early pregnancy care

Question 1

what is a threatened miscarriage?

Answer 1

vaginal bleeding in patient <24 weeks pregnant, cervical os is closed O/E. Fetus is alive + uterus is the size expected. 1/4 will go onto miscarry.

Question 2

what is your ddx for a patient with vaginal bleeding + +ve pregnancy test? How would you differentiate them clinically and via investigation?

Answer 2

miscarriage
ectopic
Miscarriage- hCG drops
Ectopic - hCG slowly rise over 48h period or plateau
Normal pregnancy- expect hCG to double in 48h period

Question 3

what is a miscarriage?

Answer 3

loss of previable pregnancy before 24 weeks, mostly with no ID cause. Most common time to lose pregnancy is before 12 weeks. 1/5 pregnancies end in miscarriage.
scan 1 Crown Rump length <7.2mm + no change on scan 1/52 later OR >7.2mm but no fetal HR.

Question 4

what is an inevitable miscarriage?

Answer 4

vaginal bleeding in patient <24 weeks pregnant, cervical os is open O/E + products of conception may be visible in cervix/ vagina.

Question 5

what is complete miscarriage?

Answer 5

vaginal bleeding in patient <24 weeks pregnant, may have noticed passing tissues at home/ before examination. O/E cervical os is closed. Scan Shows no/ minimal products of conception in uterus and uterus is no longer enlarged.

Question 6

what is an incomplete miscarriage?

Answer 6

vaginal bleeding in patient <24 weeks, may have noticed passing tissues at home/ before examination cervical os is open O/E due to some remaining products of conception within the uterus which can be seen on scan.

Question 7

what is a missed miscarriage?

Answer 7

The fetus has not developed or died in utero, but this is not recognized until bleeding occurs (but this is not always present) or ultrasound is performed. The uterus is smaller than expected from the dates and the os is closed

Question 8

How does miscarriage present?

Answer 8

vaginal bleeding heavier until tissues are passed. Pain that is severe until tissues are passed.

Question 9

How are miscarriages managed? 8-14 weeks stage?

Answer 9

Conservative- see if it occurs naturally; re-scan after 10-14 days to ensure completed, often bleed
Medical- mifepristone (anti-P), misoprostol (PG), pain + bleeding during procedure. If retained tissue/ failure/ excess bleeding, surgery req. SE: V + d
Surgical- suction + curette under local/ GA. SE: damage to cervix, uterus, infection and secondary infertility, scarring inside uterus. Not gen first line unless pt request.

Question 10

what are the RF for ectopic pregnancies?

Answer 10

IUD, previous ectopic, chlamydia infection in past (tubal damage), IVF either due to procedure itself or underlying sub fertility reason e.g. endometriosis, previous abdo/ tubal surgery, POP

Question 11

what are the red flags of a ruptured ectopic?

Answer 11

fainting
increasing abdo pain
shoulder tip pain 
signs of shock
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Question 12

How is an ectopic pregnancy managed?

Answer 12

laproscopy: remove of ectopic + salpingectomy. Risks: bleed, infection, risk to surround structures, req conversion to laparotomy, hernia, DVT/ PE. Can try to conserve the tube but risk of recurrence of ectopic + FU of hCG levels req.
methotrexate injection IM: hCG <1500, LFT derangement, mouth ulcers, risk of ectopic rupture, req FU hCG levels.
conservative watch + wait: risk of rupture, req FU hCG levels

Question 13

what is hyperemesis gravidarum? Clinical Features?

Answer 13

vomitting resulting in:
electrolyte disturbances
dehydration
weight loss (>5% pre-pregnancy weight)
ketosis
May present with oliguria + syncopal episodes secondary to hypotension
Dehydration: loss of skin turgor, furry tongue, ketotic breath, postural HT, tachycardia, muscle wasting/ weakness.

Question 14

what investigations do you do for hyperemesis gravidarum?

Answer 14

FBC- WCC infective cause for vomitting, raised haematocrit in dehydration
U+E - urea + creatinine would Indic Severe dehydration causing AKI, more common- HypoK/ Na
TFTs- often women will have TSH suppression but normal T4
Ca- hyperCa can be a cause of hyperemesis
Pelvic USS- viability + check for factors increasing risk of hyperemesis multiple pregnancies/ molar
LFT- sometimes deranged AST/ ALT
Urinanalysis- ketones indic sig dehydration/ UTI

Question 15

what are the complications of hyperemesis gravidarum?

Answer 15

VTE (increased risk due to pregnancy + dehydration)
Wernicke’s Encephalopathy- deficiency of thiamine due to malnutrition second to vomitting. Triad: ataxia, opathalmoplegia, confusion
Hypokalaemia- arrhythmias risk
Mallory Weiss Tear- caused by excessive vomitting. May cause distress to patient.
Oesophageal rupture due to forceful vomit vs closed epiglottis. Mostly managed conservatively. Facial swelling. But occasionally mediastinitis – ICU
Pneumothorax - SOB/ cough.

Question 16

how is hyperemesis gravidarum treated?

Answer 16

Rehydration with saline (optimal if HypoK but for longer infusion) or Hartmann’s for acute bolus (contains v little K) if K is within normal range. 5% dextrose is not used bc increases risk of Wernicke’s Encephalopathy. 1L over 2 hours followed by 1L over 4 hours followed by 1L over 6 hours and 1 L over 8 hours. Slow to prevent central pontine myelinolysis.
Promethazine +/ or cyclizine
2nd line: Prochloroperazine +/ or metoclopramide. Most will require a combo to control symptoms. Steroids is last resort if all anti-emetics fail

Question 17

what is your ddx for hyperemesis gravidarum?

Answer 17

UTI
Hepatitis
Enteric infection
Peptic ulcer
Pancreatitis
HyperCa
Addison's
Benign Intracranial HT

Question 18

what is a molar pregnancy? How does it present?

Answer 18

excess vomitting, vafginal bleeding, excess uterine enlargement, missed miscarriage.
gestational trophoblastic disease in which 2 sperm fertilise an egg with no genetic material producing zygote with only paternal genetic material. (Diploid bc 2 sperm)
Gold standard is surgical evacuation of uterus.

Question 19

what are the normal signs and symptoms of early pregnancy?

Answer 19

• amenorrhoea
• N +V particularly in first trimester
• increased freq of micturition due to increased plasma volume + urine prod + P on the bladder from uterus
• excessive tiredness/ fatigue, usually resolves by week 12
• breast tenderness/ heaviness
• fetal movements/ quickening ~ 20 w in nullip, ~18 in multip
• pica abnormal desire to eat something not regarded as nutritious
• vagina + cervix have blueish tinge due to blood congestion
• uterus size can be palpated via bimanual (after 12 weeks)
• fetal HR may be heard from 12w
• hCG measured in blood/ urine (released by trophoblast tissue). Peaks at 8-12 weeks gestation.

Question 20

what is your ddx for abdominal pain in early pregnancy, before 24 weeks?

Answer 20

• ectopic pregnancy: unilateral lower abdo pain at <12 weeks; associated brown vaginal bleeding; shoulder tip pain suggests haemoperitneum; Dx: serum hCG, USS, Laparoscopy
• miscarriage: lower abdo dull ache- severe continuous/ colicky pain; associated with vaginal bleeding usually. Dx: Pelvic exam, USS, +ve urine test.
• constipation: varied colicky lower abdo pain L>R. manage- high fibre diet, osmotic laxatives (Lactulose/ macrogol), glycerine suppositories.
• round ligament pain (due to stretching of the ligament): common in Tri1/Tri2 often pain Is bilateral on outer aspect of uterus radiating to groin. Aggravated by movement e.g. getting up from chair.
• fibroids: may increase in size in pregnancy compromising its own blood supply causing pain (second to necrosis), “red degeneration”. may be severe, may localise specifically + low grade pyrexia. Usually Tri1/Tri2. USS (fibroids) + FBC (leukocytosis). Analgesia until settles.
• UTI: suprapubic/ lower abdo pain + urinary symptoms. Dipstick + culture, Nitrofuratoin 100mg BD 7/7 , Paractetamol, increase fluids.

Question 21

What is your ddx for Reduced Fetal Movements?

Answer 21

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Question 22

what are the causes of IUGR?

Answer 22

placental insufficiency (by far most common) : abnormal trophoblast invasion- pre-eclampsia + placenta accreta; abruption, infarction of placenta, placenta praevia, placental haemangioma, abnormal u.c.

maternal: HT, cardiac disease, CKD, alcohol + recreational drugs, smoking, antiphospholipid syndrome, poor nutrition, low SES.
fetal: Trisomy 13, 18,21, Turner’s, Infections- CMV/ Rubella/ Toxoplasmosis, TOF, Transposition of vessels, gastroschisis, multiple pregnancy.

Question 23

What are the types of IUGR? What are the complications?

Answer 23

Symmetric: usually due to chromosomal abnormalities, small in all domains, early onset IUGR.
Assymetric: Maintained head size + heart development at expense of other organs e.g. liver, fat, muscle. Small abdo circumference + thin limbs. Often due to placental insufficiency, if sustained they will not be able to maintain head growth.
Complic: perinatal mortality 6-10x more likely, incidence of CP 4x higher, stillbirth rate higher. More likely- fetal distress + asphyxia, meconium aspiration, emergency CS, NEC, hypoG / hypoCa.

Question 24

how is Reduced Fetal movements managed?

Answer 24

duration + is this the first time this has happened, have the fetal movements stopped completely? when did it happen?
ID RF for stillbirth- multiple episodes of RFM, known IUGR, HT, DM, extremes of maternal age, primiparity, infections, bleeding, pain, smoking, placental insufficiency, congenital malformation, obesity, previous Stillbirth/ IUGR.
Auscultation handheld doppler (exclude fetal death) + CTG for 20mins
USS to detect IUGR if normal CTG + post-28/52/ have RF for IUGR. If isolated incidence, discharge and tell them return if another episode.
If repeated episodes of counsel on risk of poor fetal outcomes, USS growth and if term– induce!

Question 25

How is IUGR managed?

Answer 25

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