4- Early pregnancy complications (hyperemesis gravidarum and abortion) Flashcards
when does N and V start in pregnancy
starts 4-7 weeks
peaking around 10-12 weeks gestation
resolves 16-20 weeks
cause of N and V in pregnnacy
rapidly increasing levels of hCG produced by the placenta- triggers chemoreceptor trigger zone
- higher levels make symptoms worse
which sort of pregnancies can make n and v worse
- first pregnancy
- overweight women
- molar pregnancies
- multiple pregnancies
The severe form of nausea and vomiting in pregnancy is called
hyperemesis gravidarum
- Hyper- refers to lots, -emesis refers to vomiting
- Gravida- relates to pregnancy.
when can Hyperemesis gravidarum be diagnosed
prolonged/ protracted NVP (N+V of pregnancy) +
- More than 5 % weight loss compared with before pregnancy
- Dehydration
- Electrolyte imbalance
other signs of true HG
- marked ketosis
- nutritional def
which scale can be used to measure severity of NVP
Pregnancy-Unique Quantification of Emesis (PUQE) score. This gives a score out of 15:
< 7: Mild
7 – 12: Moderate
> 12: Severe
management of mild HG
In the community
1) Antiemetics are used to suppress nausea. Vaguely in order of preference and known safety, the choices are:
- Prochlorperazine (stemetil)
- Cyclizine
- Ondansetron
- Metoclopramide
2) Antacids can be used if acid reflux a problem
- ranitidine or omeprazole
3) Complementary therapies
- Ginger
- acupressure on the wrist at the PC6 point (inner wrist)
when should admission for HG be considered
- Unable to tolerate oral antiemetics or keep down any fluids
- More than 5 % weight loss compared with pre-pregnancy
- Ketones are present in the urine on a urine dipstick (2 + ketones on the urine dipstick is significant)
- Other medical conditions need treating that required admission
In patient care for mod-severe HG
- IV or IM antiemetics
- IV fluids (normal saline with added potassium chloride)
- Daily monitoring of U&Es while having IV therapy
- Thiamine supplementation to prevent deficiency (prevents Wernicke-Korsakoff syndrome)
- Thromboprophylaxis (TED stocking and low molecular weight heparin) during admission
In patient care for mod-severe HG
- IV or IM antiemetics
- IV fluids (normal saline with added potassium chloride)
- Daily monitoring of U&Es while having IV therapy
- Thiamine supplementation to prevent deficiency (prevents Wernicke-Korsakoff syndrome)
- Thromboprophylaxis (TED stocking and low molecular weight heparin) during admission
define termination
elective procedure to end a pregnancy
Abortion is the removal of an embryo or fetus from the uterus before viabilitoty
- spontanaeous abortion- miscarriage
- induced abortion- termination
up to how many weeks is an abortion legal
The earlier in pregnancy an abortion is undertaken, the safer it is likely to be
24 weeks
has been reduced from 28
simple criteria for abortion
An abortion can be performed before 24 weeks if continuing the pregnancy involves greater risk to the physical or mental health of:
- The woman
- Existing children of the family
The threshold for when the risk of continuing the pregnancy outweighs the risk of terminating the pregnancy is a matter of clinical judgement and opinion of the medical practitioners.
An abortion can be performed at any time during the pregnancy if:
- 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
The legal requirements for an abortion are (abortion act 1967):
- 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 are abortion services accessed
- by self-referral
- by GP
- GUM
- family planning clinic referral.
conscientious objection: if you as a doctor object to abortions what should you do
Medical professionals have the right to conscientious objection, however even those who wish to abstain from involvement in the procedure must be trained in and recognise the need for evidence based counselling and safe abortion care, including referral pathways.
pass on to another doctor able to make the referral
before having an abortion women should be offered
counselling and information to help decision making from a trained practitioner. Informed consent is essential.
termination can be managed either
medically or surgically
when is a medical abortion most appropriate
counselling and information to help decision making from a trained practitioner. Informed consent is essential.
medical mangement of abortion
It involves two treatments:
1. Mifepristone (anti-progestogen)
2. Misoprostol (prostaglandin analogue) 1 – 2 day later
Mifepristone MOA
is an anti-progestogen medication that blocks the action of progesterone, halting the pregnancy and relaxing the cervix.
Misoprostol MOA
is a prostaglandin analogue, meaning it binds to prostaglandin receptors and activates them. Prostaglandins:
- soften the cervix
- stimulate uterine contractions.
From 10 weeks gestation, additional misoprostol doses (e.g. every 3 hours) are required until expulsion.
Rhesus negative women with a gestational age of …….. weeks or above having a medical TOP should have ….. ……..
Rhesus negative women with a gestational age of 10 weeks or above having a medical TOP should have anti-D prophylaxis.
anaesthesia for surgical abortion
- Local anaesthetic
- Local anaesthetic plus sedation
- General anaesthetic
process of surgical abortion
1) prior to surgery patients are given cervical priming medications: misoprostol, mifepristone or osmotic dilators
2) Two option:
- Cervical dilatation and suction of the contents of the uterus (usually up to 14 weeks)
- Cervical dilatation and evacuation using forceps (between 14 and 24 weeks)
when is cervical dilatation and suction used
up to 14 weeks
when is cervical dilatation and evacuation used
between 14 and 24 weeks
Rhesus negative women having a surgical TOP should have
anti-D prophylaxis.
post-abortion confirmations
urine pregnancy test is performed 3 weeks after the abortion
post-abortion care
- pregnancy test
- Contraception is discussed and started where appropriate.
- Support and counselling is offered.
common presentations of abortion
vaginal bleeding and abdominal cramps intermittently for up to 2 weeks after the procedure.
Complications
- Bleeding (haemorrhage)
- Uterine rupture
- Pain
- Infection
- Failure of the abortion (pregnancy continues)
- Damage to the cervix, uterus or other structures
Complications
- Bleeding
- Pain
- Infection
- Failure of the abortion (pregnancy continues)
- Damage to the cervix, uterus or other structures
RF for HG
- First pregnancy
- Previous history of hyperemesis gravidarum
- Raised BMI
- Multiple pregnancy
- Hydatidiform mole
history for N and V
examination for N and V
investigations for HG
Bedside Tests
* Weight
* Urine dipstick: quantify ketonuria (1+ ketones)
Laboratory Tests
* Mid-stream urine
* Full blood count: anaemia, infection, haematocrit (can be raised)
* Urea and Electrolytes: hypokalaemia, hyponatraemia, dehydration, renal disease
* Blood glucose: exclude diabetic ketoacidosis if diabetic
Refractory or Severe Cases
* Liver function tests: exclude liver disease e.g. hepatitis or gallstones, monitor malnutrition
* Amylase: exclude pancreatitis
* Thyroid function tests: hypo-/hyper-thyroid
* Arterial blood gas: exclude metabolic disturbances, monitor severity
Imaging
* Ultrasound scan: confirm viability, confirm gestation, exclude multiple pregnancy and trophoblastic disease.
Signs of Severe HG
- Debilitating, chronic nausea
- Frequent vomiting of bile or blood
- Chronic ketosis and dehydration
- Muscle weakness and extreme fatigue
- Medication does not stop vomiting/nausea
- Inability to care for self (shower, prepare food)
- Loss of over 5-10% of your pre-pregnancy weight
- Weight loss (or little gain) after the first trimester
- Inability to eat/drink sufficiently by about 14 weeks
complications of HG
Neuro
- central pontine myelinolysis
- wernicke encephalopathy (due to thaimin deficiency)
GI
- oesphageal damage
- gastroparesis (delayed gastric emptying)
Malnutrition and dehydration
Acute renal failure
the right to reproductive health is defined in
the Universal Declaration of Human Rights, includes the right to have full autonomy over reproductive decisions, including how many children to have and when to have them
safe abortion care pathway
Information to provide after the abortion
Before leaving the facility, women should receive instructions about how to care for themselves after they go home, including:
- how much bleeding to expect in the next few days and weeks
- how to recognise potential complications, including signs of ongoing pregnancy
- when they can resume normal activities (including sexual intercourse)
- how and where to seek help if required
Women who want to try again to conceive should be advised to wait until after having at least one normal menstrual period, longer if chronic health problems (e.g. anaemia) require treatment.
diagnosing HG
Diagnosis of exclusion
1)History of hyperemesis in previous pregnancies
2)Usually no abdominal pain
3) Infections
* UTI, gastroenteritis, appendicitis, pancreatitis etc
4) Metabolic
* Biochemical thyrotoxicosis
* Graves disease
* Addisons, DKA
5) Drugs
* Antibiotics, iron preparations
6) Tumours
* hydatidiform mole formation, Choriocarcinoma, teratoma with elements of choriocarcinoma
* germ cell tumors
* islet cell tumor
