2: Care in early pregnancy Flashcards
How long does an average pregnancy last?
40 weeks
Pregnancy is split into three trimesters.
When does each trimester start?
First trimester starts on day after last period
Second trimester starts at 13 weeks
Third trimester starts at 28 weeks
How is gestation (i.e the length of time a woman has been pregnant) estimated?
Simple timing using date of last period, current date
Ultrasound scan - distinct appearances during each trimester
Which hormonal marker confirms pregnancy?
ßhCG
What is the sample taken to test for pregnancy?
Urine sample
What is the most common symptom complained about at the beginning of pregnancy?
PV bleeding
Usually an implantation bleed (benign)
What are three abnormal outcomes of pregnancy?
Miscarriage
Ectopic pregnancy
Molar pregnancy
What is the difference between miscarriage and molar pregnancy?
Miscarriage - natural death of a viable embryo in early pregnancy
Molar pregnancy - implantation and subsequent death of non-viable embryo
What symptoms can accompany bleeding in pregnancy?
Pain (abdominal cramps)
Hyperemesis (vomiting)
Dizziness / Syncope
What is the presentation of a miscarriage?
Bleeding +/- passed products
Abdominal/back pain - may be mistaken as period cramps
Which scan is used to check for an implanted embryo in suspected miscarriage?
Transvaginal ultrasound
In miscarriage, what is the initial abdominal pain compared to?
Period cramps
Must ask when last period was and do a urine pregnancy test
What is a rare complication of miscarriage which causes bradycardia and hypotension?
Cervical shock
Stimulation of the uterus by retained products causes vagal (parasympathetic) stimulation, causing a similar presentation to haemorrhagic or septic shock
What is the pathophysiology of miscarriage?
Bleeding > Impaired oxygen / nutrient supply to foetus > Foetal death
What is the os?
Passage between the vagina and the neck of the cervix
Women who have had a miscarriage should be scanned to check for which abnormal pregnancy?
Ectopic pregnancy
Because it’s possible that they have an implanted embryo elsewhere and a ruptured ectopic is a medical emergency
What should you measure if a patient has been bleeding profusely e.g in miscarriage?
FBC
BP
HR
haemodynamics
In which four ways can a miscarriage be managed?
Conservative - watch and wait; natural expulsion
Medical - mifepristone > misoprostol to induce an abortion
MVA (manual vacuum aspiration)
Surgical removal of contents
Which autoantibody disease causes increased risk of thrombotic events and recurrent miscarriages?
Antiphospholipid syndrome
Which antibodies are raised in APS?
Anti-Lupus anticoagulant
Anti-cardiolipin
Anti-glycoprotein
How many miscarriages must a patient have to describe them as recurrent?
3+
What is an ectopic pregnancy?
Implantation of a fertilised egg outwith the uterus
Where do ectopic pregnancies most commonly occur?
Fallopian tubes
What is the presentation of an ectopic pregnancy?
Pain
+/- bleeding, dizziness, dyspnoea (due to internal bleeding)
Which form of referred pain may women with an ectopic pregnancy experience?
Shoulder tip pain
Unusual, cause not known
Recurrent pain in a pregnant women should be a red flag for which disease?
Ectopic pregnancy
Which imaging should be done for patients with suspected ectopic pregnancy?
USS
Which view is used in USS of pregnant women?
Transvaginal view
Which hormone should be tested for in any women who may be pregnant?
ßhCG
What is a pregnancy of unknown location?
Is it a definite diagnosis?
Elevated bhCG but can’t find the embryo using ultrasound
No - wait and try again later
How is ectopic pregnancy managed surgically?
Minimal access (keyhole) surgery
or Laparotomy
Is every ectopic pregnancy managed surgically?
No - if small ectopic and not acutely unwell, watch and wait
What is a molar pregnancy?
What is the difference between molar pregnancy and ectopic pregnancy?
Non-viable fertilised egg which has implanted in the uterus (i.e wrong egg in the right place)
Results in OVERGROWTH OF PLACENTAL TISSUE around dodgy egg (“mole”)
Ectopic - right egg in the wrong place
In molar pregnancy, a non-viable egg (or mole) implants in the uterus and the placenta grows excessively around it.
What classic appearance does this tissue have?
“Bunch of grapes”
“Snowstorm appearance”
Also called a hydratidiform mole
Either on ultrasound scan, gynae exam or actively being expelled
What are the two types of abnormal egg which can cause a molar pregnancy?
Complete mole
Partial mole
Describe a
a) complete mole
b) partial mole
and how their fertilisations by sperm cells cause molar pregnancy.
a) Complete mole - egg without DNA, fertilisation by 1 sperm produces a non-viable haploid zygote, and fertilisation by 2 sperm produces a paternal diploid zygote which still isn’t viable
b) Partial mole - haploid egg which is for some reason unviable (i’ve asked), fertilisation by 1 sperm creates an unviable zygote, fertilisation by 2 sperms creates an unviable triploid zygote
What happens around the implanted mole in molar pregnancy?
Overgrowth of placental tissue
With a characteristic “bunch of grapes” appearance
The tissue created by a molar pregnancy has a classical “bunch of grapes” appearance.
What appearance does it have on ultrasound?
“Snowstorm”
What is the presentation of molar pregnancy?
Hyperemesis
Bleeding
Passage of “grape-like” tissue
Dyspnoea
What is the presentation of complete molar pregnancy on USS?
“Snowstorm”
What is a normal sign of pregnancy which mimics period bleeding?
Implantation bleeding
When does implantation bleeding occur?
What does it look like?
10 days after ovulation
Light brown, spots (i.e it shouldn’t be profuse)
What is a collection of blood between the endometrium and the embryo called?
Chorionic haematoma
What is a differential diagnosis for bleeding in pregnant women?
Abnormal pregnancy - miscarriage, ectopic, molar
Infection
Polyps / malignancy
Renal - UTI
other ones
In miscarriage, (bleeding / pain) is the predominant symptom.
bleeding
In ectopic pregnancy, (bleeding / pain) is the predominant symptom.
pain
What is Rhesus disease?
How is it treated?
Production of antibodies targeting a foetus’s red blood cells
Occurs when a mother is Rhesus-positive and baby is Rhesus-negative
Rx: anti-D immunoglobulin injections
What is the medical name for morning sickness?
Is “morning sickness” accurate?
Hyperemesis gravidarum
No - can occur at any time
What metabolic disturbances can excessive vomiting cause?
Dehydration
Ketosis
Electrolyte imbalance (e.g hypokalaemia)
What must be excluded before you can diagnose a pregnant women with hyperemesis gravidarum?
Infection e.g UTI, viral hepatitis
Peptic ulcer disease
Pancreatitis
How is hyperemesis gravidarum managed?
Replace losses - water, nutrition, vitamins
Antiemetics
Which drug may be used in recurrent, severe morning sickness?
Steroids
