early pregnancy bleeding / hyperemesis gravidarum

Question 1

threatened miscarriage

Answer 1

vaginal bleeding with or without abdominal pain while the cervix is closed and the fetus is viable inside the uterine cavity
occurs in 20% of women before 20 weeks, most common early pregnancy complication

Question 2

are women who experience threateened miscarriage more likely to miscarry

Answer 2

2.6x more likely to experience miscarriage at a later stage in pregnancy

Question 3

do you give anti-D for threatened miscarriage

Answer 3

non-sensitised rhesus negative women should receive anti-D immunoglobulin for threatened miscarriage

Question 4

earliest definitive evidence of pregnancy on US

Answer 4

gestational sac
4weeks+3 is the earliest time to see a gestation sac by TVUS

Question 5

how should you investigate for undiagnosed gestational trophoblastic disease

Answer 5

a quantBhCG should be performed in all cases of persistent or irregular vaginal bleeding after a pregnancy event (including live birth, miscarriage, termination, or ectopic pregnancy)

Question 6

management for molar pregnancy

Answer 6

suction evacuation
use of misoprostol to ripen the cervix is appropriate before suction evacuation

Question 7

hyperemesis gravidarum

Answer 7

severe nausea and vomiting
peak severity at 12 weeks, most resolve by 20 weeks

Question 8

cause of pregnancy vomititng

Answer 8

associated with rising bHCG and oestrogen levels
higher levels of bHCG seen with molar or multiple pregnancy are associated with more severe symptoms

Question 9

when is it hyperemesis gravidarum and not just morning sickness

Answer 9

when intractable vomiting is associated with weight loss >5% of prepregnancy weight, electrolyte imbalance and dehydration with ketonuria

Question 10

complications of hyperemesis gravidarum

Answer 10

severe hyperemesis gravidarum with limited pregnancy weght gain is associated with intra-uterine growth restriction, low birth weight, preterm birth and low apgars

Question 11

predisposing factors for hyperemesis gravidarum

Answer 11

multiple pregnancy
molar pregnancy
previous hyperemesis
young age
H pylori
depression or anxiety
inflammatory bowel disease
eating disorders
raised BMI
unplanned pregnancy
gastric reflux
restrictive diet
financial or other situational stresses
cultural isolaton, removal from country of origin, seperation from spouse/family

Question 12

investigations for hyperemesis gravidarum

Answer 12

weight
urinalysis: to look for ketonuria or signs of infection
blood glucose
bloods: FBC, UECs, LFTs, TFTs
ECG in case of potassium changes
US scan: arrange if this has not already been performed to exclude molar or multiple pregnancies which precipitate hyperemesis
serum magnesum, phosphate and calcium
bicarbonate level
blood gasses if required
women with diabetes should be monitored carefully as dehydration increases the risk of DKA

Question 13

dietary and lifestyle advice for HG

Answer 13

stay hydrated and have small meals regularly
avoid fatty and spicy foods
identify and avoid triggers
refer to dietitian
get adequate sleep - fatigue may aggravate symptoms
exercise
ensure good supports
refer to manage low mood and anxiety

Question 14

first-line pharmacotherapy for HG

Answer 14

pharmaceutical grade ginger: reduces nausea by increasing gastro-duodenal motility
pyridoxine (vit B6): limited data to support monotherapy
doxylamine: a sedating antihistamine

Question 15

second/third/forth line therapies for HG

Answer 15

promethazine (add a second antihiastime)
metoclopramide
prochlorperazine
ondansetron (may cause cleft palate)
hydrocortisone/prednisolone (monitor for DKA)

Question 16

Iv fluid therapy for hyperemesis gravidarum

Answer 16

dehydration can exacerbate nausea, cause headaches, muscle aches and lethargy
even if urinalysis and UEC do not suggest dehydration, use clinical judgement
use 0.9% sodium chloride

Question 17

hypokalaemia in HG

Answer 17

oral supplementation is preferred
if the patient has ECG changes or cannot tolerate oral supplements then KCl can be given IV

Question 18

preventing wernicke’s encephalopy in HG

Answer 18

thiamine 100mg daily
do not administer IV glucose: if the patient is thiamine deficient, this can worsen hyponatraemia and cause wernicke’s encephalopthy. symptoms include: ataxia, confusion or opthalmoplegia

Question 19

iron supplementation in HG

Answer 19

iron suppliments can worsen the symptoms of nausea and vomting
iron absorption increases in the second trimester so unless the pt is anaaemia, iron suppliments can be ceased or swapped for a lower dose in the first trimester
if oral iron cannot be tolerated due to nausea and vomiting, iron infusion is available