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Abdominal Pain in Early Pregnancy, CAUSATIVE AGENTS, image, Miscarriage is…

- - - - For heavy menstrual bleeding – tranexamic acid, mefenamic acid, COCP
      - GNRH agonist – to shrink fibroids, pre – surgery
      - Ulipristal acetate -oral selective progesterone modulator – can induced amenorrhoea
    - - Hysteroscopic removal – submucous fibroid
      - Myomectomy with uterine preservation – bulky fibroid and wants to preserve fertility
      - Hysterectomy – if patient has complete family
    - - Uterine artery embolization – procedure that blocks blood supply to the fibroids → shrink its size.
      - High intensity focused ultrasound – uses high- intensity ultrasonic beam that is focused with high accuracy using an extracorporeal transducer to thermally ablate the fibroids without the need to introduce needles, or probes
      - Benefits: non-invasive, non-surgical treatment, less risk, no ionizing radiation, faster recovery time and precise.
- - - - Location of appendix may migrate cephalad with the enlarging uterus, pain may be described in the right flank or even in the right upper quadrant as pregnancy advances.
    - - Cardinal features: fever, localised abdominal tenderness, muscle guarding and rebound tenderness
      - Rebound tenderness, Rovsing's sign, Psoas sign, Obturator
        sign = POSITIVE
  - - - Ultrasound: Ultrasonography is often the first-choice imaging modality during pregnancy due to its safety and lack of radiation. It can help visualize the appendix and assess for signs of inflammation.
      - Magnetic Resonance Imaging (MRI): If the diagnosis is still uncertain, MRI may be recommended. MRI is considered safe during pregnancy and can provide detailed images of the appendix and surrounding structures.
      - Computed Tomography (CT) Scans: While CT scans involve ionizing radiation and are generally avoided during pregnancy,
  - - - Delaying surgical intervention for more than 24 hours after the symptoms first appear increases the risk of perforation
      - Laparoscopic or laparotomy
  - - - Open perforation --> dissemination of pus and fecal material into the peritoneal cavity --> result in a very ill-looking & septic patient--> increased risk of preterm labor and delivery and fetal loss.
    - - require extended antibiotic treatment and likely drainage.
- - - - Suction & curettage
    - - Cervagem: Used in uterus in >20 WOG
  - - - Patient exp early pregnancy bleeding but without a clear diagnosis
        
        CF: Painless pv bleed (minimal), dull aching lower abd pain
        
        USG: IUGS seen, fetal echo +, FH +
        
        P/E: Cervical os close, uterus correspond to date
        
        Plan: Allow discharge with reassurance, can give Duphaston to prevent miscarriage, to confirm fetal viability. TCA stat if PV bleed.
    - - Miscarriage that cannot be avoided because the cervix is open, bleeding is heavy or increasing & abdominal cramping is present
      - CF: Painful, heavy PV bleed, no passing POC
      - P/E: Dilated cervical os
      - USG: IUGS seen, no fetal heartbeat
      - Plan: Counselling, keep patient in ward until expulsion has occurred completely, if expulsion not occur within 12 hours, use cervagem (medical) or manual vacuum aspiration (surgical)
    - - If bleeding has begun and the cervix is dilated, but tissue from the pregnancy still remains in the uterus
      - CF: Pass out POC but some remains in uterus, heavy PV bleed, abdominal pain
        
        P/E: Open cervical os
        
        USG: Heterogenous tissues in uterus, may/may not seen gestational sacs, any endometrial thickness
        
        Plan: Assess degree of PV bleed, IM Syntometrine, Cervagem
    - - A type of early pregnancy loss in which the dead embryo or fetus is retained in the womb for a period of time, during which the usual symptoms of miscarriage may not occur
        
        CF: PV bleed absent/ minimal, no passing out POC, loss of pregnancy symptoms
        
        **P/E: Closed os, uterus < date
        
        USG: Gestational sac seen, no fetal heart/echo noted
        
        Plan: 1) Expectant - TCA 2-4/52 then repeat scan
        2) Conservative - let POc comes out naturally
        3) Medical - Cervagem
        4) Surgical - ERPOC
    - - Cessation of vaginal bleeding with no evidence of retained products of conception or a gestation sac in a woman who previously had an ultrasound confirmed intrauterine pregnancy.
      - CF: All POC aborted, Pain, Passing out POC, minimal PV bleed
      - P/E: Small uterus, Closed os
      - USG: Empty, endometrial thickness <13mm
      - Plan: Examine POC then send for HPE, IM syntometrine, avoid sexual intercourse for 2-3 weeks
    - - Any abortion that becomes infected
      - CF: Fever, chills, flu like aches, abdominal pain, PV bleed, PV discharged (may have thick and foul odour), may lead to septic shock
      - Aetiological agent: E.coli, Streptococcus, anaerobes
      - Causes: Delay in evacuation of POC from uterus
      - Plan: D&C ASAP, Broad spectrum antibiotic (Defuroxime)
      - Complication: Pelvic abscess, septic shock, chromic PID, uterine synechae
  - - - Maternal age >35y/o
      - 2) Chromosomal abnormalities (down sx)
      - 3) Medical/endocrine disorder ( DM, hypothyroidism, PCOS)
      - 4) Uterine abnormalities (submucosal fibroids)
      - 5) Infections (TORCHES, malaria)
      - 6) Drugs/chem (tobacco,arsenic,pesticides)
      - 7) Stress
      - 8) Trauma
- - - - Uterine: empty sac, endometrial thickening
      - Extrauterine: adnexal ring, live tubal pregnancy , adnexal mass
  - - - Hemodinamically stable > consider expectant management > follow up until Bhcg undetected
      - Hemodinamically unstable: resuscitation and emergency laparoscopy and salpiengectomy
    - - Methotrexate
      - Avoid intercourse because MTX can cause teratogenic effect
    - - Salpingectomy
      - Salpingotomy
- - - - Partial Torsion
      - Complete Torsion
  - - - Ovarian Masses: Large ovarian cysts or tumors increase the risk, especially if they are larger than 5 cm.
      - Previous History: Women who have had a previous episode of ovarian torsion are at a higher risk of recurrence.
      - Pregnancy: Ovarian torsion is more common during pregnancy due to changes in anatomy and hormonal influences.
      - Fertility Treatments: Women undergoing fertility treatments that stimulate ovulation may be at an increased risk.
    - - Age: While ovarian torsion can occur at any age, it is most common during the reproductive years, particularly in women of childbearing age.
      - Ovarian Cysts: Simple ovarian cysts, even when not large, can pose an intermediate risk.
      - Endometriosis: This condition can lead to the development of adhesions and ovarian cysts, which may increase the risk.