Early pregnancy Flashcards
What is the upper limit at which pregnancies can be terminated?
24 weeks
Where can an abortion be performed and what must be done before?
By a registered medical practitioner in an NHS hospital or licensed premise
Must have 2 registered medical practitioners sign legal document
How is a pregnancy terminated before 9 weeks gestation?
Mifepristone followed 48 hours later by misoprostol (a prostaglandin)
How is a pregnancy between 9-13 weeks terminated?
Surgical dilation and suction of uterine contents
How is a pregnancy >15 weeks terminated?
Surgical dilation and evacuation of uterine contents
OR
Late medical abortion (induce mini-labour)
What is a miscarriage?
Loss of pregnancy <24 weeks gestation
How common are miscarriages?
15-20% of pregnancies miscarry
1% affected by recurrent miscarriage
How are early and late miscarriages classified?
Early <12 weeks
Late 13-24 weeks
What is the general presentation of miscarriages?
Vaginal bleeding and pain worse than normal period
Visible products of conception
Haemodynamic instability - dizzy, pallor, tachycardic
What are the “types” of miscarriage?
Threatened Inevitable Incomplete Complete (Inevitable to complete is more of a journey through these stages depending on how far through the miscarriage the women is)
Missed
Septic
What is a threatened miscarriage and when and how does it present?
Still a viable pregnancy which presents with mild painless bleeding
Cervix is closed
Often 6-9 weeks
What is an inevitable miscarriage and how does it present?
Heavy bleeding with clots and pain
Cervix is open
Progresses to incomplete then complete miscarriage
How does an incomplete miscarriage present?
Products of conception partially expelled (can be seen in the canal)
Vaginal bleeding and pain
Cervix remain open
How does a complete miscarriage present?
Empty uterine cavity - products of conception fully expelled
Heavy bleeding with cloths and pain but stops
Uterus smaller than normal
Cervix closed
What is a missed miscarriage and how does it present?
Foetus dead but retained
Asymptomatic or Hx of threatened miscarriage
Light vaginal bleed or ongoing dark discharge
Don’t normally get any pain
Small for date uterus
Cervix closed
How does a septic miscarriage present?
Infected products of conception
Fever, riggers, uterine tenderness, bleeding, discharge, pain
What are the differentials for a miscarriage?
Ectopic pregnancy has to be excluded
Implantation bleed
Malignancy
Hydatidiform Mole
What are the risk factors for miscarriage?
Mum > 30 or Dad >40yo Obesity or low BMI Previous miscarriage Parental chromosomal abnormalities Smoking and alcohol Uterine abnormalities Incompetent cervix Antiphospholipid syndrome SLE PCOS Diabetes Thyroid
How would you investigate a miscarriage?
Seen in EPAU
Transvaginal USS - definitive diagnosis, look for fetal heart activity Transabdominal USS (only if transvaginal declined) Serum HcG - rule out ectopics
How are miscarriages managed?
> 12 weeks and rhesus -ve - give anti-D
Conservative - Wait 7-14 days to pass naturally
Medical - Vaginal misoprostol - stimulate cervical ripening and myocetrial contractions
Surgical - <12 weeks = manual vacuum aspiration under local
>12 weeks - evacuation of retained POC under general
What are the side effects of misoprostol? And therefore what else do you need to prescribe
D&V
Pain
Bleeding
Analgesia and antiemetics
What are the complications of surgical miscarriage management?
Endometritis Uterine perforation Haemorrhage Bowel/bladder perforation Unsuccessful so need to repeat operation
What is classified as recurrent miscarriages?
3+ miscarriages
What investigations are done for recurrent miscarriage?
Antiphospholipid antibodies
B2 glycoprotein antibodies (antiphospholipid syndrome)
Pelvic USS - uterine anatomy
Thrombophilia screen
Karyotyping - cytogenetic analysis of POC
How are recurrent miscarriages managed?
Refer to geneticist
Cervical cerclage
Heparin therapy for thrombophilia’s
Aspirin and Heparin for antiphospholipid syndrome
What causes are associated with recurrent miscarriage?
Antiphospholipid syndrome
Parental chromosomal rearrangements
Structural abnormalities - adhesions, weak cervix, septate uterus
Endocrine disorders - diabetes, thyroid, PCOS
Bacterial vaginosis - 1st trimester
Thrombophilia
What structural abnormalities are associated with recurrent miscarriage?
Adhesions
Fibroids
Cervical weakness
Septate, arcuate or bicornuate uterus
What is an ectopic pregnancy?
Pregnancy implanted outside uterine cavity
What is the most common place for an ectopic pregnancy to implant?
Ampulla of Fallopian tubes
What are the risk factors for an ectopic pregnancy?
Previous ectopic PID - adhesions Endometriosis - adhesions Contraception (when fail) - Coils, POP, implant, tubal ligation/occlusion IVF
How do ectopic pregnancies present?
6-8 week Hx amenorrhoea then.... Unilateral lower abdominal pain Vaginal bleeding - darker then miscarriage Shoulder tip pain Cervical excitation
What is the pathway of investigation if you suspect an ectopic pregnancy?
Urine beta HCG –> Pelvic USS –> Transvaginal USS –> Pregnancy of unknown origin –> serum beta HCG
If the serum beta HCG is high in a woman with suspected ectopic pregnancy, what must be done?
Diagnostic laparoscopy
What would you expect the serum B-HCG to do in a viable pregnancy, a miscarriage and an ectopic every 48 hours?
Viable - HCG double every 48hr
Miscarriage - HCG half within 48hr
Ectopic - falls or rises outside the limits
What would indicate an ectopic pregnancy has ruptured?
Haemodynamically unstable
Peritonitis signs
DIC
When are ectopic pregnancies managed conservatively?
B-HCG <1000 and falling by 50% every 48 hours
No fetal HR
Unruptured
Mother stable and pain well controlled
What is the conservative management for ectopic pregnancy?
Watchful waiting with serum beta HCG every 48 hrs
When is an ectopic pregnancy managed medically?
Serum Beta HCG <1500 No fetal HR Unruptured Mother stable and pain well controlled (Can't be done if another intrauterine pregnancy)
How is an ectopic pregnancy managed medically?
What are the ADRs of the medication given?
IM methotrexate - disrupt cell division of foetus - pregnancy resolve
SE - abdo pain, myelosuppression, renal and liver damage, req. contraception for 6 months
When is an ectopic pregnancy managed surgically?
Serum beta HCG >5000
Can be ruptured pregnancy and fetal heartbeat visible
Severe maternal pain
(Can be done if another intrauterine pregnancy)
How is an ectopic pregnancy managed surgically?
What are the risks of this?
Laparoscopic salpingectomy - remove ectopic and tube
If contralateral tube already damaged can do salpingotomy to preserve fertility
Risks - surgical risks, damage to surrounding structures
If a Rhesus -ve woman req. surgical management, what must be done?
Give anti-D prophylaxis
What is gestational trophoblastic disease?
Spectrum of tumours arising from placental trophoblast
What are the risk factors for gestational trophoblastic disease?
Maternal age <20 or >35
Use of OCP
Previous miscarriage
How does gestational trophoblastic disease present?
Bleeding in 1st or early 2nd trimester
Exaggerated symptoms of pregnancy - hyperemesis
Large for date uterus
Very high serum beta HCG
What investigations are ordered for suspected gestational trophoblastic disease?
Serum Beta HCG - markedly high
USS
CT/MRI if metastasis suspected
What is seen on USS for gestational trophoblastic disease?
Snowstorm appearance:
Central heterogenous mass and surrounding cystic areas
What are the types of gestational trophoblast disease?
Partial molar Complete molar Choriocarcinoma Placental site trophoblastic tumour Epithelioid trophoblastic tumour
What is a partial molar pregnancy?
One ovum fertilised by 2 sperm giving 69 chromosomes
Pre-malignant condition
What is a complete molar pregnancy?
Empty ovum fertilised by sperm which duplicates giving 46 paternal chromosomes
Grow into mass with swollen chorionic villi
Pre-malignant condition
What is a choriocarcinoma?
Malignant condition of trophoblastic cells of placenta
Often co-exist with molar pregnancy
Spread to organs away from uterus
What is a placental site trophoblastic tumour?
Malignancy of intermediate trophoblasts which normally anchor placenta to uterus
Often occur following normal pregnancy
What is an epithelioid trophoblastic tumour?
Malignancy of trophoblastic placental cells
Look like choriocarcinoma under microscope
How are complete and non-viable partial moles managed?
Suction curettage
Medical evacuation with oxytocin if partial moles of greater gestation but there is a risk of trophoblastic tissue embolising
How are more complex, malignant moles managed?
Refer to specialist clinics for chemotherapy
When do pregnant women normally start to get nausea and vomiting?
4-7 weeks
If begin after 12 weeks, consider other pathological causes
What is N&V in pregnancy associated with?
First pregnancy Multiple pregnancy History of hyperemesis History of motion sickness Trophoblastic disease Hyperthyroidism Obesity
How is nausea and vomiting in pregnancy managed?
Advise it normally calms by 20 weeks
Eat small frequent meals that are low in fat
Dry biscuit on waking up
Use of ginger products
What is the guidance on antiemetics in pregnancy?
Avoid unless benefit outweigh risks esp. 1st trimester
1st line - Promethazine or cyclizine
2nd line - Metoclopramide or ondansetron
What is hyperemesis gravidarum?
Persistent and severe vomiting leading to:
- Dehydration
- Electrolyte disturbance
- Marked ketonuria
- Nutritional deficiency
- 5% weight loss
How common is hyperemesis gravidarum and when does it normally affect women?
Affect 1% of pregnancies
Commonly between 8-12 weeks but can persist upto 20
What investigations are carried out for hyperemesis gravidarum?
Renal function and electrolytes
LFT’s
Midstream Urine - infection and ketones
USS - exclude multiple or molar pregnancy
Nuchal translucency - Downs foetus increases risk
How is hyperemesis gravidarum managed?
IV fluid and electrolyte replacement Nutritional support Thiamine supplements Thromboprophylaxis (dehydrated and in bed) Anti-emetics
What electrolyte disturbances and other complications are associated with hyperemesis gravidarum?
Acidosis Raised sodium, urea and creatinine Low chloride and potassium Thiamine deficiency --> Wernicke's Mallory-Weiss tear Higher incidence of low birth weight
What does mifepristone do?
It blocks the effects of progesterone making the cervix easier to open therefore increasing the responsiveness to misoprostol
When is medical management to terminate a pregnancy contraindicated?
> 9 weeks gestation
severe asthma
?ectopic
When would you expect a pregnancy test to be negative following a termination of pregnancy?
At 4 weeks
When is fetal cardiac activity visible on TV USS
5.5 - 6 weeks
When is conservative management of miscarriage not suitable?
Previous APH or miscarriage
Infection
Bleeding disorder
Late T1
What types of miscarriage is conservative management suitable for?
Incomplete and missed
Describe an implantation bleed and when it occurs
Pale pink/brown spotting with no clots
10 days after ovulation
