent of three-dimensional ultrasound has greatly enhanced the ability to diagnose congenital uterine anomalies in an outpatient setting.
This chapter reviews evidence on various investigative modalities and management planning for women presenting to the gynaecology clinic with post-menopausal bleeding. It discusses some of the issues to be considered when planning a cost-effective, clinic-based service for these women. Dilatation and curettage (D&C) was for many years the investigation of choice in women presenting with post-menopausal bleeding. The Pipelle de Cornier is a widely used system. The system is a narrow plastic catheter, which is passed through the cervical canal into the uterine cavity. Transvaginal ultrasound (TVS) is an accurate, non-invasive diagnostic modality that enables examination of the uterine cavity and endometrium in the outpatient setting. With the uterus visualised in a longitudinal plane, the thickness of the endometrial echo can be measured. Endometrial polyps are a common finding in post-menopausal women and when they occur in association with post-menopausal bleeding they should be removed for histopathological diagnosis.