Disorders of Early Pregnancy Flashcards
What occurs after fertilisation?
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
What hormones does the trophoblast produce?
hCG (peaks at 12 weeks)
Maintains corpus luteum to produce oestrogen and progesterone
At what gestation can a heartbeat be heard?
4-5 weeks
What is a miscarriage?
Fetus dies before 24 weeks
Majority occur before 12 weeks
What are types of miscarriage?
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
What investigations are done in miscarriage?
USS - shows if fetus is viable
Should be repeated a week after
Blood test - hCG decreases
How are miscarriages managed?
Admission if ectopic, septic or heavy bleeding
Ergometrine will contract uterus if fetus is non-viable
Anti-D
What is expectant management of a miscarriage?
If no signs of infection
Passes within 2-6 weeks
What is medical management of a miscarriage?
Prostaglandin
Mifepristone - anti-progesterone
Better for missed miscarriage
What is surgical management of a miscarriage?
Evacuation of retained products of conception (ERPC) under anaesthetic
Done if heavy bleeding, infection
Tissue examined to exclude molar pregnancy
What are complications of a miscarriage?
Bleeding can be heavy
Endotoxic shock -> hypotension, renal failure, adult RDS, DIC
What is recurrent miscarriage?
Three or more in succession
Chance of miscarriage is 40%
But cause may be more likely
What causes recurrent miscarriages?
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
What abortion methods exist?
Medical - suction curettage or dilation and excavation
Surgical - mifepristone + prostaglandin
At what gestation are surgical methods used for abortion?
Surgical curettage - 7-13 weeks
Dilation and excavation - >13 weeks
Antibiotics are given
At what gestation are medical methods used for abortion?
Mifepristone is given
36-48hrs later prostaglandin is given
Most effective method before 7 weeks
What are complications of abortions?
Haemorrhage
Infection
Uterine perforation
Cervical trauma
What are the common sites for an ectopic pregnancy?
Fallopian tube Comual Ovarian Cervical Abdominal
What are risk factors for an ectopic?
PID Assisted conception Pelvic surgery Previous ectopic Smoker
How does an ectopic present?
Vaginal bleeding - dark
Abdo pain - colicky then constant (shoulder tip pain suggests intraperitoneal bleed)
Collapse
How is an ectopic investigated?
PREGNANCY TEST
USS to show intrauterine pregnancy
Levelling or reduction in serum hCG
What investigations are done on ?pregnant women?
Serum hCG >2000 should mean viable fetus on transvaginal USS
Should double every 48hrs
How is an ectopic treated?
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
What is hyperemesis gravidarum?
Nausea and vomiting in early pregnancy is so severe it causes dehydration, weight loss or electrolyte imbalances
More common in multips
What is the management of hyperemesis gravidarum?
Rule out predisposing conditions - UTIs, multiple/molar pregnancies
IV rehydration
Antiemetics - metoclopramide, thiamine
What is gestational trophoblastic disease?
Trophoblastic tissue proliferates aggressively and secretes excess hCG
ASIANS
Can be localised and none invasive - hydatidiform mole
What are the two types of molar pregnancy?
Complete - 1 sperm undergoes mitosis in empty egg = 46XX
Partial - 2 sperm entering oocyte = 69XXX
What is gestational trophoblastic neoplasia?
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
How does GTD present?
Large uterus
Pre-eclampsia and hyperthyroidism
PV bleed
Hyperemesis
What investigations are done for GTD?
USS - SNOWSTORM with complete molar
Confirm histologically
How is GTD managed?
Removed by suction curettage
Serial blood hCG - if it rises this is suggestive of malignancy
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