Early Pregnancy Flashcards
How is miscarriage defined?
Loss of pregnancy at < 24 weeks
Early miscarriage = < 12/13 weeks
Late miscarriage = 13-24 weeks
What are the risk factors for miscarriage?
Maternal age > 30-35 Previous miscarriage Obesity Chromosomal abnormalities Smoking Uterine anomalies Previous uterine surgery Anti-phospholipid syndrome Coagulopathies
What are the clinical features of miscarriage?
Vaginal bleeding + abdominal cramping
Haemodynamic instability
Abdominal tenderness
Speculum exam: open os, products of conception, bleeding
How is a miscarriage diagnosed?
Transvaginal USS
–> absence of foetal cardiac activity
What are the different types of miscarriage?
Threatened Inevitable Missed Incomplete Complete Septic
What are the features of a threatened miscarriage?
Mild bleeding +/- pain
Cervix closed
TV USS –> viable pregnancy
What are the features of an inevitable miscarriage?
Heavy bleeding, clots, pain
Cervix open
TV USS –> invernal os opened, foetus can be viable or non-viable
What are the features of a missed miscarriage?
Asymptomatic or history of threatened miscarriage
Ongoing discharge
Small for dates uterus
TV USS –> no foetal heart pulsation
What are the features of an incomplete miscarriage?
POC partially expelled
TV USS –> retained POC with endometrial diameter > 12mm AND proof that there was a intrauterine pregnancy (USS/clinically remove clots)
What are the features of a complete miscarriage?
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
What are the features of a septic miscarriage?
Infected POC –> fever, riggers, uterine tenderness, bleeding/discharge, pain
What are the options for management of a miscarriage?
Conservative (expectant)
Medical
Surgical
Anti-D prophylaxis for any rhesus negative mother > 12 weeks gestation
What is the medical management of miscarriage?
Vaginal misoprostol to stimulate cervical ripening and contractions
Mifepristone given 24-48 hours prior to misoprostol
What are the disadvantages of medical management of miscarriage?
Side effects of medication: vomiting, diarrhoea
Heavy bleeding and pain during passage of POC
Chance of requiring emergency surgical intervention
What is the surgical management of miscarriage?
Manual vacuum aspiration with local anaesthetic is < 12 weeks
Evacuation of retained POC under GA
What are the definite indications for surgical management of miscarriage?
Haemodynamic instability
Infected tissue
Gestational trophoblastic disease
What are the complications of surgical management of miscarriage?
Infection (endometritis) Uterine perforation Haemorrhage Asherman's syndrome Bowel or bladder damage Retained POC
What are the risk factors for ectopic pregnancy?
Previous ectopic PID --> adhesions Endometriosis IUD / IUS Progesterone only contraceptives Tubal ligation/occlusion Pelvic surgery Assisted reproduction
What are the clinical features of ectopic pregnancy?
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
How should a suspected ectopic pregnancy be investigated?
PREGNANCY TEST
If positive –> pelvic USS to check for intrauterine pregnancy
If no intrauterine pregnancy of USS –> pregnancy of unknown origin
What are the differentials for a pregnancy of unknown origin?
Very early intrauterine pregnancy
Miscarriage
Ectopic
Which investigation should be done for a ‘pregnancy of unknown origin’?
SERUM beta-HCG
- if > 1500 –> ectopic until proven otherwise
- if < 1500 –> recheck in 48 hours (if stable)
What are the options for management of an ectopic pregnancy?
ABCDE
Medical
Surgical
Or conservative
What is the medical management of an ectopic pregnancy?
IM methotrexate
- -> gradually resolves the pregnancy
- monitor progress with serum beta-HCG
What are the criteria for medical management of an ectopic?
Stable
Well controlled pain
beta-HCG < 1500
Unruptured ectopic without visible heartbeat
What are the side effects of medical management of ectopic pregnancy?
Methotrexate:
- abdominal pain
- myelosuppression
- renal dysfunction
- hepatitis
- teratogenesis (must use contraception for 3-6 months after use)
Treatment failure –> surgical intervention
What is the surgical management of ectopic pregnancy?
Tubal ectopic (most common) --> laparoscopic salpingectomy If damage to other tube e.g. from infection --> salpingotomy (cut in tube)
What are the indications for surgical management of ectopic pregnancy?
Severe pain
beta-HCG > 5000
Adnexal mass > 34mm
+/- foetal heartbeat on scan
What are the different types of gestational trophoblastic disease?
Premalignant (most common) - partial molar pregnancy - complete molar pregnancy Malignant (rarer) - invasive moles - choriocarcinoma - placental site trophoblastic tumour - epithelioid trophoblastic tumour
What are the clinical features of molar pregnancy?
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
How is molar pregnancy diagnosed?
Markedly increased urine + serum beta-HCG
USS
Histological examination of the POC (post treatment)
What does a molar pregnancy look like on USS?
Complete mole –> granular or snowstorm appearance with a central heterogenous mass + surrounding cysts/vesicles
Partial mole –> may exist with viable foetus
How is a molar pregnancy managed?
Registered with a specialist centre for follow up and monitoring in specialist centres
Usually suction curettage
What is implantation bleeding?
Occurs when fertilised egg has implanted in the uterine wall
About 10 days after ovulation
Usually light brown and lighter than a period
What is hyperemesis gravidarum?
When normal pregnancy vomiting becomes excessive, prolonged and begins to affect quality of life
What are the consequences of untreated hyperemesis gravidarum?
Dehydration Ketosis Electrolyte + nutritional imbalance Weight loss Altered liver function
How is hyperemesis gravidarum managed?
IV fluids + electrolytes
IV anti-emetic (if oral not tolerated)
Nutritional supplements including thiamine or pabrinex
Which antiemetics are first line for hyperemesis gravidarum?
Cyclizine
Prochlorperazine
