Early pregnancy complications Flashcards
Common early pregnancy problems
Ectopic pregnancy
Miscarriage
Gestational trophoblastic disease
Hyperemesis gravidarum
History taking
SQITAR - pain Bleeding - when, how much, pads, soaking, colour Last known menstrual period Parity and gravida Previous complications
Examinations
Abdominal - tenderness and scars
Speculum - cervical os open
Bimanual - fibroids
Investigations
Bloods - folate, FBC, LFTs, HCG, blood group, rhesus status
Abdominal USS
Transvaginal USS
Pregnancy test
Threatened miscarriage
Bleeding or pain up to 24 weeks of gestation with a viable ongoing pregnancy
Inevitable miscarriage
Cervix is open
Products of conception have not yet been passed
Incomplete miscarriage
Cervix is open
Some POC passed
Bleeding and pain persists
Some remaining products of conception identified
Complete miscarriage
Cervix closed
No products of conception left - empty sac
Bleeding and pain reduced
USS classifications
Missed miscarriage - no cardiac pulsation
Blighted ovum - empty sac
Incomplete miscarriage - mass within uterus
Complete miscarriage - Empty uterine cavity after previous USS showed mass
Pregnancy of unknown location
Empty uterine cavity
High HCG
Fetal heartbeat
Risk factors for miscarriage
Environmental:
- Smoking
- Alcohol
- Advanced age
- Consanguinity
Fetal abnormality:
- chromosomal
PMHx
- thyroid diseases
- PCOS
- Folate deficiency
- Previous miscarriage
- Antiphospholipid syndrome
- Uterine malformations
Management options for miscarriage
Expectant
Medical - misoprostol
Surgical - vacuum aspiration
When can expectant method of miscarriage be done
No fetal HR
Low HCG
When can medical method of miscarriage be done
No fetal HR
Raised HCG
When can surgical method of miscarriage be done
Fetal HR present
Raised HCG
Advantages of expectant method
Natural
Can occur in own home
Disadvantages of expectant method
Waiting
Can take up to 2 weeks
Pain, nausea, cramping, bleeding
May be unsuccessful
Advantages of medical method
Mimics natural miscarriage
Can be in own home
Disadvantages of medical method
Pain Cramping Nause Vomiting May fail and require surgery
Advantages of the suction curette
Quick
Hospital controlled
Can do sterilisation or IUC at same time
Disadvantages of the suction curette
Risk of uterine perforation Risk of cervical injury Risk of haemorrhage Risk of pelvic infection Asherman's syndrome
Definition of recurrent miscarriage
Loss of 3 consecutive conceptions with the same partner
Differentials for ectopic pregnancy
Incomplete miscarriage
Early pregnancy
Gestational trophoblastic disease - molar pregnancy
Risk factors for ectopic pregnancy
Previous ectopic Asherman's syndrome Endometriosis STI history/ PID Tubal surgery Tubal pathology POP/IUCD
Ectopic pregnancy presentation
Unilateral pain Sudden onset Vaginal bleeding Fainting/ dizziness Shoulder tip pain Nausea and vomiting
Investigations for ectopic pregnancy
Pregnancy test
Bloods - FBC, CRP
TV USS
Management of ectopic pregnancy
Methotrexate if HCG < 5000
Surgical salpingectomy if HCG > 5000
When to do medical management for ectopic pregnancy
HCG < 5000
Asymptomatic
Ectopic < 3.5cm
No free fluid on scan
When to do surgical management for ectopic pregnancy
HCG > 5000
Symptomatic
Ectopic > 3.5cm
Free fluid on scan
How long should you avoid conceiving after an ectopic
3 - 6 months
Follow up for medical mx ectopic
1 month follow up for scan and weekly bloods
Wait 3 wks max for pregnancy test to be negative
Trophoblastic disease
Abnormal fertilisation causing a tissue mass
Complete mole
empty egg 1 sperm - 46 XX
Partial mole
egg and 2 sperm - 69 XXY/ XXX
Choriocarcinoma
Molar pregnancies have the potential to invade or spread which becomes malignant and termed choriocarcinoma
Treatment of choriocarcinoma
Chemotherapy - methotrexate
Symptoms and signs of molar pregnancy
Bleeding Hyperemesis Large for dates Very high beta HCG levels HTN
Investigations for molar pregnancy
Pregnancy test BP Bloods - HCG, FBC, TSH, Group and save TV USS Histology
USS appearance of molar pregnancy
Snowstorm appearance
Management of molar pregnancy
Surgical curettage + histology
Notify trophoblastic screening centre
Follow up pregnancy test after 3 weeks
Follow up of serum and urine HCG levels
Hyperemesis gravidarum
Excessive nausea and vomiting in early pregnancy
Symptoms of hyperemesis gravidarum
Severe dehydration Deranged bloods MArked ketosis Weight loss Nutritional deficiency
Risk factors
Twins Trophoblastic disease Hyperthyroidism Nulliparity Obesity
Complication of hyperemesis gravidarum
Can be associated with thyrotoxicosis
Differentials for hyperemesis gravidarum
Molar pregnancy Normal nausea of pregnancy UTI Gastroenteritis Appendicitis Thyrotoxicosis
Investigations for hyperemesis gravidarum
Basic observations Abdominal examination Bloods - FBC, TSH, LFTs, U+Es, HCG Urine sample - ketones TV USS
Treatment of hyperemesis gravidarum
IV fluids
Thiamine and folic acid - as not eating
Antiemetic
Consider thromboprophylaxis if dehydrated
Red flags of hyperemesis gravidarum
Weight loss
Long period of not eating
Dizziness
Reduced fetal movements
How does smoking affect hyperemesis gravidarum
Decreases risk
