Bleeding in Early Pregnancy Flashcards by Kerry Hendrie

How long is a normal pregnancy?

About 40 weeks

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When is the 1st trimester completed?

12 weeks

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When is the 2nd trimester completed?

28 weeks

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When is the 3rd trimester completed?

40 weeks

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Implantation normally only takes place in which layer of the uterus?

Endometrium of the uterine cavity

Any further is abnormal

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What happens in miscarriage?

Normal embryo

Pregnancy fails to be maintained due to immature uterus

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Describe the clinical presentation of a miscarriage

Bleeding (more than cramping)
Period-like cramping
Passed products

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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)

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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)

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What is ectopic pregnancy?

Abnormal implantation anywhere but the uterus

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What is the commonest site of an ectopic pregnancy?

Ampulla of fallopian tube

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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

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List investigations for ectopic pregnancy

Transvaginal US scan (empty uterus/pseudosac, adenexa mass, free fluid POD)
Serum beta-HCG
FBC, G+S, glucose etc.

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What is a molar pregnancy?

Abnormal/non-viable embryo with overgrowing placental tissue and chorionic villi swollen with fluid

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Which cancer risk is increased with molar pregnancy? What type of molar pregnancy is this most common?

Choriocarcinoma

Complete molar pregnancy

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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

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Describe the clinical presentation of molar pregnancy

Hyperemesis
Varied bleeding and passage of “grape-like” tissue
Occassional SOB

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Describe the diagnostic technique and result found in molar pregnancy

USS

Snowstorm appearance with/without fetus

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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