cOGText: Early Pregnancy

Question 1

What are Cervical polyps?

Symptoms?

Answer 1

benign, localised inflammatory outgrowths.

May be asymptomatic, can bleed if ulcerated (as they can be exposed to acidic vagina). May be removed, may be left alone.

Question 2

1. The cells in the fertilised ovum divide, progressing to a ___, then the ___ as it travels along the fallopian tube to the uterus.
2. The blastocyst will implant into the uterine lining during days __-__, the inner cells develop into the ____ and the outer cells invade the endometrium and become the ____.
3. T/F: Any uterine wall can house the pregnancy.

Answer 2

1. morula, blastocyst
2. 5-8, embryo, placenta
3. true

Question 3

1. What is an ectopic pregnancy?
2. What is the most common site?
3. Where else can the pregnancy implant?

Answer 3

1. any pregnancy that implants in an abnormal location, i.e. outside the endometrial cavity.
2. within the fallopian tube (interstitial, isthmic, ampullary, fimbrial)
3. ovary, peritoneum or peritoneal cavity, cervix, c-section scar or other abdominal organs.

Question 4

1. What is a Molar pregnancy?
2. What are the 2 classifications?
3. How does a partial mole present?
4. How does a complete mole present?
5. A complete mole carries a 2.5% risk of which cancer?

Answer 4

1. Gestational Trophoblastic Disease: non-viable fertilised egg with an overgrowth of placental tissue swollen with fluid, appears as “grape-like clusters”.
2. Partial: one set of DNA from the egg, two from the sperm (either 2 sperms fertilising the egg or one sperm reduplicating DNA material) = triploidy. Complete: an egg without any DNA and two sets from the sperm (either 2 sperms fertilising the egg or one sperm reduplicating DNA material) = diploidy.
3. Overgrowth of placental tissue with or without a foetus.
4. No foetus, only an overgrowth of placental tissue.
5. Choriocarcinoma

Question 5

1. Urine pregnancy test detects which hormones?
2. Some urinary pregnancy tests are highly sensitive and will detect pregnancies as early as __ IU (international units).
3. How should HCG levels change in a normally developing early singelton pregnancy?
4. T/F: N&V are often worse in higher levels of HCG (multiple pregnancy, molar pregnancy).
5. N&V normally begins to improve as the HCG reaches a peak at ___ weeks.

Answer 5

1. human chorionic gonadotrophin (HCG)
2. 20
3. should double every 48 hours
4. True - theorised that HCG causes N&V
5. 12-14

Question 6

1. The placenta and foetal heart develop and begin to function by week __
2. At this time Human Placental Lactogen is produced. What effects does this have?

Answer 6

1. 5
2. has growth hormone-like effects and decreases insulin resistance in the mother. Is also involved in breast development, alongside rising levels of oestrogens – why tender breasts are a sign of early pregnancy.

Question 7

Physiological Changes in early pregnancy

1. cardiac output
2. why do pregnant women have a lower Hb?
3. what is implantation bleeding
4. T/F: implantation bleeding should not be treated seriously

Answer 7

1. increased CO (due to an increase in blood volume) to cope with the demands of the uteroplacental circulation. Starts at week 6 and can cause a raised HR, ECG changes, functional murmurs and other heart sounds.
2. As CO increases, so does plasma volume which in turn decreases haemoglobin by dilution (anaemia is <110 g/l in 1st trimester).
3. minimal bleeding early in pregnancy, common – around 20% of pregnancies. Just before the woman’s period would have been due.
4. False - although it can be normal, any bleeding in pregnancy should be considered as a symptom of a threatened miscarriage

Question 8

1. What causes implantation bleeding?
2. How does it vary from normal period bleeding?
3. What is a subchorionic haematoma?
4. Symptoms?
5. Outcomes?

Answer 8

1. The fertilised egg has implanting in the uterine wall
2. Occurs about 10 days after ovulation. Is generally light brown and lighter than a period.
3. a collection of blood between the chorion and the uterine wall (may be seen when investigated a threatened miscarriage)
4. Vary based on the size. Bleeding, cramping and threatened miscarriage.
5. Usually self-limiting and resolve, but large haematomas can lead to miscarriage/ may be a source of infection or irritability.

Question 9

1. The cervix has which two types of epithelium?
2. what separates the two types?
3. Why are cervical erosions/ ectropians more likely to form during pregnancy?

Answer 9

1. Ectocervix (tough, squamous) and endocervix (columnar)
2. The squamo-columnar junction: called the transitional zone
3. Position of transitional zone alters as a physiological response to pregnancy - can lead to exposure of the endocervical epithelium to the acid environment of the vagina > cervical ectropion (can be a cause of early pregnancy bleeding)

Question 10

Suggest some possible causes of bleeding in early pregnancy

Answer 10

Think about the structures top down: from the uterine cavity, cervix, vagina,

• implantation bleed
• subchorionic haematoma
• miscarriage
• cervical ectropion
• cervical polyp
• cervical premalignancy/ malignancy
• vaginal premalignancy/ malignancy
• STI
• domestic abuse (unexplained genital injury)
• haematuria (UTI, kidney stones, malignancy)
• PR bleeding (haemarrhoids, anal fissures, gastroenteritis, IBD, malignancy

Question 11

1. what is a miscarriage
2. Presentation?

Answer 11

1. pregnancy loss after a postivie urinary pregnancy test, between conception and 23+6 weeks
2. May have bleeding and abdo pain (usually crampy). Sometimes passed products.

Question 12

Define:

1. Threatened miscarriage
2. what will be seen on USS?
3. Inevitable miscarriage?
4. on USS?
5. Incomplete miscarriage
6. Complete miscarriage
7. Septic miscarriage
8. Recurrent miscarriage
9. Missed miscarriage

Answer 12

1. When there’s a risk to the pregnancy and bleeding +/- cramping. Cervical os is closed.
2. evidence of an intrauterine pregnancy, if the foetal pole is present and >7mm a foetal heart should be present.
3. Symptoms consistent with miscarriage and the pregnancy can’t be saved. Cervical os is open, possibly with products of conception sitting at it
4. May reveal a viable pregnancy or products that are in the process of expulsion
5. Some of the products have already been passed, but some remain in the uterus.
6. All of the products are passed and the uterus is empty (speculum may reveal products in the cervix ajd cervical os may be closing if all products have been passed)
7. Infection alongside incomplete/ complete miscarriage. May have fevers, rigors, uterine tenderness, bleeding, offensive discharge and pain. Inflammatory markers raised
8. 3 or more consecutive pregnancy losses
9. No symptoms of miscarriage or Hx of threatened miscarriage, but on USS there is no viable pregnancy.

Question 13

After 3 or more consecutive pregnancy losses (recurrent miscarriage), what should the woman be investigated for?

Answer 13

Antiphospholipid Syndrome, Thrombophilia, Balanced Translocations and/or uterine abnormality (if late first trimester losses)

In some women, no underlying cause found.

Question 14

What are some potential causes for a missed miscarriage?

Answer 14

• anembryonic pregnancy (empty gestational sac, no foetus)
• early foetal demise (pregnancy in situ with mean sac diameter >25mm and/or a foetal pole >7mm but no foetal heartbeat present).

Question 15

Suggest some potential causes of miscarriage?

Answer 15

• Embryo: Chromosomal abnormalities
• Maternal: PCOS, uncontrolled diabetes, increasing age, heavy smoking, alcohol/ drug misuse (e.g. cocaine), severe hypertension, obesity
• Uterine: Septate uteri, bicornate uteri, unicornate uteri
• Immunologic: APS (inc. Lupus Anticoagulant and Anticardiolipin antibody)
• Infections: Cytomegalovirus, Rubella, Toxoplasmosis, Listeria
• Iatrogenic: after CVS/ Amniocentesis

Question 16

1. T/F: Antiphospholipid syndrome is a treatable cause of recurrent miscarriage
2. Ass. with which antibodies?
3. Why can these lead to miscarriage?

Answer 16

1. True
2. Lupus anticoagulant, Anticardiolipin antibodies, Anti-B2 glycoprotein-1 antibodies
3. They can: inhibit trophoblastic function and differentiation; create a localised inflammatory response at the maternal-foetal interface and, later, cause thrombosis of the uteroplacental vasculature.

Question 17

Cervical shock

1. can occur during which type of miscarriage?
2. Presentation?
3. Treatment?

Answer 17

1. incomplete - where the products are sitting in the cervix
2. cramps, severe abdominal pain, nausea, vomiting, sweating, fainting, bradycardia and hypotension.
3. Resuscitate with IV fluids and possibly uterotonics (IV fluids may not correct the hypotension, which is caused by vagal stimulation). Defintive: remove products from the cervix (sometimes using speculum and sponge forceps)

Question 18

Presentation of:

1. miscarriage?
2. ectopic pregnancy?
3. what signs may be seen on examination of a woman with an ectopic pregnancy?
4. Molar pregnancy? (Gestational Trophoblastic Disease)
5. Diagnosis?

Answer 18

1. Bleeding, often with pain. Can also be signs of haemorrhage and haemodynamical instability (requiring immediate surgical evacuation)
2. Localised abdo/pelvic pain and light PV bleeding. May have dizziness, shoulder-tip pain, SOB, collapse, breast tenderness, GI/ urinary symptoms, passage of tissue, rectal pressure or pain on defecation.
3. Pallor, haemodynamic instability, peritonism, guarding, abdo/ pelvic tenderness, adnexal tenderness, cervical motion tenderness, abdominal distention, enlarged uterus or orthostatic hypotension. Acute abdo if ruptured.
4. Often hyperemesis. Also fundus large for dates, varied bleeding, passing “grape-like” tissue and occasional SOB.
5. USS. The HCG is often very high

Question 19

1. What is an important initial investigation to offer in early pregnancy if not already done?
2. Important Ix for a suspected miscarriage?
3. What would levels of hCG look like in a miscarriage?

Answer 19

1. pregnancy test (urinary hCG)
2. FBC, G&S (assess haemodynamic stability and confirm rhesus status), hCG and USS
3. Halve every 48 hours

Question 20

1. Important Ix for an ectopic pregnancy?
2. What would hCG levels look like?
3. What would be the USS findings?

Answer 20

1. Same as for miscarriage: FBC, G&S, hCG and transvaginal USS
2. Suboptimal HCG rise (often doesn’t double every 48 hr).
3. Empty uterus/ presence of pseudo sac. Adnexal mass and free fluid in Pouch of Douglas (raising concern of rupture). If in fallopian tube, may be an adnexal mass separate to the ovary (may contain a gestational sac +/- foetus)

Question 21

1. Ix for molar pregnancy?
2. hCG findings?
3. USS findings?
4. treatment?

Answer 21

1. hCG, USS
2. greatly raised HCG levels
3. typical “snowstorm” appearance +/- foetus
4. Bloods (Hb and crossmatch) prior to surgical evacuation as increased risk of haemorrhage during the procedure

Question 22

Management of threatened miscarriage?

Answer 22

mostly watchful waiting with realistic discussions with the couple

Question 23

Management of missed/ incomplete miscarriage?

Answer 23

• Conservative: pregnancy will be passed with time (usually offered for up to 2 weeks)
• Medical: misoprostol
• Surgical: surgical evacuation under GA or manual vacuum aspiration under LA.
• ABCDE + resuscitation if haemodynamically unstable.

(NB: complete miscarriage = no physical Rx but still require emotional support)

Question 24

how can women with antiphospholipid syndrome or thrombophilia reduce the risk of future miscarriages

Answer 24

• Low dose aspirin started before/ when the pt takes a positive pregnancy test
• Daily Fragmin (LMWH) injections when intrauterine pregnancy confirmed

Question 25

Ectopic pregnancy

1. when would surgical management be indicated?
2. what does conservative management involve?
3. what about medical management?
4. Surgical management?

Answer 25

1. Significant pain, adnexal mass ≥35mm, ectopic with visible foetal heartbeat on USS, HCG ≥5000 IU/L
2. Allow nature to take its course. Return for repeat HCG on days 2, 4 and 7 after original test. If measurements fall by at least 15% from the previous value then they can be repeated weekly until negative (<20IU/L) result obtained.
3. Either a single or 2 separate doses of methotrexate and continued HCG monitoring.
4. Laparoscopy and removal of ectopic pregnancy, usually via salpingectomy.

Question 26

Management of uspected gestational trophoblastic disease? (either complete or partial mole)

Answer 26

Surgical management. Send tissue for histology to determine if it was a partial or complete mole.

Once diagnosis confirmed, follow up at a dedicated centre for Molar Pregnancy Services.

Question 27

Hyperemesis

1. Features suggestive of hyperemesis gravidarum (c.f. pregnancy sickness)
2. Potential consequences?
3. How is it diagnosed?
4. Management?
5. Risk ass with Metoclopramide? Rx?
6. What might be prescribed to treat associated reflux?
7. In protracted, severe cases?
8. Also important to consider what prophylactic medication?

Answer 27

1. Excessive sickness, prolonged into 2nd trimester, beginning to alter woman’s quality of life.
2. Dehydration, ketosis, electrolyte and nutritional imbalance, weight loss, altered liver function.
3. By excluding other causes of excessive, prolonged vomiting: UTI, gastritis, peptic ulcer, viral hepatitis and pancreatitis.
4. Provide IV rehydration and electrolytes with an anti-emetic (1st line Cyclizine or Prochlorperazine 8 hourly. 2nd line: Ondansetron or Metoclopramide 8 hourly. Nutritional/ vitamin supplements e.g. Thiamine (PO) or Pabrinex (IV). May need NG feed/ TPN.
5. Oculogyric crisis: treatable with Procyclidine
6. Ranitidine (H2 receptor blocker) or omeprazole (PPI)
7. Oral steroids (Prednisolone)
8. thromboprophylaxis (pregnancy + dehydration = hypercoagulable state)