Early Pregnancy

Question 1

Causes of bleeding in early pregnancy

Answer 1

Implantation bleeding

Sub-chorionic haematoma

Cervical causes:
Infecon
Malignancy ( important to take a smear history)
Polyp

Vaginal causes:
Infection
Malignancy (rare)

Unrelated : Haematuria, PR bleeding etc.

Question 2

Snowstorm appearance on ultrasound

Answer 2

Molar pregnancy

Question 3

Definition of Early fatal demise or Non-Continuing Pregnancy (NCP)

Answer 3

pregnancy in-situ, no heartbeat, Mean Sac Diameter > 25mm, Fetal Pole > 7mm

Question 4

Causes of miscarriage

Answer 4

Chromosomal abnormality
Immune cause : Antiphospholipid Syndrome APS (includes Lupus Anticoagulant LAC, and Anticardiolipin antibody ACA and b2Glycoprotein1 antibody).
Infections : Cytomegalovirus (CMV), Rubella, Toxoplasmosis, Listeria.
Severe emotional upsets, extreme physical stress.
Iatrogenic loss (after Chorionic Villus Sampling CVS causing infection or uterine irritability.
“Associations”: heavy smoking, cocaine, alcohol misuse.
Uncontrolled Diabetes.
Cervical incompetence and shortened cervix.
Vaginal (bacterial) infections.

Question 5

Pathophysiology of miscarriage

Answer 5

Bleeding from placental bed or chorion causing hypoxia and villous/placental dysfunction

This causes embryonic demise

Question 6

NICE guidance for threatened miscarriage

Answer 6

Micronised Progesterone (protects the womb)

400 mg PV b.d. till 16 weeks if viable intrauterine pregnancy is noted on scan
(unless there is a history of previous miscarriage)

Question 7

Treatment for miscarriage

Answer 7

Conservative, medical, Manual Vacuum Aspiration, surgical intervention if required (in which case, anti-D is administrated)

Question 8

Presentation + findings of ectopic pregnancy

Answer 8

Pain > bleeding, dizziness / collapse / shoulder tip pain, shortness of breath, sometimes diarrhoea

Pallor, haemodynamic instability, signs of peritonism, guarding + tenderness

Question 9

Gold standard investigation for ectopic pregnancy

Answer 9

Trans-vaginal scan (TVS)

(empty uterus, no free fluid, no Pouch of Douglas)

Question 10

Management of ectopic pregnancy in acutely unwell patient

Answer 10

Laparoscopic salpingectomy

Question 11

Management of ectopic pregnancy in stable patient

(with low levels of BhCG and a small, unruptured ectopic pregnancy)

Answer 11

Methotrexate

(sometimes conservative management is used in patients who are very well - counselling necessary)

Question 12

Pathology of molar pregnancy

Answer 12

Overgrowth of placental tissue with chorionic villi swollen with fluid rich in hCG; giving picture of “grape like clusters”

Question 13

Important complication of molar pregnancy

Answer 13

A complete mole has 2.5% risk of developing into a Choriocarcinoma

Question 14

Molar pregnancy management

Answer 14

Surgical: uterine evacuation + send tissue for histology

Question 15

When does implantation bleeding occur?

Answer 15

Approx. 10 days post-ovulation

(Bleeding is light/brownish and self-limiting

Question 16

What is this?

Answer 16

Chorionic haematoma

Question 17

What is a sub-chorionic haematoma ?

Answer 17

Pooling of blood between endometrium and the embryo due to separation

(Reassurance + surveillance)

Question 18

Diagnosis ?

Answer 18

Cervical polyp

Question 19

Diagnosis ?

Answer 19

Cervical cancer

Question 20

Excessive nausea and vomiting that alters quality of life =

Answer 20

Hyperemesis Gravidarum (HG)

Question 21

Scoring system of nausea and vomiting in pregnancy

Answer 21

PUQE score