12 - Early Pregnancy Flashcards
What is the definition of the following:
- Missed miscarriage
- Threatened miscarriage
- Inevitable miscarriage
- Incomplete miscarriage
- Anembryonic pregnancy
Miscarriage is the spontaneous termination of a pregnancy before 24 weeks
Early is before 12 weeks gestation, Late is 12-24 weeks
What are some risk factors for a miscarriage?
- Maternal and Paternal Age >30-35 (increase in chromosomal abnormalities)
- Black ethnicity
- Previous miscarriage
- Obesity
- Chromosomal abnormalities
- Smoking
- Uterine anomalies
- Poorly controlled diabetes
- Poorly controlled thyroid disease
- Previous uterine surgery
- Anti-phospholipid syndrome
- Coagulopathies
What are some of the clinical features of a miscarriage?
Vaginal bleeding often with cramping pain similar to period
Signs on examination:
- Haemodynamic instability – pallor, tachycardia, tachyopnea, hypotension.
- Abdomen – may be distended and tenderness
- Speculum – assess diameter of the cervical os, and observe for any products of conception in cervical canal, or local areas of bleeding.
- Bimanual – assess any uterine tenderness and adnexal masses
What are some differentials for a miscarriage?
- Ectopic Pregnancy
- Hydatidiform mole
- Cervical/uterine malignancy
In ectopic pain is often first and dominant symptom, and if vaginal bleeding does occur it is minor in comparison to a miscarriage
What investigations are done for a woman with a suspected miscarriage (positive pregnancy test + PV bleeding +/- pain)?
Referred to Early Pregnancy Assessment Unit if over 6 weeks
- Transvaginal US (can use abdominal if CI but not as sensitive and specific)
- Serial b-HCG to see if ectopic
How is a miscarriage diagnosed based on US findings?
IMPORTANT CARD
Three key features that occur sequentially and as each appears previous feature become less relevant in assessing viability:
- Mean Gestational Sac Diameter: If <25mm, a repeat scan needs to be arranged in 10-14 days. If >25mm and no fetal pole this is a anembryonic pregnancy
- Fetal Pole and Crown-Rump Length: Fetal pole visible when mean gestational sac diameter is 25mm or more so if pole and crown-rump<7mm wait 1 week after to ensure heartbeat develops. If sac is 25mm with no fetal pole repeat scan in 1 week and if still not visible it is an embryonic pregnancy
- Fetal Heartbeat: If present pregnancy is viable. Will only see when crown-rump length >7mm. If no heartbeat scan repeated in 1 week to confirm non-viable
If a woman is less than 6 weeks pregnant and is having a suspected miscarriage, how is this managed?
Expectant Management (Watch and Wait)
- No referral to EPAU as pregnancy will be too small to be seen at this stage
- Repeat a urine pregnancy test after 7–10 days and to return if the test is positive or if her symptoms continue or worsen — referral should be arranged
- A negative pregnancy test means that the pregnancy has miscarried.
How do you interpret serial hCG tests for a suspected miscarriage, done 48 hours apart?
- Levels fall: foetus likely will not develop or has been a miscarriage
- Slight increase or a plateau: may be an ectopic
- Large increase: suggests foetus is growing normally
How is a threatened miscarriage managed?
- If fetal heartbeat advise women if still bleeding after 14 days to come back for further assessment. If not continue routine antenatal care
- If woman has fetal heartbeat and has had a miscarriage before give her vaginal micronised progesterone 400 mg twice daily up to 16th week of pregnancy
How is a miscarriage over 6 weeks managed?
All women should be offered counselling and support regardless of mod of management
Expectant (await spontaneous miscarriage)
- Offered first line
- Given 1-2 weeks to spontaneously miscarry then repeat pregnancy test three weeks after bleeding to confirm miscarriage
- Persistent or worsening bleeding needs further assessment as may be incomplete miscarriage
Medical
- Misoprostol: prostaglandin analogues, soften cervix and cause uterus to contract
- Pain relief and antiemetic
- Take pregnancy test 3 weeks later to confirm miscarriage
Surgical
- Manual vacuum aspiration: local
- Electric vacuum aspiration: GA
- Misoprostol is given before to soften cervix
- Anti-Rhesus D prophylaxis if Rhesus Negative
How is misoprostol given and what are the side effects of this?
Vaginal Suppository or PO
- Heavier bleeding
- Pain
- Vomiting
- Diarrhoea
What are some advantages and disadvantages to the expectant management of a miscarriage?
- Advantages: Can remain at home, no side effects of medication, no anaesthetic or surgical risk.
- Disadvantages: Unpredictable timing, heavy bleeding and pain during passage, chance of being unsuccessful requiring further intervention and need for transfusion.
- Contraindications: Infection, high risk of haemorrhage, previous traumatic incident e.g stillbirth, previous miscarriage
What are some advantages and disadvantages to the medical management of a miscarriage?
- Advantages: Can be at home if patient desires, with 24/7 access to gynaecology services, avoid anaesthetic and surgical risk
- Disadvantages: Side effects of medication: vomiting/diarrhoea, heavy bleeding and pain during passage of POC, chance of requiring emergency surgical intervention
- Follow-up: Pregnancy test 3 weeks later
What is the difference between the two surgical managements for a miscarriage?
Manual vacuum aspiration: local anaesthetic applied to cervix. A tube inserted through cervix into uterus. Syringe then manually used to aspirate contents of the uterus. Must be below 10 weeks gestation and easier if given birth before
Electric vacuum aspiration: general anaesthetic, through the vagina and cervix without any incisions.
Cervix gradually widened using dilators, and the products of conception are removed through the cervix using an electric-powered vacuum.
What are the risks of surgical management for a miscarriage?
Anaesthetic risk
Infection (endometeritis)
Uterine perforation
Haemorrhage
Ashermen’s syndrome
Bowel or bladder damage
Retained products of conception
How is a septic miscarriage managed?
How is an incomplete miscarriage managed?
Needs treating as if retained products of conception can lead to infection
- Medical management (misoprostol)
- Surgical management (evacuation of retained products of conception)
How is a evacuation of retained products of conception (ERPC) carried out?
- General Anaesthetic
- Cervic dilated and retained products removes using vacuum aspiration and curettage
- Endometritis risk
What is some general advice to give a women who is going through a miscarriage?
- Sex: can resume once symptoms have completely settled
- Wish to conceive: menstruation tends to resume at 4-8 weeks, give routine pre-conception advice
- Do not wish to conceive: offer suitable contraceptive options
What is a recurrent miscarriage?
Three or more consecutive miscarriages before 24 weeks of gestation
Do investigations after 3 or more first trimester miscarriages or after 1 or more second trimester miscarriages
What are some causes of recurrent miscarriages?
- Idiopathic
- Antiphospholipid syndrome
- Hereditary thrombophilias
- Uterine abnormalities
- Cervical incompetence
- BV
- PCOS
- Genetic factors (balanced translocations)
- Chronic diseases e.g diabetes, untreated thyroid disease, SLE
How is antiphospholipid syndrome diagnosed and managed in regards to recurrent miscarriage?
Test for antiphospholipid antibodies
May have history of DVT or SLE
Give low dose aspirin plus LMWH to reduce rate of miscarriage as miscarriage caused by thrombosis as they are in hyper coagulable state
What are some hereditary thrombophilias that can cause recurrent miscarriage?
- Factor V Leidein
- Factor II (Prothrombin)
- Protein S deficiency
What are some uterine abnormalities that cause recurrent miscarriage?
- Uterine septum
- Unicornuate uterus
- Bicornuate uterus
- Didelphic uterus
- Cervical insufficiency
- Fibroids
What is chronic histiocytic intervillositis?
Rare cause of recurrent miscarriage in second trimester. Can also cause IUGR
Histiocytes and Macrophages build up in placenta causing inflammation and adverse outcomes
Diagnosed by placental histology showing infiltrates of mononuclear cells in intervillous spaces
What are some risk factors for recurrent miscarriage?
- Advancing maternal and paternal age - reduced quality of oocytes
- Number of previous miscarriages
- Smoking, Alcohol and Caffeine consumption
What are some investigations done for recurrent miscarriage?
- Antiphospholipid antibodies
- Test for hereditary thrombophillias inc platelet count!!!!
- Pelvic US for structural abnormalities
- Genetic testing on both parents and products of conception
How is recurrent miscarriage managed?
Refer to specialist recurrent miscarriage clinic
Some trials state vaginal progesterone pessaries during early pregnancy if recurrent miscarriages presenting with bleeding
Genetic Abnormalities: IVF with pre-implantation genetic analysis, Adoption, Gamete donation
Anatomical Abnormalities: Cervical cerclage if cervical weakness but risk of membrane rupture and stimulating uterine contractions
Thrombophillias: Heparin treatment during pregnancy
APS: Low dose aspirin a plus LMWH
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Where are some common locations for an ectopic pregnancy?
Ampulla and Isthmus of the fallopian tube
- Ovary
- Cervix
- Abdomen
What are some risk factors that increase the chance of an ectopic pregnancy?
- Previous PID
- IUD
- POP
- Older age
- Smoker
- Pelvic surgery
- Previous ectopic pregnancy
- Endometriosis
What ectopics have a higher risk of mortality and why?
At interstitium of fallopian tube so it is wider so can grow larger before being discovered so more bleeding when rupture
They are also difficult to pick up on US so need MRI or diagnostic laparoscopy
What are some of the signs and symptoms of an ectopic pregnancy?
Usually present around 6-8 weeks gestation so ask about missed periods and unprotected sex. PAIN MOST COMMON SYMPTOM!
Symptoms
- Abdominal/pelvic pain
- Vaginal bleeding
- Missed period
- Shoulder tip pain (sign of rupture and intra-abdominal bleeding, indicative of blood irritating the diaphragm)
- Urinary discomfort
- GI upset
- Dizziness or Syncope (blood loss)
Signs
- Cervical motion tenderness
- Rebound tenderness, peritonism
- Pallor
- Pelvic mass
Why is there vaginal bleeding in an ectopic pregnancy?
Decidual breakdown in the uterine cavity due to suboptimal β-HCG levels
Bleeding from a ruptured ectopic usually intra-abdominal, not vaginal
May be like prune juice
What may be the presentation of a ruptured ectopic?
- Haemodynamic Instability (pallor, increased capillary refill time, tachycardia, hypotension
- Peritonitis (guarding)
- Fullness in Pouch of Douglas on PV exam
What investigations should you do for a suspected ectopic pregnancy?
DO NOT DO PV EXAM AS RISK OF RUPTURING!
- Urine b-hCG
- Urinalysis
- Transvaginal US
- Serum b-hCG (if above inconclusive)
- Clotting Screen and Group and Save
If cannot find may consider MRI for interstitial ectopic
How may a tubal ectopic pregnancy appear on US?
Use transvaginal as transbdominal has lower sensitivity and specificity
- May see gestational sac in tube (yolk sac and fetal pole)
- May seem empty gestational sac (blob sign, bagel sign)
- Empty uterus
- Fluid in the uterus
- Mass that moves separately from the ovary
How do you tell the difference between a corpus luteum and an ectopic on US?
Corpus Luteum will move with ovary but ectopic will move separately
What is a pregnancy of unknown location?
When a woman has a positive pregnancy test but no evidence of pregnancy on US so could be
- Ectopic
- Miscarriage
- Very early intrauterine pregnancy
Need to do serum hCG and repeat in 48 hours!!
How can serum b-HCG help diagnose a pregnancy with unknown location?
Fetus should be visible on scan once b-hCG >1500
Initial β-HCG level >1500 iU and no intrauterine pregnancy on TVUS:
- Considered ectopic until proven otherwise
- Do diagnostic laparoscopy
Initial β-HCG level <1500 iU:
- Repeat in 48 hours
- In viable pregnancy, would be expected to double every 48 hours (>63% rise). Repeat scan in 1-2 weeks
- In a miscarriage, HCG level would be expected to halve every 48 hours (<50% drop). Repeat pregnancy test in 2 weeks
- In ectopic rise of less than 63%
An unruptured ectopic can be managed conservatively (expectant), medically and surgically.
What is the criteria for expectant management and how are they managed?
Not first line option! Need to be able to attend follow up
Await natural termination with easy access to EPAU if condition changes
Serum B-hCG should be monitored every 48 hrs to ensure it is falling by at least 15% of the level until it falls to approximately <5mIU/ml
How are patients medically managed with an ectopic pregnancy and what is the criteria for this management?
Criteria: HCG must be below 1500 confirmed absence of intrauterine pregnancy on US, no heartbeat, no symptoms of rupture, no pain
IM Methotrexate : anti-folate cytotoxic agent causing termination
Serum β-HCG level is monitored regularly to ensure the level is declining (by >15% in day 4-5). If no decline, repeat dose
Need access to EPAU and given safety net advice on symptoms of rupture
What are some side effects of IM methotrexate for an ectopic?
Need to be advised not to get pregnant for 6 months after use as highly teratogenic
- PV bleeding
- N+V
- Abdominal Pain
- Stomatitis
What women are offered surgical management for an ectopic pregnancy and what are the options for this?
Indications: Significant pain, Adnexal Mass >35mm, Visible heartbeat, HCG >5000 or between 1500 and 5000 but cannot attend follow up
Laparoscopic Salpingectomy: First line. Key hole removal of fallopian tube and pregnancy
Laparoscopic Salpingotomy: For woman at increased risk of infertility so try to preserve tube. Cut made into fallopian tube and ectopic removed. Higher failure rate (1 in 5 women)
Anti-Rhesus D: All rhesus negative women having surgical management of ectopic
What are the disadvantages of surgical management for an ectopic?
- General anaesthetic risk
- Risk of damage to neighbouring structures like the bladder, bowel, ureters
- DVT/PE
- Haemorrhage
- Infection
- Salpingotomy risk of treatment failure
Who can you refer women who have had an ectopic to?
May need counselling as traumatic and queries about future fertility and strains on relationships
When should a woman be offered a choice between medical or surgical management for an ectopic?
- b-hCG 1500-5000
- No pain
- No heartbeat
- No intrauterine pregnancy
- <35mm
What follow up needs to be done for a woman following a Salpingectomy or Salpingotomy for an ectopic?
Salpingotomy, take 1 serum hCG measurement at 7 days after surgery, then 1 serum hCG measurement per week until a negative result is obtained
Salpingectomy should take a urine pregnancy test after 3 weeks. Advise women to return if positive.
How do serum b-hCG change with the following:
- Normal Pregnancy
- Miscarriage
- Ectopic
What is a molar pregnancy?
Hyatidform mole is a tumour that grows like a pregnancy in the uterus
Arises from abnormality in chromosomal number during fertilisation
Partial or Complete Mole
What is the difference between a partial and complete molar pregnancy?
These tumours are usually benign but can invade into myometrium and become malignant. Invasive moles
Complete Mole: Two sperms fertilise an ovum that contains no genetic material. Two sperm combine genetic material and start to divide and grow into a tumour. No fetal material
Partial Mole: Two sperm cells fertilise a normal genetic containing ovum so cell has three sets of chromosomes. Some fetal material may form
What are some risk factors for gestational trophoblastic disease?
- Maternal age <20 or >35
- Previous gestational trophoblastic disease
- Previous miscarriage
- Use of the oral contraceptive pill
How may a molar pregnancy present?
- Vaginal bleeding and abdominal pain early in pregnancy
- Increased enlargement of uterus
- More severe morning sickness
- Abnormally high b-hCG
- Thyrotoxicosis (as b-hCG similar to T3/T4)
How is a molar pregnancy investigated?
- Blood B-hCG levels: markedly elevated
- TVUS: Snowstorm appearance if complete mole
- Histological examination of the products of conception: if partial mole and there is a fetus, do histology on placenta after delivery
How is a molar pregnancy managed?
Need to register woman with registered GTD centre registered for follow-up and monitoring in future pregnancies
- Evacuation of Uterus using Suction Curettage
- If fetal development as partial mole do medical evacuation
- Monitor hCG levels until normal, if do not fall may need systemic chemotherapy as can metastasis
- Anti-D Prophylaxis if Rhesus Negative
What is hyperemesis gravidarum?
Refers to persistent and severe vomiting during pregnancy, which leads to weight loss, dehydration and electrolyte imbalances
- More than 5 % weight loss compared with before pregnancy
- Dehydration
- Electrolyte imbalance
What is the normal pattern of nausea and vomiting in pregnancy?
Usually starts around 4-7 weeks, peaks around 8-12 weeks and resolves by 20 weeks
Due to b-hCG
Worse in molar pregnancies and multiple pregnancies
How can you assess the severity of hyperemesis gravidarum?
Pregnancy-Unique Quantification of Emesis (PUQE) score out of 15
- < 7: Mild
- 7 – 12: Moderate
- > 12: Severe
What are some differentials for severe nausea and vomiting in pregnancy apart from hyperemesis gravidarum?
Should consider alternative diagnosis for sure if starts past 10+6 gestation
- Gastroenteritis
- Acute pancreatitis
- PUD
- Gastritis
- H.pylori infection
- Cholecystitis
- Urinary tract infections
- Metabolic conditions (e.g. DKA)
- Drug-induced nausea & vomiting
What investigations are done for hyperemesis gravidarum?
Bedside
- Weight
- Urine dipstick: quantify ketonuria (1+ ketones)
Laboratory Tests
- Mid-stream urine
- Full blood count: anaemia, infection,
- Urea and Electrolytes: hypokalaemia, hyponatraemia, dehydration, renal disease
- Blood glucose: exclude DKA
Refractory or Severe Cases
- LFTs: exclude liver disease e.g. hepatitis or gallstones, monitor malnutrition
- Amylase: exclude pancreatitis
- TFTs: hypo-/hyper-thyroid
- ABG: exclude metabolic disturbances
Imaging
- US: confirm viability, confirm gestation, exclude multiple pregnancy and trophoblastic disease
What are the recommended antiemetic therapies in hyperemesis gravidarum?
ALWAYS GIVE IV THIAMINE DUE TO RISK OF WERNICKE’S
- First-line: cyclizine, prochlorperazine, promethazine, chlorpromazine
- Second-line: metoclopramide, domperidone
- Third-line: corticosteroids (initially hydrocortisone IV converted to prednisolone orally when able)
How is hyperemesis gravidarum managed based on severity? (See image)
Antiemetics and Fluid resuscitation
- Mild – community with oral antiemetics, oral hydration, dietary advice and reassurance
- Moderate (or cases where community management has failed) – ambulatory daycare. This involves IV fluids, parenteral antiemetics and thiamine. The patient should be managed until ketonuria resolves.
- Severe – inpatient management
What fluids are given in hyperemesis gravidarum?
0.9% saline plus KCl
Do no give Dextrose without Pabrinex first as will precipitate any Wernicke encephalopathy
Apart from anti emetics and fluid, what other treatment options are needed for hyperemesis gravidarum?
- H2 receptor antagonists or PPI: reflux, oesophagitis or gastritis
- Thiamine: for prolonged vomiting to prevent Wernicke’s encephalopathy
- Thromboprophylaxis (TED and LMWH): for all women requiring admission
Can also try ginger and acupressure on wrist
When are women sent to be inpatients with hyperemesis gravidarum?
What are some complications of hyperemesis gravidarum?
- Mallory-Weiss tears
- Malnutrition and anorexia
- Dehydration leading to ketosis and venous thromboembolism
- Metabolic disturbance such as hyponatraemia, Wernicke’s encephalopathy, kidney failure, hypoglycaemia
- Low birth weight
- Premature labour
What are the five categories for requesting a TOP under the Abortion Act 1967?
A. Must be before 24th week and that the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman or any existing children of her family
B. Termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman
C. That the continuance of the pregnancy would involve risk to the life of the pregnant woman, greater than if the pregnancy were terminated
D. That there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped.
When can an abortion legally be carried out after 24 weeks of pregnancy?
- Continuing the pregnancy is likely to risk the life of the woman
- Terminating the pregnancy will prevent “grave permanent injury” to the physical or mental health of the woman
- There is “substantial risk” that the child would suffer physical or mental abnormalities making it seriously handicapped
What are the legal requirements for an abortion?
- Two registered medical practitioners must sign to agree abortion is indicated
- It must be carried out by a registered medical practitioner in an NHS hospital or approved premise
How can a woman seek abortion services?
- Self referral
- GP
- GUM
- Marie Stopes UK: telephone, less than 10 weeks gestation, medication can be issued over the phone
Doctors who object to abortions should pass on to another doctor able to make the referral
What should women be given before an abortion?
Counselling and information to aid decision making
How is an abortion medically managed?
- Mifepristone (anti-progestogen)
- Misoprostol (prostaglandin analogue) given 1-2 days later
If over 10 weeks gestation and rhesus negative should give Anti-D prophylaxis
How is an abortion surgically managed?
Before abortion, medications are used for cervical priming with misoprostol, mifepristone or osmotic dilators.
Osmotic dilators inserted into the cervix, that gradually expand as they absorb fluid, opening the cervical canal.
- Cervical dilatation and suction of the contents of the uterus (up to 14 weeks)
OR
- Cervical dilatation and evacuation using forceps (14 to 24 weeks)
Rhesus negative women having a surgical TOP should have anti-D prophylaxis.
Offer doxycycline for infection prophylaxis
What post-abortion care is offered to women?
- Explain they may experience vaginal bleeding and abdominal cramps intermittently for up to 2 weeks after the procedure
- Urine pregnancy test 3 weeks later to confirm termination
- Contraception advice
- Support and Counselling offered, explain what they might see on passage of fetus
What are some complications with an abortion?
- Bleeding
- Pain
- Infection
- Failure of the abortion (pregnancy continues)
- Damage to the cervix, uterus or other structures
What supplements are recommended to women in pregnancy?
- Folic Acid 400 micrograms per day - All woman pre-pregnancy and up to 12 weeks gestation. Reduce neural tube defects
- Vitamin D 10 micrograms (400 units) per day -Recommended throughout pregnancy and breastfeeding. Helps fetal bone formation
What can drugs given to the mother do to the baby at different stages in the pregnancy?
First trimester: congenital malformations, greatest risk 3rd to 11th week
Second and third trimester: can affect the growth or functional development of the fetus
Shortly before term or during labour: adverse effects on labour or on the neonate after delivery.
Not all the damaging effects of intrauterine exposure to drugs are obvious at birth, some may only manifest later in life. Such late-onset effects include malignancy, e.g. adenocarcinoma of the vagina after puberty in females exposed to diethylstilbestrol in the womb
What is the principles of prescribing in early pregnancy?
Should only be prescribed if the expected benefit to the mother is thought to be greater than the risk to the fetus
All drugs should be avoided if possible during first trimester
What women are at a higher risk of having a baby with a neural tube defect and therefore need 5mg of folic acid supplementation instead of 400 micrograms?
- Either parent has a neural tube defect
- Previous pregnancy affected by neural tube defect
- Diabetes
- Anti-epilepsy medicine
What are some good things to do when planning a pregnancy?
- Folic Acid supplements
- Stop smoking
- Cut out alcohol
- Lower BMI <25
- Check had 2 doses of MMR. If haven’t have this then wait 1 month to get pregnant
- Consider screening for sickle cell and thalassemia
What website can you refer a woman to who is planning a pregnancy and doesn’t know which medication she will need to stop?
BUMPS - Best Use of Medicine in Pregnancy
https://www.medicinesinpregnancy.org/Medicine–pregnancy/
At what gestation can you palpate the uterus?
12 weeks reaches top of pubic bone so will feel it between 12-14 weeks
What are some of the side effects of ovulation induction?
- Bloating
- Nausea
- Headaches
- Loss of breath
- Hot flashes
- Weight gain
- Tenderness in the pelvic region
- Blurry vision
What is Naegele’s rule?
Used to calculate the EDD based on the first day of LMP
- The calculation is to add one year and seven days to the first day of the LMP and subtract three months
Important to stress this is an ESTIMATE
What are some things that may make Naegele’s rule inaccurate?
- Women with irregular or long cycles
- Those recently using COCP
How do we date a pregnancy?
From first day of LMP
Use this until the dating scan at 13 weeks +6
How does antenatal care vary for twins?
What are some complications of multiple pregnancies for mother and babies?
When can a woman with twins have a vaginal birth?
Always active management of third stage!!
