Early Pregnancy Flashcards by Megan Rose

How is miscarriage defined?

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

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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

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What are the clinical features of miscarriage?

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

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How is a miscarriage diagnosed?

Transvaginal USS

–> absence of foetal cardiac activity

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What are the different types of miscarriage?

Threatened
Inevitable
Missed
Incomplete
Complete
Septic

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What are the features of a threatened miscarriage?

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

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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

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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

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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)

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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

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What are the features of a septic miscarriage?

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

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What are the options for management of a miscarriage?

Conservative (expectant)
Medical
Surgical

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

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What is the medical management of miscarriage?

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

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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

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What is the surgical management of miscarriage?

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

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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