Early Pregnancy Flashcards
Normal and Complications
Define and describe normal early pregnancy
Expected date of delivery (EDD) - 40 weeks from last menstrual period Gestational days (fertilisation age) - number of days since fertilisation
Briefly describe normal fertilisation
Occurs in the tube
Transportation of embryo along the tube
Implantation into the endometrium approximately 6 days post-fertilisation
Which two hormones rise throughout pregnancy (and which one dips at the end)
Oestrogen
Progesterone - dips slightly when approaching term
Definition of miscarriage and recurrent miscarriage
Pregnancy loss before 24 weeks gestation
Recurrent
- 3 or more consecutive miscarriages
Definition of the clinical types of miscarriage
Threatened - bleeding with continued intra-uterine pregnancy
Inevitable - bleeding with non-continuing intra-uterine pregnancy
Incomplete - incomplete passage of pregnancy tissue
Complete - all pregnancy tissue expelled and uterus is empty
Delayed/missed/early embryonic demise - fetus dies in-utero prior to 24 weeks (visible in uterus, no heart beat)
Septic - complicated by an intra-uterine infection
Causes and associated risk factors of miscarriage
Idiopathic
Genetic abnormality (chromosomal common)
Endocrine factors
- early failure of the corpus luteum
- those with thyroid disease or DM at high risk of miscarriage
Maternal illness and infection
- severe febrile illness (flu, pyelitis and malaria)
- other illness involving CV, hepatic and renal systems are also risk factors
Uterine abnormalities
- e.g. bicornuate or subseptate uterus
Cervical incompetence
- commonly caused by mechanical dilation or damage during labour
Autoimmune factors
- antiphosphlipid antibodies
- thrombosis of uteroplacental vasculature and impaired trophoblast functio
Thrombophilic deficits
- defects in the natural inhibitors of coagulation (protein C and S)
Alloimmune factors
Define an ectopic pergnancy
A problem with tubal transportation, causing implantation outwith the uterine cavity
- commonly a tubal pregnancy (95%)
Risk factors for an ectopic pregnancy
Previous ectopic Endometriosis PID Pelvic surgery - including C-section, sterilisation and appendicectomy Contraception - POP, IUS/IUD Assisted conception techniques Smoking
Clinical presentation of ectopic pregnancy
In the presence of a positive pregnancy test - asymptomatic - vaginal bleeding - pelvic discomfort/pain - pain when opening bowel Maternal collapse or hypovolaemic shock
How is an ectopic pregnancy managed?
Emergency
- ABCDE and senior
- theatre to remove source of bleeding and stabilise patient
Non-emergency
- expectant management involves waiting to see if the pregnancy dissolves (done id mild/no symptoms and/or pregnancy can’t be found)
- methotrexate (anti-folate medication) if pain free, unruptured and no medical CIs
- salpingotomy is POC can be removed
- salpingectomy if tube is damaged
- anti-D if mother is Rh negative after ectopic management
Define gestational trophoblastic disease
Group of conditions characterised by abnormal proliferation of trophoblastic tissue with HCg production
- can be malignant or pre-malignant
Describe the types of gestational trophoblastic disease
Premalignant - partial hydatiform mole (triploid), most present as failed pregnancy - complete hydatiform mole (diploid) Malignant - invasive mole - choriocarcinoma - placental site trophoblastic tumour
Define hyperemesis gravidarum
Characterised by severe nausea and vomiting, weight loss and dehydration
- symptoms often get better after 20 weeks, but can last the whole pregnancy
Investigations of early pregnancy with pain or bleeding
Examination
- assess pain and bleeding (?haemodyamically stable)
- any products of conception? - examine them
Ultrasound (TV or TA)
Serum HCG tracking with/without serum progesterone
Assess FBC and blood group
High vaginal swab - looking for infection
Miscarriage USS definitions
No fetal heart activity and >7mm crown to rump length on TV scan (rescan in 10 days)
Empty sac when mean gestational sac diameter >25mm on TV scan
Retained tissue 0 in an incomplete miscarriage
Empty uterus
- complete passage of tissue
- pregnancy too early to visualise
- ectopic
Describe how Rhesus status and anti-D factor in miscarriage
Anti-D required IF
a) the mother is Rh -ve
AND
b) after an operation for ectopic pregnancy, after an evacuation of retained POC (at any gestation) OR after any episode of bleeding after 12 weeks
Anti-D immunoglobulin prevents women with Rh -ve blood devleoping an immune response to a RH +ve fetus
Management of miscarriage and their success rates
Expectant (65% success)
Medical (70% success)
Surgical (98% success)
What is expectant management of miscarriage
Offered to women who miscarry before 3 weeks gestation
Involves waiting for the POC to pass by themselves (2 weeks maximum - then intervention required)
How are miscarriages managed medically?
Prostaglandin analogue
- misoprostol
- oral or vaginal, depending on gestation
Products normally pass in 24-48 hours
What is the surgical management of a miscarriage
Cervical priming is required (misoprostol)
Electrical vacuum aspiration under GA as day case
OR
Manual vacuum aspiration under LA as an outpatient
Treatment of choice in heavy bleeding or a bulky uterus (suggesting a large residuum of retained products)
Management of trophoblastic disease
Pregnancy is terminated bu vacuum aspiration
All cases of molar pregnancy in the UK should be registered with on of the trophoblast screening centres - they will arrange a follow up (Dundee in Scotland)
Several hCG estimations are performed for a period of 6 months or 2 years (initially every 2 weeks)
If histological evidence shows malignant change, chemotherapy with methotrexate and actinomycin D is employed
Management of hyperemesis gravidarum
Dry, bland food and oral rehydration
Anti-emetics (safe in pregnancy - pyridoxine/doxylamine, antihistamines and diphenhydramine)
Vitamins B6 and B12
Steroids
If nausea can’t be controlled, then hospital admission may be required
- IV fluids and anti-emetics
