Early Pregnancy complications Flashcards
1
Q
When do early pregnancy complications tend to arise?
A
- 0-12 WEEKS – 1/5 Chance
- But can be up to 24 weeks – pain and bleeding
- >24 weeks – still birth
2
Q
What are the most common types of early pregnancy complications?
A
- Miscarriage
- Ectopic pregnancy
- Gestational trophoblastic disease
- Hyperemesis gravidarum
- Pregnancy of unknown location
3
Q
What Ix are important for identifying causes of early pregnancy complications>
A
- Urine pregnancy test
- USS – Trans-abdominal (TA) vs Trans-vaginal (TV) – look for heartbeat
- If need to exclude ectopic: Serum βhCG
- Discriminatory level >1500 – and nothing in uterus? Ectopic
- Serial measurements – doubling time/rate of change
- Serum Progesterone
- Blood group: FBC – Hb <105 (loss of bloods), platelet – clotting risk, WCC – septic infection, , UE (AKI), crossmatch and G+S – RhD status, clotting screen – PT and APTT
4
Q
What are the different types of miscarriage and what do they involve?
A
- Threatened Miscarriage - Bleeding and or pain up to 24/40 with a viable ongoing pregnancy. Mild sx and closed cervical os.
- Inevitable miscarriage – severe sx, Cervix os is open, Products of conception (POC) have not yet been passed, but they inevitably will. Will end up complete.
-
Incomplete miscarriage
- Some POC have been passed
- Some tissues and blood clot remain within the uterus
- Cervix os open
- Bleeding and pain usually persist
- Septic Miscarriage: If POC infected → septic patient. Unusual in this country - Rare where Termination of pregnancy (TOP) is legal, where patients are screened for chlamydia and gonorrhoea
-
Complete miscarriage
- All products of conception have been passed
- Complete sac identifiable
- Bleeding and pain reduced
- Cervix now closed
- Cannot diagnose with USS – this can be helpful but no strict cut offs
-
Missed miscarriage
- Asymptomatic or hx of threatened miscarriage
- On-going discharge, small for dates uterus
- No fetal heart pulsation in a fetus where crown rump length is >7mm*
5
Q
What can be used to manage the profuse bleeding of miscarriage
A
Ergometrine
6
Q
What are the TVS USS characteristics that can be seen with different types of miscarraige?
A
- Missed miscarriage / Early fetal demise: Failed pregnancy with no cardiac pulsations on USS. Pt body has not still recognised this fact and continues to experience pregnancy sx.
- Blighted ovum / Anembryonic pregnancy: Failed pregnancy with empty gestation sac i.e. no fetus present – fetus too small to see on USS
- Incomplete miscarriage / Retained products of conception: Echogenic mass of blood clot and tissue within the uterine cavity >20mm in Anterior-posterior (AP) diameter
-
Complete miscarriage – empty uterine cavity – rough guide AP < 20mm
- Must have seen IUP on scan before PUL (pregnancy of unknown location) - Think about an ectopic pregnancy or intrauterine pregnancy
7
Q
What 3 features does TVS USS look at?
A
- Mean gestational sac diameter
-
Fetal pole and crown-rump length
- expected once the mean gestational sac diameter is 25mm or more
- Without a fetal pole, the scan is repeated after one week before confirming an anembryonic pregnancy.
-
Fetal heartbeat – if visible, the pregnancy is considered viable. Expected once the crown-rump length is 7mm or more.
- Crown rump <7mm without a fetal heartbeat, the scan is repeated after at least one week to ensure a heartbeat develops.
- Crown-rump length > 7mm , without a fetal heartbeat, the scan is repeated after one week before confirming a non-viable pregnancy.
8
Q
How is miscarriage managed?
A
- Conservative:
-
<6 weeks: expectant mx: Wait for POC to pass naturally over 2 weeks; can be longer.
- USS useless, repeat urine pregnancy test 7-10 days later
- >6 weeks: EPAU referral, USS: location + viability of pregnancy
- 24h access to gynae services required
-
<6 weeks: expectant mx: Wait for POC to pass naturally over 2 weeks; can be longer.
-
Medical management (>6 weeks)
-
Misoprostol (prostaglandin) – more doses if >9/40 size
- SE: heavier bleeding, pain, diarrhoea, NV
- Pregnancy test after 3 weeks
-
Misoprostol (prostaglandin) – more doses if >9/40 size
-
Surgical management SERPC
- Suction curettage is used to empty to the uterus.5min procedure under GA day case
- indications: GTD, haemodynamically unstable, infected POC
- Prostaglandins (misoprostol) are given before surgical management to soften the cervix.
- Return to normal physically in 24h
- Bleeding for 1-2 weeks
-
Incomplete miscarriage
- Medical management (misoprostol)
- Surgical management (evacuation of retained products of conception). Complication: endometrietis
- Missed miscarraige: mifepristone + misoprostol
- If > 12 weeks + Rh -ve -> anti D
9
Q
What is a recurrent miscarriage?
A
- The loss of ≥ 3 CONSECUTIVE pregnancies with SAME partner
- Theoretically will be expected in 0.3%
- Actually affects 1% of all women
10
Q
What are some of the causes of recurrent miscarraige?
A
- Balanced (Robertsonian) translocations, Antiphospholipid syndrome
- Endocrine: thyroid, PCOS, DM
- Uterine anomalies: cervical weakness, fibroids, acquired uterine abnormalities – such adhesions (Asherman’s syndrome)
- Inherited thrombophilias: Factor V Leiden, prothrombin gene mutation and deficiencies of protein C/S and antithrombin III
- RF: age, PMH of miscarriages, lifestyle
11
Q
How are recurrent miscarriages mxd?
A
- Genetic Abnormalities: referred to a clinical geneticist, Genetic counseling, preimplantation genetic screening w/ IVF
-
Anatomical Abnormalities: cervical weakness, cervical cerclage.
- SE: bleeding, rupture, contractions
- cervical sonographic surveillance.
- Thrombophilias & Antiphospholipid Syndrome: thrombophilia - heparin; anti phospholipid: low-dose aspirin plus heparin
12
Q
Where are ectopic pregnancies most likely?
A
- Tubal (>99%): Ampullary (55%); Isthmic (25%) ; Fimbrial (17%); Interstitial, Bilateral (Very rare)
- Ovarian (0.5%)
- Abdominal(1/15,000) – momentum. Primary/Secondary
- Cervical (0.03%)
- Uterine (Rare) Diverticulum / Intramural /Rudimentary horn (cornual) / Scar – becoming more common
- Heterotopic (1/4000) – with IVF (1/35-100), ovulation induction
13
Q
What ix are used for recurrent miscarriage?
A
- Antiphospholipid syndrome: lupus anticoagulant, anticardiolipin antibodies or anti-B2-glycoprotein antibodies - 2 +ve tests
- Inherited thrombophilia screen – including Factor V Leiden, prothrombin gene mutation and protein S deficiency.
- Karyotyping: Cytogenetic analysis + Parental peripheral blood karyotyping
- Imaging: Pelvic ultrasound scan
14
Q
What are some of the RFs for ectopic pregnancies?
A
- Previous ectopic
- Tubal surgery
- Tubal pathology
- Previous PID
- Endometriosis
- Pregnancy with Cu IUCD
- POP
- Older age
- Smoking
15
Q
What is the presenting hx of an ectopic pregnancy?
A
- Unilateral pain RIF/ LIF
- Irregular PV spotting/ bleeding – in miscarriage the bleeding is very heavy, fainting, dizziness, collapse, shoulder tip pain (diaphragmatic pain from haemoperitoneum)
- Constant lower abdominal pain or pelvic tenderness
- Also ask about dizziness/ syncope (blood loss); shoulder tip (peritonitis)
- N+V
