Early Pregnancy Flashcards
Describe features of normal pregnancy hormones?
HCG peaks at around 12 weeks and then falls, plateauing at 24 weeks.
Progesterone and oestrogen continue to risk throughout 40 weeks
What is the definition of miscarriage and stillbirth
Miscarriage - pregnancy loss before 24 weeks gestation.
Stillbirth - any fetus born dead at or after 24 weeks
What is the definition of the following:
Threatened miscarriage,
Inevitable miscarriage,
Incomplete,
Complete,
Delayed/missed/silent,
Septic,
Recurrent
Threatened miscarriage - bleeding with continuing intrauterine pregnancy(closed cervix)
Inevitable miscarriage - Bleeding with non-continuing intrauterine pregnancy (cervix open)
Incomplete - incomplete passage of tissue.
Complete - All pregnancy tissue expelled and uterus now empty.
Delayed/missed/silent - fetus died in-utero before 24 weeks.
Septic - complicated by intrauterine infection.
Recurrent - 3 or more consecutive miscarriages.
What is the clinical presentation of a miscarriage?
Positive pregnancy test with vaginal bleeding, pelvic pain or asymptomatic
What are the investigations for miscarriage?
Clinical exam - haemodynamic stability, assess pain and bleeding.
Ultrasound scan (transabdominal or transvaginal.
Examination of the products of conception (POC),
Serum HCG tracking.
Assess FBC and blood group
What are the ultrasound definitions of miscarriage?
No fetal heart activity when >7mm in crown-rump length on TV scan.
Empty sac when gestation sac > 25mm in diameter on TV scan.
If uterus empty then complete miscarriage, ectopic pregnancy or pregnancy too early to visualize
What is the managmenet of a miscarriage?
Conservative/expectant - follow up and review every 7-14 days.
Medical - Misoprostol (oral of vaginal)
Surgical - Priming with misoprostol, electrical vacuum aspiration under GA or manual vacuum aspiration under LA.
When is Anti-D required/not required during a miscarriage?
Required for rhesus -ve - Surgical management < 12 weeks gestation. Sensitizing event >12 weeks.
Not required for rhesus -ve if threatened or complete miscarriage or medical management
What are the causes of Miscarriage?
Unexplained (~50%),
Maternal age,
Fetal chromosomal abnormality,
Immunological (autoimmune - Antiphospholipid),
Endocrine - PCOS or poorly controlled DM.
Uterine anomalies,
Infection,
Environment (smoking/alcohol),
Cervical weakness
What is the management of recurrent miscarriage?
Depending on cause:
Aspirin and LMWH if antiphospholipid syndrome.
Clinical genetics
Cervical cerclage if length <25 mm
Supportive care
What are the risk factors for ectopic pregnancies?
Previous ectopic pregnancy.
Endometriosis,
Pelvic infection (chlamydia),
Pelvic surgery,
Contraception (POP, IUD/IUS),
Assisted contraception techniques,
Cigarette smoking.
What is the clinical presentation of an ectopic pregnancy?
Vaginal bleeding (brown spotting to heavy bleeding),
Pelvic discomfort or pain (one sided +/- shoulder tip pain),
Pain opening bowels,
Maternal collapse or hypovolaemic shock.
What are the investigations for ectopic pregnancies?
Clinical exam - pain, bleeding, bimaual exams, vaginal swabs.
Ultrasound - transabdominal or TV
Serum HCG tracking
FBC and blood group
Describe features of HCG tracking in ectopic pregnancies
Measure 48hr apart if patient is stable.
If increases > 66% then likely intrauterine pregnancy.
If <66% increase or <50% decrease then likely ectopic.
If >50% decreasing then suggests failing pregnancy of unknown location (PUL)
What is the emergency management of ectopic pregnancies?
ABC resusitation.
Involve gynae, anaesthetics and haemtology.
Prep patient for theater.
What is the non-emergent management of ectopic pregnancies?
Conservative.
Medical - methotrexate.
Surgical - laparotomy or laparoscopy. Salpingectomy is 1st line. Salpingostomy if problem problem with colateral tube. (risk of oophorectomy)
Rhsus - Anti-D required if Rh -ve and had surgical management. Anti-D not required if ectopic is managed conservatively or medically.
What is the criteria for giving methotrexate in ectopic pregnancies?
Pain free, unruptured ectopic <35mm, serum HCG < 5000, able to return for follow up and no medical contraindications.
Cannot get pregnant until 12 weeks after the HCG falls below 5 (time required to replenish folic acid).
Associated with 7% risk of tubal rupture
Describe features of salpingotomy
Opening of affected tube and removal of POC. 1 in 5 require follow up
Describe features of gestational trophoblastic disorders
Spectrum of disorders originating from placental trophoblast:
Complete hydatidiform mole (premalignant),
Partial hydatidiform mole (premalignant),
Choriocarcinoma
Invasive mole,
Placental site trophoblastic tumour
Describe features of partial and complete hydatidiform mole
Partial - 2 sperm and 1 egg. 0.5% risk of malignancy.
Complete - Sperm fertilizes an empty ovum. 1-2% risk of malignany.
Describe the clinical features of a molar pregnancy?
More severe morning sickness,
Vaginal bleeding,
Increased enlargement of uterus.
Abnormally high hCG.
Hyperthyroidism - stimulation of thyroid due to high HCG levels.
US shows snowstorm appearence.
What are the risk factors for gestational trophoblastic disease
Maternal age <20 or >35
Previous gestational trophoblastic disease,
Previous miscarriage,
Use of OCP
What are the investigations for gestational trophoblastic disease?
Ultrasound - snowstorm appearance,
Histology - suction curettage.
Register with specalist centre
How can you support a woman after pregnancy loss?
Support groups - mscarriage association UK.
Sensitive disposal of pregnancy tissue.
Local book of remembrance
What is the definition of hyperemesis gravidarum
Persistent vomiting in pregnancy causing weight loss (>5% of body mass), dehydration and electrolyte imbalance
What are the affects of hyperemesis gravidarum
Wernicke’s encephalopathy. Central pontine myelinolysis (rapid correction of hyponatraemia). Maternal death.
Infants - IUGR,
What are the investigations for HG?
Urinary ketones and dip.
Bloods: UEs, LFTs, TFTs.
Ultrasound scan - multiple pregnancy, molar pregnancy
What is the management of HG?
Oral intake
IV fluids,
Regular antiemetics,
Omeprazole,
VTE prophylaxis,
Vitamin replacement,
Oral steroids,
TPN,
Assessment of fetal growth
