NICE have released new guidance on the management of ectopic pregnancy and miscarriage in women and given that my current post is in obstetrics and gynaecology I felt that this was particularly relevant! Complications in early pregnancy are common and distressing for the patient. Historically, in cases where ectopic pregnancies have led to patient deaths, a common contributing factor has been the failure of team looking after the patient to make the correct diagnosis in a case where the presentation was atypical. Clinicians should therefore have a higher index of suspicion for ectopic pregnancy as a cause of acute illness.
Common symptoms of ectopic pregnancy include: abdominal or pelvic pain, amenorrhoea or a missed period, PV bleeding, dizziness/syncope, shoulder tip pain, urinary symptoms, breast tenderness and pain on defecation. Any patient with pain and abdominal tenderness, pelvic tenderness and cervical motion tenderness should be referred immediately to gynaecology services, ideally an early pregnancy assessment service offering serum hCG measurement and trans-vaginal / abdominal US scanning.
Management of miscarriage - expectant management should normally be the initial management strategy (7-14 days). Explore other options if late in 1st trimester and at increased risk of haemorrhage or previous traumatic experience eg. still birth. Medical management involves vaginal misoprostol for treatment of missed or incomplete miscarriage.
Terminology used in Describing Miscarriage in the First Trimester:
- Complete miscarriage - all of the tissue has left the uterus
- Confirmed miscarriage - a non-viable intra-uterine pregnancy diagnosed on US scan
- Incomplete miscarriage - non-viable pregnancy in which the process of miscarriage has begun (eg. bleeding, pain), but pregnancy tissue remains in the uterus
- Missed miscarriage - a non-viable pregnancy identified on US scan without bleeding and pain
- Threatened miscarriage - Vaginal bleeding in the presence of a viable pregnancy
Diagnosis and Management of SVT
SVT comprises a group of conditions where atrial or AV node tissues are essential for sustaining the arrhythmia, produced either by disorders of impulse formation and/or disorders of impulse conduction. Symptoms include palpitations, chest pain, anxiety, light-headedness, shortness of breath and (uncommonly) syncope. Initial management is to slow AV node conduction either using vagal manoeuvres or adenosine. Catheter ablation is usually curative and has high long-term success rates. Every effort should be made to capture the arrhythmia on a 12-lead ECG. Giving the patient a copy of the ECG to keep can be useful. Echocardiogram is an imprortant investigation to identify underlying structural abnormalities such as left ventricular impairment.
Differential Diagnosis of a Narrow Complex Tachycardia:
- Sinus tachycardia
- AV nodal re-entrant tachycardia
- Atrioventricular re-entry tachycardia
- Atrial Tachycardia
- Atrial Flutter
- Atrial Fibrillation
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