Bleeding in Early Pregnancy Flashcards
How long is a normal pregnancy?
About 40 weeks
When is the 1st trimester completed?
12 weeks
When is the 2nd trimester completed?
28 weeks
When is the 3rd trimester completed?
40 weeks
Implantation normally only takes place in which layer of the uterus?
Endometrium of the uterine cavity
Any further is abnormal
What happens in miscarriage?
Normal embryo
Pregnancy fails to be maintained due to immature uterus
Describe the clinical presentation of a miscarriage
Bleeding (more than cramping)
Period-like cramping
Passed products
What are the 6 types of miscarriage?
Threatened (os closed, risk to pregnancy)
Inevitable (os open and product at site, pregnancy cant be saved)
Incomplete (part of pregnancy lost)
Complete (product at vagina/empty uterus, all pregnancy lost)
Early fetal demise (prenancy-in-situ, no heartbeat)
Anembryonic pregnancy (no fetus, empty sac)
How can a miscarriage be managed?
Ensure haemodynamic stability
FBC, G+S, BhCG, USS, histology
Deciding whether to discharge or admit
Conservative management (emotional support (couple care), info leaflets, support group contacts) Medical management (misoprostol) Surgical management (antiD administration)
What is ectopic pregnancy?
Abnormal implantation anywhere but the uterus
What is the commonest site of an ectopic pregnancy?
Ampulla of fallopian tube
Describe the clinical presentation of an ectopic pregnancy
Pain (dull ache to sharp stabbing, more than bleeding) Bleeding Dizziness Breathlessness Collapse, pallor Shoulder-tip pain Peritonism, guarding, tenderness
List investigations for ectopic pregnancy
Transvaginal US scan (empty uterus/pseudosac, adenexa mass, free fluid POD)
Serum beta-HCG
FBC, G+S, glucose etc.
What is a molar pregnancy?
Abnormal/non-viable embryo with overgrowing placental tissue and chorionic villi swollen with fluid
Which cancer risk is increased with molar pregnancy? What type of molar pregnancy is this most common?
Choriocarcinoma
Complete molar pregnancy
What’s the difference between complete + partial molar pregnancy?
Complete: no fetus, 1 or 2 sperms fertilise egg that has no DNA
Partial: may have fetus, 1 or 2 sperms fertilise egg causing triploidy
In both there is overgrowth of placental tissue
Describe the clinical presentation of molar pregnancy
Hyperemesis
Varied bleeding and passage of “grape-like” tissue
Occassional SOB
Describe the diagnostic technique and result found in molar pregnancy
USS
Snowstorm appearance with/without fetus
What is chorionic haematoma? What are the clinical signs? How is it managed?
Pooling of blood between endometrium and embryo due to separation
Bleeding, cramping, threatened miscarriage
Self-limiting (reassurance and surveillance)
Where does fertilisation take place?
In fallopian tube
Bleeding usually occurs in the…
1st trimester
Very common in early pregnancy (20%)
State the marker found in a positive urine pregnancy test
BhCG (high sensitivity)
List tools used in the diagnosis of miscarriage
Scan (confirm pregnancy in situ, process of expulsion, empty uterus)
Speculum (confirms if os closed (threatened), products site at open os (inevitable), or in vagina (complete)
List causes of miscarriage
Chromosomal (embryonic abnormality)
Immunologic (antiphospholipid syndrome)
Infections (CMV, rubella, toxoplasmosis, listeria)
Environmental
Severe emotional upsets
Iatrogenic after CVS (infection or uterine irritability)
Associations (smoking, cocaine, alcohol misuse)
What is meant by ‘recurrent miscarriage’? List some common causes
3 or more pregnancy losses
APS, thrombophilia, balanced translocation , uterine abnormality, age, previous miscarriages
List management options for ectopic pregnancy
Surgical if acutely unwell
Medical if stable, low BhCG, ectopic small, unruptured WITH IV METHOTREXATE
Conservative management
List management options for molar pregnancy
Surgical (antiD administration) and tissue for histology
Follow up with molar pregnancy services
What is implantation bleeding? What are the clinical signs? How is it managed?
Fertilised egg implants in uterine wall
Light-brown limited bleeding, 10 days post-ovulation
Often mistaken for a period
Self-limiting (watchful waiting)
List cervical causes of bleeding in early pregnancy
Ectopy/ectropion
Infections (chlamydia, gonoccal, bacterial)
Polyp
Malignancy (growth or generalised angry presentation)
What clinical presentation would suggest a cervical cause of bleeding in early pregnancy?
Never had smear, history of missed attendance at coloscopy
List vaginal causes of bleeding in early pregnancy
Infections (trichomoniasis (strawberry vagina), bacterial vaginosis, chlamydia)
Malignancy (ulcers, rare)
Forgotten tampon
State the main urinary cause of unrelated bleeding. Which questions is it important to ask in the history to rule this out?
UTI with haematuria
Dysuria, frequency, sexual history, PMHx of UTI
State the main GI cause of unrelated bleeding. Which questions is it important to ask in the history to rule this out?
Haemorrhoids in the bowel, rarely malignancy
Constipation
PR bleeding
What red flag would alert you to a diagnosis of ectopic pregnancy?
Repeated abdominal/ pelvic pain or pain requiring opiates in pregnant women
What medication must be administered before surgery for ectopic pregnancy or molar pregnancy? Why?
AntiD administration
To provide protection for rhesus negative women
What is hyperemesis gravidarum?
Excessive, protracted, QoL altering vomiting in 1st trimester (0.3-3%)
Mild, limited vomiting is common in 1st trimester
List the clinical signs of hyperemesis gravidarum
Dehydration, ketosis Electrolyte and nutritional disturbance Weight loss, altered liver function Signs of malnutrition Emotional instability, anxiety, depression
List differential diagnoses for hyperemesis gravidarum
DIAGNOSIS OF EXCLUSION UTI Gastritis Peptic ulcer Viral hepatitis Pancreatitis
List management options for hyperemesis gravidarum
Rehydration, electrolyte replacement Parenteral antiemetics Nutritional and vitamin supplement NG feeding, TPN Steroid use Thromboprophylaxis
List 1st line antiemetics for use in hyperemesis gravidum
Cyclizine
Prochlorperazine
List 2nd line antiemetics used in hyperemesis gravidum
Ondansetron
Metoclopramide
What is the indication for steroid use in hyperemesis gravidum? What is the first line choice?
Recurrent, severe cases
Oral prednisolone
State a H2 receptor blocker licensed for use in hyperemesis gravidum
Ranitidine
State a PPI licensed for use in hyperemesis gravidum in pregnancy
Omeprazole
State the main nutrition and the main vitamin supplement used in hyperemesis gravidum
Thiamine
Pabrinex IV
State a site of ectopic pregnancy that should be considered in women who have already given birth
CS scar
