Early Pregnancy Care Flashcards
what happens at ovulation?
ovum released into fallopian tube where it is fertilized
what happens after ovum is fertilized?
cells divide and the fertilized ovum becomes a morula then a blastocyst
blastocyst travels along fallopian tube to the uterus where it implants into uterine lining at day 5-8
what happens after the blastocyst implants into uterine wall at day 5-8?
inner cells develop into the embryo
outer cells invade the endometrium and become the placenta
what are the possible outcomes of fertilization?
- embryo in normal location and normal development = live birth
- normal/abnormal embryo in a normal location but ending in miscarriage
- normal embryo in abnormal location (ectopic pregnancy)
- abnormal embryo (molar pregnancy)
most common site for ectopic pregnancy?
fallopian tube (interstitial, isthmic, ampullary or fimbrial) can also implant in ovary, peritoneum, cervix, scar tissue etc
what is a molar pregnancy?
gestational trophoblastic disease in which there is a non-viable fertilized egg with an overgrowth of placental tissue swollen with fluid
2 classifications of molar pregnancy?
partial and complete
what is a partial mole?
one set of DNA from the egg and 2 set from the sperm (3 sets overall)
what is a complete mole?
no DNA in the egg
2 sets in the sperm (either 2 sperm fertilizing the egg or 1 diploid sperm cell)
which type of mole has a foetus?
only a partial mole
complete mole is just an overgrowth of placental tissue
at what point is HCG detectable?
some sensitive tests can pick it up a levels as low as 20 IU
how should HCG increase in a normal pregnancy?
should double every 48 hrs
when does nausea and vomiting usually resolve by?
around 16 weeks (when HCG levels peak)
when do placenta and foetal heart develop and begin to function?
week 5
what hormone is produced from developing placenta?
human placental lactogen (HPL)
what does HPL do?
has growth hormone like effects and decreases insulin resistance in the mother
also involved in breast development (alongside oestrogen)
what physiological changes happen in early pregnancy (non-hormonal)?
increases in CO increased plasma volume raised HR ECG changes functional murmurs reduced Hb (due to dilution in larger blood volume)
what usually causes minimal bleeding in early pregnancy?
implantation bleeding
occurs in 20% of pregnancy
happens just before when womans period would have been due (usually about 10 days after ovulation)
describe implantation bleeding
light brown
small volume
(earlier and lighter than would be expected from a period)
usually resolves as the pregnancy continues
what is a subchorionic haematoma?
collection of blood between the chorion and the uterine wall
symptoms of subchorionic haematoma?
symptoms vary based on size of haematoma and how long it carries on for
symptoms include bleeding, cramping and threatened miscarriage
risks of subchorionic haematoma?
usually self resolve
large haematomas may lead to miscarriage or be a source of infection or irritability
describe types of epithelium in the cervix?
ectocervix = tough, squamous epithelium endocervix = columnar epithelium
what is the transitional zone?
squamo-columnar junction between ectocervix and endocervix
how does position of transitional zone change?
position changes as a physiological response to menarche, pregnancy and menopause?
what can happen as a result of transitional zone changing position in pregnancy?
can lead to exposure of the delicate endocervical epithelium to the acidic environment of the vagina
this leads to a cervical erosion (aka ectropion) which can bleed
what are cervical polyps?
benign localised inflammatory outgrowth
can be asymptomatic or can bleed if ulcerated
management of cervical polyps?
can be removed if needed
can just be left alone
definition of miscarriage?
spontaneous loss of pregnancy between conception and 23+6 weeks
symptoms of miscarriage?
usually have bleeding, crampy abdominal pain
some women describe or bring in passed products
classifications of miscarriage
threatened inevitable incomplete septic recurrent missed
threatened miscarriage?
when there is risk to pregnancy
bleeding but no cramping
cervical os is closed
US will show intra-uterine pregnancy
when should a foetal heart be present?
if foetal pole is present and measuring >7mm
what is an inevitable miscarriage?
symptoms consistent with miscarriage and the pregnancy cannot be saved
US scan may show a viable pregnancy or products that are in the process of expulsion
cervical os is open
may see products of conception sitting in cervical os
what is an incomplete miscarriage?
where some of the products have already passed but there are some products remaining in the uterus
speculum may or may not reveal products in the cervix
os may be closing if all products of conception have passed
what is a complete miscarriage?
where all products have passed
what is a septic miscarriage?
where there is an infection alongside an incomplete or a complete miscarriage
woman may experience typical sepsis features
what is a recurrent miscarriage?
3 or more consecutive pregnancy losses
what should be done if a woman has recurrent miscarriage?
referral to clinic to be assessed for antiphospholipid syndrome, thrombophilia, balanced translocations and/or uterine abnormalities
what is a missed miscarriage?
no symptoms of miscarriage or a history of threatened miscarriage
but US shows no viable pregnancy
what can cause missed miscarriage?
anembryonic pregnancy (where there is no foetus, just an empty sac) early foetal demise
embryo causes of miscarriage?
chromosomal abnormalities
maternal causes of miscarriage?
PCOS diabetes increasing age heavy smoking alcohol drugs severe hypertension obesity
uterine causes of miscarriage?
septate uteri
bicornate uteri
unicornate uteri
immunologic causes of miscarriage?
APS
infectious causes of miscarriage?
CMV
rubella
toxoplasmosis
listeria
iatrogenic causes of miscarriage?
after chorionic villous sampling or amniocentesis
what can increase risk of recurrent miscarriage?
increasing maternal/paternal age
previous miscarriages
obesity
APS
structural abnormality in one of the parents (usually a balanced translocation)
cervical weakness can cause second trimester miscarriage (not really proven)
acquired thrombophilia
how do previous miscarriages impact risk of further miscarriages
risk of miscarriage increases with each subsequent miscarriage, reaching approximately 40% risk after 3 miscarriages
main hypothesis of miscarriage pathophysiology?
bleeding from chorion or placental bed causes villous/placental dysfunction which starves the foetus of oxygen causing foetal demise
when does cervical shock occur?
occurs during incomplete miscarriage where the products are sitting in the cervix
symptoms of cervical shock?
cramps severe abdominal pain nausea vomiting sweating fainting bradycardia hypotension
management of cervical shock?
may need fluid resuscitation
may need uterotonics
only real treatment is to remove the products from the cervix (can be done using speculum and sponge forceps)
predominant symptom of miscarriage?
bleeding
often have pain of varying amounts
can be haemodynamically unstable if losing a lot of blood
how does ectopic usually present?
localised pelvic pain
light PV bleeding
may have discharge, shoulder tip pain, shortness of breath, dizziness, collapse, breast tenderness, GI symptoms, urinary symptoms, passage of tissue, rectal pressure or pain on defecation
examination signs of ectopic?
pallor haemodynamic instability (tachycardia, hypotension etc) signs of peritonism guarding general abdo/pelvic pain adnexal tenderness cervical motion tenderness abdo distension enlarged uterus orthostatic hypotension
how does molar pregnancy usually present?
hyperemesis
other symptoms include large for dates fundus, can have bleeding
some woman describe passing a “grape like” tissue
can have shortness of breath
how is molar pregnancy diagnosed?
US scan HCG levels (very high)
how much of a drop in HCG is suspicious of miscarriage?
drop of 50% every 48 hrs
investigations in ectopic?
bloods (FBC, G&S, HCG)
transvaginal US
HCG will not rise as much as its meant to (doesnt double every 48 hrs)
US features of molar pregnancy?
snowstorm appearence
with or without foetus present
management of molar preganncy?
surgical evacuation of uterus
monitor HCG for 6 months afterwards
how is a threatened miscarriage managed?
mostly just watchful waiting with emotional support and realistic discussions about what to expect
how is a missed or incomplete miscarriage managed where the woman is haemodynamically stable?
should be offered conservative, medical or surgical management
alongside emotional support etc
conservative miscarriage management?
pregnancy passes with time
offered for up to 2 weeks but can be extended of patient wishes
medical management of miscarriage?
similar to termination of pregnancy
involves administration of misoprostol
can be done at home or in hospital
surgical management of miscarriage?
surgical evacuation of uterus under general anaesthetic
or
manual vacuum aspiration under local anaesthetic
how is an inevitable or incomplete miscarriage managed if haemodynamically unstable?
ABCDE
resuscitation
further management depends on how unwell they are but surgical may be the only option
management of septic miscarriage?
ABCDE
resuscitation
active management of the miscarriage (medical/surgical)
start sepsis 6
management of recurrent miscarriage due to thrombosis (APS, thrombophilia etc)?
low dose aspirin and daily fragmin injections to reduce further miscarriage risk
aspirin can be started before or when patient takes +ve pregnancy test
LMWH should be started when IU pregnancy is confirmed
when is conservative management of ectopic appropriate?
well patient compliant with regular follow up haemodynamically stable small, unruptured ectopic low HCG levels
what does conservative management of ectopic involve?
similar to miscarriage
allows nature to run course
patient asked to return for repeat HCG levels on days 2, 4 and 7 after their initial test
if HCG falls by at least 15% from previous value then they can be repeated weekly until a negative test (<20IU/L) is obtained
when is surgical management of ectopic needed?
large ectopic acutely unwell rupturing/ruptured ectopic significant pain adnexal mass >35mm ectopic with a visible heartbeat on US HCG >5000
what is involved in surgical management of ectopic?
laparoscopy and removal of ectopic pregnancy, usually via salpingectomy
laparotomy may be required if laparoscopy not possible
how is molar pregnancy managed?
surgical
tissue is collected and sent for histology to determine whether partial or complete mole
once diagnosis made the woman will be followed up at one of the molar pregnancy services
who is given anti D in early pregnancy?
all rhesus negative women that are undergoing a surgical procedure
require a dose of 500 IU anti-D
risks of hyperemesis gravidarum?
dehydration ketosis electrolyte imbalance weight loss altered liver function mental health problems anxiety and depression increased thrombosis risk (dehydration causes hypercoagulable state)
management of hyperemesis gravidarum?
IV rehydration
electrolyte replacement
anti-emetic (try oral first then other route if not tolerated)
may give PPI/ranitidine to help reflux
prednisolone may be used in protracted, severe cases
first line anti-emetics in hyperemesis gravidarum?
cyclizine (50mg oral/IM/IV 8 hourly)
prochlorperazine (12.5mg IM/IV 8 hourly)
second line anti-emetics in hyperemesis gravidarum?
ondansetron (4-8mg IM 8 hourly for max 5 days)
metoclopramide (5-10mg IM 8 hourly)
risk of ondansetron?
cleft palate
risk of metoclopramide?
oculogyric crisis which is treatable with procyclidine
what nutritional supplements are given in hyperemesis gravidarum?
thiamine (50mg tds)
or pabrinex IV
may need NG feeding for TPN in severe enough
