Early Pregnancy Care (miscarriage, ectopic, molar, hyperemesis) Flashcards
What are the most common causes for bleeding during early pregnancy?
Miscarriage, ectopic pregnancy, benign lesions in the lower genital tract
What is miscarriage and what causes it?
Pregnancy loss less than 24 weeks gestation, caused by:
- spontaneous
- chromosomal abnormalities
- endocrine factors (failure of progesterone and corpus luteum eg. in PCOS)
- maternal illness and infection
- maternal lifestyle and drug history (smoking, obesity, alcohol)
- uterine abnormalities (eg. bicornuate uterus)
- cervical incompetence
- autoimmune factors
- thrombophilic defects
What is threatened miscarriage?
Vaginal bleeding but no miscarriage occurs
What is inevitable/incomplete miscarriage?
Abdo pain and increasing vaginal bleeding, but with the products of conception remaining in the cervix or vagina
What is complete miscarriage?
Complete expulsion of the products of conception, accompanied by vaginal bleeding and pain, which subsides on complete expulsion
What is missed miscarriage?
No symptoms of miscarriage, but foetus has died or never developed, which can be shown on the 12 week scan
What is recurrent miscarriage?
Three or more successive pregnancy losses prior to viability (24 weeks)
How should an incomplete miscarriage be managed?
Conservative: wait for products to pass (expectant)
Medical: prostaglandin analogue (misoprostol) causing passage of products within 48-72 hours (but bleeding may continue up to 3 weeks)
Surgical: dilatation of the cervix and suction curettage to remove the products, which are then sent to histology
What is ectopic pregnancy?
Pregnancy occurring outside the uterine cavity..this can occur in the fallopian tubes, cervix, ovaries, abdomen
What are the risk factors for ectopic pregnancy?
- Previous history of PID
- Previous tubal surgery
- Failed sterilisation
- IUD
- Previous ectopic pregnancy
What is the classical presentation of an ectopic?
Amenorrhoea for 6-8 weeks, followed by lower abdo pain and uterine bleeding, and shoulder tip pain if severe
How is an ectopic pregnancy managed?
Conservative: None
Medical: Administer methotrexate
Surgical: Salpingectomy or salpingotomy
What is trophoblastic disease (AKA molar pregnancy)?
Replacement of fetus by hydatidiform mole (grapelike vesicles) due to abnormal development of placental tissue. It causes excessive secretion of hCG.
Types:
- Hydatidiform moles (complete or partial)
- Invasive mole
- Choriocarcinoma (metastasis)
It is thought to be caused by fertilisation with two sperm
How does molar pregnancy present?
Early pre-eclampsia, heavy vaginal bleeding, hyperemesis gravidarum and spontaneous miscarriage at 20 weeks (exaggerated symptoms of pregnancy due to elevated hCG)
USS shows ‘snowstorm’ appearance
How is molar pregnancy managed?
Termination of pregnancy by suction curettage, but it may require chemotherapy
What is hyperemesis gravidarum?
Persistent pregnancy-related vomiting associated with weight loss of more than 5% of body mass, severe hydration and electrolyte disturbance
What are the risk factors for hyperemesis gravidarum?
- Multiple pregnancy
- Hydatidiform mole
NB both of these conditions involve high levels of hCG
How is HG managed?
Conservative: diet, powdered ginger, vitamin supplements (thiamine), MONITOR bloods
Medical: anti-emetics (antihistamines), fluids, steroids (if severe)
What is the risk of leaving HG untreated?
Wernicke’s encephalopathy (due to thiamine/B12 deficiency), renal and hepatic failure
How can early pregnancy problems be investigated?
Bedside: urine pregnancy test
Bloods: serum beta-hCG
Imaging: pelvic ultrasound (abdo/transvaginal), laparoscopy
Why do some women collapse in early pregnancy?
Progesterone causes vasodilatation and postural hypotension that can lead to syncope
What could be the causes of elevated levels of hCG if the patient is not pregnant?
- Ectopic pregnancy
- Miscarriage
- Molar pregnancy
- Testicular/ovarian cancer
What are the risk factors for molar pregnancy?
- Extremes of reproductive age
- Asian ethnicity
- Previous molar pregnancy
