Complications in the first 20 weeks

Question 1

What is a miscarriage?

Answer 1

Pregnancy loss that occurs before 20 weeks

Question 2

Abortion

Answer 2

Both spontaneous and elective - before 20 weeks

Question 3

Recurrent miscarriages

Answer 3

3 or more consecutive before 20 weeks

Question 4

Causes of miscarriage

Answer 4

aneuploidy (missing/extra chromosones)
maternal conditions (viral infections, unstable diabetes)
uterine and cervical (weak cervix, fibroids, congenital abnormality of the uterus)
drug abuse (smoking, DV)
balanced translocation from partner (genetic)
obesity, leptin, stress, caffeine
age

Question 5

Types of miscarriage

Answer 5

threatened (some bleeding)
inevitable
complete (products of conception expelled)
incomplete (products of conception partially expelled)
anembryonic (fetus dies or fails to develop but placental tissue continues to function)
missed (fetus dies but cervix closed)

Question 6

How to diagnose

Answer 6

physical exam
labs
USS
obs

Question 7

Management

Answer 7

rest
reassurance
surgical
medical

Question 8

Care options

Answer 8

expectant
medical
surgical

Question 9

Expectant

Answer 9

wait and see
effective

Question 10

Medical

Answer 10

comprehensive history taking
confirm dates
USS for viability
speculum
informed consent
operative under GA
oral misoprostal 1200 ug divided by 4 doses over 24 hrs
combination of misoprostol and mifepristone is approved for medical termination of early intrauterine pregnancy in Australia and New Zealand. Mifepristone is administered as a single 200mg oral dose, followed by an oral dose of 800μg misoprostol 36–48 hours later.

Question 11

Surgical

Answer 11

comprehensive history taking
confirm dates
USS for viability
speculum
informed consent
operative under GA
misoprostol 400ug S/L 2 hr prior to surgery
gemeprost PV 1mg
I.V Syntocinon reduce blood loss and to decrease the risk of uterine perforation by causing the uterus to contract and thicken.
Vacuum aspiration is preferred over sharp curettage in cases of incomplete miscarriage. Routine use of a metal curette after suction curettage is not required.

Question 12

Incidental causes

Answer 12

Cervical carcinoma (1 in 6000 births). The most frequently diagnosed cancer in pregnancy. Is treatable if detected early. 80% of cases detected in pregnancy are diagnosed in the first or second trimester. Hence need for cervical smears. CIN is the precursor to invasive cancer of the cervix.
* Cervical pathology - ectropion/erosion, polyps.
* Varicosities of the cervix, vagina or vulva.
* Diagnostic error e.g. bleeding from the urinary tract or haemorrhoids.
* General maternal conditions – infections
* ‘Weakened’ cervix

Question 13

Gestational trophoblastic disease (molar pregnancy)

Answer 13

term covering both the benign hydatidiform mole and choriocarcinoma which is malignant.
is the gross malformation of the trophoblast in which the chorionic villi are abnormal, they proliferate and become avascular.

Question 14

how does molar pregnancy present?

Answer 14

villi up to 3cm in length = complete or partial moles
10 weeks by dark brown vaginal bleeding - may pass vesicular tissue

Question 15

molar pregnancy - aetiology

Answer 15

age <20 and >40
environment
poor nutrition
previous 1:100 chance in subsequent

Question 16

molar pregnancy incidence

Answer 16

rare
asian women 2.0 per 1000 pregnancies
caucasian 0.57-1.1 per 1000
can lead to cancer

Question 17

diagnosis molar pregnancy

Answer 17

A positive sign of hydatidiform mole is vesicular shapes on U/S creating a ‘snowstorm’ appearance and elevated serum ßhCG levels.

Question 18

Complete molar pregnancy

Answer 18

develops from abnormal fertilisation and abnormal development of the placental tissue.
Arises from an ‘empty egg’ which has lost its maternal genetic material. It shows total hydatidiform change with no evidence of an embryo or normal placental tissue. Proliferation of the trophoblast cells is marked. Complete moles are more likely to develop malignant change of the trophoblast cells = choriocarcinoma

Question 19

Partial molar pregnancy

Answer 19

is associated with a fetus even if the only evidence is traces of a microscopic fetal circulation. The karyotype is abnormal and has duplicate paternal genetic material. Most common is triploidy 69XXX or XXY instead of 46 and is the result of fertilisation by more than one sperm. Partial moles are less likely to develop malignant change

Question 20

signs and symptoms of molar pregnancy

Answer 20

bleedings
hyperemesis
uterine enlargement
absent FHR
early onset preeclampsia
signs of hyperthyroidism

Question 21

Management

Answer 21

remove all trophoblast tissue
Women are advised to avoid hormonal family planning methods and use barrier contraception until ßhCG levels are within normal limits and not to conceive until levels have been normal for 6 months .
* Persistent ßhCG elevation = presence of choriocarcinoma and requires tertiary centre referral.
* Serial serum quantitative ßhCG every 1-2 weeks until 3 consecutive tests show normal levels, after which ßhCG levels should be determined at 3 month intervals for 6 months after the spontaneous return to normal
F/U every 8 weeks for twelve months with urine pregnancy tests due to the risk of persistent trophoblastic disease or choriocarcinoma (10% of cases)
* Treatment with chemotherapy in cases of myometrial invasion or evidence of trophoblastic metastases to the brain, liver or lungs.
* The need for chemotherapy following a complete mole is 15% and after a partial mole 0.5%

Question 22

risks before evacuation (molar)

Answer 22

• haemorrhage
• trophoblastic invasion and perforation of the myometrium
• dissemination of possibly malignant cells
• Risks during evacuation:
• haemorrhage
• perforation by instruments
• dissemination of possibly malignant cells
• emergency hysterectomy

Question 23

Ectopic pregnancy

Answer 23

pregnancy in which implantation and the products of conception develop outside the uterine cavity
the fallopian tube is 95% of cases
1-2% of pregnancies
Mortality 10-15% deaths related to haemorrhage

Question 24

Ectopic (location)

Answer 24

Fertilisation is in the ampulla of the tube, the dilated end, furthest away from the uterus. The ampulla is also the most common site of ectopic implantation (90%) followed by the isthmus. Interstitial implantation is rare but dangerous because it ends in rupture of the uterine muscle with severe haemorrhage

Question 25

length of ectopic pregnancy influenced by …

Answer 25

location in fallopian tube
isthmic type occurs earlier around 6-8 weeks, has more severe bleeding and more often the tube ruptures as the diameter of the lumen is narrow.

Question 26

risk factors of ectopic

Answer 26

Previous tubal or pelvic infection/inflammation with residual endothelial damage or distortion by adhesions e.g chlamydia
Previous tubal or pelvic surgery e.g attempted sterilisation, reversal of sterilisation
Women who conceive with an IUD in situ due to infection or altered tubal motility
Assisted reproduction using ovulation stimulating drugs that can affect tubal motility e.g clomid and IVF techniques
Congenital tube abnormality such as hypoplasia, elongation or diverticulum
Migration of the ovum across the pelvic cavity to the fallopian tube on the side opposite to the follicle from which ovulation occurred. This can delay transportation of the fertilised ovum (blastocyst) to the uterus.
Maternal cigarette smoking is a main risk factor - thought to affect the ciliary action in the fallopian tubes

Question 27

Unruptured ectopic

Answer 27

symptoms of early pregnancy and varying degrees of abdominal and pelvic pain. The uterus still reaches the size of a gravid uterus of the same maturity and this may confuse diagnosis.

Question 28

Ruptured ectopic

Answer 28

collapse and weakness, fast and weak pulse of 110bpm or more, hypotension, dizziness, hypovolaemia, acute abdominal and pelvic pain, abdominal distension, rebound tenderness and pallor, shoulder pain. Bleeding occurs as the decidua degenerates and as a result of accumulated blood in the tube.

Question 29

diagnosis ectopic features

Answer 29

Abdominal pain: constant or cramp-like and usually always present.
Bleeding occurs after the death of the ovum and is an effect of oestrogen withdrawal.
Internal blood loss, collapse and shock if severe.
Closed cervix.
Pelvic and abdominal examination elicit extreme tenderness over the gravid tube and in one or both fossa. Resistance to palpation and guarding occurs in cases of severe intraperitoneal bleeding

Question 30

Medical management ectopic

Answer 30

Timely assessment and careful history taking
Always suspect a tubal pregnancy diagnosis until proven otherwise
Confirm the pregnancy by a pregnancy test and determine gestation if LMP known
Arrange transvaginal USS to exclude an intrauterine pregnancy and lab studies

Question 31

methotrexate

Answer 31

treatment for an unruptured ectopic pregnancy, aids in tubal preservation, and is important for future fertility attempts particularly couples using ART.
NB: is cytotoxic. Caution with pregnant women
Action: Is a folic acid antagonist that interferes with DNA synthesis and cell multiplication = dissolution of the ectopic mass and results in resorption of the conceptus
Women must have an unruptured ectopic on U/S.
Serum βHCG level, FBC, renal function, and LFTs must be done and be within normal limits before IM injection by medical staff.
Hospitalised for 4 hours for observations and may then be discharged. Causes nausea and vomiting.
F/U: Day 4 HCG titre, Day 7 HCG titre and repeat bloods, then weekly HCG titre until negative. Average resolution of the ectopic pregnancy is 6 weeks.
F/U in EPAS and advise not to conceive for 3 months post Methotrexate administration

Question 32

surgery for ruptured ectopic

Answer 32

Restore the blood volume by RBCs or volume expander
Laparoscopic salpingectomy advised as conservation of the tube increases the risk of a further ectopic pregnancy, or
Laparotomy if extensive intraperitoneal bleeding
Advice on prognosis for fertility. Chances of infertility problems are up to 40-50% if the tube is removed.
Increased risk of future ectopic pregnancy is 10-15%, a 10% risk of persistent trophoblast, and therefore F/U serial hCG levels at weekly intervals.
Correct anaemia.
Schedule a follow up visit at 4 weeks

Question 33

midwifery management ectopic

Answer 33

present to A&E and are often cared for in the antenatal/gynaecology ward.
Provide post-operative care as indicated.
Administer pain relief.
Assess Rhesus status, if Rh negative must give Anti D (250 I.U).
Emotional support: acknowledgement of the loss and that it is acceptable to grieve for the pregnancy and tube (if this was also removed).
Social work support and counselling should be offered.
DOCUMENTATION

Question 34

hyperemesis gravidarum

Answer 34

excessive vomiting in pregnancy that begins between 4-10 weeks, should resolve 20 weeks
Hypovolaemia and electrolyte imbalance are corrected by IV infusion.
If left untreated hyperemesis worsens and occasionally causes Wernicke’s encephalopathy, hepatic and renal involvement leading to coma and death.

Question 35

hyperemesis incidence

Answer 35

0.3-3% admission

Question 36

investigations hyperemesis

Answer 36

bloods - FBC, urea and electrolytes, liver function, thyroid
urine - UA for ketones, microscopy and cultures
radiology - USS

Question 37

medical management

Answer 37

Ensure correct diagnosis
Assess physical condition
Treat S/S of dehydration: elevated haematrocrit, electrolyte disturbance and ketonuria

Question 38

Initial treatment hyperemesis

Answer 38

NBM and give IV therapy to correct hypovolaemia and electrolyte imbalance. Drugs that are often considered as additional therapy include:
* Anti-emetics (Maxalon, Ondansetron) - can affect baby’s development of organs
* Pyridoxine (Vitamin B6 mainly for nausea),
* Antihistamines (doxylamine, cyclazine, promethazine)
* Oral steroids Short term enteral nutrition or TPN.

Question 39

cervical insufficiency/incompetence/weak cervix

Answer 39

Painless dilatation of the cervix in the second or early third trimester, often with bulging membranes through the cervix.
Risk of miscarriage if the membranes rupture.
Causes: cervical trauma from past cone biopsy, D&C, TOP, congenital weakness of the cervix.
Recurs in subsequent pregnancies.
Cervical cerclage: Shirodkar (purse string) suture is put around the neck of the cervix around 14 weeks, and left insitu until 38 weeks or at the onset of labour when it is removed.