Early pregnancy complications Flashcards
what does this picture show?
- ectopic pregnancy
fertilisation occurs where?
- fallopian tube
what kind of cell migrates to the uterine cavity once fertilised for implantation?
- morula/blastocyst
what uterine wall houses the pregnancy within the endometrium?
- any wall
is vaginal spotting or bleeding common in early pregnancy?
- yes
what are 3 types of abnormal pregnancy outcomes?
- miscarriage - normal embryo, implantation within uterus
- ectopic - abnormal site of implantation outside uterus
- molar - abnormal embryo within the uterus
what is implantation bleeding?
what is sub-chorionic haematoma?
- when blood forms between the wall of your uterus and chorionic membrane during pregnancy
- chorionic membrane is outermost layer separating the embryo’s amniotic sac from the wall of uterus
- sub-chorionic haematoma can shrink in size and resolve on its own
what are cervical causes of bleeding for other reasons other than pregnancy?
- infection
- malignancy (important to take a smear hx)
- polyp
what are vaginal causes for bleeding?
- infection
- malignancy (rare)
- unrelate: haematuria, PR bleeding etc
what is a threatened miscarrige?
- risk to pregnancy
- ongoing pregnancy w vaginal bleeding w/or w/o period cramping
inevitable miscarriage?
- pregnancy cannot be saved
incomplete miscarriage?
- part of pregnancy is already expelled
complete miscarriage?
- all of pregnancy is expelled, uterus is empty on scan
early fetal demise or non continuing pregnancy NCP
- pregnancy in situ, no heartbeat
- mean sac diameter >25mm, fetal pole >7mm
anembryonic pregnancy?
- no fetus, empty sac
what is cervical shock?
- can be an acute clinical emergency
- presents w cramping, N/V, sweating, fainting
- resolves quickly if products removed from cervix, resus w IVI (intravenous infusion) and uterotonics may be required
immune cause of miscarriage?
- antiphospholipid syndrome APS
infectious causes of miscarriage?
- CMV, rubella, toxoplasmosis, listeria
what risk factors assoc w miscarriage?
- heavy smoking, cocaine, alcohol misuse
- uncontrolled diabetes
vaginal risk factors assoc w miscarriage?
- bacterial infections
investigations for miscarriage?
- full blood count, group and save, serum hCG, US, histology
treatment for miscarriage?
- conservative
- medical
- manual vacuum aspiration (MVA)/surgical
-> anti-D administration if surgical intervention is needed
what can you give a patient till 16 weeks for a viable intrauterine pregnancy is noted on scan (after hx of prev miscarriage)
- micronised progesterone 400mg PV
what point are you referred for recurrent miscarriage?
- referred if 3 or more pregnancy losses or
- if 2 losses and >35 years
- known assoc APS
what do you look for in recurrent miscarriage?
- APS
- uterine abnormality - late first trimester losses
- balanced translocation is a rare cause
- uterine NK cells
independent risk factors - age and previous miscarriage
in evidence of APS you have found a viable pregnancy what do you do?
- give LDA (low dose aspirin) and daily fragmin injections
if >35 and had 2 or more pregnancy losses what tx can you give?
- progesterone pessary in unexplained cases
where is a common site for an ectopic pregnancy?
- fallopian tube
- intersitial
- isthmis
- ampullary
- fimbrial
other sites: ovary, peritoneum, other organs e.g. liver, cervix, C-section scar
what is presentation of ectopic pregnancy?
- pain, bleeding, dizziness/collapse/shoulder tip pain, SOB, rare px of diarrhoea
findings of a women who has had an ectopic pregnancy?
- pallor
- haemodynapic instability
- signs of peritonism
- guarding and tenderness
‘red flag’ signs in ectopic pregnancy
- abdnominal and or pelvic pain
- pain requiring opiates in a woman known to be pregnancy
- repeated presentations
Ix of an ectopic pregnancy?
FBC, G+S, bhCG, US
- TVS is gold standard: empty uterus/pseudosac and or mass in adenexa, free fluid in pouch of douglas
- PUL is halfway dx is no pregnancy is located on US
- serum hCG - assess doubling 48 hrs apart
- combo of factors to help assess severity - symptoms, USS findings, blood tests and surgical early warning signs
Mx of ectopic?
- surgical mx - acutely unwell patient: laparoscopic salpingectomy (removal of tube)
- if cons surgery is needed salpingotomy (preserving the tube) can be considered w follow-up as protocol
- medical mx if women stable, low BhCG and ectopic is small and unruptured - MTX 1 or 2 doses
- cons mx - for well patient
how does pregnancy of unknown location present?
- amenorrhoea
- abdominal pain
what do you see on scan of PUL?
- no evidence of pregnancy in uterus, fallopian tube, cervix, c-section scar or abdominal cavity
mx of PUL?
- managed conservatively if pain settles, and all parameters within criteria
what is molar pregnancy?
- gestational trophoblastic disease
- outcome of a non-viable fertilised egg
- pathology - overgrowth of placental tissue w chorionic villi swollen w fluid rich in hCG,, giving picture of ‘grape like clusters’
what are the 2 types of molar pregnancy?
- complete
- partial
-> a complete mole has 2.5% risk of developing into a choriocarcinoma
what is a complete mole?
- egg without DNA
- 1 or 2 sperms fertilise, result in diploid (paternal contribution only)
- no fetus
- overgrowth of placental tissue
what is a partial mole?
- haploid egg
- 1 sperm - or 2 sperms fertilising egg result in triploidy
- may have fetus
- overgrowh of placental tissue
what is the typical appearance of a complete molar pregnancy?
- ‘snowstorm’ appearance created by the multiple placental vesicles
- +/- fetus, theca lutein cysts
molar pregnancy issues at presentation
- hyperemesis, hyperthyroidism, early onset pre-ecclampsia
- varied bleeding, passage of ‘grapelike tissue’
- rare cases: SOB (due to embolization to lungs) or seizures (mets to brain)
mx of molar pregnancy
- surgical procedure (uterine evacuation) and tissue sent to histo to ascertain type
- registration and follow up w molar pregnancy services
- centres in UK: London, Sheffield, Dundee
what is implantation bleeding?
- occurs when fertilised egg implants in the endometrial lining
- occurs about 10 days post-ovulation
- bleeding is light/brownish and self-limiting
- occasionally mistaken as a period
what is chorionic haematoma?
- pooling of blood between endometrium and embryo due to seperation: sub-chorionic haematoma
symptoms of chorionic haematoma?
- bleeding, cramping, threatened miscarriage
tx of chorionic haematoma?
- usually self-limited and resolve
- large haematomas may be source of infection, irritability, miscarriage
- suveillance…
what does this image show?
- chorionic haematoma
cervical polyp
cervical cancer
3 types of vaginal infections?
- thrichomoniasis - strawberry vagina
- BV
- chlamydia
other vaginal causes of miscarriage?
- malignancy
- forgotten tampon
BV tx
- metronidazole 400mg 2x daily for 7 days
- avoid alcohol during medication
- option of vaginal gel
chlamydia tx
- erythromycin, amoxicillin
- test of cure 3 week later
- liaise w sexual health, include partner tracing
main predominant symptom in ectopic px?
- pain
- dull ache to sharp stabbing
- peritonism in cases causes rigidity, rebound tenderness
what does torsion of existing ovarian cyst usually occur?
- towards end of 1st trimester when uterus climbs out of pelvis into abdomen
rhesus neg women should be offered anti-D for miscarriage, molar px, ectopic when managed surgically? true or false
- true
- aim to neutralise the anti-D antigen and prevent sensitisation of immune system from forming anti-D antibody
what is hyperemesis gravidarum?
- pregnancy complication that is characterized by severe nausea, vomiting, weight loss and possibly dehydration
- symptoms may last the entire pregnancy but usually get better after the 20th week
what is mx for hyperemesis gravidarum?
- determined by severity
inpatient admission
- IV infusion (fluids - normal saline w added KCl), NG tube, TPN
- parenteral antiemetics: 1st and 2nd line
- electrolyte balance
- thyroid function (thiamine supplementation to prevent deficiency)
- thromboprophylaxis: TEDS (TED sotcking and low molecular weight heparin), fragmin, hydration, mobility
- emotional support
- dietician support
- last resort: TOP
when does HG most commonly occur?
- first trimester
- can begin as early as around time of missed period and continue beyond first trimester
what kind of metabolic changes happen to women with HG
- dehydration
- ketosis
- electrolyte and nutritional disbalance
what is a consequence of HG?
- weight loss, altered liver function (up to 50%)
- can also cause emotional instability, anxiety - severe cases -> depression
what antiemetics are used in HG
- prochlorperazine
- cyclizine
- ondansetron
- metoclopramide
what kind of syndrome can occur in women presenting w mod-severe cases of HG and a low thyroid function?
- Wernicke-korsakoff syndrome
name some cervical causes of bleeding in early pregnancy?
- ectopy/ectropion
- infections: chlamydia, gonococcus, or bacterial
- polyp
- malignancy: growth or generalised angry erosion presenation
-> may give hx of missed attendance at colonscopy or not having had a smear…
treatment for implantation bleeding?
- usually settles and pregnancy continues
