Early Pregnancy Flashcards
What is the early pregnancy period?
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
Early pregnancy conditions and their symptoms
-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
Important questions for history taking
-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
Investigations in early pregnancy
-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
What can be seen at a 6+4 week gestation scan?
-Intra-uterine gestational sac
-Foetal pole (developing embryo)
-Yolk sac
-Signs of cardiac activity
Maternal risk factors for miscarriage
-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
Foetal risk factors for miscarriage
-Chromosomal abnormalities (Trisomy)
-Congenital anomalies
Investigations in ectopic pregnancy
-Positive pregnancy test
-Scan: (transvaginal) empty uterus, adnexal mass, free fluid in pelvis
-Bimanual examination: cervical excitation (warn patient)= intraperitoneal inflammation
Risk factors for ectopic pregnancy
-Previous ectopic ( recurrence risk 11%)
-Surgery
-Smoker
-IVF
-Abdominal/ pelvic infection- PID, STDs, appendicitis
Presentation of ectopic pregnancy
-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
Expected HCG trends in early pregnancy
-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%
Describe molar pregnancy/ gestational trophoblastic disease
-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?
Management of miscarriage
-Watchful waiting and TLC
-Misoprostol (encourages contractions to dispel)
-Suction evacuation of uterus (EVAC)
Management of ectopic pregnancy
-BHCG tracking if very low
-Methotrexate deep IM
-Dependent on location of pregnancy: surgery
=Salpingectomy
=Salpingostomy (20% chance of residual ectopic tissue)
=Cystectomy
=Oophorectomy
Management of molar (GTD)
-Methotrexate (used only for metastatic disease)
-Suction evacuation of uterus
=Discharged when bHCG normalises
Describe hyperemesis gravidarum
-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
Risk factors for hyperemesis gravidarum
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.
Investigations of hyperemesis gravidarum
-Bloods: FBC, U&Es, TFTs
-Ultrasound: in extreme cases of HG to exclude multiple or molar pregnancy
PUQE severity score
Referral criteria for nausea and vomiting in pregnancy
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.
Management of hyperemesis gravidarum
-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
Complications of hyperemesis gravidarum
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
Presentation and investigation of miscarriage
-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
Definition of recurrent miscarriage
-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
Definition of miscarriage
-Spontaneous loss of pregnancy before the fetus reaches viability which includes all pregnancy losses from the time of conception until 24 weeks of gestation
Types of miscarriage
-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
Risk factors for recurrent miscarriage
-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
Investigations of recurrent miscarriage
- 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) - Genetic
=Cytogenetic analysis of pregnancy tissue on third and subsequent miscarriage 2nd trimester: parental peripheral blood karyotyping when unbalanced structural chromosomal abnormality - Anatomical
=Congenital uterine anomalies (3D USS) - Endocrine
=TFT, TPO antibodies
=Diabetes and hyperprolactinaemia if suspicions - Immune
=Not routine - Infective
=Not routine - Male factor
=Not routine
Treatment of recurrent miscarriage
-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??
