Disorders of Early Pregnancy

Question 1

What occurs after fertilisation?

Answer 1

Oocyte is fertilised in the ampulla of fallopian tube to form zygote

Mitotic division occurs as zygote is swept towards uterus by ciliary action and peristalsis

Normally enters uterus on day 4, morula becomes blastocyst by developing fluid filled cavity within

Outer layer of blastocyst becomes trophoblast -> placenta which invades endometrium on day 6-12

Question 2

What hormones does the trophoblast produce?

Answer 2

hCG (peaks at 12 weeks)

Maintains corpus luteum to produce oestrogen and progesterone

Question 3

At what gestation can a heartbeat be heard?

Answer 3

4-5 weeks

Question 4

What is a miscarriage?

Answer 4

Fetus dies before 24 weeks

Majority occur before 12 weeks

Question 5

What are types of miscarriage?

Answer 5

Threatened - bleeding but fetus is still alive and os is closed

Inevitable - heavy bleeding, fetus is alive but os is OPEN

Incomplete - some fetal parts have passed but os is OPEN

Complete - all fetal tissue has passed, bleeding has decreased and os is closed

Septic - contents of uterus are infected -> endometritis

Missed - uterus is smaller than expected and os is closed

Question 6

What investigations are done in miscarriage?

Answer 6

USS - shows if fetus is viable
Should be repeated a week after

Blood test - hCG decreases

Question 7

How are miscarriages managed?

Answer 7

Admission if ectopic, septic or heavy bleeding

Ergometrine will contract uterus if fetus is non-viable

Anti-D

Question 8

What is expectant management of a miscarriage?

Answer 8

If no signs of infection

Passes within 2-6 weeks

Question 9

What is medical management of a miscarriage?

Answer 9

Prostaglandin
Mifepristone - anti-progesterone
Better for missed miscarriage

Question 10

What is surgical management of a miscarriage?

Answer 10

Evacuation of retained products of conception (ERPC) under anaesthetic

Done if heavy bleeding, infection

Tissue examined to exclude molar pregnancy

Question 11

What are complications of a miscarriage?

Answer 11

Bleeding can be heavy

Endotoxic shock -> hypotension, renal failure, adult RDS, DIC

Question 12

What is recurrent miscarriage?

Answer 12

Three or more in succession
Chance of miscarriage is 40%
But cause may be more likely

Question 13

What causes recurrent miscarriages?

Answer 13

Antiphospholipid antibodies causing thrombosis in uteroplacental circulation
Tx: aspirin and LMWH

Chromosomal defect - 4%
Mx: clinical geneticist, CVS, amniocentesis

Anatomical factors - do USS, usually cause late miscarriage

Infection - treat BV

Others - obesity, smoking, PCOS, excess caffeine

Question 14

What abortion methods exist?

Answer 14

Medical - suction curettage or dilation and excavation

Surgical - mifepristone + prostaglandin

Question 15

At what gestation are surgical methods used for abortion?

Answer 15

Surgical curettage - 7-13 weeks

Dilation and excavation - >13 weeks

Antibiotics are given

Question 16

At what gestation are medical methods used for abortion?

Answer 16

Mifepristone is given
36-48hrs later prostaglandin is given

Most effective method before 7 weeks

Question 17

What are complications of abortions?

Answer 17

Haemorrhage
Infection
Uterine perforation
Cervical trauma

Question 18

What are the common sites for an ectopic pregnancy?

Answer 18

Fallopian tube
Comual
Ovarian
Cervical
Abdominal

Question 19

What are risk factors for an ectopic?

Answer 19

PID
Assisted conception
Pelvic surgery
Previous ectopic
Smoker

Question 20

How does an ectopic present?

Answer 20

Vaginal bleeding - dark
Abdo pain - colicky then constant (shoulder tip pain suggests intraperitoneal bleed)
Collapse

Question 21

How is an ectopic investigated?

Answer 21

PREGNANCY TEST
USS to show intrauterine pregnancy
Levelling or reduction in serum hCG

Question 22

What investigations are done on ?pregnant women?

Answer 22

Serum hCG >2000 should mean viable fetus on transvaginal USS

Should double every 48hrs

Question 23

How is an ectopic treated?

Answer 23

Conservative: if small and unruptured, low hCG or location not known, can watch and wait

Medical: if unruptured with no cardiac activity, single dose methotrexate with serial hCG
May need second dose

Laparoscopic or laparatomic removal of the affected tube

Question 24

What is hyperemesis gravidarum?

Answer 24

Nausea and vomiting in early pregnancy is so severe it causes dehydration, weight loss or electrolyte imbalances

More common in multips

Question 25

What is the management of hyperemesis gravidarum?

Answer 25

Rule out predisposing conditions - UTIs, multiple/molar pregnancies

IV rehydration
Antiemetics - metoclopramide, thiamine

Question 26

What is gestational trophoblastic disease?

Answer 26

Trophoblastic tissue proliferates aggressively and secretes excess hCG

ASIANS

Can be localised and none invasive - hydatidiform mole

Question 27

What are the two types of molar pregnancy?

Answer 27

Complete - 1 sperm undergoes mitosis in empty egg = 46XX

Partial - 2 sperm entering oocyte = 69XXX

Question 28

What is gestational trophoblastic neoplasia?

Answer 28

Invasive mole or choriocarcinoma
15% of complete moles
0.5% of partial moles
Can also follow miscarraige or normal pregnancy

Spread to lungs
Very sensitive to chemo
Very good survival

Question 29

How does GTD present?

Answer 29

Large uterus
Pre-eclampsia and hyperthyroidism
PV bleed
Hyperemesis

Question 30

What investigations are done for GTD?

Answer 30

USS - SNOWSTORM with complete molar

Confirm histologically

Question 31

How is GTD managed?

Answer 31

Removed by suction curettage
Serial blood hCG - if it rises this is suggestive of malignancy

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