Early Pregnancy Flashcards
Define MISCARRIAGE. What are the subtypes of miscarriage?
Miscarriage is the loss of a foetus < 20 weeks gestational age.
Miscarriage affects between 1 in 4 to 1 in 6 pregnancies.
There are FIVE types of miscarriage:
- complete miscarriage –> PV bleeding + loss of all products of conception
- incomplete miscarriage –> PV bleeding + some retained products of conception
- threatened miscarriage –> PV bleeding + closed cervix
- inevitable miscarriage –> PV bleeding + open cervix
- missed miscarriage –> nil PV bleeding but loss of foetus
What are some risk factors for miscarriage?
✔️ increasing maternal age ✔️ BMI < 18 or > 35 ✔️ previous miscarriage ✔️ smoking, alcohol and drug use during pregnancy ✔️ pregnancy trauma ✔️ maternal infection
Describe clinical presentation of miscarriage / spontaneous abortion.
✔️ PV bleeding / abnormal discharge
✔️ crampy abdominal pain
✔️ loss of pregnancy symptoms (e.g. nausea)
✔️ cervical shock (hypotension, bradycardia) due to stimulation of the vagus nerve by retained POC
What are the types of management available for spontaneous miscarriage / abortion?
EXPECTANT MANAGEMENT
✔️ involves allowing the products of conception to pass on their own
✔️ 70 to 80% success rate in the first trimester
✔️ should not be done beyond 13 weeks gestation
✔️ requires follow up testing (e.g. serum beta-hCG, USS, patient symptoms etc).
MEDICAL MANAGEMENT
✔️ generally recommended up until 12+6 weeks gestation, although can be extended into the second trimester
✔️ indicated in the context of failed expectant management, inevitable abortion and haemodynamically stable patients
✔️ mifeprestone (anti-progesterin) plus misoprostol (prostaglandin analogoue) are given orally; repeat dose of misoprostol in 7 days is associated with improved outcomes
✔️ follow up involves USS, beta-hCG levels (serum) and patient symptoms
SURGICAL MANAGEMENT
✔️ indicated in failed medical management, retained products of conception and haemodynamically unstable patients
✔️ D+C is the gold-standard
How would you council a woman on becoming pregnant after a miscarriage / spontaneous abortion.
✔️ normal period should return within 4 to 8 weeks
✔️ wait until 2 to 3 normal cycles before trying to conceive again
✔️ council that miscarriage affects between 1 in 4 to 1 in 6 pregnancies
✔️ early folic acid supplementation
✔️ early USS and engagement with medical services
✔️ offer social work / psychological services
Define RECURRENT PREGNANCY LOSS.
What are some risk factors for recurrent pregnancy loss?
In a woman < 35 years, recurrent pregnancy loss is defined as three consecutive pregnancy losses; in a woman > 35 years, it is defined as two consecutive pregnancy losses.
Risk factors include: ✔️ anti-phospholipid syndrome ✔️ increasing maternal age ✔️ other chromosomal abnormalities ✔️ inborn errors of metabolism ✔️ uncontrolled diabetes mellitus
Define ECTOPIC PREGNANCY.
Ectopic pregnancy occurs when the products of conception implant outside of the uterus in places such as the fallopian tubes, ampulla, fimbriae, ovaries and abdomen.
Describe some risk factors for ectopic pregnancy.
✔️ previous ectopic pregnancy ✔️ young maternal age ✔️ history of STIs or PID ✔️ previous abdominal / pelvic surgery ✔️ intrauterine device ✔️ adhesions ✔️ IVF ✔️ exogenous hormone use (e.g. progesterone, oestrogen)
What are the three clinical presentations for ectopic pregnancy?
- ruptured ectopic pregnancy –> presents are hypovolemic shock (hypotension, tachycardia, hypoxemia etc) plus sudden onset, severe abdominal pain +/- PV bleeding
- spontaneous resolution –> pregnancy resolves on its own
- spontaneous abortion –> presents similar to miscarriage; treat as a miscarriage
What are the indications for EXPECTANT MANAGEMENT of ectopic pregnancy?
✔️ haemodynamically stable
✔️ beta-hCG < 200 milli international units / mL
✔️ patient understands the risks of ectopic pregnancy
✔️ patient has access to medical services
✔️ patient wiling and able to comply with close follow up
✔️ transvaginal USS shows no extra-uterine sac
What are the indications for MEDICAL MANAGEMENT of ectopic pregnancy?
✔️ haemodynamically stable
✔️ beta-hCG < 5,000 milli international units / mL and decreasing
✔️ adnexal mass < 3 to 4 cm
✔️ no foetal HR detected on USS
✔️ no contraindications to methotrexate
✔️ mother able and filling to engage in follow up
Medical management involves single or double dose of a “medium dose” methotrexate. Folic acid supplementation is also necessary. The patient should be placed on a form of reliable contraception for three months.
What are the indications for SURGICAL MANAGEMENT of ectopic pregnancy?
✔️ haemodynamically UNSTABLE
✔️ beta-hCG > 5,000 milli international units / mL or increasing
✔️ adnexal mass > 3 to 4 cm
✔️ contraindications to methotrexate
✔️ unable to comply to follow up procedures
✔️ foetal HR detected
Surgical management may either be:
- salpingectomy (removal of the fallopian tube) –> associated with a 10% reduction in fertility
- salpingostomy (removal of the sac with preservation of the fallopian tube) –> 4 to 11% have retained products of conception; may require methotrexate therapy
Define GESTATIONAL HYPERTENSION.
Gestational hypertension is defined as a blood pressure > 140 / 90 mmHg that develops > 20 weeks gestational age during pregnancy.
There are four types of gestational hypertension:
- gestational hypertension –> HTN that develops > 20 weeks gestation
- chronic hypertension –> pre-existing HTN
- pre-eclampsia –> gestational hypertension that involves at least ONE other organ system
- pre-eclampsia + chronic hypertension –> pre-eclampsia that develops in a woman who has a background of chronic hypertension (pre-existing prior to pregnancy)
What is the classification of gestational hypertension severity?
MILD:
✔️ SBP between 140 to 150 mmHg
✔️ DBP between 90 to 100 mmHg
MODERATE:
✔️ SBP between 150 to 160 mmHg
✔️ DBP between 100 to 110mmHg
SEVERE:
✔️ SBP between 160 to 170 mmHg
✔️ DBP between 110 to 120 mmHg
LIFE-THREATENING
✔️ SBP > 170 mmHg
✔️ DBP > 110mmHg
How is gestational HTN screened for?
Maternal BP should be measured at every antenatal visit.
Symptoms of pre-eclampsia should also be elicited, including: ✔️ blurred vision ✔️ headaches ✔️ swelling of the peripheries ✔️ foetal movements
Identify first-line management of GESTATIONAL HTN.
- methyldopa (alpha-adrenergic receptor agonist)
- labetolol (beta-blocker)
- nifedipine (calcium channel blocker)
Aim is SBP < 140mmHG and DBP < 85 mmHg
Define PRE-ECLAMPSIA.
Pre-eclampsia is defined as the onset of hypertension > 20 weeks gestation PLUS involvement of at least one other organ system.
What are some risk factors for pre-eclampsia?
✔️ previous pregnancy with pre-eclampsia ✔️nulliparous women (healthy) ✔️ gestational or chronic hypertension (40% risk of develop PET in the context of GHTN) ✔️ pre-existing diabetes mellitus or GDM ✔️ increasing maternal age (>40 years) ✔️ low maternal age (<16 years) ✔️ antiphospholipid syndrome (APS) ✔️ systemic lupus erythematous ✔️ obesity ✔️ twin pregnancies ✔️ inter-pregnancy interval > 5 years
Outline the general mechanism of pre-eclampsia.
Pre-eclampsia is a disorder of placentation; shallow placentation is associated with decreased perfusion to the placenta.
Maternal blood pressure increases to try and increase perfusion to the placenta.
Release of reactive oxygen species, nitric oxide, endothelial growth factor 1 etc. lead to damage to the endothelium and increased vascular permeability.
Systemic vasodilation and dysfunction leads to capillary leakage and vasospasm.
THE KEY ELEMENT OF PATHOPHYSIOLOGY IS ENDOTHELIAL DYSFUNCTION.
Identify how systemic involvement may present in the context of PRE-ECLAMPSIA.
CARDIO - hypertension, peripheral oedema
RESP - pleural effusion, pulmonary oedema
NEURO - dizziness, headaches, blurred vision, cerebral oedema
RENAL - proteinuria, increased creatinine
HEPATIC - elevated transaminases, RUQ pain, jaundice, easy bruising, inflammation and swelling of the liver capsule
HAEM - anaemia, thrombocytopenia, DIC
PLACENTA - placental insufficiency
FOETAL - IUGR
Identify appropriate investigations for PRE-ECLAMPSIA.
BEDSIDE Ix
✔️ urine dipstick - proteinuria (PCR, ACR)
✔️ ECG - electrolyte abnormalities, pericardial effusions
✔️ blood glucose level
BLOOD Ix ✔️ FBC - anaemia, thrombocytopenia ✔️ Inflammatory markers ✔️ UECs - electrolyte abnormalities ✔️ LFTs - abnormal transaminases, abnormal coags ✔️ Coags - DIC ✔️ D-Dimer and Fibrinogen - DIC ✔️ LDH and haptoglobin - haemolytic screen
IMAGING Ix
✔️ CXR - pleural effusion, pulmonary oedema
Outline the management principles for PRE-ECLAMPSIA.
- Admit to hospital
- Continuous monitoring of maternal BP and foetal CTG
- Blood pressure management - labetolol, methyldopa, nifedipine
✔️ methyldopa is best used in chronic hypertension (first trimester)
✔️ labetolol is best used for PET - Give aspirin if between 16 to 24 weeks
- Magnesium sulphate - for neuro protection and reduce the risk of eclampsia
✔️ give MgSO4 if signs of cerebral irritability in mother
✔️ 4g loading over 10 to 20 mins plus 1g per hour for 24 hours - Maternal steroids if < 34 weeks
- Induce labour (when risks of prolonging pregnancy outweigh the benefits) - aim for vaginal delivery unless contraindicated
What are some complications of PRE-ECLAMPSIA in terms of maternal, neonatal and obstetric?
MATERNAL COMPLICATIONS ✔️ eclampsia ✔️ seizures ✔️ cerebral haemorrhage ✔️ renal failure ✔️ DIC ✔️ pulmonary oedema ✔️ PPROM and PTL
OBSTETRIC COMPLICATIONS ✔️ premature delivery ✔️ placental abruption ✔️ uteroplacental insufficiency ✔️ increased risk of C/S
NEONATAL COMPLICATIONS
✔️ all complications associated with premature delivery
✔️ IUGR
✔️ hypoglycaemia
What is HELLP Syndrome?
✔️ haemolysis
✔️ elevated liver enzymes
✔️ low platelets
What is ECLAMPSIA?
Eclampsia develops from pre-eclampsia and is characterised by the onset of generalised tonic-clonic seizures.
How is ECLAMPSIA managed?
- Termination of seizures (4g MgSO4 loading dose over 20 mins + continuous 1g infusion over 24 hours; give diazepam if still seizing)
- Prevent recurrence (MgSO4)
- Treat HTN (methyldopa, nifedipine, labatolol)
- Delivery baby (NVD or C/S)
Define GESTATIONAL DIABETES.
Gestational diabetes is defined as insulin resistance and hyperglycaemia that develops within the 2nd or 3rd trimester of pregnancy.
This is due to catabolic state of second and third trimester and the relative insulin resistance that develops to maintain hyperglycaemia for foetal development.
What are some risk factors for GESTATIONAL DIABETES?
✔️ previous gestational diabetes ✔️ obesity ✔️ maternal age > 40 years ✔️ twin pregnancy ✔️ PCOS ✔️ medications (e.g. atypical antipsychotics, corticosteroids) ✔️ previous large baby
Outline the screening protocol for GESTATIONAL DIABETES.
LOW RISK: 75g OGTT between 24 to 28 weeks GA
HIGH RISK: 75g OGTT between 12 to 16 weeks GA with repeat between 24 to 28 weeks if negative
Diagnostic Values:
✔️ fasting > 5.1 mmol / L
✔️ 1-hour > 10.0mmol / L
✔️ 2-hour > 8.5 mmol / L
Outline the appropriate management of GESTATIONAL DIABETES.
Management of gestational diabetes has four components:
- nutrition
- physical activity and exercise
- self-monitoring of glucose
- hypoglycaemic agents
NUTRITION ✔️ referral to a dietician ✔️ medical nutrition therapy (MNT) ✔️ 2,000 kCal diet ✔️ 175g carbohydrates / day (low GI)
PHYSICAL ACTIVITY
✔️ 30 mins per day
✔️ referral to exercise physiologist (?)
SELF-MONITORING OF GLUCOSE
✔️ initially 1 x fasting + 3 x post-prandial measurements
✔️ may be stretched out to daily or every second day monitoring
✔️ aim for fasting < 5.0mmol / L, 1-hour < 7.4 mmol / L and 2-hour < 6.7 mmol / L
✔️ HbA1c between 4.5 to 5.5%
HYPOGLYCAEMIC AGENTS
✔️ metformin –> commence on 500mg PO, daily and increase as necessary (maximum 3g per day)
✔️ insulin –> review weekly
✔️ referral to endocrinologist is essential
DELIVERY
✔️ timed delivery between 38 to 39 weeks
✔️ considered LCSC if > 4.5kg
F/U with OGTT is required at 8 to 12 weeks postpartum.
What are some indications for delivery in ECLAMPSIA?
MATERNAL INDICATIONS ✔️ gestation > 37 weeks ✔️ reducing platelet count ✔️ abnormal / worsening LFTs ✔️ unable to control HTN ✔️ pulmonary oedema ✔️ persistent or worsening neurological symptoms
FOETAL INDICATIONS
✔️ foetal distress
✔️ placental abruption
✔️ non-reassuring foetal status
Describe complications of GESTATIONAL DIABETES.
MATERNAL COMPLICATIONS
✔️ increased risk of diabetes mellitus post-delivery
✔️ increased risk of pre-eclampsia and eclampsia
✔️ increased risk of pre-term labour
✔️ increased risk of PROM and PPROM
NEONATAL COMPLICATIONS ✔️ macrosomnia ✔️ hypoglycaemia ✔️ risk of DM and insulin resistance in future ✔️ IUGR
OBSTETRIC COMPLICATIONS ✔️ shoulder dystocia ✔️ obstructed labour --> need to convert to C/S ✔️ stillbirth ✔️ increased risk of C/S
Outline how to council a woman with pre-existing DM (either Type 2 or Type 1) on conception.
✔️ diabetes increasing maternal and foetal mortality during pregnancy –> automatically high risk pregnancy
✔️ insulin requirement DOUBLES due to increased insulin resistance
✔️ hypoglycaemic agents should be changed to insulin
✔️ HbA1c should be optimised prior to conception
✔️ folic acid supplementation is necessary prior to conception and throughout first trimester of pregnancy (commence on 4g per day)
✔️ maintain BGL between 5.6 and 6.7 mmol / L in early pregnancy to avoid malformation (e.g. skeletal, cardiac, neural tube)
What are MATERNAL and FOETAL complications of DIABETES during pregnancy?
MATERNAL COMPLICATIONS ✔️worsening of renal disease, cardiovascular disease and other complications of diabetes ✔️ increased insulin requirement ✔️ PROM, PPROM and PTL ✔️ pre-eclampsia, HELLP and eclampsia ✔️ intra-uterine foetal demise / stillbirth ✔️ PPH ✔️ lifetime risk of DM
FOETAL COMPLICATIONS ✔️ macrosomnia ✔️ shoulder dystocia ✔️ Erb's palsy ✔️ hypoglycaemia ✔️ IUGR --> foetal death ✔️ congenital anomalies (e.g. neural cord, cardiovascular, MSK) ✔️ lifetime risk of insulin resistance and T2DM
How should DIABETES medications be handled during pregnancy and delivery?
If on METFORMIN:
✔️ cease before spontaneous delivery
✔️ cease one day before delivery (C/S)
If on INSULIN:
✔️ titrate according to BGL in spontaneous delivery
✔️ cease night before C/S (give morning dose)
What are the objectives of management in PRE-ECLAMPSIA?
- Prevent complications (e.g. HELLP, eclampsia, renal failure, pulmonary oedema)
- Delivery of newborn in good conditions with minimal trauma to the mother.
Explain why anaemia occurs during pregnancy?
?Dilutional anaemia that occurs in the late second or third trimester.
Dilutional anaemia occurs due to a mismatch in terms of RBC volume and plasma volume.
Important to exclude:
✔️ IDA
✔️ B12 or folate deficiency
✔️ haemolytic anaemia
How is GDM followed up following pregnancy?
OGTT at 12 weeks post-partum.
Signs of CHORIOAMNIONITIS.
✔️ uterine tenderness
✔️ fever
✔️ tachycardia + tachyponea
What is a missed miscarriage?
No FHR on USS.
Foetus has died but not been expelled.
Define HYPEREMESIS GRAVADIUM.
Hyperemesis gravadium is a subcategory of pregnancy related nausea and vomiting characterised by >5% weight loss and ketonuria.
It is believed to be mediated by increased beta-hCG, with risk factors including:
✔️ multiple gestation
✔️ molar pregnancy
Outline appropriate investigations for HYPEREMESIS GRAVADIUM.
✔️ urine dipstick (ketonuria) ✔️ blood glucose levels ✔️ ABG ✔️ FBC + WCC ✔️ UECs ✔️ eLFTs ✔️ Vitamin B12 + folate levels ✔️ thiamine levels ✔️ abdominal USS --> exclude molar pregnancy or multiple pregnancy
Outline the appropriate inpatient management of HYPEREMESIS GRAVDIUM.
✔️ IV fluids –> rehydrate to “wash out” ketones
✔️ metoclopramide 10mg PO, 3 to 4 times daily
✔️ vitamin B6 supplementation (pyridoxine)
✔️ consider thiamine 100mg PO
✔️ treat reflux symptoms, if present
✔️ prednisolone if irretractable vomiting
Patients are appropriate to send home when able to eat and drink.
