Early pregnancy Flashcards
Define miscarriage and foetal demise
Miscarriage spontaneous termination of pregnancy before 20 weeks Foetal demise – demise after 20 weeks of gestation or when the foetus is more than 500g
What percentages of early pregnancy end in miscarriage How many women will experience bleeding in first trimester and how many of these will miscarry What is the chance of miscarriage in a viable foetus seen on POCUS
20-30 25% of women will experience some bleeding – of these 50% will miscarry When viable foetus is seen on ultrasound miscarriage occurs in 3-6%
Discuss risk factors for miscarraige
Increasing maternal age Increasing paternal age, alcohol use, increased parity, history of prior miscarriage, Alcohol use poorly controlled DM Thyroid disease obesity low maternal BMI Maternal stress history of PV bleeding
Discuss pathophysiology of miscarriage
Most miscarriages are due to foetal malformation or chromosomal abnormalities In most miscarraige the foetal death of preceeds symptoms of miscarriage by several weeks
Discuss terminology associated with miscarriage
Broadly divided into three categories
1: threatened miscarriage: bleeding but with closed cervical os – risk of miscarriage in this population is 35-50% -inevitable miscarraige – cervical os is open
2: incomplete miscarriage – products of conception are present at the cervical os or in the vaginal canal
3: Completed miscarriage – the uterus has expelled all of the products of conception, the cervic is closed and the uterus is contracted
Discuss ultrasound finding and gestational stage
What is the discrimatory zone
Gestational sac –
5 weeks Discrimninatory zone –
5-6 weeks Yolk sac –
6 weeks Upper discriminatory zone
6-7 weeks Foetal pole
7 weeks Foetal heart beat 7 weeks
The discrimnatory zone is the level of BHCG in which bedside ultrasound should be able to identify foetal structures – 6500 for transabdominal 1000 -2000 for transvaginal
Name the structures seen on the following early pregnancy ultrasound
Discuss DDX of early pregancny bleeding
Miscarriage
Molar pregnancy
Ectopic
Discuss management of threatened miscarraige in the ED
If HD stable and ectopic has been excluded minimal further management is needed.
Those women who are resus -ve should be given anti D
Although more than 50% of women who present with early pregancny bleeding treatment to prevent miscarraige is not useful as foetal demise has likley occured several weeks prior to presentation.
In most cases miscarige is the bodies way of expelling an abnormal or underdevloped foetus
Advise should be given that moderate daily activities do not affect preganancy. Tampons, intercourse and other activities that might introduce infection should be avoided
Re-assure patient that they have done nothing wrong – minor falls, injuries or stress do not effect
Discuss management of incomplete miscarraige
Includes expectant management, medical management with misoprostol or surgical evacuation.
When miscarriage is incomplete the uterus may be unable to contract fully to limit bleeding. Gental removal of tissue form the cervical os can drastically reduce slow bleeding
Discuss misoprostol
Prostoglandin analouge- binds to myometrial cells to cause strong myometrial contractions leading to expulsion of tissue. Acts on EP2-4 receptors not EP1 limiting toxicity
Useful in treatment of, incomplete miscarraige, termination of pregnancy, PPH, induction of labor, ulcer prevention
Discuss epidiemiology and risk factors of ectopic pregnancy
Third leading cause of maternal death, responsible for 4% -10%
Estimated to account for 2% of all pregancny
Incidence is highest in women aged 25-34,
Hetrotropic pregnancy historically rare 1 in 4000 becoming more common in IVF assisted pregnancy
Risk factors
High: Previous ectopic, previous tubal surgery, tubal pathology, IUD, sterilization previous IVF
Moderate: Current use of OCP, PID, STI, smoking, previous spont abortion,
Mild: Infertility, >40, vaginal douching, age at first intercourse <18, previous appendectomy
Discuss pathophysiology of ectopic pregnancy
Ovum implants arround day 8-9
Risk factors for an abnormal site of implantation include
- prior tubal infection (PID)
- Anatomical abnormalities in the fallopian tube
- Assisted reproduction
- Abnormal endometrium
- Previous ectopic – risks of subsequent ectopic is 22%
- IUD
- Smoking
- Advanced age
When abnormal implanation occurs foetal development is slow which can result in low or declining BHCG – cannot exclude on 1 BHCG
Three outcomes of an ectopic are possible
- spontaneous involution
- Tubal abortion into the peritoneal cavity or vagina
- Rupture of the preganncy with internal or vaginal bleeing
Implantation in the uterine horn is particularly dangerous becuase the growing embryo can use the myometrial blood supply to grow larger (12-14 weeks) before rupture
Discuss clinical signs and symtpoms
Delayed menses, followed by abdominal paina and bleeding – very varied
Risk factors are absent in 15-20% of ectopic cases
Abdominal pain is very severe peritonitic in nature, shoulder tip pain indicates rupture and diaphragm irritation
Signs include – vaginal bleeding, tender abdomen, tender adenexa, adenexal mass in 10-20% of patient
Discuss ultrasound finding in patient with suspected ectopic pregnancy
Diagnostic of intrauterine pregnancy
- Double gestational sac – see pciture
- Intrauterine feotal pole or yolk sac
- Intrauterine foetal heart activity
Diagnostic of ectopic gestation
- Ectopic in fallopian tube
- extopic feotal heart activity
- ectopic foetal pole
Suggestuive of ectopic gestation
- moderate or large cul-de-sac fluid without intrauterine pregnancy
- adnexal mass without intrauterine pregnancy
Discuss hormonal assays in management of ectopic pregnancy
Serves two roles
- Serial levels can be taken in stable patients – normally doubles every 1.8-3 days in the first 6-7 weeks of pregnancy – serial levels can be taken 72 hours apart and if they fall or rise slowly suggestive of abnormality
- Can be used to estimate whether foetus should be identified on ultrasound
Discuss management of ectopic pregnancy
In HD unstable – fluid/blood resuscitation urgent laporotomy, all patient who are RH -ve should be given antiD
In stable patients - methotrexate is the most commonly used medical management – tubal mass should be smaller than 3.5 cm to be treated medically – increasing HCG levels have been shown to be associated with failure of methotrexate management
Best candidates for medical managements are: HD stable, nil feotal heart rate, bhcg <5000
Contraindications to methotrexate: viable intrauterine, comorbidities in which methotrexate would be unwise, sensitivity to same, breast feeding
Discuss rupture corpus luteum cyst
A luteum cyst occurs after an egg has been released from a follicle
The ruptured follicle begins producing large quantities of estrogen and progesterone in preparation for conception
If pregnancy does not occur normal degrade however has the possible to bleed into themselves causing sharp abdominal pain – may lead to ovarian torsion
Can occur in pregnancy
Define complete and incompete molar pregancy
Complete mole –> caused by ferilization of an ovum without maternal DNA and subsequent duplication of the haploid genome
Incomplete mole –> normal ovum fertilized by two sperm. The duplication of the triploid
Discuss clinically features of molar pregnancy
Major risk factor is advanced maternal age –
Patients present with abdominal pain, nausea and vomiting, or vaginal bleeding- if miscarraige does occur it is usually in the 2nd trimester and the patient or physician may note the passage of grapelike hydatid vesciles
The characteristic snowstorm appearance on ultrasound showing hyropic vesicles
Discuss complications of molar pregnancy
Complications of molar preganncy include pre-eclampsia or eclampsia which can develop before 24 weeks of gestation, respiratory failure or distress from PE or trophoblastic cells, hyperemesis gravidarum and significant uterine bleeding
Following evacuation of a molar pregnancy patient must be mopnitored in the OPD for trophoblastic sequelae. Patients are at increased risk of an invasive mole, a benign tumor that invades the uterine wall and metastasizes to the lungs or vagina
Also at risk of choriocarcinoma a malignant tumor that invades the uterine wall and disseminates to the lungs, brain and liver via vasculature route
Discuss bleeding in later pregnancy
Occurs in only approximatley 4% of pregnancy with 20% of miscariages occuring after the first trimester.
The most important DDX is placental abruption and placentae previa
Discuss abruptio pacentae
Seperation of the placenta from the uterine wall is believed to account for appoximatly 30% of episodes of bleeding during the second half of pregnancy
In non trauamtic abrutpion spontaneous haemorryhage into the decidua basalis occurs causing separation and comparession of the adjacent planentae
Abruption i smost clearly associated with maternal hypertension and pre-eclampsia. It is also more common with maternal age younger than 20 or greater than 35, parity of 3 or more, unexplained infertility, history of smoking, thrombophilia, prior miscarriage, prior abruption and cocaine
Discuss clinical features abruption
Vaginal bleeding occurs in 70% of cases. Blood is characteristically dark and amount is often insignificant but can range to life threatening haemorrhage
Uterine tenderness or pain is seen in approxiamtly 2/3rds of women, with uterine irritabiliy or contraction seen in 1/3
With significant seperation there is evident foetal distress and the maternal coagulation cascade is triggered leading to DIC
Wide range of symptoms from asymptomatic to tetanic contraction, foetal distress, DIC and maternal tachycardia in sever. Severe abruption is associated with significant pain and maternal hypotension from conealed or evident haemorrhage.
Discuss placenta pravia
Implantation of the placenta over the cervical os
Risk is increased with maternal age, smoking, multiparity, c-section, prior miscarriage or induced abortions and preterm labour
Bleeding occurs when marginal placental vessels implanted in the lower uterine segment are tone either as the lower uterine wall elongates or with cervical dilation near the time of delivery
Discuss clinical features of placenta previa
Painless fresh vaginal bleeding is the most common symtpom.
in 20% of cases there is some degree of uterine irritbailty- this is usually mild. Vaginal examination usually reveals bright red blood from the cervical os. -All patients with painless second trimester bleeding should be assumed to have placenta previa
Digital or instrumental probing of the cervix should be avoided yuntil the diagnosis is exclude via ultraosund. Injudicious vaginal examination can precipitate severe hamerrohage
Most cases of placenta praevia identified during the mid trimester resolve by time of delivery as the lower uterine segment elongates and the placenta no longer overlaps the os
Discuss management of abpruption and praevia
ABCD
If RH -ve should receive anti D 300 mic
O&G input
Foetal monitorign
Discuss Rhesus (Anti D) immunization in pregnancy
Occurs when a Rh -ve women is exposed to RH psotive foetal blood
Small amount of feotal cells enter the maternal circulation throughout pregnancy - bute the maternal immune system is triggered only by sgnificant laods fo foetal cells
Sensitization occurs in yup to 15% of RH -ve women carrying Rh Positve fetuses. To prevent this antiD immun globulin is routinely administered to motehrs at approximatly 28 weeks of pregnancy
Other events that should have anti D include: spont miscarriage, threatened miscarriage, surgery for extopic pregnancy and amniocentesis.
50 mic anti D <12weeks and 300mic after
Discuss appendicits in pregnacny
occurs with the same incidence as non pregnant patients. During the first half of gestation presentation is the same. But clinical picture can become more atypical in the second half of gestation
Traditionally the appendix was thought to be displace counterclockwise out of the right lower quadrant with its ultimate lolcation deepo in the right upper quadrant
Displacement of the abdominal wall away from the abdominal vicera can result in difficulty in palpation of organs and loss of signs of peritoneal irritation.
During its migration the appendix is very close to the right kidney resulting in a high incidence of pyuria and flank pain
Discuss liver disorders during pregnancy
Hepatitis is the most common cause of lidver disease accounting for 40% of cases of jaundice. management and treatment are supportive and unchanged from those for non pregnant patients. Hep E however may have a more aggresive course in pregnancy a
Acute fatty liver of pregnancy is a disorder of the third trimester and can result in liver failure, complciated labour and feotal mortality. The disease is rare occuring most commonly in primiparous women with twin gestation. Clinical features include nausea and vomiting associated with malaise or jaundice during the third trimester should trigger consideration of acute fatty liver. May progress to coaguloapthy jaundice siezures DIC and hepatic encephaoloapthy. May require stabilisation from seizures or coma. Hypoglycaemia can occur which should be rapidly corrected.
Intrahepatic cholestasis of pregnancy also temred idiopathic jaundice of pregnacny and icterus gravidarum is a rare syndrom taht occurs during the third trimester of prenancy- characterised by cholestasis and dilated canaliculi with a normal liver. Clinical features include generalised pruritis and mild jaundice - usually presenting complaint is pruritis only begins in the palms and soles and ascends to the trunk. - resolution occurs with delivery of the baby
Discuss nasuea and vomiting in pregnancy
Nausea and vomitng are extremly common in pregnancy particularly from 6-20 weeks of gestation. Symptoms are usually self limited and often resolve with lifestyle changes such as diet modification and avoidance of environmental trigger.
Ginger has been found to be quite effective as an anti-emetic
Hyperemesis Gravidarum occurs in approxiamtly 1% of pregnancy and is defined by nausea and vomting that cause starvation metbaolism, weight loss greater than 5% and prolonged ketonemia and keonuirai. -Without treatment there is an increased risk fo micronutrient defiecny and there respective sequalea
Management involves appropraite rehydration + thiamine. Antiemetics as per pregnancy with pyridoxine being useful.
Discuss VTE in pregnancy
Accounts for 20% of all maternal mortality
Pregnancy is a hypercoagubale state with increased coagulation factors and stasis Risk of VTE in pregnancy increase 5-6 times
Pre test probability score WELLS cannot be used as pregnant patients were excluded from the study
D-Dimer rises from the second trimester and remains evlevated for 4-6 weeks post partum
Discuss alcohol abuse during pregnancy
Associated with increased risk of miscarraige and intrauterine foetal demise.
Foetal alcohol sydnrome is characterized by at least one of a series of morphological abnormalities in assoaicetion with heavy ETOH use including midfacial hypoplasia, flat philtrum low nasal birdge epicanthal folds shortened palpebral fissue low set ears and microcephaly.
Treatment of an alcohol dependent mother is dicciult as with non pregnant patients withdrawal symptoms are likley to manifest 6-24 hours after last consumption.
Discuss the use of methamphatamines and cocaine in pregnancy
Maternal cocaine and methamphetamine use is independtly linked to IUGR from imparied placental circulation and preterm birth less than 36 weeks, preeclampsia, IUFD and GDM.
Cocaine increase the risk of placental abruption and infarction.
