Complications of early pregnancy

Question 1

Miscarriage - def & types

Answer 1

• Spontaneous loss of a pregnancy before 24 weeks gestation
• First Trimester: before 13 weeks
• Complete miscarriage: all products expelled and bleeding stopped
• Threatened: when a patient knows she is pregnant, she is bleeding but she hasn’t not miscarriaged yet
• Missed miscarriage: pregnancy failed but no bleeding
• Recurrent: spontaneous consecutive loss of three pregnancies before 24 weeks gestation

Question 2

Miscarriage - Causes

Answer 2

Foetal:

• abnormal zygotic development
• aneuploid abortion

Maternal:

• Systemic: infectious, chronic d/s, TB, carcinomatosis, coeliac sprue
• Local: trauma, Asherman’s syndrome, uterine leiomyomas, incompetent cervix
• Endocrine: hypothyroidism, DM, progesterone deficiency
• Env: smoking, alcohol, caffeine, radiation

Paternal

Question 3

Miscarriage - S&S

Answer 3

• Known pregnancy or period of amenorrhoea present with vaginal bleeding prior 24 week gestation
• Lower abdominal cramping
• LBP

Question 4

Miscarriage - Management

Answer 4

o Hospital- USS
o Threatened miscarriage: if bleeding gets worse or persists for 14 days- return for assessment otherwise normal ANC
o Depending on type: complete no Rx, missed/incomplete miscarriage-misoprostol (vaginal or oral), surgery (suction or ERPC)

Question 5

Ectopic pregnancy - what is it?

Answer 5

= Pregnancy outside uterine cavity

Question 6

Ectopic pregnancy - where?

Answer 6

Most tubal, can occur abdomen, ovary, cervix, caesarean scar

Question 7

Heterotopic pregnancy - def

Answer 7

Multiple gestation with 1 in the uterine cavity & the other outside of the uterus

Question 8

Ectopic pregnancy - causes

Answer 8

Fallopian tube damage

Question 9

Ectopic pregnancy - risks

Answer 9

• Previous ectopic
• PID
• Damage due to surgery (sterilisation, reversal sterilisation, tubal reconstruction)
• IUD
• Assisted fertility
• Smoking, age
• Multiple partners

Question 10

Ectopic pregnancy - Cx

Answer 10

maternal death
tubal rupture
intra-abdominal bleeding
spontaneous abortion 
recurrence

Question 11

Ectopic pregnancy - S&S

Answer 11

o	Abdominal/pelvic pain
o	GI symptoms
o	Fainting, dizziness
o	Low BP 
o	Shoulder tip pain
o	Vaginal bleeding
o	May not have symptoms of pregnancy (+ hCG)

Question 12

Ectopic pregnancy - Tx

Answer 12

o Wait and see but monitored -hCG
o Drug: methotrexate then monitor
o Surgery: emergency

Question 13

Trophoblastic disorder - what is it?

Answer 13

• Hydatidiform/ molar pregnancy: unsuccessful pregnancy- issues with development
• Can contain no foetal tissue

Question 14

Trophoblastic disorder - When is it more common?

Answer 14

• More common at extremes of fertility age- early or perimenopausal
• Over 35 years ➤ 2 fold risk, over 40 ➤ 5 to 10 fold risk

Question 15

Trophoblastic disorder - S&S

Answer 15

o Through routine USS
o Positive hCG
o Vaginal bleeding- 50% cases
o Hyperemesis: high hCG
o Signs of hyperthyroidism due to high levels of hCG
o Examination- wrong size for dates, ovarian cysts, bulky uterus
o Rarely: twins- viable foetus and mole

Question 16

Trophoblastic disorder - Ix

Answer 16

o	Bloods: platelets and look for anaemia, liver function tests 
o	Clotting
o	Beta-hCG 
o	USS 
o	Imaging- chest X-ray

Question 17

Trophoblastic disorder - Tx

Answer 17

o Surgery
o Treatment
o Considered malignant if serum hCG levels plateau or rise once pregnancy removed- 15- 20% cases
o 1 in 500-600 pregnancies will be choriocarcinoma - increases with age
o If neoplastic- staging
o Metastases- lungs, brain, liver, GI tract

Question 18

N&V in pregnancy - causes

Answer 18

o hCG
o Oestrogen
o Nutritional deficiency (hyperemesis gravidarium deficient in vitamin B6)
o Gastric dysfunction- increased progesterone

Question 19

Hyperemesis gravudarum - S&S

Answer 19

prolonged nausea and vomiting
dehydration
electrolyte imbalance
ketosis

Question 20

N&V in pregnancy - associated factors

Answer 20

o	Female foetus
o	Previous history in pregnancies
o	History of motion sickness
o	History of migraines
o	First pregnancy
o	Obesity
o	Stress

Question 21

N&V in pregnancy - Management

Answer 21

o History: onset, duration, what is being tolerated, associated symptoms, coexisting conditions eg diabetes
o Examine for dehydration, test for ketones
o Reassure
o Small frequent meals, drink little and often
o Ginger and acupressure (NICE, 2008) evidence weak
o Rest
o Urgent medical care: very dark urine, abdominal pain, fever, faint, dizziness, vomiting blood, inability to keep food or fluids down for 24 hours