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Obs and Gynae > Early Pregnancy > Flashcards

Early Pregnancy Flashcards

1
Q

What is the early pregnancy period?

A

0-13 weeks
=1st trimester

-4-5 weeks: small intrauterine fluid collection with rounded eggs (thickened lining)- double sign
-5.5 weeks: yolk sac, unequivocal sign of pregnancy
-6 weeks: embryo appears adjacent to yolk sac
-7-8 weeks: amnion, cardiac activity

-1 month: red currant
-2: cherry
-3: plum
-4: pear
-5: grapefruit
-6: papaya
-7: pineapple
-8: cantaloupe
-9: watermelon

Palpate fundus at umbilicus: 20 weeks

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2
Q

Early pregnancy conditions and their symptoms

A

-Miscarriage
-Ectopic pregnancy
-Molar pregnancy
-Hyperemesis gravidarum

Commonest presentation in early pregnancy: no symptoms, incidental finding of positive pregnancy test
-Vaginal bleeding (embryo implants into lining, other bleeding common but not normal)
-Abdominal/pelvic pain
-Nausea and vomiting

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3
Q

Important questions for history taking

A

-First day of last menstrual period= D0 =if they have a 4-week cycle and 2 weeks late at the point of positive pregnancy test, they are ~6weeks pregnant
-Cycle length
-Date of first positive pregnancy test
-Episodes of U.P.S.I- emergency contraception/ current contraception failures
-Gravidity= number of pregnancies in total
-Parity= number of pregnancies carried till viability ( 24 weeks)
-Obstetric history
-Medical & Surgical history ( STDs, cervical smears etc)
-Social history: smoking, alcohol, BMI, who knows, what do they want to do

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4
Q

Investigations in early pregnancy

A

-Urine pregnancy test ( measure of bHCG)
-Blood tests: serum bHCG, Full blood count, U& electrolytes, liver function tests
-Imaging: ultrasound, CT (critically unwell), MRI (less radiation)
-Diagnostic Laparoscopy

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5
Q

What can be seen at a 6+4 week gestation scan?

A

-Intra-uterine gestational sac
-Foetal pole (developing embryo)
-Yolk sac
-Signs of cardiac activity

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6
Q

Maternal risk factors for miscarriage

A

-Age (extremes)
-Infection (UTI)
-Smoking
-BMI <18 or >30
-Maternal co-morbidities e.g. SLE, hypertension, diabetes
-Abnormal pelvic anatomy-bicornuate uterus, fibroids, uterine polyps, LLETZ- a cause of 2nd trimester and later miscarriage

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7
Q

Foetal risk factors for miscarriage

A

-Chromosomal abnormalities (Trisomy)
-Congenital anomalies

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8
Q

Investigations in ectopic pregnancy

A

-Positive pregnancy test
-Scan: (transvaginal) empty uterus, adnexal mass, free fluid in pelvis
-Bimanual examination: cervical excitation (warn patient)= intraperitoneal inflammation

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9
Q

Risk factors for ectopic pregnancy

A

-Previous ectopic ( recurrence risk 11%)
-Surgery
-Smoker
-IVF
-Abdominal/ pelvic infection- PID, STDs, appendicitis

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10
Q

Presentation of ectopic pregnancy

A

-Signs of internal bleeding: peritoneal inflammation (referred shoulder pain worse on lying flat)
-Urinary symptoms
-Diarrhoea
-Pain opening bowels
-Signs of decompensation: lactate, haemoglobin, tachycardia

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11
Q

Expected HCG trends in early pregnancy

A

-Viable intra-uterine pregnancy: increases by at least 50% every 48hrs (visible on ultrasound at HCG >1500-2000)
-Miscarriage: drops by up to 50% every 48hrs
-Ectopic pregnancy: sub-optimal rise <50%/ sub optimal drop <50%

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12
Q

Describe molar pregnancy/ gestational trophoblastic disease

A

-Prevalence: 1 in 600-700
-Complete mole: no foetal parts, diploid 46 XX, XY ( risk of malignant transformation)
-Partial mole: fetus may be present, triploid 69 XXY…

Placenta doesn’t develop properly
-Presentation: severe hyperemesis, high hCG, large bump for dates/gestation, metastatic ability
-Pathology: abnormal hydropic chorionic villi (typical snowstorm or cluster of grapes appearance). Fibroids/ clots?

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13
Q

Management of miscarriage

A

-Watchful waiting and TLC
-Misoprostol (encourages contractions to dispel)
-Suction evacuation of uterus (EVAC)

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14
Q

Management of ectopic pregnancy

A

-BHCG tracking if very low
-Methotrexate deep IM
-Dependent on location of pregnancy: surgery
=Salpingectomy
=Salpingostomy (20% chance of residual ectopic tissue)
=Cystectomy
=Oophorectomy

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15
Q

Management of molar (GTD)

A

-Methotrexate (used only for metastatic disease)
-Suction evacuation of uterus
=Discharged when bHCG normalises

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16
Q

Describe hyperemesis gravidarum

A

-Severe nausea and vomiting associated with dehydration+/- weight loss in early pregnancy
=5% pre-pregnancy weight loss
dehydration
electrolyte imbalance

-Affects 1-3 in 100 pregnancies
-Tends to resolve by 16-20 weeks, most common 8-12 weeks
-Associated with multiple, molar pregnancies and thyrotoxicosis

17
Q

Risk factors for hyperemesis gravidarum

A

increased levels of beta-hCG
multiple pregnancies
trophoblastic disease
nulliparity
obesity
family or personal history of NVP

Smoking is associated with a decreased incidence of hyperemesis.

18
Q

Investigations of hyperemesis gravidarum

A

-Bloods: FBC, U&Es, TFTs
-Ultrasound: in extreme cases of HG to exclude multiple or molar pregnancy

PUQE severity score

19
Q

Referral criteria for nausea and vomiting in pregnancy

A

NICE recommend considering admission in the following situations:
Continued nausea and vomiting and is unable to keep down liquids or oral antiemetics
Continued nausea and vomiting with ketonuria and/or weight loss (greater than 5% of body weight), despite treatment with oral antiemetics
A confirmed or suspected comorbidity (for example she is unable to tolerate oral antibiotics for a urinary tract infection)

They also recommend having a lower threshold for admission to hospital if the woman has a co-existing condition (for example diabetes) that may be adversely affected by nausea and vomiting.

20
Q

Management of hyperemesis gravidarum

A

-Correct dehydration with IV or oral fluids (potassium added)
-Anti-emetic and anti-acid therapy:
-Cyclizine 50mg IM/IV/PO TDS, ondansetron 4mg IM/IV/PO TDS (cleft lip), prochloperazine 12.5mg IM BD, steroid treatment, PPI- omeprazole 20mg BD PO, metoclopramide (extrapyramidal SE no more than 5 days)
-Thromboprophylaxis- dehydration increases risk of VTE
-Vitamin supplementation- folic acid & thiamine

21
Q

Complications of hyperemesis gravidarum

A

Women with hyperemesis gravidarum may develop dehydration, weight loss and electrolyte imbalances. Other complications include:
acute kidney injury
Wernicke’s encephalopathy
oesophagitis, Mallory-Weiss tear
venous thromboembolism
fetal outcome
studies generally show little evidence of adverse outcomes for birth weight/other markers for mild-moderate symptoms
severe NVP resulting in multiple admissions and failure to ‘catch-up’ weight gain may be linked to a small increase in preterm birth and low birth weight

22
Q

Presentation and investigation of miscarriage

A

-Blood clot in early pregnancy
-1 in 4 end in miscarriage, but unlikely to have more than one (down to 3%)
-Speculum (cervical os open or closed- open means definite miscarriage, closed= threatened miscarriage)
-USS: empty uterus/ no cardiac activity if CRL 7+ cm/ mean sac diameter 20cm to make decision

23
Q

Definition of recurrent miscarriage

A

-3 or more first trimester miscarriages
=Not restricted to consecutive only or with same partner only (maternal pathology will not differ)
-Most cases are unexplained

-If after 2 first trimester miscarriages there is clinical suspicion these are pathological and not sporadic, evaluation recommended

=Risk of miscarriage directly related to outcomes of previous pregnancies
=Average observed incidence higher than chance alone
=Tends to occur even if fetus has no chromosomal abnormalities

24
Q

Definition of miscarriage

A

-Spontaneous loss of pregnancy before the fetus reaches viability which includes all pregnancy losses from the time of conception until 24 weeks of gestation

25
Q

Types of miscarriage

A

-Sporadic
=Most commonly in 1st trimester and often result of random fetal chromosomal abnormalities
=Incidence increases with age and affects 10-50% women aged 20-45 years respectively

-Recurrent
=1% women where random anomalies rare in 2nd trimester

26
Q

Risk factors for recurrent miscarriage

A

-Advancing maternal age: decline in number and quality of remaining oocytes= aneuploidy in fertilised embryos
-Paternal age 40+
-Previous miscarriages
-Black African and black Caribbean
-Obesity BMI below 19, above 25
-Smoking
-Alcohol 10 units
-Caffeine
-Thrombophilia (antiphospholipid syndrome- antibodies) and inherited
-Parental chromosomal rearrangements (translocation)
-Fetal Chromosome anomaly (trisomy, polyploidy, monosomy, structural abnormalities)
-Congenital uterine anomalies (septate, bicornuate)
-Acquired uterine anomalies (myoma? endometrial polyp? intrauterine adhesions)
-Cervical insuffiency (2nd trimester)

-Uncontrolled diabetes (High HBA1c= malformation)
-Subclinical hypothyroidism
-Thyroid autoantibodies
-PCOS (insulin resistance)
-Prolactin imbalance
-Luteal phase defect?

-Peripheral immune factors (HLA, cytokines)
-Uterine NK cells
-Genital tract infections
-Male: increased sperm DNA fragmentation

27
Q

Investigations of recurrent miscarriage

A
  1. Thrombophilia
    =APS: x2 positive tests at least 12 weeks apart (and at least 6 weeks post miscarriage) for lupus anticoagulant or aCL antibodies of IgG/M more than 40 GPL or MPL
    =Factor V Leiden, prothrombin gene mutation and protein S deficiency is second trimester (inherited)
  2. Genetic
    =Cytogenetic analysis of pregnancy tissue on third and subsequent miscarriage 2nd trimester: parental peripheral blood karyotyping when unbalanced structural chromosomal abnormality
  3. Anatomical
    =Congenital uterine anomalies (3D USS)
  4. Endocrine
    =TFT, TPO antibodies
    =Diabetes and hyperprolactinaemia if suspicions
  5. Immune
    =Not routine
  6. Infective
    =Not routine
  7. Male factor
    =Not routine
28
Q

Treatment of recurrent miscarriage

A

-Lifestyle
=BMI between 19 and 25
=Smoking cessation
=Limit alcohol consumption and caffeine (<200mg)

-Thrombophilia
=Aspirin (150mg) and heparin (LMWH subcut from positive pregnancy test to 34 week gestation) in APS

-Balanced translocations: preimplantation genetic diagnosis and gamete donation

-Resection of uterine septum?

-Thyroxine supplementation not routinely recommended for TPO but moderate SCH (TSH>4)

-Progesterone supplementation (bleeding early pregnancy- 400mcg vaginally x2 daily at time of bleeding until 16 weeks)

-Corticosteroids and metformin??

Obs and Gynae (29 decks)

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