Disorders Of Early Pregancy

Question 0

What is an incomplete miscarriage?

Answer 0

Some foetal parts have been passed but the os is usually open

Question 1

What is a threatened miscarriage?

Answer 1

There is bleeding but the foetus is still alive, the uterus is the size expected from the dates and the os is closed.

Only 25% will go on to miscarry

Question 2

What is a complete miscarriage?

Answer 2

All foetal tissue has been passed.

Bleeding has diminished, the uterus is no longer enlarged and the cervical os is closed

Question 3

What is an inevitable miscarriage?

Answer 3

The bleeding is usually heavier

Although the foetus may still be alive, the cervical os is open.

Miscarriage is about to occur

Question 4

What are the clinical features of miscarriage on history and examination?

Answer 4

History:
Vaginal bleeding - may be clots or tissue
Low abdominal pain

Examination
Uterine size and state of the cervical os should be examined, as these vary with the type of pregnancy

Question 5

What investigations are indicated in suspected miscarriage?

Answer 5

Speculum examination- for state of cervical opening
Ultrasound scan - confirms location and size of gestational sac
Bloods- FBC and blood group
Serum b-hcg levels may be useful

Question 6

How is miscarriage managed?

Answer 6

Counsel patient
Give Anti-D to Rhesus negative women

May require mechanical dilatation and curettage of the uterus for the evacuation of retained products of conception if the miscarriage is complete. This is done under anaesthetic

Or misoprostolol

Or spontaneous resolution waited for two weeks

Question 7

What is the definition of recurrent miscarriage?

Answer 7

When three or more miscarriages occur in succession

This affects 1% of couples

The chance of having a further miscarriage is 40%, but having further investigations is indicated

Question 8

What investigations are indicated in recurrent miscarriage?

Answer 8

Autoimmune screen, thrombophilia screen
Karyotyping of both parents
Pelvic ultrasound

Question 9

What are the causes of recurrent miscarriage?

Answer 9

Autoimmune disease
Chromosomal defects
Poly cystic ovary syndrome
Uterine abnormality 
Infection 
Obesity, smoking and higher maternal age are implicated

Question 10

What is he most common cause of miscarriage?

Answer 10

Greater than 60% are due to isolated non-recurring chromosomal abnormalities

Question 11

How common is spontaneous miscarriage?

Answer 11

15 percent of clinically recognised pregnancies

Question 12

How common are ectopic pregnancies?

Answer 12

1% of pregnancies

Question 13

What are the risk factors for ectopic pregnancy?

Answer 13

Maternal age
Number of sexual partners
Use of IUD
PID
After pelvic surgery

Question 14

What are the clinical features of ectopic pregnancy?

Answer 14

Lower abdominal pain - colicky
Dark vaginal bleeding
Syncopal episodes and shoulder tip pain may be a result if intraperitoneal blood loss

On examination:
Tachycardia due to blood loss
Abdominal guarding/rebound tenderness
Cervical excitation

Question 15

What investigations are indicated in suspected ectopic pregnancy?

Answer 15

Urine hcg (pregnancy test)
FBC and cross match
Ultrasound to detect intrauterine pregnancy- if not present, either ectopic or less than five weeks gestation
Serum hcg - repeat in 48 hours - If there is a change in concentration between 50% decline and 63% rise inclusive over 48 hours, suggestive of ectopic
Consider transvaginal ultrasound if uterus is empty
Consider laparoscopy if repeat hcg is above 600 and absence of intrauterine gestational sac on USS

Question 16

What is the management of ectopic pregnancy?

Answer 16

Admit if symptomatic
IV access
Give anti d if Rhesus negative

Surgical:
Laparoscopy and remove affected tube (salpingostomy)

Medical:
Single dose methotrexate - if hcg is <3000, patient is clinically stable, ectopic is less than 3cm on ultrasound

May require repeat dose

Question 17

What is gestational trophoblastic disease, and what are the different types?

Answer 17

Trophoblastic tissue (part of the blastocyst) invades the endometrium and proliferates, secreting hcg

Hydatiform mole: localised and non invasive proliferation

Invasive mole: proliferation has characteristics if malignancy

Choriocarcinoma: invasive mole that has metastasis

Complete mole: entirely paternal, when a sperm fertilises an empty ovum and undergoes mitosis

Partial mole: triploid, derived from two sperms and one egg

Question 18

What are the clinical features of GTD?

Answer 18

Vaginal bleeding, may be heavy
Severe vomiting

Large uterus
Early pre-eclampsia and hyperthyroidism may occur

Question 19

How is GTD investigated?

Answer 19

Post excision histology necessary for diagnosis

USS may show uterus with swollen villi

Question 20

How is GTD managed?

Answer 20

Suction curettage
Serial blood:urine hcg taken for 6-24 months. if persistently high, this is suggestive of malignancy

Up to 29% will develop a persistent trophoblastic tumour

Question 21

What is the medical management of ectopic pregnancy?

Answer 21

Single dose methotrexate

Indicated if:
Hcg is <3cm on ultrasound

Check hcg on days 4 and 7 post injection - if no 15% drop, give second dose

After methotrexate, avoid pregnancy for three months and abstain from intercourse until pregnancy is finished

Question 22

When is urgent laparotomy indicated in suspected ectopic?

Answer 22

Haemodynamically unstable, with live, bleeding ectopic

Laparoscopy may be attempted instead but if very Ill, need to stop the bleeding