Early Pregnancy Flashcards
what is the pathophysiology of ectopic pregnancy?
pregnancy which is implanted at a site outside of the uterine cavity
- 97% tubal
- 3% ovary, cervix or peritoneum
trophoblast invades the tubal wall, producing bleeding which may dislodge embryo
what are the possible consequences of an ectopic pregnancy?
- tubal abortion
- tubal absorption: if the tube does not rupture, the blood and embryo may be shed or converted into a tubal mole and absorbed
- tubal rupture
what are some risk factors for an ectopic pregnancy?
*anything slowing the ovums passage to the uterus
- damage to tubes: PID, surgery
- previous ectopic
- endometriosis
- IUCD
- POP - fallopian tube ciliary dysmotility
- IVF - 3% of pregnancies are ectopic
- iatrogenic - pelvic surgery, reversal of sterilisation, assisted reproduction ie. embryo transfer in IVF
how might an ectopic present?
*leading sx of ectopic pregnancy is pain → lower abdo/ pelvic pain, with or without vaginal bleeding with potential hx of amenorrhoea
shoulder tip pain - irritation of diaphragm by blood in peritoneal cavity
vaginal discharge - brown, prune juice colour
what might you see on examination in an ectopic pregnancy?
- localised abdominal tenderness
- vaginal examination revelas cervical excitation, adnexal tenderness
- full pouch of Douglas
- haemodynamic instability
- peritonitis signs
what are some differentials for an ectopic?
- Miscarriage
- Ovarian cyst accident (this refers to cyst haemorrhage, torsion or rupture)
- Acute pelvic inflammatory disease
- Urinary tract infection
- Appendicitis
- Diverticulitis
how would you investigate an ectopic?
- pregnancy test
- B-HCG serum
- pelvic USS
- urinalysis
- any swabs etc for differentials
how is an ectopic managed immediately?
A to E
medical for those who are stable, pain controlled, no visible heart beat
IM methotrexate - anti-folate cytotoxic agent that disrupts the folate dependent cell division
what are the advantages and disadvantages of medically managing an ectopic?
- advantages: avoids the complications of surgery, pt can be at home
- disadvantages: potential side effects methotrexate like abdo pain, myelosuppression, renal dysfunction, hepatitis, teratogenesis ((advice contraception for 3-6m after), if fails surgery needed
when would you offer surgical and discuss the advantages and disadvantages?
severe pain, serum B-HCG >5000, adenexal mass >34mm, foetal heart beat visible on scan
- advantages: reassurance about definitive treatment, high success rate
- disadvantages: GA risk, risk of damage to neighbouring structures like bladder, bowel, ureters, DVT, PE, haemorrhage, infection, wisk of tx failure with salpingotomy if some pregnancy remains
when would you offer a salpingostomy over a salpingectomy?
- if damage to contralateral tube from infection, disease or surgery - salpingotomy (a cut in fallopian tube)
- can be performed to remove ectopic and salvage the tube to preserve future fertility
- HCG follow up is required until the level reaches <5iU (negative), to ensure there is no residual trophoblast
- risk of recurrent ectopic pregnancy in the salvaged tube will be increased
what should you remember for someone who is having surgical mx of ectopic?
Anti-D prophylaxis → rhesus negative women who receive surgical mx
when would you manage an ectopic conservatively?
for stable pt where rupture is unlikely with well controlled pain, low basleine B-HCG, small unruptured ectopic on USS
- Advantages:Avoid the risks of medical and surgical management, can be done at home.
- Disadvantages:Failure or complications necessitating medical or surgical management (25% of patients), rupture of ectopic
what are some differentials for bleeding in first trimester?
Spontaneous abortion
Ectopic pregnancy
Hydatidiform mole
what are some differentials for bleeding in second trimester?
Spontaneous abortion
Hydatidiform mole
Placental abruption
what are some differentials for bleeding in third trimester?
Bloody show
Placental abruption
Placenta praevia
Vasa praevia
what is a spontaneous abortion?
loss of pregnancy at less than 24 weeks gestation
- early (1st trimester) more common than late miscarriage
- occurs in 20-25% pregnancies
what are the classifications for abortion?
- threatened: mild bleeding, pain, cervix closed, pregnancy viable
- inevitable: heavy bleeding, clots, pain, cervix open
- missed: asymptomatic with no foetal heartbeat
compare incomplete vs complete pregnancy?
POC** partially expelled – Sx of missed miscarriage or bleeding/clots
Hx of bleeding, passing clots and POC and pain. Sx settling/settled now, no POC
how is a threatened miscarriage managed?
If heavy bleeding admit/observe, if not reassure and back to GP/Midwife
* If >12 weeks & Rhesus negative: Anti-D
how is an inevitable miscarriage managed?
If heavy bleeding admit/observe
* Offer conservative/medical/surgical options. Likely to proceed to incomplete/complete miscarriage
* If >12 weeks & rhesus negative: Anti-D
what is the management of a missed miscarriage?
May want to rescan and second person to confirm
* Manage conservatively (lower success rated), medically or surgically
* If >12 weeks & rhesus negative: Anti-D
what are some causes of
- early - aneuploidy, abnormal foetal development
- mechanical - cervical weakness
- uterine abnormalities
- chronic maternal disease - SLE, DM
- infection - CMV
- foetal cause
- no cause
what are some risk factors of spontaneous abortion?
- maternal age >30-35 (chromosomal abnormalities)
- previous miscarriage
- obesity
- chromosomal abnormalities in parents
- smoking
- uterine abnormalities
- fibroids
- previous uterine surgery
- anti-phospholipid syndrome
- coagulopathies
what are some clinical features of a miscarriage?
- vaginal bleeding - may include clots or POC
- haemodynamic instability if bleeding excessive
- suprapubic, cramping pain (similar to primary dysmenorrhoea)
what features are seen on examination of miscarriage?
- haemodynamic instability
- abdo exam - distended, localised tenderness
- speculum - assess diameter of cervical os, observe any POC in cervical canal, local bleeding
- bimanual - assess uterine tenderness, adnexal masses or collection (ectopic)
what are some ways of investigating miscarriage?
EPAU
imaging - transvaginal USS, doppler
bloods: serum b-HCG, FBC, blood groups, rhesus status, triple swabs
evaluate conservative management of miscarriage?
- advantages - can remain at home, no side effects, no anaesthetic risk
- disadvantages - unpredictable timing, heavy bleeding, pain during passage of POC, chance of being unsuccessful
what are some contraindications for conservative mx of miscarriage?
infection, high haemorrhage risk, coagulopathy or haemodynamic instability
how is medical management done for miscarriage?
Mifepristone is a progesterone receptor antagonist → weakening of attachment to the endometrial wall + cervical softening and dilation + induction of uterine contractions
vaginal misoprostol (prostaglandin analogue) to stimulate cervical ripening and myometrial contractions
evaluate medical management for miscarriage?
- advantages - home if patient desires, avoid anesthetic risk
- disadvantages - side effects of meds, D+V, heavy bleeding, pain during POC, chance of emergency surgical intervention
- follow up - pregnancy test 3w later
what is the surgical management for miscarriage?
manual vacuum aspiration with local if >12w, evacuation of retained POC (ERPC)
ERPC, the patient is under a general anaesthetic, a speculum is passed to visualise the cervix, it is dilated allowing suction tube to be passed and remove the products of conception
evaluate the surgical management of a miscarriage?
- advantages - planned, unaware during procedure GA
- disadvantages - Anaesthetic risk, infection (endometeritis), uterine perforation, haemorrhage, Ashermen’s syndrome, bowel or bladder damage, retained products of conception
what do you have to make sure to do after a miscarriage?
- help with grief
- offer follow up
- respect wishes of dealing with foetal products
- give in opaque container
what are some causes of recurrent miscarriages?
endocrine: PCOS, thyroid, DM
infection: BV in first 3m
chromosomal, uterine abnormalities
thrombophilia - protein c/s
anti phospholipid syndrome
how is recurrent miscarriages managed?
- genetic clinic
- cervical cerclage
- Previous poor obstetric history (≥3x 2trimester losses)
- Cervical length shortening on USS (<25mm before 24/40 and a previous 2trimester loss)
- Symptomatic women with premature cervical dilatation and exposed fetal membranes in the vagina
- low dose aspirin plus heparin for antiphospholipid
what is a hydatidiform mole?
- tumours consist of proliferating chorionic villi which have swollen and degenerated
- derived from chorion and makes lots of hCG exaggerating pregnancy sx
what are some risk factors for hydatidiform mole?
- higher rates in latin american, asian and middle eastern women
- past moles
- extreme maternal age
- FHx
how would a mole pregnancy present?
- exaggeration of normal pregnancy sx with extreme b-HCG
- hyperemesis gravidarum
- vaginal bleeding - prune juice discharge which accumulated in uterine cavity and oxidised
- may look like frogspawn
- pelvic discomfort - pain or pressure
what signs are seen on examination of a mole?
- uterus larger than expected
- possible adenexal mass
- possible grape like mass in vagina
how is a mole investigated?
- transvaginal USS
- central heterogenous mass with numerous anechoic spaces
- snowstorm, cluster of grapes, honeycomb appearance
- b-HCG
- bloods
how is a mole managed?
- tell anaesthetist as b-HCG can act like TSH and cause thyrotoxic storm at evacuation
- gentle suction to remove molar tissue
- histology
- anti-D if Rh-ve
- avoid pregnancy until b-HCG normal for 6m
- oral contraceptives can be used if levels drop rapidly
what are some molar pregnancy complications?
- invasive moles metastasise - lung, vagina, brain, skin and liver
- choriocarcinoma
- hyperthyroidism
- pre-eclampsia
- RDS
what is a bloody show?
small amount of blood and mucus released from the vagina as a result of cervix dilating and softening and effacing to dilate in preparation for labour
- mucus plug blocks the opening of the cervix during pregnancy to protect the baby from bacteria
- blood from your cervix is mixed in with the mucus plug, it is called a bloody show
how does a bloody show present?
- can be red, brown, pink and jelly or string-like
- no more than a tablespoon or two of blood
- triggers
- sexual intercourse
- membrane sweeping
- trauma
- symptoms
- cramping
- pelvic pressure
- contractions
how would a placental abruption present?
- abdominal pain → posterior placental abruptions with back pain
- vaginal bleeding
- uterine contractions
- dizziness and loss of consciousness
- Clinical exam
- woody, tense uterus
- foetal heart may be absent or distressed
how is placental abruption managed?
- foetus alive → no signs of distress → observe closely is <36w→ induce and deliver vaginally is >36w
- foetus alive → signs of distress → immediate C-section
- foetus dead → induce vaginal delivery unless haemodynamically compromised → C-section
how is placental praevia managed?
- 16-20w → if identified rescan at 32w, and again at 36w
- in still at 36w, delivery via C-section
- risk of spontaneous labour, associated haemorrhage
what is vasa praevia?
fetal blood vessels (the two umbilical arteries and single umbilical vein) arewithin the fetal membranesand run across theinternal cervical os and not protected within umbilical cord or placenta
how is vasa praevia managed?
- elective C- section at 34-36 w
- corticosteroids from 32w to promote foetal lung maturity
- APH → C-section required
what is hyperemesis gravidarum?
persistent and severe vomiting during pregnancy, leading to weight loss, dehydration and electrolyte imbalances
what is the physiology of hyperemesis?
normally startsbetween4 and 7 weeks’ gestation. It reaches a peak in the 9thweek, and settles by week 20
what is the pathophysiology of hyperemesis?
increasing levels of b-HCG released by placenta which stimulate chemoreceptor trigger zone in brainstem feeding onto vomiting centre of brain
what are some risk factors for hyperemesis?
- First pregnancy
- Previous history of hyperemesis gravidarum
- Raised BMI
- Multiple pregnancy
- Hydatidiform mole
which score is used in hyperemesis?
Pregnancy-Unique Quantification of Emesis(PUQE) score; a score of 6 correlates to mild NVP, 7-12 moderate and 13-15 severe
what are some differentials for hyperemesis?
Infections: Gastroenteritis, urinary tract infection, hepatitis, and meningitis
Gastrointestinal problems: Appendicitis, cholecystitis, bowel obstruction
Metabolic conditions: Diabetic ketoacidosis, thyrotoxicosis
Drug toxicity
Molar pregnancy: Characterized by abnormally high levels of beta-hCG due to gestational trophoblastic disease, which can cause severe nausea and vomiting
how is hyperemesis investigated?
- electrolyte levels
- bedside - weight, urine dip
- lab - midstream urine, FBC, U&E, glucose
- refractory cases
- LFT to exclude liver disease
- amylase - pancreatitis
- thyroid function
- ABG - monitor severity
- imaging - USS to confirm gestation, viability, exclude honeycomb etc
how is hyperemesis managed?
- mild - community with oral antiemetics, oral hydration, dietary advice, reassurance
- moderate - ambulatory daycare, IVF, parenteral antiemetics, thiamine, until ketonuria resolves
- severe - inpatient
how is hyperemesis managed as an inpatient?
- IV hydration with 0.9% saline with potassium chloride as indicated
- H2 receptor antagonist or PPI for reflux, oesophagitis, gastritis
- thiamine - prolonged vomiting to prevent wernickes
- thromboprophylaxis
what antiemetics are given in hyperemesis?
- first line: cyclizine, prochlorperazine
- second: metoclopramide for 5 days max
- third: hydrocortisone IV
