Bleeding in Early Pregnancy Flashcards
A foetus is normally carried to what gestation?
40 weeks
Describe the trimesters of pregnancy?
1st = up to 13 weeks, 2nd = up to 28 weeks, 3rd = up to 40 weeks
What marker is used to detect pregnancy on a urine pregnancy test? What level of this suggests a positive pregnancy test?
Beta hCG / > 20IU
Fertilisation occurs where?
In the ampulla of the fallopian tube
8-9 days after fertilisation in the ampulla of the fallopian tube, what happens to the blastocyst?
It migrates to and implants in the endometrium of the uterine cavity
What is a complication that can arise in early pregnancy due to an abnormal site of implantation?
Ectopic pregnancy
What is a complication that can arise in early pregnancy due to an abnormal embryo?
Molar pregnancy
What is the most common problem in early pregnancy?
Bleeding
Bleeding in early pregnancy is most commonly caused by what? What are some diagnoses you still must exclude?
Miscarriage / ectopic pregnancy, GTD, infection, polyps, trauma or cancer
What is implantation bleeding?
A normal, physiological bleed which happens at the time of blastocyst implantation
Cervical ectopy can also be a cause of bleeding in early pregnancy, what is this? What makes a diagnosis of this more likely than miscarriage?
A physiological change in pregnancy where the columnar epithelium of the endocervical canal extends onto the ectocervix where it is prone to trauma. If the bleeding comes on after/during intercourse, this is a likely cause.
PV bleeding in early pregnancy may be confused for what?
Haematuria or a PR bleed
What is a miscarriage?
The spontaneous end of a pregnancy before the foetus has reached the age of viability (24 weeks)
How common are miscarriages? Do they become more or less likely as the pregnancy proceeds?
20% of pregnancies / become less likely as the pregnancy proceeds
What is the first line investigation of all women of reproductive age presenting with symptoms which could be caused by a miscarriage?
beta hCG urinary pregnancy test
If you take repeated beta hCG measurements during a miscarriage, what happens to the levels?
They decrease
Describe the main symptoms of miscarriage?
Bleeding is the primary symptom, it may also be associated with crampy abdominal pain similar to a period
How is a miscarriage diagnosed in an asymptomatic woman?
US scan showing empty sac
What two things are usually diagnostic of a miscarriage?
Empty gestational sac or absence of foetal heartbeat
When is the foetal heartbeat usually audible?
After around 12 weeks it should be auscultated with a Doppler
If a miscarriage is suspected at < 12 weeks gestation or a foetal heartbeat is not heard, what is the best investigation to do?
Transvaginal ultrasound
In a person with suspected miscarriage, what is a transvaginal ultrasound used to assess?
If the pregnancy is in situ, in the presence of expulsion or if there is an empty sac
What examination should be performed on someone presenting with suspected miscarriage? What is the purpose of this?
PV / speculum examination to confirm how far the miscarriage has got
If there are any products of conception in the cervix, what should be done?
They should be removed to reduce blood loss and pain
Name the 4 different types of miscarriage and how they progress?
Threatened, inevitable, incomplete, complete
What happens in a threatened miscarriage?
There are symptoms of miscarriage but the cervical os is closed
What happens in an inevitable miscarriage?
There are symptoms of miscarriage and the cervical os is open and products may be visualised
What happens in an incomplete miscarriage?
There are symptoms of miscarriage and some of the products have been passed into the vagina
What happens in a complete miscarriage?
All of the products of the pregnancy are lost to the vagina, symptoms start to settle
What is the most common cause of a miscarriage?
Underlying embryonic abnormality
What are some immunological causes of a miscarriage?
SLE, APS
What are some infective causes of a miscarriage?
CMV, rubella, toxoplasmosis, listeria
What are some less common causes of miscarriage?
Structural deformities, iatrogenic, exposure to teratogens, trauma/emotional upset
What is an independent risk factor for miscarriage?
Increased parental age (decreased gamete quality)
Essentially failure at what stages of embryonic development may result in miscarriage?
Fertilisation, formation of the zygote, implantation, placental support
Miscarriage can result in cervical shock. What may this cause? How can it be resolves?
Cramps, N+V, sweats, fainting - will resolve if the products are removed
What is the management of a miscarriage with heavy bleeding or significant pain?
Admission for definitive treatment either medical or surgical
What is the management of a miscarriage with light or no bleeding?
Conservative outpatient management with a follow up scan after 2-3 weeks to confirm an empty uterus
Describe the medical management of a miscarriage?
Repeated doses of prostaglandins (misoprostol) are given orally or vaginally until the miscarriage completes, usually after 6-12 hours
Describe the surgical management of a miscarriage?
Dilatation of the cervix and suction evacuation of the uterus to remove the products of conception
How should cervical shock be managed?
IV fluids, removal of any products
What is the prognosis following a miscarriage?
Most women will go on to have a normal uterine pregnancy in the future, though the risk of subsequent miscarriage increases with every pregnancy loss
What defines recurrent miscarriage?
3 or more pregnancy losses
What are some causes of recurrent miscarriage?
APS, thrombophilia, balanced translocations, uterine abnormalities
Recurrent miscarriages due to uterine abnormalities usually present when?
Late in the 1st trimster
What are some investigations for recurrent miscarriage?
Anti-cardiolipin antibody, karyotyping, thrombophilia screen, US of pelvis or hysteroscopy
What are some independent risk factors for recurrent miscarriage?
Increased age and previous miscarriages
A woman of reproductive age presents with unilateral abdominal pain and a positive pregnancy test is diagnosed with what until proven otherwise?
Ectopic pregnancy
What is an ectopic pregnancy?
A pregnancy that has implanted outside the uterus
What is the risk if an ectopic pregnancy ruptures?
This is a life threatening emergency that requires urgent surgery
What is the most common site of an ectopic pregnancy?
Fallopian tubes
What is the most common feature of an ectopic pregnancy?
Unilateral lower abdominal pain
Apart from pain, what are some other features of an ectopic pregnancy?
Bleeding, dizziness/collapse, shoulder tip pain, dyspnoea
Dizziness/collapse seen in an ectopic pregnancy suggests what?
Significant intra-abdominal bleeding
What may be seen on examination of someone with an ectopic pregnancy?
Pallor, tachycardia, hypotension, guarding and tenderness (signs of peritonism)
What do tachycardia and hypotension indicate in a woman with an ectopic pregnancy? What is the management?
Haemodynamic instability due to tubal rupture and intra abdominal haemorrhage. Requires immediate resuscitation and surgical intervention
What investigations would be done for a suspected ectopic pregnancy?
FBC, G&S, hCG, US
What type of pelvic ultrasound is the gold standard in a suspected ectopic pregnancy?
Transvaginal
There is a slightly increased risk of ectopic pregnancy with what fertility treatment?
IVF
What will an US scan of an ectopic pregnancy show?
Empty uterus, mass in adnexa, free fluid in PoD
What will happen with multiple measurements of beta hCG in an ectopic pregnancy?
It will increase slowly or remain static
What are some red flag signs for an ectopic pregnancy?
Repeated admissions with abdominal/pelvic pain or pain requiring opiates in a woman known to be pregnant
How should an ectopic pregnancy be managed if the woman is unwell?
Surgically
How should an ectopic pregnancy be managed if the woman is stable, with low levels of beta hCG and a small, unruptured ectopic?
Medical management with methotrexate
How should an ectopic pregnancy be managed if the patient is well, with minimal pain, low beta hCG and a pregnancy not visible on US?
Conservatively, and followed up a while later to ensure hCG levels have normalised
What is the key risk factor for ectopic pregnancy?
Tubal damage
What is a pregnancy of unknown location?
When the beta hCG is raised but the pregnancy cannot be found anywhere
What are some causes of a pregnancy of unknown location?
The pregnancy is still to evolve, there is an ectopic which can’t be seen, the patient has had a missed miscarriage and the hCG is still to decrease
If a patient with pregnancy of unknown location is haemodynamically stable, how should they be managed?
Take beta hCG levels 48 hours apart to check for doubling which suggests a normal pregnancy
What is a molar pregnancy?
A type of gestational trophoblastic disease where a non-viable fertilised egg implants into the uterus
Molar pregnancy is more common in who?
Teenagers or women > 45
Describe what happens once a molar pregnancy has implanted?
There is overgrowth of placental tissue which grows as a mass
Describe a complete mole?
Caused by a single (that duplicates) or two sperm combining with an egg which has lost its DNA
How many chromosomes will a complete molar pregnancy have?
46 (diploid)
DNA from which parent(s) will be present in a complete molar pregnancy?
The father only
Describe a partial mole?
A haploid egg is fertilised by two sperm, or one sperm that duplicates itself
How many chromosome will a partial molar pregnancy have?
69 (triploid)
DNA from which parent(s) will be present in a partial molar pregnancy?
Both mother and father
Will a foetus be present in an a) complete b) partial molar pregnancy?
a) no b) yes, but it will be grossly abnormal
How are most partial molar pregnancies diagnosed?
On histology after a miscarriage
With a complete mole, there is a 2.5% risk of developing what?
Choriocarcinoma (a malignant tumour of trophoblast cells)
What is the most common presentation of a molar pregnancy?
Bleeding in the 1st/2nd trimester +/- the passage of grape like tissue
What are some presenting features of a molar pregnancy?
Bleeding, hyperemesis, dyspnoea, fundus > dates
What causes hyperemesis in a molar pregnancy?
Excessive beta hCG
What will an ultrasound of a molar pregnancy show?
Snowstorm appearance +/- foetus
How is a molar pregnancy managed?
Surgical evacuation of the pregnancy and tissue samples for histology, as well as follow up at a molar pregnancy service until hCG levels are undetectable
After a molar pregnancy, what happens with regards to future pregnancies?
They are monitored for molar pregnancy, but recurrence is unlikely
When does implantation bleeding usually occur?
About 10 days after ovulation
How would you describe the bleeding seen in implantation bleeding? What can it be mistaken for?
Light, brownish and limited, can be mistaken for a period
What is the management and outcomes of implantation bleeding?
Watchful waiting, usually settles and pregnancy continues
What is a chorionic haematoma?
A pooling of blood between the endometrium and the embryo due to separation
What may a chorionic haematoma cause?
Bleeding, cramping and threatened miscarriage
What is the management and outcomes of chorionic haematoma?
Reassurance and surveillance, usually self-limited and resolve
What are some vaginal causes of bleeding that may be mistaken for PV bleeding in early pregnancy?
Infections, malignancy, forgotten tampon
What are some urinary causes of bleeding that may be mistaken for PV bleeding in early pregnancy?
Haematuria from a UTI
What are some bowel related causes of bleeding that may be mistaken for PV bleeding in early pregnancy?
Haemorrhoids, cancer
