Early pregnancy Flashcards
Risk factors for Miscarriage
- advancing age
- 2 or more consecutive miscarriages
- Uncontrolled DM/thyroid
- Uterine abnormalaities e.g. cone biopsy
- smoking/alcohol
- weight - over or under
- invasive prenatal testing/chromosomal anomalies
what % of pregnancies end in early miscarraige
15-20%
Risk factors for ectopic pregnancy
Previous PID Smoking prior tubal surgery Hx of infertility Assisted conception
What investigations should be carried out if suspecting an ectopic pregnancy
- FBC, G&S
- Serum progesterone and HCG
- US
- 2 large bore cannulas
What may you seen on USS in ectopic pregnancy
Extra uterine pregnancy
intra peritoneal haemorrage
NB. No signs of ectopic does not rule it out
What progesterone and bHCG would you expect to see in a viable pregnancy
- bHCG increasing >53% every 48 hours
- Progesterone >60
Who can have medical management of an ectopic pregnancy
- HCG <3000
- <3cm if seen on scan
- No fetal activity
- Aysmptomatic/mild
What is the medical management of an ectopic pregnancy
- methotrexate - folate antagonist
- Repeat HCG in 4-7 days
- repeat dose if bHCG <15%
- reliable contraception for 3 months after
- Low threshold for representing
Who should have surgical management of an ectopic pregnancy
- unstable
- symptomatic
What is a threatened miscarriage
Confirmed pregnancy
Vaginal bleeding
Os closed
75% settle
What is an inevitable miscarriage
bleeding
cervical os is open
What is an incomplete miscarriage
Some pregnancy tissue remains in the womb
What is a delayed miscarriage
Pregnancy stopped growing or no fetal heart beat
no bleeding or sx
Cervical Os is closed
What should you ALWAYS as when seeing a patient who’s bleeding in early pregnancy
- LMP
- date of first pregnancy test
- severity of bleeding
- pain: referred, shoulder tip, rectal
At what point would you begin to see finding on USS in early pregnancy
- sac begins to be seen 4.5-5 weeks
- no findings prior to this
How do you diagnose a miscarriage on USS
- Crown-rump length <7mm
- No fetal heart detection
- Mean gestational sac diameter of 25mm with no yolk sac or embryo
What are the risks/disadvantages of expectant management of miscarriage
- infection 1%
- haemorrhage 2%
- Risk of retained tissue (>6w)
- Uncertainty
- bleeding at home
- passing concepti
What is expectant management
- watch and wait -> effective 50%
- Usually takes around 3 weeks
- Pregnancy test after 1 week
- Rescan if still bleeding days 10-14
Who can have expectant management
not bleeding heavily
not missed/delayed miscarriage
What is used in medical management
- Misoprostol - vaginal pessary or 2 tablets
- effective 80-90%
- takes up to 3 weeks
- Can be done as an inpatient or outpatient
- pregnancy test at 3 weeks
What are the risks/disadvantages of medical management of miscarriage
Painful
Very heavy bleeding
Infection 1%
Haemorrhage 1%
What does misoprostol do?
Causes uterine contractions
Safety net for a woman who is miscarrying
- heavy or prolonged vaginal bleeding
- smelly vaginal discharge
- fever/flu symptoms
- increasing abdominal pains
- loss of appetite
What is surgical management of a miscarriage
operation to remove tissue under general or local anaesthetic - 95% effective
- Given a tablet/pessary to soften cervix then tissue is removed
- done within a few days
What are the risks of surgical management of miscarriage
Infection 1% Heavy bleeding damage to the womb 1/30 000 require hysterectomy uterine adhesions risks of GA
What happens to tissue in surgical removal
- remains can be tested to ensure it was a pregnancy and no abnormal cells were there
- chose to bury or cremate the remains
- discuss further with a nurse
What advise should you give RE vaginal bleeding following a miscarriage
- Heavy for a few days then lessen to brown
- Sanitary towels over tampon - reduce ifnection
- bleed 1-2 weeks
- regular period in 4-6 NB. NOW FERTILE!!!
When can you return to work after a miscarriage
- rest for a few days before starting routine activities
- most return in a week but variable
When can you have sex after a miscarriage
whenever you both feel ready
What is triple testing
- optional maternal blood test weeks 14-20
- detects down syndrome and spina bifida
- 3-7 days for results to come back
- if results low, no further action
what does triple testing assess
AFP
hCG
Oestradiol
What may you see in triple testing if down syndrome is present
HCG raised
AFP and oestradiol reduced
Explain spina bifida
- incomplete closure of spinal cored
- may lead to disability
- hydrocephalus
- incontinence
What is hydrocephalus
increased pressure in fluid in the brain which can gradually damage the brain function esp. if untreated
What is the management of chicken pox exposure in pregnant women
- urgently check mother of VZIG if any doubt whether she has had chicken pox
- If not immune, VZIG immunoglobulin immediately (up to 10 days post exposure)
What is the management of pregnant women with chicken pox
Oral aciclovir within 24 hours of onset of rash
Features of fetal varicella syndrome
- skin scarring
- eye defects (microphthalmia)
- limb hypoplasia
- microcephaly
- learning disabilities
What are the risk of fetal varicella syndrome in infants of mothesr exposed to chicken pox
- 1% <20 weeks
- few 20-28
- 0 <28 weeks
What is the risk to the mother if exposed to chickenpox during pregnancy
5 times greater risk of pneumonitis
What the causes of recurrent miscarriage
- Idiopathic (particularly in older women)
- Antiphospholipid syndrome
- Other thrombophilias (usually second trimester)
- Uterine abnormalities unsupportive of pregnancy (usually second trimester)
- Genetic factors in parents (e.g. balanced translocations in parental chromosomes)
- Chronic histiocytic intervillositis
- Other chronic disease (e.g. diabetes or SLE)
What investigations should you conduct for recurrent miscarriages
Antiphospholipid antibodies
Pelvic ultrasound
Genetic testing on parents (microarray test)
What is Chronic histiocytic intervillositis
- A rare cause of recurrent miscarriages, particularly in the second trimester.
- This can also lead to IUGR and intra uterine death.
- Diagnosed by placental histology showing inflammatory infiltrates by mononuclear cells in the intervillous spaces of the placenta.
What are the legal requirements for a termination of pregnancy
- 2 medical practitioners must sign to agree that the abortion is indicated.
- It must be carried out by a medical practitioner in an NHS or licensed premise
What is a medical termination of pregnancy
- Mifepristone (anti-progestogen) to followed 1-2 days later with misoprostol (prostaglandin)
- Up to 9 weeks gestation
What is a surgical termination of pregnancy
- Cervical dilatation and suction of the contents of the uterus (usually up to 15 weeks)
- Cervical dilatation and evacuation using forceps (between 15 and 24 weeks)
What must you tell a patient Post termination of pregnancy
- Often left with temporary vaginal bleeding and abdominal cramps.
- Use contraception (fertility usually returns immediately)
What are the complications of termination of pregnancy
- Infection (common and if untreated could lead to pelvic inflammatory disease)
- Bleeding (common)
- Pain (common)
- Failure of abortion (pregnancy continues)
- Damage to local structures such as the cervix or uterus
What is the criteria hyperemesis gravidarum
- > 5 % weight loss (compared with pre-pregnancy)
- Dehydration
- Electrolyte imbalance
what causes severe nausea and vomiting in early pregnancy
- high beta hcg: molar pregnancies and multiple pregnancies
- worse in first pregnancy
- worse in obese/overweight women
How do you assess the severity of nausea and vomiting in pregnancy
Pregnancy-Unique Quantification of Emesis Score (PUQE).
This gives a score out of 15:
Mild <7
Moderate 7-12
Severe >12
Which anti-emetics can be prsecribed for nausea and vomting
- Prochlorperazine (stemetil)
- Cyclizine
- Ondansetron
- Metoclopramide (short term use only – theoretical risk of oculogyric crisis)
What complementary therapies do the RCOG recomemned for morning sickness
- Ginger
- Acupressure on the wrist at the P6 point (inner wrist)
- Acupuncture
When should admission be considered for women with severe morning sickness
- Unable to tolerate oral antiemetics / keep down any fluids
- Ketones on urinalysis
- electrolyte imbalances (e.g. hypernatraemia)
- co-morbidities
Management of severe hyperemesis gravidarum
- IV antiemetics
- IV fluids
- Thiamine supplementation to prevent deficiency (prevents Wernicke-Korsakoff syndrome)
- Thromboprophylaxis
What is a hyaditiform mole
Tumour that grows in the uterus - molar pregnancy
2 types: complete and partial
What is a complete mole
two sperm cells fertilise an ovum that contains no genetic material (an “empty ovum”). These sperm then combine genetic material and the cells start to divide and grow into a tumour called a complete mole. No fetal material will form.
What is a partial mole
two sperm cells fertilise a normal ovum (containing genetic material) at the same time. The new cell now has three sets of chromosomes (it is a haploid cell) and this starts to divide and two into a tumour called a partial mole. In a partial mole, some fetal material may form.
What signs may indicate a molar pregnancy over a normal pregnancy
- More severe morning sickness.
- Vaginal bleeding
- Increased enlargement of the uterus
- Abnormally high bHCG
- Thyrotoxicosis (bHCG can mimimic TSH and stimulate the thyroid to produce excess T3 and T4)
What will you see on pelvic USS if there is a molar pregnancy
- snowstorm appearance
- must be confirmed with histology after evacution
What is the management of a molar pregnancy
- Evacuation of the uterus
- Send the products of conception for histology
- Refer to the gestational trophoblastic disease centre
- Measurements of bHCG to ensure they return to normal
- Occasionally the mole can metastasise and the patient may require chemotherapy
What are the risks of smoking in pregnancy
- Intrauterine growth restriction
- Miscarriage
- Stillbirth
- Pre-term labour
- Placental abruption
- Pre-eclampsia
- Cleft lip / palate
What medications and supplements should you take pre-conception
- Take folic acid 400mcg from before pregnancy to 12 weeks (reduces neural tube defects)
- Take vitamin D supplement
What should you avoid during pregnancy
- Alcohol
- Liver and pate- Vitamin A
- Avoid unpasturised dairy or blue cheese (listeriosis)
- Avoid undercooked or raw poultry (salmonella)
