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.
