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Year 4 - Obs and Gynae > Early Pregnancy complications > Flashcards

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
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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
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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
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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*
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5
Q

What can be used to manage the profuse bleeding of miscarriage

A

Ergometrine

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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
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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.
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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
  • Medical management (>6 weeks)
    • Misoprostol (prostaglandin) – more doses if >9/40 size
      • SE: heavier bleeding, pain, diarrhoea, NV
    • Pregnancy test after 3 weeks
  • 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
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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
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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
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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
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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
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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
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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
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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
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16
Q

On examination of the cervix what is identfified with ectopic pregnancy and where else is this seen?

A
  • Cervical excitation - (pain when moving the cervix during a bimanual examination).
  • Cervical motion tenderness – move it left or right. – ectopic + PID
17
Q

What is the gold standard ix for ectopic and what is seen?

A
  • Gold standard: TVS USS
    • Gestational sac (“blob sign”, “bagel sign” or “tubal ring sign) containing a yolk sac or fetal pole may be seen in a fallopian tube
    • A mass representing a tubal ectopic pregnancy moves separately to the ovary. The mass may look similar to a corpus luteum; however, a corpus luteum will move with the ovary.
    • Possible empty uterus or fluid in the uterus which may get mistaken as a gestational sac ‘pseudogestational sac’
18
Q

What other ix are useful for diagnosing an ectopic pregnancy?

A
  • FBC, G+S, LFT (methotrexate), serum progesterone and hCG.
19
Q

How are ectopic pregnancies managed?

A
  • Expectant management - must meet criteria:
    • Increasingly offered
    • 24 hour access to gynae services
    • Take HCG every 48h till confirmed fall, then weekly after.
    • Methotrexate IM (buttocks): teratogenic so use contraception for 3 months after – LFTs
      • Criteria: HCG level must be < 1500 IU
      • Confirmed absence of intrauterine pregnancy on ultrasound
  • Surgical:
    • 1st Lap. Salpingectomy / Salpingotomy may be used in women at increased risk of infertility - +anti D
20
Q

What is the criteria for expectant management?

A
  • Assymptomatic
  • No rupture
  • HCG <1500
  • Adnexal mass <3.5cm
  • No pain
  • No heartbeat
  • Pt stable + good pain relief
21
Q

What is pregnancy of unknown location?

A
  • Positive pregnancy test but not evidence of pregnancy on USS
  • Cannot exclude an ectopic pregnancy
22
Q

How are pregnancy of unknown locations investigated?

A
  • Ix: Serum HCG to monitor a pregnancy of unknown location. Repeat after 48h
23
Q

In a normal intrauterine pregnancy, what levels of HCG should we expect to see?

A
  • Rate of doubling every 48h
  • >63% - strongly indicates pregnancy
24
Q

What levels of HCG indicate a miscarriage?

A
  • Fall <50%
  • Progesterone <20nmol/l
  • Pregnancy should be visible on USS when HCG >1500
25
Q

How are pregnancy of unknown locations managed?

A
  • HCG rise >66% in 48h: arrange rescan 10-14 days
  • HCG rise < 66% in48h – monitor and rescan with senior decision
  • HCGs plateauing/ fluctuating – senior advise. Asymptomatic – cont. with expectant mgmt./ methotrexate
26
Q

What is gestational trophoblastic disease?

A
  • A spectrum of disorders of trophoblastic development
  • Can give rise to pre malignant (hydatiform/ molar pregnancy) or malignant moles
27
Q

What are the different types of you can get with GTD?

A
  • Premalignant - hydatiform mole
    • Partial mole - egg, 2 sperm
    • Complete mole - empty egg, 1 sperm
  • Malignant
    • Choriocarcinoma - a malignancy of the trophoblastic cells of the placenta. It commonly, but not exclusively, co-exists with a molar pregnancy. mets to lungs
    • Invasive mole
    • Placental site trophoblastic tumour - a malignancy of the intermediate trophoblasts, which are normally responsible for anchoring the placenta to the uterus.
    • Epithelioid trophoblastic tumour - a malignancy of the trophoblastic placental cells, which can be very difficult to distinguish from choriocarcinoma
28
Q

How does GTD present?

A
  • Hyperemesis: N+V - increased titre of B-hCG
  • Bleeding, haemorrhage
  • Uterus bigger than it should be
  • Hyperthyroidism (thyrotoxicosis)
  • Anaemia
29
Q

How is GTD diagnosed?

A
  • TVS USS - snowstorm sign
    • Vesicles thinning the uterine cavity give a snow storm appearance on USS
  • Confirmation on histological dx of retained POC
  • urine + blood b-HCG
30
Q

How are GTDs managed?

A
  • At one of the 3 specialist centres
  • SERPC: suction curettage
  • Medical evacuation: only if they are of greater gestation
    • Risk: thromboembolyzing the trophoblastic tissue
    • Choriocarcinoma: methotrexate
  • Other: avoid getting pregnant for 6 months
  • Repeat HCG serum+ urine post 3 weeks
31
Q

What is hyperemesis gradivarum?

A
  • Diagnosis of exclusion: excessive nausea and vomiting in early pregnancy
  • N+V affected 80%, third most common cause of admission in early pregnancy
  • Most of what we label as “hyperemesis” is normal!
32
Q

When do normal sx of N+V start in pregnancy?

A
  • Start from 4 – 7 weeks
  • Worst around 10 – 12 weeks
  • Resolve by 16 – 20 weeks
  • Symptoms can persist throughout pregnancy
33
Q

What increases your risk of hyperemesis?

A
  • Multiple pregnancies
  • Molar pregnancy
  • Previous HG
34
Q

How does hyperemesis present?

A
  • Nausea, vomiting
  • Hypersalivation
  • Spitting
  • Loss of weight
  • Inability to tolerate foods fluids.
35
Q

How can hyperemesis be quantified?

A

PUQE score

  • <7 mild
  • 7-12: moderate
  • >12: severe
36
Q

What is the definition of true hyperemesis?

A
  • Weight loss >5%
  • Dehydration
  • Fluid inbalance
37
Q

What are some of the possible pathophysiology for hyperemesis?

A
  • elevated HCG
  • elevated O + P
  • Psychosocial
  • H pylori
38
Q

What Ix are useful for hyperemesis?

A

Urine: pregnancy test. dipstick

Bloods: FBC, UE, LFT, amylase, TFTs

USS: to rule out ectopic, GTDs

39
Q

How is Hyperemesis managed?

A
  1. Rehydration: avoid glucose (precipitates wernickes), give K+ if needed
  2. Thiamine, pabrinex, folic acid
  3. Anti emetic
    1. 1st: prochlorperazine, cyclizine
    2. 2nd: metacloperamide, ondansetron
  4. Acid reflux: ranitidine
  5. Consider thromboprophylaxis: enoxaparin

Year 4 - Obs and Gynae (7 decks)

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