Early pregnancy Flashcards
What is an ectopic pregnancy?
When a pregnancy is implanted outside of the uterus
- Most common site: fallopian tube
- Can implant in entrance to the fallopian tube (cornual region), ovary, cervix, or abdomen
Where is the most common site for an ectopic pregnancy?
What are the risk factors for an ectopic pregnancy?
(anything slowing the ovum’s passage to the uterus)
- Previous ectopic pregnancy
- Previous PID (damage to tubes)
- Previous surgery to the fallopian tubes
- Intrauterine devices (coils)
- Older age
- Smoking
- Progesterone only pill
- IVF- 3% pregnancies are ectopic
When does an ectopic pregnancy present?
6-8 weeks gestation
What are the classic features of an ectopic pregnancy?
- Missed period
- Constant lower abdo pain in the right or left iliac fossa
- Vaginal bleeding
- Lower abdo or pelvic tenderness
- Cervical motion tenderness (pain when moving the cervix during a bimanual examination)
What is the investigation of choice for diagnosing a miscarriage?
Transvaginal ultrasound scan- to identify the location of the pregnancy and whether there is a fetal pole and heartbeat
If a TV USS is unacceptable offer a transabdominal USS and explain the limitations of this method
What may be seen on a transvaginal ultrasound for an ectopic pregnancy?
- Gestational sac containing a yolk sac or fetal pole may be seen in a fallopian tube
- Sometimes a non specific mass may be seen in the tube
- Mass containing empty gestational sac- blob/ bagel/ tubal ring sign
- An empty uterus
- Fluid in uterus which may be mistaken as gestational sac- pseudogestational sac
How is a tubal ectopic pregnancy differentiated from a corpus luteum?
Tubal ectopic pregnancy moves separately to the ovary where as a corpus luteum will move with the ovary
What is a pregnancy of unknown location? How do you confirm it?
Woman has a positive pregnancy test but there is no evidence of pregnancy on the ultrasound scan
- hCG can be tracked to monitor a pregnancy of unknown location
- The serum hCG is repeated after 48 hrs to measure the change from baseline
- The developing syncytiotrophoblast of the pregnancy produces hCG, it will double every 48 hrs in an intrauterine pregnancy
- Rise of 63% or more indicates intrauterine pregnancy
- USS after 1-2 weeks to confirm this - pregnancy visible on USS once hCG is > 1500 IU/L
- This will not be the case in a miscarriage/ ectopic pregnancy
- A fall of 50% or more hCG is likely a miscarriage
- Urinary pregnancy test should be carried out after 2 weeks to confirm the miscarriage is complete
Where are women with pelvic pain or tenderness and a positive pregnancy test referred to?
Early pregnancy assessment unit or gynaecology service
What are the three options for terminating an ectopic pregnancy?
- Expectant management (awaiting natural termination)
- Medical managment (methotrexate)
- Surgical management (salpingectomy or salpingotomy)
What is the criteria for expectant management?
- Followup needs to be possible to ensure successful termination
- Ectopic needs to be unruptured
- Adnexal mass <35mm
- No visible heartbeat
- No significant pain / asymptomatic / clinically stable
- HCG level <1000 IU/L
What is the criteria for methotrexate termination of ectopic pregnancy?
- HCG level must be <1500 IU/L
- Confirmed absence of intrauterine pregnancy on ultrasound
- No significant pain
- Have an unruptured tubal ectopic pregnancy with an adnexal mass smaller than 35 mm with no visible heartbeat
- Do not have intrauterine pregnancy as confirmed by USS
- Are able to return for follow up
How is methotrexate given for termination?
Intramuscular injection into a buttock - results in spontaneous termination
What are women advised regarding pregnancy after methotrexate termination?
Not to get pregnant for 3 months
What are the side effects of methotrexate management of ectopic?
- Vaginal bleeding
- Nausea and vomiting
- Abdo pain
- Stomatitis (inflammation of the mouth)
Who requires surgical mangement for ectopic pregnancy?
Those who do not meet the criteria for expectant or medical management
Offered first line to those who are unable to return for follow up, and:
- Significant pain
- Adnexal mass > 35mm
- Fetal heartbeat visible on USS
- hCG > 5000 IU/L
- Can be ruptured
What are the options for surgical managment of ectopic pregnancy?
- Laparoscopic salpingectomy
- First-line
- General Anaesthetic
- Keyhole surgery with removal of the affected fallopian tube along with the ectopic prenancy inside the tube
- Laparoscopic salpingotomy
- May be used in women at increased risk of infertility due to damage of the other tube
- Aim to avoid removing the affected fallopian tube
- A cut is made in the fallopian tube, the ectopic pregnancy is removed, the tube is closed
- Increased risk of failure to remove the ectopic pregnancy; up to 1 in 5 require further mx with methotrexate or salpingectomy
Also give anti rhesus D prophylaxis to those who are rhesus negative having surgical mx of ectopic pregnancy
What is a miscarriage?
Spontaneous termination of a pregnancy
Early: before 12 weeks gestation
Late: between 12-24 weeks gestation
What is a missed misscarriage?
Fetus is no longer alive, but no symptoms have occured
What is a threatened miscarriage?
Vaginal bleeding with a closed cervix and a fetus thats alive
What is an inveitable miscarriage?
Vaginal bleeding with an open cervix
What is an incomplete miscarriage?
Retained products of conception which remain in the uterus after the miscarriage
What is a complete miscarriage?
A full miscarriage has occured and there are no products of conception left in the uterus
What is anembryonic pregnancy?
Gestational sac is present but contains no embryo
What is the investigation of choice for diagnosing a miscarriage?
Transvaginal ultrasound scan
What are the three key features which a sonographer looks for in an early pregnancy?
- Mean gestational sac diameter
- Fetal pole and crown rump length
- Fetal heartbeat- when this appears the pregnancy is considered viable
(appear sequentially as pregnancy develops, as each appear the previous feature becomes less relevant in assessing viability of the pregnancy)
At what length of crown-rump is a fetal heartbeat expected?
7mm or more
What happens if there is a crown rump length of 7mm or more without a fetal heartbeat?
Scan is repeated after one week before confirming a non-viable pregnancy
When is a fetal pole expected?
Once the mean gestational sac diameter is 25mm or more
What confirmatory investigation is done when there is a mean gestational sac diameter of 25mm or more without a fetal pole?
Scan is repeated after one week before confirming an anembryonic pregnancy
What is the management of women with a pregnancy less than 6 weeks gestation presenting with bleeding?
Managed expectantly provided they have no pain and no other complications or risk factors e.g. previous ectopic
- This means awaiting the miscarriage with Ix or treatment
- USS is unlikely to be helpful as the pregnancy will be too small to be seen
- Repeat urine pregnancy test after 7-10 days, if negative, miscarriage can be confirmed
- When bleeding continues or pain occurs- further ix is indicated
How to manage a women with a positive pregnancy test and bleeding?
Referral to an early pregnancy assessment unit for women with a positive pregnancy test
What are the investigations for a woman presenting after 6 weeks gestation and bleeding?
Ultrasound scan to confirm the location and viability of the pregnancy - essential to always consider and exclude an ectopic pregnancy
What are the three options for managing a miscarriage?
- Expectant managment (do nothing and await a spontaneous miscarriage)
- Medical managment (misoprostol- postaglandin analogue, activates prostaglandins softening the cervix and stimulating uterine contractions. Vaginal suppositry or an oral dose)
- Surgical managment (manual vacuum aspiration under local anaesthetic or electric vacuum aspiration under general anaesthetic)
When is expectant management offered for miscarriages in over 6 weeks gestation?
First-line for women without risk factors for heavy bleeding or infection
1-2 weeks are given to allow the miscarriage to occur spontaneously (repeat urine pregnancy test should be performed three weeks after bleeding and pain settle to confirm miscarriage is complete)
In an expectant miscarriage, when are further assessments and repeat ultrasounds warranted?
Persistent or worsening bleeding - indicates an incomplete miscarriage and require additional management
What is misoprostol?
Prostaglandin analogue - it binds to prostaglandin receptors and activates them
What do prostaglandins do?
Soften the cervix
Stimulate uterine contractions
How is misoprostol given to expedite the process of miscarriage?
Vaginal suppository
Oral dose
What are the side effects of misoprostol?
- Heavier bleeding
- Pain
- Vomiting
- Diarrhoea
What are the two options for surgical management of a miscarriage?
Manual vacuum aspiration under local anaesthetic as an outpatient
- Tube attached to a syringe is inserted through the cervix into the uterus
- Manually use the syringe to aspirate contents of uterus
- More appropriate for parous women (given birth before)
Electric vacuum aspiration under general anaesthetic
- Electric powered vacuum removes contents of uterus through the cervix
Prostaglands (misoprostol) given before surgical mx to soften cervix
Anti rhesus D prophylaxis needs to be given to rhesus negative women prior to surgical mx of ectopic pregnancy
What is an incomplete miscarriage? Describe the management options?
Retained products of conception (fetal or placental tissue) remains in the uterus - risk of infection
Mx:
- Medical- misoprostol
- Surgical- evacuation of retained products of conception (ERPC)- surgical procedure under GA
- The cervix is gradually widened using dilators, the retained products are manually remoed using vacuum aspiration and curettage (scarping)
- Key complication is endometritis- infection of endometrium
What is recurrent miscarriage defined as?
Three or more consecutive miscarriages
What are the rates of miscarriage?
10% in women aged 20 – 30 years
15% in women aged 30 – 35 years
25% in women aged 35 – 45 years
50% in women aged 40 – 45 years
When are miscarriage investigations initiated?
3 / more first trimester miscarriages
2 / more second trimester miscarriages
What are the causes of miscarriage?
Idiopathic (particularly in older women)
Antiphospholipid syndrome
Hereditary thrombophilias
Uterine abnormalities eg uterine septum
Genetic factors in parents (e.g. balanced translocations in parental chromosomes)
Chronic histocytic intervillositis
Smoking
Other chronic diseases e.g. diabetes, untreated thyroid disease and SLE, PCOS
What is antiphospholipid syndrome? How can it occur?
Disorder associated with antiphospholipid antibodies where blood becomes prone to clotting - patient is in a hyper-coagulable
Main associations: Thrombosis (both venous and arterial) and complications in pregnancy, particularly recurrent miscarriages, and thrombocytopenia, prolonged APTT
Can occur on its own or secondary to autoimmune condition such as SLE
How is the risk of miscarriage in patients with antiphospholipid syndrome reduced?
- Low dose aspirin
- Low molecular weight heparin
What are some key hereditary thrombophilias to remember?
Factor V Leiden (most common)
Factor II (prothrombin) gene mutation
Protein S deficiency
What uterine abnormalities can cause recurrent miscarriages?
Uterine septum (a partition through the uterus)
Unicornuate uterus (single-horned uterus)
Bicornuate uterus (heart-shaped uterus)
Didelphic uterus (double uterus)
Cervical insufficiency
Fibroids
What is chronic histiocytic intervillositis?
Rare cause of recurrent miscarriages - particularly in 2nd trimester
It can also lead to intrauterine growth restriction (IUGR) and intrauterine death
The condition is poorly understood- histiocytes and macrophages build up in placenta causing inflammation and adverse outcomes, diagnosed by placental histology showing infitlrates of mononuclear cells in the intervillous spaces
What are the investigations for patients with recurrent miscarriages?
- Antiphospholipid antibodies
- Testing for hereditary thrombophilias
- Pelvic ultrasound
- Genetic testing of the products of conception from the third or future miscarriages
- Genetic testing on parents
What may help during early pregnancy for women with recurrent miscarriages and bleeding?
Vaginal progesterone pessaries (evidence from PRISM trial) - may become guidelines in future but current guidelines state that there is insufficient evidence for progesterone supplementation
What are the Acts which govern over abortions?
1967 Abortion Act
1990 Human Fertilisation and Embryology Act (altered and expanded act and reduced the latest gestational age where an abortion is legal from 28 to 24 weeks)
Key points
- 2 registered medical practitioners must sign a legal document (in an emergency only one is needed)
- Only a registered medical practitioner can perform an abortion, which must be in a NHS hospital or licensed premise
When can an abortion be performed before 24 weeks?
If continuing the pregnancy involves greater risk to the physical or mental health of:
- The woman
- Existing children of the family
When can an abortion be performed at any time during the pregnancy?
- Continuing pregnancy is likely to risk the life of the woman
- Terminating the pregnancy will prevent “grave permanent injury” to the physical or mental health of the woman
- There is substantial risk that the child would suffer physical or mental abnormalities making it severely handicapped
What are the legal requirements for an abortion?
- Two registered medical practioners must sign to agree abortion is indicated
- Must be carried out by regustered medical practioner in an NHS hospital or approved premise
How may abortion services be accessed?
Self-referral or by GP, GUM or family planning clinic referral
What if a doctor objects to abortions?
They should pass the referral on to another doctor to make the referral
What is the name of a charity that provides abortion services?
Marie Stopes UK
Who do Marie Stopes offer a service to?
Women less than 10 weeks gestation - consultations are help by telephone and medication are issued remotely to be taken at home
When can medical abortion be used?
Most appropriate in early pregnancy but can be used at any gestation
Describe the medical approach to an abortion?
Mifepristone (anti-progestogen)
- Blocks action of progesterone halting the pregnancy and relaxing the cervix
Misoprostol (prostaglanding analogue) 1 - 2 days later
- Binds to prostaglandin receptors and activates them
- Prostaglandins soften the cervix & stimulate uterine contractions
- From 10 weeks gestation, additional misoprostol doses (eg every 3 hrs) are required until expulsion
Also give anti-D prophylaxis to rhesus negative women with a gestational age of 10 weeks or above
What medications are used for cervical priming before a surgical abortion ?
Softening and dilating the cervix with:
- Misoprostol (prostaglandin analogue, activates prostaglandin receptors, softens cervix & stimulates uterine contractions)
- Mifepristone (anti-progestogen, blocks progesterone halting the pregnancy & softening the cervix)
- Osmotic dilators (inserted into the cervix, gradually expand & absorb fluid, opening the cervical canal)
What are the options for surgical abortion?
Cervical dilatation and suction of the contents of the uterus (usually up to 14 weeks)
Cervical dilatation and evacuation using forceps (between 14 and 24 weeks)
Give anti D prophylaxis to rhesus negative women, should be considered evern <10weeks gestation
What symptoms can a woman expect after an abortion?
Vaginal bleeding and abdominal cramps intermittently for up to 2 weeks after the procedure
Urine pregnancy test at 3 weeks to confirm its complete
What are some complications of a termination of pregnancy?
Bleeding
Pain
Infection
Failure of the abortion (pregnancy continues)
Damage to the cervix, uterus or other structures
When is nausea common in pregnancy?
Early on (peaking around 8-12 weeks gestation)
What is hyperemesis gravidarum?
Severe form of nausea and vomiting
It occurs in around 1% of pregnancies and is thought to be related to raised beta hCG levels. Hyperemesis gravidarum is most common between 8 and 12 weeks but may persist up to 20 weeks
When do symptoms of nausea and vomiting usually begin and end in pregnancy?
Begin in weeks 4-7 and resolve by 16-20 weeks
What hormone is thought to be responsible for N&V in pregnancy?
Human chorionic gonadotropin (hCG) - theoretically higher levels causes worse symptoms
What types of pregnancies are N&V more common in?
Molar pregnancies
Multiple pregnancies
First pregnancy
Overweight women
How can a diagnosis of N&V in pregnancy be made?
Needs to start in first trimester
Otherwise exclude other causes
Along with long standing N&V, what else is needed to diagnose hyperemesis gravidarum?
- More than 5% weight loss compared with before pregnancy
- Dehydration
- Electrolyte imbalance
How is the severity of hyperemesis gravidarum assessed?
Using the pregnancy-unique quantification of emesis (PUQE) score - giving score out of 15
< 7 = mild
7-12 = moderate
>12 = severe
Which antiemetics are used to suppress nausea in pregnancy?
Vaguely in order of preference and known safety, the choices are:
- Prochlorperazine (stemetil)
- Cyclizine
- Ondansetron
- Metoclopramide
What medication can be used if acid reflux is a problem in pregnancy?
Ranitidine or omeprazole
What alternate therapies may be used for nausea and vomiting in pregnancy?
Ginger
Acupressure on the wrist at the PC6 point (inner wrist) may improve symptoms
When should admission be considered for N&V during pregnancy?
Unable to tolerate oral antiemetics or keep down any fluids
More than 5 % weight loss compared with pre-pregnancy
Ketones are present in the urine on a urine dipstick (2 + ketones on the urine dipstick is significant)
A confirmed or suspected comorbidity (for example she is unable to tolerate oral antibiotics for a urinary tract infection)
NICE CKS also recommend having a lower threshold for admitting to hospital if the woman has a co-existing condition (for example diabetes) that may be adversely affected by nausea and vomiting
How can moderate-severe cases of pregnancy N&V be treated on admission?
IV or IM antiemetics
IV fluids (normal saline with added potassium chloride)
Daily monitoring of U&Es while having IV therapy
Thiamine supplementation to prevent deficiency (prevents Wernicke-Korsakoff syndrome)
Thromboprophylaxis (TED stockings and LMWH) during admission
What is a molar pregnancy?
Where a hydatiform mole (a type of tumour) grows like a pregnancy inside the uterus
What are the two types of molar pregnancies?
Complete mole
- When 2 sperm cells fertilise an ovum that contains no genetic material- an empty ovum
- These sperm then combine genetic material and the cells divide and grow into a tumour
- No fetal material formed
Partial mole
- When 2 sperm cells fertilise a normal ovum containing genetic material at the same time
- The new cell now has 3 sets of chromosomes
- The cell divides and multiplies into a tumour called a partial mole
- Some fetal material may form
What can indicate a molar pregnancy over a normal pregnancy?
- More severe morning sickness
- Vaginal bleeding
- Increased enlargement of uterus
- Abnormally high hCG
- Thyrotoxicosis (hCG can mimic TSH and stimulate the thyroid to produce excess T3 and T4)
What does ultrasound of a molar pregnancy show?
Snowstorm appearance of the pregnancy
How is a diagnosis of molar pregnancy made?
Ultrasound and confirming with histology of the mole after evacuation
How are molar pregnancies managed?
- Evacuation of the uterus to remove the mole (products of conception need to be sent for histological examination to confirm molar pregnancy)
- Pts referred to gestational trophoblastic disease centre for mx and follow up
- hCG levels monitored until they return to normal
- Occasionally the mole can metastasise- pt may require systemic chemotherapy
Broadly describe the management for hyperemesis gravidarum?
- antihistamines should be used first-line
- oral cyclizine or oral promethazine is recommended by Clinical Knowledge Summaries (CKS)
- oral prochlorperazine is an alternative
- ondansetron and metoclopramide may be used second-line
- metoclopramide may cause extrapyramidal side effects. It should therefore not be used for more than 5 days
- ondansetron during the first trimester is associated with a small increased risk of the baby having a cleft lip/palate. The Medicines and Healthcare products Regulatory Agency (MHRA) advise that if ondanestron is used then these risks should be discussed with the pregnant woman
- ginger and P6 (wrist) acupressure: CKS suggest these can be tried but there is little evidence of benefit
- admission may be needed for IV hydration
What are the main differential diagnoses for bleeding in the first trimester?
- Ectopic pregnancy- most important cause as ectopics can be life-threatening
- Implantation bleeding- diagnosis of exclusion
- Miscellaneous conditions
- Cervical ectropion
- Vaginitis
- Trauma
- Polyps
What are the key causes of bleeding in the first, second and third trimester?
- FIRST TRIMESTER
- Spontaenous abortion
- Ectopic pregnancy
- Hydatiform mole
- SECOND TRIMESTER
- Spontaneous abortion
- Hydatidiform mole
- Placental abruption
- THIRD TRIMESTER
- Bloody show
- Placental abduription
- Placental praevia
- Vasa praevia
What are the features of Hydatidiform mole?
Typically bleeding in first or early second trimester associated with exaggerated symptoms of pregnancy e.g. hyperemesis. The uterus may be large for dates and serum hCG is very high
Differentials for bleeding in first trimester?
- miscarriage
- ectopic pregnancy
- the most ‘important’ cause as missed ectopics can be potentially life-threatening
- implantation bleeding
- a diagnosis of exclusion
- miscellaneous conditions
- cervical ectropion
- vaginitis
- trauma
- polyps
Associations with hyperemesis gravidarum?
- multiple pregnancies
- trophoblastic disease including molar pregnancy
- hyperthyroidism
- nulliparity
- obesity
Differentiate between a cmplete and incomplete hydatidiform mole?
- A complete hydatidiform mole occurs when all of the genetic material comes from the father. There will be no foetal parts present and snowstorm appearance is seen on ultrasound. Vaginal bleeding early in pregnancy is often the presenting feature.
- Incomplete hydatidiform mole occurs due to two sets of paternal chromosomes and one set of maternal chromosomes. There are often foetal parts present and snowstorm appearance is not seen on ultrasound.
