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Obstetrics & Gynaecology > Bleeding in early pregnancy > Flashcards

Bleeding in early pregnancy Flashcards

1
Q

Benign causes of bleeding in early pregnancy

A
  • Infection: cervix, vagina or STI
  • Cervical changes: progesterone influence
  • Sex
  • Implantation bleed
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2
Q

Serious causes of bleeding in early pregnancy

A
  • Miscarriage
  • Ectopic
  • Gestational trophoblastic diseases
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3
Q

How can miscarriage be classified?

A

Threatened: body shows signs that indicate miscarriage may occur, os closed

Inevitable: heavy vaginal bleeding and cramping, os open

Complete/ incomplete: all pregnancy tissue has been expelled/ pregnancy tissue remains in uterus but no foetus or no viable foetus (no heartbeat)

Missed/ silent: baby died in uterus, signs of pregnancy may have faded but otherwise nothing unusual

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4
Q

Definition and epidemiology of micarriage

A

Spontaneous loss of the pregnancy before foetus reaches viability

  • Up to 20% of all clinically recognised pregnancies (80% within 1st trimester)
  • 50,000 admissions in the UK annually
  • Significant distress to patient
  • UK viability is 23+6 weeks
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5
Q

Causes of miscarriage

A
  • Foetal chromosomal abnormalities (trisomy 21 - Down’s, trisomy 12, Patau’s, trisomy 18 - Edward’s)
  • Hormonal factors: PCOS, inadequate luteal function, diabetes, thyroid dysfunction
  • Immunological causes: auto or alloimmune
  • Uterine anomalies: septated, Asherman syndrome, fibroids
  • Infections
  • Environmental factors: alcohol, smoking
  • Unexplained
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6
Q

Management of miscarriage

A
  • Emotional time so sensitive empathic approach
  • Medical or surgical management or expectant management which entails waiting for the miscarriage to complete spontaneously
    • Woman’s preference takes precedence
    • Expectant management is an option for women who aren’t bleeding heavily but this can take weeks
  • Medication: miscarriage is induced by prostaglandins e.g. misoprostol oral or vaginal. Use of progesterone antagonist mifepristone administered 12-48hr before prostaglandin increases success rate
  • Surgery: dilation of the cervix and suction of uterus
  • Emergency surgery required if: profuse bleeding, tachycardia, anaemia, need for immediate fluid resuscitation

Viable pregnancy

  • Reassure
  • If bleeding getting worse or >14 days - reassess
  • Continue or start antenatal care
  • Anti-D if required

Confirmed incomplete, missed or inevitable miscarriage

  • First line is expectant management over 7-14 days if accepted by mother
  • Exclude complicated factors
  • Reassess after 14 days if no bleeding

Complete miscarriage

Pregnancy test at home in 3 weeks and return for assessment if +

Retained products of conception

If small and minimal bleeding can be managed conservatively

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7
Q

Medical management of miscarriage

A
  • Misoprostol - synthetic prostaglandin E1
  • Evacuation of retained products of contraception
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8
Q

Epidemiology of ectopic pregnancy

A

1/100 pregnancies

1/30 in high risk population

Risk factors:

  • Pelvic infection
  • Previous ectopic
  • Previous surgery
  • Endometriosis
  • IVF

50% occur with no risk factors

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9
Q

What is a heterotopic pregnancy?

A

Combined intrauterine and ectopic - rare

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10
Q

Define recurrent miscarriage

A

3+ miscarriages in a row

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11
Q

Investigations and management for recurrent miscarriage

A

Investigations

  • Antiphospholipid antibodies: anticardiolipin
  • Cytogenic analysis
  • USS to check uterine anatomy: fibroids, congenital uterine anomaly
  • Inherited thrombophilia screen
  • Parental karyotype

Treatment

  • Low dose aspirin + heparin]genetic counselling
  • Assisted conception
  • Surgery
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12
Q

What is the most common cause of bleeding in early pregnancy?

A

Miscarriage

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13
Q

What is the evidence for intervention in the reduction of incidence of miscarriage?

A
  • Little evidence to suggest that any intervention reduces incidence
  • Women with antiphospholipid syndrome: low dose aspirin and low molecular weight heparin improves live birth rate of future pregnancies to 70%
  • Cases of excessive shortening of the cervix can be alleviated by placement of a cervical suture
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14
Q

What investiations are done if a woman presents with suspected miscarriage?

A
  • Urinary pregnancy test - serial measurements of hCG are more useful than a single measurement, decreasing levels generally indicates miscarriage
  • USS - is foetal heartbeat not heard of pregnancy <12 weeks a USS is done
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15
Q

Aetiology of ectopic pregnancy

A
  • Damage to Fallopian tube = key risk factor
  • Common risk factors: PID, previous ectopic, tubal surgery, IUD, smoking, IVF failed emergency contraceptive
    • Key to maintain high index of suspicion
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16
Q

Clinical features of ectopic pregnancies

A
  • Unilateral lower abdo pain is most common presenting complaint
  • Often vagina bleeding
  • Irritation of diaphragm >> innervated by phrenic nerve can cause shoulder tip pain
  • Fainting or collapse suggest intra-abdo bleeding
  • Examination: unilateral tenderness, cervical excitation &/ adenexal mass
  • Clinical signs of haemodynamic compromise or peritoneal irritation, tachycardia, hypotension, abdo guarding suggest tubal rupture and haemorrhage
17
Q

Diagnosis of ectopic pregnancy

A

Empty uterus + positive pregnancy test = ectopic until proven otherwise

18
Q

Investigations for ectopic pregnancy

A
  • Transvaginal USS: empty uterus, adnexal mass and free fluid in rectouterine pouch. If live, the adnexal mass might have a heartbeat.
  • Serial hCG measurements: in a viable uterine pregnancy levels double every 48hrs. If levels rise slowly or remain static this suggests ectopic
19
Q

Management of ectopic pregnancy

A
  • Expectant management providing pain is minimal and serum hCG is falling and the ectopic isn’t visible on USS - women are monitored to make sure hCG levels fall
  • Medication: if pain is minimal, adnexal mass is <4cm and hCG = <1500IU/L. Methotrexate causes tubal abortion before tube ruptures. Given as single IM injection. hCG levels initially rise and then fall. 15% require second dose. Women must avoid pregnancy for 3mo because methotrexate is teratogenic
  • Surgery: if haemodynamic compromise, salpingectomy

**Expectant management of methotrexate are only given if woman can attend for follow up**

20
Q

Gestational trophoblastic disease

A
  • Rare in UK - 0.1% of pregnancies
  • South east Asia - 1% of pregnancies

Gestational trophoblastic disease includes:

  • Benign disorders of trophoblastic proliferation such as complete or partial hydatidiform moles
  • Neoplastic trophoblastic disease does example invasive moles, choriocarcinoma and placental site trophoblastic tumours

Trophoblastic disease more common in teenagers and >45

21
Q

What is a hydatidiform molar pregnancy?

A
  • A complete hydatidiform mole is created when two separate spermatozoa fertilise an empty ovum (an egg with no functional DNA). Makes a diploid conceptus 46 XX. Mass forms but no foetus
  • Partial hydatidiform mole results when two spermatozoa fertilise a normal egg. Makes a triploid conceptus 69 XX. Abnormal foetus forms but cannot survive or develop into baby
22
Q

Clinical features of a molar pregnancy

A
  • Vaginal bleeding in first or second trimester in often the only the presenting complaint
  • USS: multiple cystic areas are visible within placental mass and contain either no recognisable foetus (complete mole) or grossly abnormal foetus (partial mole)
  • Serum hCG extremely high
23
Q

Management of molar pregnancy

A
  • Surgical evacuation of pregnancy is recommended
  • Follow up carried out at regional trophoblastic screening centres where hCG levels are monitored until undetectable
  • Persistent trophoblastic disease warrants chemo
24
Q

What is hyperemesis gravidarum?

A

Can cause dehydration and malnutrition which can cause hyponatremia and thiamine deficiency which can cause Wernicke’s encephalopathy

35% of women have symptoms that reduce their QoL

1% have hyperemesis gravidarum wand require hospital treatment for dehydration

25
Q

Clinical features of hyperemesis gravidarum

A

Persistent vomiting accompanied by weight loss exceeding 5% of pregnancy body weight is diagnostic of hyperemesis gravidarum

26
Q

Epidemiology of hyperemesis gravidarum

A
  • More common in 1st pregnancy
  • More common in women who experience nausea related to other things e.g. migraine
27
Q

Investigations if woman has hyperemesis gravidarum

A
  • Exclude other causes of nausea and vomiting and assess severity
  • Urinalysis: patients with ketonuria are usually admitted for rehydration. Signs of infection may indicate precipitating factor
  • Bloods: electrolyte imbalance due to vomiting
  • Ultrasound: hydatidiform molar pregnancy and multiple pregnancies are associated with hyperemesis

Bloods:

  • FBC: anaemia
  • U&E: hyponatremic, hypokalaemic, hyochloraemic
  • Metabolic acidosis indicates severe disease
  • LFTs: increased bilirubin, AST and ALT but frank jaundice is rare
28
Q

Management of hyperemesis gravidarum

A

Mainly supportive, IV fluid, antiemetics, vitamins

Prevention of DVT if dehydration is severe and mobility limited

29
Q

Bleeding in pregnancy with repsect to trimester

A
  • 1st trimester: miscarriage, ectopic, hydatidiform mole
  • 2nd trimester: miscarriage, hydatidiform mole
  • 3rd trimester: bloody show, placental abruption, placenta praevia, vasa praevia
  • Also consider STI, cervical polyps
30
Q

Symptoms of placental abruption

A
  • Constant lower abdo pain and
  • shock greater than expected
  • tense tender uterus with normal lie and presentation
  • coagulation problems
  • foetal heart may be distressed
  • consider pre-eclampsia, DIC, anuria
31
Q

Causes of abdominal pain in pregnancy

A

Early: miscarriage, ectopic

Abruption

Symphysis pubis dysfunction: ligament laxity increases due to hormona changes and pain can raidate to groins and thighs, causes a waddling gait

Pre-eclampsia/ HELLP

Appendicitis

UTI

32
Q

What is gestational trophoblastic disease?

A

AKAmolar pregnancy

Can be benign or malignant

0.1% pregnancies in the UK

1% pregnancies SE Asia

Chromosomally abnormal pregnancies that have the potntial to become malignant

33
Q

Risk factors for molar pregnancies

A

Maternal age extremes

Previous molar pregnancy

34
Q

Outline the two types of molar pregnancies

A

1) Complete: chromosomally empty egg fuses with a normal sperm and sperms genetic material doubles forming a mass but no foetus

  • Placenta secretes huge amount of B-hCG - BhCG can mimic TSH causing tachycardia, anxiety, insomnia and palpitations, abdo grows rapidly so uterus too large for dates

2) Incomplete mole: normal egg fertilised by 2 sperm forming an organism w/ 69 chromosomes and non-viable foetal parts

  • More BhCG than normal but less than complete moletherefore no symptoms of hyperthyroidism
35
Q

Clinical features of molar pregnancy

A

Vaginal bleeding in 1st/2nd trimester

USS; multiple cystic areas within placenta, no recognisable foetal parts (complete), grossly abnormal foetus (incomplete), snow storm/ swiss cheese

Extremely high BhCG

*Moles = pre-malignant conditions

36
Q

Management of molar pregnancies

A

Surgical evacuation or pregnancy

Follow up at trophoblastic screening centres and monitor until BhCG levels fall

If levels don’t fall may suggest residual tissue or malignancy

37
Q

What is choriocarcinoma?

A

Malignant transformation of the placenta, can develop following normal pregnancy or molar pregnancy

Persistent trophoblastic disease is malignancy related only to molar pregnancies and not normal pregnancies

Obstetrics & Gynaecology (25 decks)

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