Early Pregnancy Flashcards
Define ectopic pregnancy
Any pregnancy which is implanted outside of the uterine cavity
Most common site is ampulla and isthmus of fallopian tube
Risk factors for ectopic pregnancy
PMH - previous ectopic - PID - endometriosis SH - smoking Contraception - IUD or IUS - POP - tubal ligation or occlusion Iatrogenic - pelvic surgery - assisted reproduction
Clinical features of ectopic pregnancy
Lower abdominal/pelvic pain +/- vaginal bleeding
Shoulder tip pain
Vaginal discharge - brown in colour
Abdominal tenderness, cervical excitation and/or adnexal tenderness
May be signs of shock if ruptured
What causes vaginal bleeding in ectopic pregnancy?
Decidual breakdown in the uterine cavity due to suboptimal β-HCG levels
Bleeding from a ruptured ectopic pregnancy is usually intra-abdominal, not vaginal
Differential diagnosis of ectopic pregnancy
Miscarriage Ovarian cyst accident - rupture, haemorrhage or torsion Acute PID UTI Appendicitis Diverticulitis
Investigations for ectopic pregnancy
Pregnancy test - urine beta-hCG
Pelvic USS - look for intrauterine by TA and TV
If unable to find pregnancy on USS but serum hCG positive = pregnancy of unknown location
Criteria for ectopic pregnancy
If the initial β-HCG level is >1500 iU and there is no intrauterine pregnancy on transvaginal ultrasound
- then this should be considered an ectopic pregnancy until proven otherwise
-diagnostic laparoscopy should be offered
If the initial β-HCG level is <1500 iU and the patient is stable, a further blood test can be taken 48 hours later:
- In a viable pregnancy, hCG level would be expected to double every 48 hours
- In a miscarriage, hCG level would be expected to halve every 48 hours
- Where the increase or drop in the rate of change is outside these limits, an ectopic pregnancy cannot be excluded and the patient should be managed accordingly
Differentials of pregnancy of unknown location
Very early intrauterine pregnancy
Miscarriage
Ectopic pregnancy
Medical management of ectopic pregnancy
IM Methotrexate
- anti-folate cytotoxic agent that disrupts folate dependent cell division of developing foetus
Serum b-hCG level monitored regularly to ensure the level is declining - >15% in day 4-5
- if doesn’t decline a repeat dose is administered
Advantages/disadvantages of medical management of ectopic pregnancy
Advantages
- avoid complications of surgical management
- patient can go home after injection
Disadvantages
- side effects of methotrexate - abdo pain, myelosuppression, renal dysfunction, hepatitis, teratogenesis - contraception for 3-6 months
- treatment can fail -> surgical intervention
Factors affecting type of management of ectopic pregnancy
Medical management - stable with well controlled pain - beta-hCG levels < 1500 iU/ml - unruptured without visible heartbeat - patient should have access to 24 hr gynaecology services Surgical management - severe pain - serum hCG > 5000 - adnexal mass > 34 mm - foetal heartbeat visible on scan Conservative/expectant - clinically stable and pain free - adnexal mass less than 34mm and no FH - beta hCG < 1000
Surgical management of ectopic pregnancy
Surgical removal of ectopic
- laparoscopic salpingotomy/salpingectomy
HCG follow up required until level reaches < 5 to ensure no residual trophoblast
All rhesus negative women should be offered anti-D propohylaxis
Advantages/disadvantages of surgical management of ectopic
Advantages - reassurance about when definitive treatment provided - high success rate Disadvantages - GA risk - risk of damage to neighbouring structures - bladder, bowel, ureters - DVT/PE - haemorrhage - infection - risk of failure with salpingotomy
Conservative management of ectopic pregnancy
Watchful waiting of stable patient while allowing ectopic to resolve naturally
Serum b-hCG monitored every 48 hours to ensure falling by equal to or greater than 50% until reaches < 5
The patient should have access to 24-hour gynaecology services and informed of the symptoms of rupture
Advantages/disadvantages of conservative management of ectopic pregnacy
Advantages
- avoid risk of medical and surgical management
- can be done at home
Disadvantages
- failure or complications -> medical or surgical management
- rupture of ectopic
Complications of untreated ectopic pregnancy
Fallopian tube rupture
- blood loss -> hypovolaemic shock -> organ failure and death
Define miscarriage
Loss of pregnancy at less than 24 weeks gestation
- occur in 20-25% of pregnancies
Risk factors for miscarriage
Maternal age > 30 Previous miscarriage Obesity Chromosomal abnormalities Smoking Uterine abnormalities Previous uterine surgery Anti-phospholipid syndrome Coagulopathies
Clinical features of a miscarriage
Vaginal bleeding - may include passing clots and products of conception
Excessive bleeding can lead to haemodynamic instability -> dizziness, pallor and SOB
Examination findings of miscarriage
Haemodynamically instability - pallor, tachycardia, tachypnoea, hypotension
Abdominal examination - abdominal distention with areas of tenderness
Speculum examination - assess diameter of cervical os and observe for any products of conception of bleeding
Bimanual examination - uterine tenderness or adnexal masses or collections
Differential diagnosis of miscarriage
Ectopic pregnancy
Hydatidiform mole
Cervical/uterine malignancy
Investigations for suspected miscarriage
Imaging - TV USS - small CRL or lack of foetal heartbeat Blood tests - serum bHCG - FBC - blood group and rhesus status - triple swabs and CRP if pyrexial
Management of miscarriage
Conservative - allows POC to pass naturally
Medical - vaginal misoprostol to stimulate cervical ripening and myometrial contractions
- preceded by mifepristone 24-48 hours earlier
Surgical
- manual vacuum aspiration with local anaesthetic is <12 weeks
- evacuation of retained products of conception (ERPC) - patient is under GA, speculum to visualise cervix, dilated and suction tube passed to remove POC
Advantages/disadvantages of conservative management of miscarriage
Advantages
- can remain at home, no side effects of medication, no anaesthetic or surgical risk
Disadvantages
- unpredictable timing, heaving bleeding and pain during passage or POC, change of failure needing further management
Contraindications
- infection, high risk of haemorrhage (coagulopathy)
Advantages/disadvantages of medical management of miscarriage
Advantages
- can be at home as long access to 24/7 gynae services, avoid anaesthetic and surgical risk
Disadvantages
- side effects of medication (vomiting, diarrhoea), heaving bleeding, pain during passage of POC, chance of emergency surgery
Advantages/disadvantages of surgical management of miscarriage
Definite indications
- haemodynamically unstable, infected tissue, gestational trophoblastic disease
Advantages
- planned procedure, unaware during process
Disadvantages
- anaesthetic risk, infection, uterine perforation, haemorrhage, bowel or bladder damage, retained products of conception
Define recurrent miscarriage
The occurrence of three or more consecutive pregnancies that end in miscarriage of the foetus before 24 weeks of gestation
Aetiology of recurrent miscarriage
Antiphospholipid syndrome - association between antiphospholipid antibodies and vascular thrombosis or pregnancy failure/complications Genetic factors - parental chromosomal rearrangements - embryonic chromosomal abnormalities Endocrine factors - DM - high HBA1c - thyroid disease - PCOS Anatomical factors - uterine malformations - septate, bicornuate or arcuate uterus - cervical weakness - acquired abnormalities - adhesions Infective agents Inherited thrombophilias
Risk factors for recurrent misscarriage
Advancing maternal age
Number of previous miscarriages - risk of further miscarriage increases after each successive pregnancy loss
Lifestyle - maternal cigarette smoking, moderate to heavy alcohol use, caffeine consumption
Investigations for recurrent miscarriage
Blood tests - antiphospholipid antibodies - inherited thrombophilia screen Genetic tests (Karyotyping) - cytogenic analysis - parental peripheral blood karyotyping Imaging - pelvic USS
Management of recurrent miscarriage
Genetic abnormalities
- referred to clinical geneticist
- familial chromosome studies and preimplantation genetic screening
Anatomical abnormalities
- cervical cerclage - suture added to close cervix
Thrombophilias
- heparin therapy
- low dose aspirin plus heparin for antiphospholipid syndrome
Define gestational trophoblastic disease
Group of pregnancy related tumours
- pre-malignant conditions - partial and complete molar pregnancy
- malignant conditions - invasive mole, choriocarcinoma, placental trophoblastic site tumour and epithelioid trophoblastic tumour
Pathophysiology of molar pregnancies
Partial molar pregnancy - one ovum with 23 chromosomes is fertilised by 2 sperm - produces cells with 69 chromosomes (triploidy)
Complete molar pregnancy - one ovum without any chromosomes is fertilised by one sperm which duplicates - leads to 46 chromosomes of paternal origin alone
Usually benign but can become malignant - invasive mole
Malignant gestational trophoblastic disease
Choriocarcinoma - malignancy of trophoblastic cells of placenta
- commonly co-exists with molar pregnancy
- characteristically metastasises to lungs
Placental site trophoblastic tumour - malignancy of intermediate trophoblasts which normally responsible for anchoring placenta
- occur after normal pregnancy (most common), molar pregnancy or miscarriage
Epithelioid trophoblastic tumour - malignancy of trophoblastic placental cells - mimics cytological features of squamous cell carcinoma
Risk factors for gestational trophoblastic disease
Maternal age <20 or > 35
Previous gestational trophoblastic disease
Previous miscarriage
Use of COCP
Clinical features of gestational trophoblastic disease
Molar pregnancies commonly present with vaginal bleeding and abdo pain in early pregnancy
Uterus is larger than expected
Hyperemesis - increased titre of B-hCG
Hyperthyroidism - stimulation of thyroid due to high HCG levels
Anaemia
Investigations for gestational trophoblastic disease
Urine b-hCG
Serum b-hCG - elevated
USS
- complete mole has granular/snowstorm appearance with central heterogeneous mass and surrounding multiple cystic vesicles
Histological examination of products of conception
Management of gestational trophoblastic disease
Women diagnosed with GTD should be registered for follow-up/monitoring
Molar pregnancy
- suction curettage
- medical evacuation - greater gestation with foetal development
- anti-D prophylaxis for rhesus negative
GTD
- specialist treatment centre
- single/multiple agent chemo +/- surgery
Define placental abruption
part or all of the placenta separates from the wall of the uterus prematurely
- important cause of antepartum haemorrhage
Pathophysiology of placental abruption
Rupture of the maternal vessels within the basal layer of the endometrium
- Blood accumulates and splits the placental attachment from the basal layer
- The detached portion of the placenta is unable to function, leading to rapid foetal compromise
Types of placental abruption
Revealed – bleeding tracks down from the site of placental separation and drains through the cervix -> vaginal bleeding
Concealed – the bleeding remains within the uterus, and typically forms a clot retroplacentally -> bleeding is not visible, but can be severe enough to cause systemic shock
Risk factors for placental abruption
- Placental abruption in previous pregnancy
- Pre-eclampsia and other hypertensive disorders
- Abnormal lie of the baby e.g. transverse
- Polyhydramnios
- Abdominal trauma
- Smoking or drug use
- Bleeding in the first trimester, particularly if a haematoma is seen inside the uterus on a first trimester scan.
- Underlying thrombophilias
- Multiple pregnancy
Clinical features of placental abruption
Antepartum haemorrhage - painful vaginal bleeding
Woody vagina on examination
History for antepartum haemorrhage
How much bleeding was there and when did is start?
Was it fresh red or old brown blood, or was it mixed with mucus?
Could the waters have broken (membranes ruptured?)
Was it provoked (post-coital) or not?
Is there any abdominal pain?
Are the fetal movements normal?
Are there any risk factors for abruption? e.g. smoking/drug use/trauma – domestic violence is an important cause
General examination for antepartum haemorrhage
Pallor, distress, check capillary refill, are peripheries cool?
Is the abdomen tender?
Does the uterus feel ‘woody’ or ‘tense’ (which may indicate placental abruption)?
Are there palpable contractions?
Check the lie and presentation of the fetus/fetuses. Ultrasound can be used to help.
Check fetal wellbeing with a cardiotocograph (CTG) at 26 weeks gestation or above: (otherwise auscultate the fetal heart only).
Read the hand-held pregnancy notes: are there scan reports? This will be helpful in establishing whether there could be placenta praevia
Assessment of antepartum bleeding
Externally e.g. by looking at pads.
Cusco speculum examination: avoid this until placenta praevia has been excluded by USS
Look for whether blood is fresh red or dark. How much blood is there? Are there clots? Are there any cervical lesions? Is there any cervical dilatation, or any chance that the membranes have ruptured?
Take triple genital swabs to exclude infection if the bleeding is minimal
Digital vaginal examination: A digital vaginal examination with known placenta praevia should NOT be performed as it could cause massive bleeding.
In minor bleed, when placenta praevia is excluded, it can help to establish whether the cervix is beginning to dilate
Avoid digital VE if the membranes have ruptured
Differential diagnosis of placental abruption
Placenta praevia Marginal placental bleed Vasa praevia Uterine rupture Local genital causes - benign or malignant lesions - polyps, carcinoma, cervical ectropion - infections - candida, BV and chlamydia
Define vasa praevia
Foetal blood vessels run near the internal cervical os
Clinical features of vasa praevia
Vaginal bleeding
Rupture of membranes
Foetal compromise
Investigations for antepartum haemorrhage
Haematology - FBC, clotting profile, Kleihauer test, G+S and cross-match Biochemistry - U+E, LFTs Assess foetal wellbeing - CTG Imaging - USS
Management of placental abruption
ABCDE approach
Emergency delivery
- indicated in presence of maternal/foetal compromise
- usually by C-section
Induction of labour
- haemorrhage at term without maternal/foetal compromise
Conservative management
Anti-D within 72 hours if rhesus D negative
Define placenta praevia
Placenta is fully or partially attached to the lower uterine segment
Pathophysiology of placenta praevia
Minor placenta praevia – placenta is low but does not cover the internal cervical os
Major placenta praevia – placenta lies over the internal cervical os
Risk factors for placenta praevia
Previous caesarean section High parity Maternal age > 40 years Multiple pregnancy Previous placenta praevia History of uterine infection Curettage to endometrium after miscarriage or termination
Clinical features of placenta praevia
Antepartum haemorrhage - painless vaginal bleeding
Management of placenta praevia
ABCDE approach
Usually identified on 20 week scan
Placenta praevia minor – a repeat scan at 36 weeks is recommended, as the placenta is likely to have moved superiorly
Placenta praevia major – a repeat scan at 32 weeks is recommended, and a plan for delivery should be made at this time
C-section is safest mode of delivery - elective at 38 weeks
Give anti-D within 72 hours if rhesus negative women
