Disorders Of Early Pregnancy

Question 1

Clinical features of miscarriage

Answer 1

Bleeding
+- pain due to uterine contractions

Some tenderness on examination, uterus size and so status dependent on type of miscarriage

Question 2

Investigations required with bleeding in early pregnancy

Answer 2

TVUS
Serum BetaHCG
FBC- Hb
Rhesus group

Question 3

Causes of sporadic miscarriage

Answer 3

> 60% chromosomal abnormalities (often trisomies)

Not caused by: stress, intercourse, exercise or emotional trauma

Outcome in 15% of clinically recognised pregnancies

Question 4

Causes of recurrent miscarriage

Answer 4

Antiphoholipid syndrome - anti cardiolipin abs and anti lupus ag
Aspirin + low dose LMWH
Chromosomal defects - both parents karyotype
Anatomical abnormalities - hysterosalpingogram
Infection (late miscarriage, treat BV)

Question 5

Termination of Pregnancy - statutory grounds

Answer 5

Up to 24 weeks:
Continuing would involve greater risk to physical or mental health of either pregnant woman or children in the family
Beyond 24 weeks:
Risk of serious handicap due to mental or physical abnormalities if born
Risk of grave injury to mental health of woman / risk to life

Question 6

Termination of pregnancy - types

Answer 6

Medical: anti progesterone mifepristone + prostaglandin misoprostol 36-48hrs later
> 22 wks KCl first into umbilical vein - feticide (for fetal abnormality)
Surgical: 13 wks dilation + evacuation
abx cover req for all surgical TOP

Question 7

Termination of Pregnancy - complications

Answer 7

Haemorrhage: 1/1000
Infection: up to 10%
Uterine perforation: 1-4/1000
Cervical trauma
Failure
Multiple surgical ToP assoc w incr risk of subsequent preterm delivery

Question 8

Ectopic pregnancy

Answer 8

1/60-100 pregnancies
Mortality: 17/100000 ectopics
More common with advanced maternal age
95% in Fallopian tubes
Other sites: Cornu, cervix, ovary, abdominal cavity
RF: prev ectopic, PID, smoker, IUD, IVF

Question 9

Ectopic pregnancy - presentation

Answer 9

Bleeding: small scanty dark PV blood
Pain: colicky Abdo pain -> constant
Amenorrhoea: 4-10 wks
Red flag: shoulder tip pain/syncope = intra peritoneal blood loss
Abdo exam: abdo and rebound tenderness
Bimanual: adnexal tenderness, smaller than expected uterus, os closed

Question 10

Ectopic pregnancy suspected - investigations

Answer 10

Urine B-HCG

TVUS: no intrauterine preg: missed miscarriage,

Question 11

Interpreting quantitative serum B-HCG results

Answer 11

> 1000 = intrauterine pregnancy usually visible on TVUS
66% in 48hrs= earlier intrauterine pregnancy
Plateau/decline = ectopic/ non-viable intrauterine pregnancy

Question 12

Risk factors for ectopic pregnancy

Answer 12

PID
Prev inflammatory disease?
Prev gynae surgery, esp tubal
Prev ectopic
Assisted reproduction
Endometriosis
IUD
POP