Early Pregnancy

Question 1

How is miscarriage defined?

Answer 1

Loss of pregnancy at < 24 weeks
Early miscarriage = < 12/13 weeks
Late miscarriage = 13-24 weeks

Question 2

What are the risk factors for miscarriage?

Answer 2

Maternal age > 30-35
Previous miscarriage
Obesity
Chromosomal abnormalities
Smoking
Uterine anomalies
Previous uterine surgery
Anti-phospholipid syndrome
Coagulopathies

Question 3

What are the clinical features of miscarriage?

Answer 3

Vaginal bleeding + abdominal cramping
Haemodynamic instability
Abdominal tenderness
Speculum exam: open os, products of conception, bleeding

Question 4

How is a miscarriage diagnosed?

Answer 4

Transvaginal USS

–> absence of foetal cardiac activity

Question 5

What are the different types of miscarriage?

Answer 5

Threatened
Inevitable
Missed
Incomplete
Complete
Septic

Question 6

What are the features of a threatened miscarriage?

Answer 6

Mild bleeding +/- pain
Cervix closed
TV USS –> viable pregnancy

Question 7

What are the features of an inevitable miscarriage?

Answer 7

Heavy bleeding, clots, pain
Cervix open
TV USS –> invernal os opened, foetus can be viable or non-viable

Question 8

What are the features of a missed miscarriage?

Answer 8

Asymptomatic or history of threatened miscarriage
Ongoing discharge
Small for dates uterus
TV USS –> no foetal heart pulsation

Question 9

What are the features of an incomplete miscarriage?

Answer 9

POC partially expelled
TV USS –> retained POC with endometrial diameter > 12mm AND proof that there was a intrauterine pregnancy (USS/clinically remove clots)

Question 10

What are the features of a complete miscarriage?

Answer 10

History of bleeding, passing clots and pain
Symptoms settling now
TV USS –> no POC in uterus, endometrium < 15mm diameter AND proof that there was a pregnancy

Question 11

What are the features of a septic miscarriage?

Answer 11

Infected POC –> fever, riggers, uterine tenderness, bleeding/discharge, pain

Question 12

What are the options for management of a miscarriage?

Answer 12

Conservative (expectant)
Medical
Surgical

Anti-D prophylaxis for any rhesus negative mother > 12 weeks gestation

Question 13

What is the medical management of miscarriage?

Answer 13

Vaginal misoprostol to stimulate cervical ripening and contractions
Mifepristone given 24-48 hours prior to misoprostol

Question 14

What are the disadvantages of medical management of miscarriage?

Answer 14

Side effects of medication: vomiting, diarrhoea
Heavy bleeding and pain during passage of POC
Chance of requiring emergency surgical intervention

Question 15

What is the surgical management of miscarriage?

Answer 15

Manual vacuum aspiration with local anaesthetic is < 12 weeks
Evacuation of retained POC under GA

Question 16

What are the definite indications for surgical management of miscarriage?

Answer 16

Haemodynamic instability
Infected tissue
Gestational trophoblastic disease

Question 17

What are the complications of surgical management of miscarriage?

Answer 17

Infection (endometritis)
Uterine perforation
Haemorrhage
Asherman's syndrome
Bowel or bladder damage
Retained POC

Question 18

What are the risk factors for ectopic pregnancy?

Answer 18

Previous ectopic
PID --> adhesions
Endometriosis
IUD / IUS
Progesterone only contraceptives 
Tubal ligation/occlusion
Pelvic surgery
Assisted reproduction

Question 19

What are the clinical features of ectopic pregnancy?

Answer 19

PAIN - lower abdominal/pelvic
+/- vaginal bleeding
History of amenorrhoea
Shoulder tip pain - blood in peritoneal cavity irritating diaphragm
Vaginal diacharge - brown (decidua breaking down)

Examination:

• abdominal tenderness, cervical excitation +/- adnexal tenderness
• haemodynamic instability + peritonitis if ruptured

Question 20

How should a suspected ectopic pregnancy be investigated?

Answer 20

PREGNANCY TEST
If positive –> pelvic USS to check for intrauterine pregnancy
If no intrauterine pregnancy of USS –> pregnancy of unknown origin

Question 21

What are the differentials for a pregnancy of unknown origin?

Answer 21

Very early intrauterine pregnancy
Miscarriage
Ectopic

Question 22

Which investigation should be done for a ‘pregnancy of unknown origin’?

Answer 22

SERUM beta-HCG

• if > 1500 –> ectopic until proven otherwise
• if < 1500 –> recheck in 48 hours (if stable)

Question 23

What are the options for management of an ectopic pregnancy?

Answer 23

ABCDE

Medical
Surgical
Or conservative

Question 24

What is the medical management of an ectopic pregnancy?

Answer 24

IM methotrexate

• -> gradually resolves the pregnancy
• monitor progress with serum beta-HCG

Question 25

What are the criteria for medical management of an ectopic?

Answer 25

Stable
Well controlled pain
beta-HCG < 1500
Unruptured ectopic without visible heartbeat

Question 26

What are the side effects of medical management of ectopic pregnancy?

Answer 26

Methotrexate:
- abdominal pain
- myelosuppression
- renal dysfunction
- hepatitis
- teratogenesis (must use contraception for 3-6 months after use)
Treatment failure –> surgical intervention

Question 27

What is the surgical management of ectopic pregnancy?

Answer 27

Tubal ectopic (most common) --> laparoscopic salpingectomy
If damage to other tube e.g. from infection --> salpingotomy (cut in tube)

Question 28

What are the indications for surgical management of ectopic pregnancy?

Answer 28

Severe pain
beta-HCG > 5000
Adnexal mass > 34mm
+/- foetal heartbeat on scan

Question 29

What are the different types of gestational trophoblastic disease?

Answer 29

Premalignant (most common)
- partial molar pregnancy
- complete molar pregnancy
Malignant (rarer)
- invasive moles
- choriocarcinoma
- placental site trophoblastic tumour
- epithelioid trophoblastic tumour

Question 30

What are the clinical features of molar pregnancy?

Answer 30

Vaginal bleeding + abode pain early in pregnancy
Uterus larger than expected for gestation + soft, boggy consistency
Passing ‘grape-like’ tissue
Later symptoms:
- hyperemesis
- hyperthyroidism
- anaemia

Question 31

How is molar pregnancy diagnosed?

Answer 31

Markedly increased urine + serum beta-HCG
USS
Histological examination of the POC (post treatment)

Question 32

What does a molar pregnancy look like on USS?

Answer 32

Complete mole –> granular or snowstorm appearance with a central heterogenous mass + surrounding cysts/vesicles

Partial mole –> may exist with viable foetus

Question 33

How is a molar pregnancy managed?

Answer 33

Registered with a specialist centre for follow up and monitoring in specialist centres
Usually suction curettage

Question 34

What is implantation bleeding?

Answer 34

Occurs when fertilised egg has implanted in the uterine wall
About 10 days after ovulation
Usually light brown and lighter than a period

Question 35

What is hyperemesis gravidarum?

Answer 35

When normal pregnancy vomiting becomes excessive, prolonged and begins to affect quality of life

Question 36

What are the consequences of untreated hyperemesis gravidarum?

Answer 36

Dehydration
Ketosis
Electrolyte + nutritional imbalance
Weight loss
Altered liver function

Question 37

How is hyperemesis gravidarum managed?

Answer 37

IV fluids + electrolytes
IV anti-emetic (if oral not tolerated)
Nutritional supplements including thiamine or pabrinex

Question 38

Which antiemetics are first line for hyperemesis gravidarum?

Answer 38

Cyclizine

Prochlorperazine