Early Pregnancy Flashcards
1
Q
Sources of progesterone during pregnancy?
A
The corpus luteum is the primary source of progesterone at the start of pregnancy, however, the corpus luteum breaks down eventually. So from the 8th week of pregnancy, the main source of progesterone is the placenta.
2
Q
Before what gestation is bleeding in pregnancy classified as early pregnancy bleeding?
A
20 weeks
3
Q
Causes of bleeding in early pregnancy
A
Miscarriage
Molar pregnancy
Ectopic pregnancy
4
Q
What is classified as a miscarriage?
A
Any bleeding +/- pain in early pregnancy (before 20 weeks)
5
Q
Classification of miscarriage?
A
Threatened miscarriage
Missed miscarriage
Complete miscarriage
Incomplete miscarriage
Inevitable miscarriage
Septic miscarriage
6
Q
What is a threatened miscarriage?
A
Threatened miscarriage – vaginal bleeding with a CLOSED cervix and a fetus that is alive (HR present)
Most make it to full term
7
Q
What is a missed miscarriage?
A
Missed miscarriage – the fetus is no longer alive (negative HR), but no symptoms have occurred, cervix CLOSED
8
Q
How can a woman with a threatened miscarriage with a history of 4 or more miscarriages or a confirmed previous miscarriage be managed?
A
Vaginal progesterone tablets
9
Q
What is an inevitable miscarriage?
A
Inevitable miscarriage – vaginal bleeding with an OPEN cervix but fetous still in utero
10
Q
What is a complete miscarriage?
A
Complete miscarriage – a full miscarriage has occurred, and there are no products of conception left in the uterus
Very heavy bleeding
Cervix may be open or closed depending on timeline
11
Q
What is an incomplete miscarriage?
A
Incomplete miscarriage – retained products of conception remain in the uterus after the miscarriage
Patient has began to pass products of conception
Cervix OPEN
Pt still bleeding on presentation
Tissues oresent on scan but no feotus
12
Q
How will a septic miscarriage present
A
Hx of bleeding with infection and temperature
13
Q
What is an anembryonic pregnancy?
A
Anembryonic pregnancy – a gestational sac is present but contains no embryo
14
Q
Investigation of choice for ?Miscarriage?
A
Transvaginal ultrasound scan
15
Q
What are the key features that the sonographer looks for in an early pregnancy?
A
Mean gestational sac diameter
Fetal pole and crown-rump length
Fetal heartbeat
These appear sequentially as the pregnancy develops. As each appears, the previous feature becomes less relevant in assessing the viability of the pregnancy.
16
Q
Normal site of pregnancy implantation?
A
Upper 1/3 posterior wall of posterior cervix
17
Q
Bleeding in miscarriage vs ectopic
A
Ectopic: less bleeding, endometrial tissue
Miscarriage: Heavier bleeding, products of conception
18
Q
When is a pregnancy considered viable?
A
When a fetal heartbeat is visible, the pregnancy is considered viable
19
Q
A fetal heartbeat is expected once the crown-rump length reaches what?
A
7mm or more
20
Q
When the crown-rump length is less than 7mm, without a fetal heartbeat, what should be done?
A
Scan is repeated after at least one week to ensure a heartbeat develops
21
Q
When there is a crown-rump length of 7mm or more, without a fetal heartbeat, how is the pregnancy confirmed to be non viable?
A
When there is a crown-rump length of 7mm or more, without a fetal heartbeat, the scan is repeated after one week before confirming a non-viable pregnancy.
22
Q
Management of miscarriage before 6 weeks?
A
Women with a pregnancy less than 6 weeks’ gestation presenting with bleeding can be managed expectantly provided they have no pain and no other complications or risk factors (e.g. previous ectopic). Expectant management before 6 weeks gestation involves awaiting the miscarriage without investigations or treatment. An ultrasound is unlikely to be helpful this early as the pregnancy will be too small to be seen.
A repeat urine pregnancy test is performed after 7 – 10 days, and if negative, a miscarriage can be confirmed. When bleeding continues, or pain occurs, referral and further investigation is indicated.
23
Q
Management of miscarriage past 6 weeks gestation?
A
The NICE guidelines (2019) suggest referral to an early pregnancy assessment service (EPAU) for women with a positive pregnancy test (more than 6 weeks’ gestation) and bleeding.
The early pregnancy assessment unit will arrange an ultrasound scan. Ultrasound will confirm the location and viability of the pregnancy. It is essential always to consider and exclude an ectopic pregnancy.
There are three options for managing a miscarriage:
Expectant management (do nothing and await a spontaneous miscarriage)
Medical management (misoprostol)
Surgical management
24
Q
Expectant management of miscarriage
A
Expectant management is offered first-line for women without risk factors for heavy bleeding or infection.
1 – 2 weeks are given to allow the miscarriage to occur spontaneously. A repeat urine pregnancy test should be performed three weeks after bleeding and pain settle to confirm the miscarriage is complete.
Persistent or worsening bleeding requires further assessment and repeat ultrasound, as this may indicate an incomplete miscarriage and require additional management.
25
Medical management of miscarriage
Misoprostol is a prostaglandin analogue, meaning it binds to prostaglandin receptors and activates them. Prostaglandins soften the cervix and stimulate uterine contractions.
Medical management of miscarriage involves using a dose of misoprostol to expedite the process of miscarriage. This can be as a vaginal suppository or an oral dose.
26
Misoprostol main side effects
Heavier bleeding
Pain
Vomiting
Diarrhoea
27
Surgical management of miscarriage
Surgical management can be performed under local or general anaesthetic.
There are two options for surgical management of a miscarriage:
Manual vacuum aspiration under local anaesthetic as an outpatient
Electric vacuum aspiration under general anaesthetic
Prostaglandins (misoprostol) are given before surgical management to soften the cervix.
28
Surgical miscarriage management - manual vacuum aspiration
Manual vacuum aspiration involves a local anaesthetic applied to the cervix. A tube attached to a specially designed syringe is inserted through the cervix into the uterus. The person performing the procedure then manually uses the syringe to aspirate contents of the uterus. To consider manual vacuum aspiration, women must find the process acceptable and be below 10 weeks gestation. It is more appropriate for women that have previously given birth (parous women).
29
Surgical miscarriage management - electric vacuum aspiration
Electric vacuum aspiration is the traditional surgical management of miscarriage. It involves a general anaesthetic. The operation is performed through the vagina and cervix without any incisions. The cervix is gradually widened using dilators, and the products of conception are removed through the cervix using an electric-powered vacuum.
30
Which women having a miscarriage should be offered anti-rhesus D
Anti-rhesus D prophylaxis is given to rhesus negative women having surgical management of miscarriage.
31
An incomplete miscarriage occurs when retained products of conception (fetal or placental tissue) remain in the uterus after the miscarriage. Retained products create a risk of infection. How is it managed?
There are two options for treating an incomplete miscarriage:
Medical management (misoprostol)
Surgical management (evacuation of retained products of conception)
Evacuation of retained products of conception (ERPC) is a surgical procedure involving a general anaesthetic. The cervix is gradually widened using dilators, and the retained products are manually removed through the cervix using vacuum aspiration and curettage (scraping). A key complication is endometritis (infection of the endometrium) following the procedure.
32
What is an ectopic pregnancy?
Ectopic pregnancy is when a pregnancy is implanted outside the uterus. The most common site is a fallopian tube. An ectopic pregnancy can also implant in the entrance to the fallopian tube (cornual region), ovary, cervix or abdomen.
33
Factors that can increase the risk of ectopic pregnancy?
Previous ectopic pregnancy
Previous pelvic inflammatory disease
Previous surgery to the fallopian tubes
Intrauterine devices (coils)
Older age
Smoking
34
At what gestation does ectopic pregnancy tend to present?
6-8 weeks
35
Signs/symptoms of ectopic pregnancy
The classic features of an ectopic pregnancy include:
Missed period
Constant lower abdominal pain in the right or left iliac fossa
Vaginal bleeding
Lower abdominal or pelvic tenderness
Cervical motion tenderness (pain when moving the cervix during a bimanual examination)
It is also worth asking about:
Dizziness or syncope (blood loss)
Shoulder tip pain (peritonitis)
36
TVUSS in ectopic pregnancy
A 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. When a mass containing an empty gestational sac is seen, this may be referred to as the “blob sign”, “bagel sign” or “tubal ring sign” (all referring to the same appearance).
A mass representing a tubal ectopic pregnancy moves separately to the ovary. The mass may look similar to a corpus luteum; however, a corpus luteum will move with the ovary.
Features that may also indicate an ectopic pregnancy are:
An empty uterus
Fluid in the uterus, which may be mistaken as a gestational sac (“pseudogestational sac”)
37
What is a pregnancy of an unknown location?
A pregnancy of unknown location (PUL) is when the woman has a positive pregnancy test and there is no evidence of pregnancy on the ultrasound scan. In this scenario, an ectopic pregnancy cannot be excluded, and careful follow up needs to be in place until a diagnosis can be confirmed.
38
How can pregnancy of unknown location be monitored?
Serum human chorionic gonadotropin (hCG) can be tracked over time to help monitor a pregnancy of unknown location. The serum hGC level is repeated after 48 hours, to measure the change from baseline.
39
beta hCG in intrauterine vs ectopic pregnancy
The developing syncytiotrophoblast of the pregnancy produces hCG. In an intrauterine pregnancy, the hCG will roughly double every 48 hours. This will not be the case in a miscarriage or ectopic pregnancy.
40
Monitoring beta hCG in ?ectopic pregnancy
A rise of more than 63% after 48 hours is likely to indicate an intrauterine pregnancy. A repeat ultrasound scan is required after 1 – 2 weeks to confirm an intrauterine pregnancy. A pregnancy should be visible on an ultrasound scan once the hCG level is above 1500 IU / l.
A rise of less than 63% after 48 hours may indicate an ectopic pregnancy. When this happens the patient needs close monitoring and review.
A fall of more than 50% is likely to indicate a miscarriage. A urine pregnancy test should be performed after 2 weeks to confirm the miscarriage is complete.
Monitoring the clinical signs and symptoms is more important than tracking the hCG level, and any change in symptoms needs careful assessment.
41
Management of an ectopic pregnancy?
Expectant management (awaiting natural termination)
Medical management (methotrexate)
Surgical management (salpingectomy or salpingotomy)
42
Criteria for expectant management of an ectopic pregnancy?
Follow up needs to be possible to ensure successful termination
The ectopic needs to be unruptured
Adnexal mass < 35mm
No visible heartbeat
No significant pain
HCG level < 1500 IU / l
43
Criteria for medical management of an ectopic pregnancy?
Follow up needs to be possible to ensure successful termination
The ectopic needs to be unruptured
Adnexal mass < 35mm
No visible heartbeat
No significant pain
HCG level must be < 5000 IU / l
Confirmed absence of intrauterine pregnancy on ultrasound
44
Medical management of ectopic pregnancy
Methotrexate is highly teratogenic (harmful to pregnancy). It is given as an intramuscular injection into a buttock. This halts the progress of the pregnancy and results in spontaneous termination.
Women treated with methotrexate are advised not to get pregnant for 3 months following treatment. This is because the harmful effects of methotrexate on pregnancy can last this long.
Common side effects of methotrexate include:
Vaginal bleeding
Nausea and vomiting
Abdominal pain
Stomatitis (inflammation of the mouth)
45
Indications for surgical management of ectopic pregnancy?
Pain
Adnexal mass > 35mm
Visible heartbeat
HCG levels > 5000 IU / l
Patient preference
46
Surgical management of ectopic pregnancy
Laparoscopic salpingectomy is the first-line treatment for ectopic pregnancy. This involves a general anaesthetic and key-hole surgery with removal of the affected fallopian tube, along with the ectopic pregnancy inside the tube.
Laparoscopic salpingotomy may be used in women at increased risk of infertility due to damage to the other tube. The aim is to avoid removing the affected fallopian tube. A cut is made in the fallopian tube, the ectopic pregnancy is removed, and the tube is closed.
There is an increased risk of failure to remove the ectopic pregnancy with salpingotomy compared with salpingectomy. NICE state up to 1 in 5 women having salpingotomy may need further treatment with methotrexate or salpingectomy.
Anti-rhesus D prophylaxis is given to rhesus negative women having surgical management of ectopic pregnancy.
47
Most common site of ectopic pregnancy implantation?
Ampullary portion of the fallopian tube
48
What is classed as recurrent miscarriage?
Recurrent miscarriage is classed as three or more consecutive miscarriages.
49
In a woman with a history of miscarriages when should investigations be commenced?
Following:
Three or more first-trimester miscarriages
One or more second-trimester miscarriages
50
Potential causes of miscarriage?
Idiopathic (particularly in older women)
Antiphospholipid syndrome
Hereditary thrombophilias
Uterine abnormalities
Genetic factors in parents (e.g. balanced translocations in parental chromosomes)
Chronic histiocytic intervillositis
Other chronic diseases such as diabetes, untreated thyroid disease and systemic lupus erythematosus (SLE)
51
The risk of miscarriage in patients with antiphospholipid syndrome is reduced by using what?
The risk of miscarriage in patients with antiphospholipid syndrome is reduced by using both:
Low dose aspirin
Low molecular weight heparin (LMWH)
52
Most common inherited thrombophillias?
Factor V Leiden (most common)
Factor II (prothrombin) gene mutation
Protein S deficiency
53
What uterine abnormalities may cause miscarriage?
Uterine septum (a partition through the uterus)
Unicornuate uterus (single-horned uterus)
Bicornuate uterus (heart-shaped uterus)
Didelphic uterus (double uterus)
Cervical insufficiency
Fibroids
54
What is chronic histiocytic intervillositis and what are its implications on pregnancy? How is it diagnosed?
Chronic histiocytic intervillositis is a rare cause of recurrent miscarriage, particularly in the second trimester. It can also lead to intrauterine growth restriction (IUGR) and intrauterine death.
The condition is poorly understood.
Histiocytes and macrophages build up in the placenta, causing inflammation and adverse outcomes.
It is diagnosed by placental histology showing infiltrates of mononuclear cells in the intervillous spaces.
55
Patients presenting with recurrent miscarriage should be referred to a specialist in recurrent miscarriage for further investigation. What investigations might be included?
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
56
What is the legal framework for TOP, and which act expands on this?
The legal framework for a termination of pregnancy is the 1967 Abortion Act.
The 1990 Human Fertilisation and Embryology Act altered and expanded the criteria for an abortion, and reduced the latest gestational age where an abortion is legal from 28 weeks to 24 weeks.
57
An abortion can be performed before how many weeks if continuing the pregnancy involves greater risk to the physical or mental health of:
The woman
Existing children of the family?
24 weeks
58
Under what criteria can an abortion be performed at ANY point during a pregnancy?
Continuing the 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 seriously handicapped
59
What are the legal requirements for an abortion?
Two registered medical practitioners must sign to agree abortion is indicated
It must be carried out by a registered medical practitioner in an NHS hospital or approved premise
60
How can patients be referred to abortion services?
Self
GP
GUM
Family planning clinic referral
61
Before how many weeks gestation can remote abortion services be accessed?
10 weeks
62
Which drugs are involved in a medical abortion?
Mifepristone (anti-progestogen)
Misoprostol (prostaglandin analogue) 1 – 2 day later
63
Action of mifepristone in a medical abortion?
Mifepristone is an anti-progestogen medication that blocks the action of progesterone, halting the pregnancy and relaxing the cervix.
64
Action of misoprostol in a medical abortion?
Misoprostol is a prostaglandin analogue, meaning it binds to prostaglandin receptors and activates them. Prostaglandins soften the cervix and stimulate uterine contractions. From 10 weeks gestation, additional misoprostol doses (e.g. every 3 hours) are required until expulsion.
65
Rhesus negative women with a gestational age of over how many weeks having a medical TOP should have anti-D prophylaxis.
10 weeks
66
What medications are used prior to a surgical abortion and why?
Prior to surgical abortion, medications are used for cervical priming.
This involves softening and dilating the cervix with misoprostol, mifepristone or osmotic dilators. Osmotic dilators are devices inserted into the cervix, that gradually expand as they absorb fluid, opening the cervical canal.
67
What are the methods of surgical abortion and at what gestation are they used?
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)
68
Prophylaxis following surgical abortion
Rhesus negative women having a surgical TOP should have anti-D prophylaxis. The NICE guidelines (2019) say it should be considered in women less than 10 weeks gestation.
69
For how long after an abortion may a patient experience vaginal bleeding and abdominal cramps?
Women may experience vaginal bleeding and abdominal cramps intermittently for up to 2 weeks after the procedure.
70
Potential complications of abortion
Bleeding
Pain
Infection
Failure of the abortion (pregnancy continues)
Damage to the cervix, uterus or other structures
71
How and when can the completion of an abortion be confirmed?
A urine pregnancy test is performed 3 weeks after the abortion to confirm it is complete.
72
Around what gestation do N&V peak?
8 – 12 weeks gestation
73
When does N&V in pregnancy begin?
4 – 7 weeks
74
When are N&V symptoms in pregnancy worst?
10-12 weeks
75
When do N&V symptoms in pregnancy tend to resolve by?
16-20 weeks
76
What hormone is thought to be responsible for nausea and vomiting in pregnancy?
Human chorionic gonadotropin (hCG)
77
Nausea and vomiting are more severe in molar pregnancies and multiple pregnancies - why?
Higher levels of human chorionic gonadotropin (hCG)
78
In what situations might nausea and vomiting in pregnancy be more severe?
Molar pregnancies
First pregnancies
Multiple pregnancies
Obese/overweight women
79
What is hyperemesis gravidarum
Hyperemesis gravidarum is the severe form of nausea and vomiting in pregnancy.
80
RCOG guidelines for diagnosing hyperemesis gravidarum?
“protracted” NVP plus:
More than 5 % weight loss compared with before pregnancy
Dehydration
Electrolyte imbalance
81
How can the severity of NVP be quantified?
Pregnancy-Unique Quantification of Emesis (PUQE) score. This gives a score out of 15:
< 7: Mild
7 – 12: Moderate
> 12: Severe
82
What antiemetics can be used in pregnancy?
Prochlorperazine (stemetil)
Cyclizine
Ondansetron
Metoclopramide
83
Management of NVP
Prochlorperazine (stemetil)/Cyclizine/Ondansetron/Metoclopramide
Ranitidine or omeprazole can be used if acid reflux is a problem.
The RCOG also suggest complementary therapies that may be considered by the woman:
Ginger
Acupressure on the wrist at the PC6 point (inner wrist) may improve symptoms
84
When should patients with hyperemesis gravidarum be considered for admission?
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)
Other medical conditions need treating that required admission
85
Moderate-severe cases of hyperemesis gravidarum may require ambulatory care (e.g. early pregnancy assessment unit) or admission for what treatments?
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 stocking and low molecular weight heparin) during admission
86
What is a hydatidiform mole?
A hydatidiform mole is a type of tumour that grows like a pregnancy inside the uterus. This is called a molar pregnancy. There are two types of molar pregnancy: a complete mole and a partial mole.
87
What is a complete mole?
A complete mole occurs when two sperm cells fertilise an ovum that contains no genetic material (an “empty ovum”). These sperm then combine genetic material, and the cells start to divide and grow into a tumour called a complete mole. No fetal material will form.
88
What is a partial mole?
A partial mole occurs when two sperm cells fertilise a normal ovum (containing genetic material) at the same time. The new cell now has three sets of chromosomes (it is a haploid cell). The cell divides and multiplies into a tumour called a partial mole. In a partial mole, some fetal material may form.
89
Molar pregnancy behaves like a normal pregnancy. Periods will stop and the hormonal changes of pregnancy will occur. There are a few things that can indicate a molar pregnancy versus a normal pregnancy, such as what?
More severe morning sickness
Vaginal bleeding
Increased enlargement of the uterus
Abnormally high hCG
Thyrotoxicosis (hCG can mimic TSH and stimulate the thyroid to produce excess T3 and T4)
Ultrasound of the pelvis shows a characteristic “snowstorm appearance” of the pregnancy.
90
How is molar pregnancy diagnosed?
Provisional diagnosis can be made by ultrasound and confirmed with histology of the mole after evacuation.
91
Management of molar pregnancy?
Management involves evacuation of the uterus to remove the mole.
The products of conception need to be sent for histological examination to confirm a molar pregnancy.
Patients should be referred to the gestational trophoblastic disease centre for management and follow up.
The hCG levels are monitored until they return to normal.
Occasionally the mole can metastasise, and the patient may require systemic chemotherapy.
92
Absolute indications for ERPC
Haemodynamically unstable, infected tissue, gestational trophoblastic disease.
93
Why is folic acid started pre conception?
Folic acid is started pre-
conception because the neural tube is formed within the first 28 days of
an embryo's development - and thus any defect may already be present if
a woman waits until her missed period.
94
Certain women are at an increased risk of neural tube defects and thus
should take an increased dose of 5mg folic acid. Women falling into this
category include which conditions?
Previous child with NTD
Diabetes mellitus
Women on antiepileptic
Obese (body mass index >30kg/m?)
HIV +ve taking co-trimoxazole
Sickle cell
95
What is given in medical manage,ent of a miscarriage
vaginal misoprostol only
96
Potential complications of surgical TOP
Infection can happen in up to 10% of TOP cases. Antibiotics are given to reduce the risk of infection. Signs and symptoms of an infection are unlikely to occur so soon after the procedure.
Retained tissue pregnancy occurs in less than 1% of cases.
Haemorrhage occurs in less than 1% of cases, but is more likely to occur in pregnancies greater than 20 weeks gestation.
Failure occurs in less than 1% of cases.
Injury to the cervix occurs in less than 1% of cases.
97
How long is it normal for a pregnancy test to remain positive past 4 weeks
Termination of pregnancy: Urine pregnancy test often remains positive for up to 4 weeks following termination. A positive test beyond 4 weeks indicates incomplete abortion or persistent trophoblast
98
Snow storm apperance on TVUSS
Hydatidiform mole - 'snow storm' appearance on ultrasound scan
99
Pregnant women who are < 6 weeks gestation and present with vaginal bleeding and no pain can be managed how?
Pregnant women who are < 6 weeks gestation and present with vaginal bleeding and no pain can be managed expectantly
100
What risk factors would mean a woman should take 5mg of folic acid rather than 400mcg for the first 12 weeks of pregnancy?
either partner has a NTD, they have had a previous pregnancy affected by a NTD, or they have a family history of a NTD
the woman is taking antiepileptic drugs or has coeliac disease, diabetes, or thalassaemia trait
the woman is obese (defined as a body mass index [BMI] of 30 kg/m2 or more).
101
How long is considered normal for a positive pregnancy test following a termination?
Urine pregnancy test often remains positive for up to 4 weeks following termination. A positive test beyond 4 weeks indicates incomplete abortion or persistent trophoblast
102
In the case of pregnancy of unknown location, serum bHCG levels above what? points toward a diagnosis of an ectopic pregnancy
>1,500
103
Possible sites of ectopic pregnancy?
tubal ectopic: 93-97%
ampullary ectopic: most common ~70% of tubal ectopics and ~65% of all ectopics
isthmal ectopic: ~12% of tubal ectopics and ~11% of all ectopics
fimbrial ectopic: ~11% of tubal ectopics and ~10% of all ectopics
interstitial ectopic/cornual ectopic: 3-4%; also essentially a type of tubal ectopic
ovarian ectopic/ovarian pregnancy; 0.5-1%
cervical ectopic/cervical pregnancy; rare <1%
scar ectopic: site of previous Caesarian section scar; rare
abdominal ectopic: rare; ~1.4%
104
Ectopic pregnancy in which location is most associated with an increase risk of rupture?
The isthmus of the fallopian tube is least able to expand to accommodate the growing embryo/fetus and is therefore most prone to rupture
