Early Pregnancy Complications Flashcards
Define ectopic pregnancy
Any pregnancy that implants outside of the endometrial cavity. 97% are implanted in a fallopian tube.
What is the most common implantation site for ectopic pregnancy?
Fallopian tube, specifically the ampulla.
Where does fertilisation of the oocyte happen?
Fertilisation of the oocyte typically takes place in the ampulla of the fallopian tube
Name two mechanisms that assist the conceptus in reaching the endometrial cavity.
This occurs due to tubal peristalsis alongside ciliary motion and tubal fluid flow
Any dysfunction in the movement of the conceptus to the endometrial cavity can prevent it from implanting in the correct place. What could cause that dysfunction?
tubal surgery, salpingitis, PID can prevent the conceptus from implanting in the correct place
A pregnancy that implants in the fallopian tube can cause what?
A pregnancy that implants in the fallopian tube will grow and eventually lead to rupture and catastrophic bleeding.
Most tubal ectopics implant in the ____.
ampulla (widest point).
Name one risk factor for ectopic pregnancy.
- Previous ectopic pregnancy 2. Cu-IUD use (although background risk of pregnancy is obviously much lower). 3. Chronic salpingitis (tubal inflammation) 4. PID
Presentation of ectopic preganancy
Typically presents at 6-8 weeks after LMP; at this point the conceptus has grown to sufficient size to cause symptoms / signs.
Symptoms of ectopic preganancy
: lower abdominal pain, amenorrhea, PV bleeding, urge to defecate, shoulder pain.
Signs of ectopic preganancy
: lower abdominal tenderness / adnexal tenderness, cervical motion tenderness
Differentials of ectopic preganancy
miscarriage, appendicitis and ovarian torsion.
Any female of childbearing age presenting with abdominal pain should be offered
a ____ to exclude ectopic pregnancy
UPT (urine pregnancy test)
The following signs / symptoms occur due to intraperitoneal bleeding and are indicative of rupture
urge to defecate, shoulder tip pain, cervical motion tenderness.
Investigations for ectopic pregnancy
- Urine pregnancy test 2. Transvaginal ultrasound scan 3. Serial serum beta-hCG if no pregnancy found on USS.
Different types of management for ectopic preganancy>
Expectant, Medical and Surgical
Expectant Managment of ectopic preganancy
No criteria for surgical intervention can be present - Measure beta-hCG on days 0, 2, 4, and 7; if drop of more than 15% from previous measurement, repeat weekly until beta-hCG is less than 20IU/L. If not, refer for further management.
Medical management of ectopic pregnancy
oral methotrexate - as long as no surgical criteria are met. Take UPT three weeks later
Surgical management of ectopic pregnancy
salpingectomy / salpingotomy
when is a salpingectomy / salpingotomy indicated for ectopic pregancy
indicated if any of the following features are present: ○ Ruptured ectopic ○ Significant pain ○ Heartbeat on USS ○ >35mm diameter of pregnancy ○ Serum beta-hCG > 5000IU/L
What is the first-line surgical intervention for ectopic pregnancy?
Salpingectomy.
When is a salpingotomy offered instead?
unless there are risk factors for infertility; in which case, salpingotomy (opening of tube for removal of ectopic) is recommended. Salpingotomy is less effective than salpingectomy. Advise UPT 3 weeks post surgery.
What is the definition of a pregnancy of unknown location (PUL)?
Positive UPT with no pregnancy visualized on ultrasound.
What investigation is crucial for diagnosing and managing PUL?
Serial serum beta-hCG measurements. (2 measurements taken 48hrs apart)
What does a >63% increase in beta-hCG over 48 hours indicate?
Likely viable intrauterine pregnancy; offer a scan in 7–14 days.
What does a >50% decrease in beta-hCG over 48 hours suggest?
Likely non-viable pregnancy; advise UPT in 14 days.
Fill in the blank: If the beta-hCG change falls between these parameters, further review is required for ___________.
?Ectopic pregnancy.
Define Ectopic Pregnancy
Implantation of a fertilised ovum outside the uterus.
What % of ectopic pregancies occur in the fallopian tubes?
0.97
What % of ectopic pregancies occur in the ovaries?
0.02
What % of ectopic pregancies occur in the abdomen?
0.01
Which parts of the fallopian tube are common sites for ectopic pregancies?
-Ampulla of the fallopian tube most common site, followed by isthmus
Risk Factors for ectopic pregnancies
● Previous ectopic pregnancy
● Previous infections
● Previous surgery to fallopian tubes
● Intrauterine device
● Progesterone only pill
● IVF
● Increasing age
● Smoking
● Adhesions
Signs and Symptoms of ectopic pregancies
● Symptoms present 6-8 weeks gestation
● PV bleeding
● Unilateral abdo pain & tenderness
● Pelvic pain
● Shoulder tip pain
● Amenorrhoea 6-8 weeks
● Urinary discomfort, GI upset
● If ruptured (emergency) → heavy bleeding, fainting, shock
When would an ectopic pregnancy become a gynaecological emergency?
● Previous ectopic pregnancy
● Previous infections (PID, salpingitis)
● Previous surgery to fallopian tubes (D&C, tubal ligation)
● Intrauterine device (IUD)
● Progesterone only pill
Explain why ectopic pregnancies can give you shoulder tip pain?
Shoulder tip pain; ruptured ectopic pregnancy → peritonitis. Referred pain from the diaphragm irritation; phrenic nerve.
Ix for Ectopic Pregnancy
● Abdo exam- unilateral abdo pain, rebound tenderness, guarding
● Pregnancy test- positive
● Adnexal mass moving separately to the ovary
● Urinalysis
● Bloods = FBC, U&E, CRP, LFTs, clotting screening, Group and save, serum B-hCG
Gold Standard Ix for Ectopic Pregnancy
GOLD = Transvaginal US (exclude intrauterine pregnancy & locate ectopic pregnancy)
Conservative Management for Ectopic Pregnancy
watchful waiting for 48hrs if patient is stable and pain free
● Size <35mm
● No foetal heartbeat
● Serum hCG <1000 IU/L
● Asymptomatic
● Patient can return for follow up
Medical Management for Ectopic Pregnancy
IM methotrexate
● Size < 35mm
● No foetal heartbeat
● Serum hCG < 1500 IU/L
● No significant pain
● Patient can return for follow up
Surgical Management for Ectopic Pregnancy
(for unstable pt):
● 1st Line = Laparoscopic salpingectomy
● Salpingotomy
● Post-operative methotrexate
Always do surgery if there is a foetal heartbeat
● Size >35mm
● Foetal heartbeat present
● Serum hCG >5000 IU/L (decrease over time)
● Patient in significant pain
What is the definition of a miscarriage?
Spontaneous loss of pregnancy before 24 weeks of gestation (NICE CKS).
Name some causes of miscarriage.
Chromosomal abnormalities, hormonal factors, thrombophilia/autoimmunity, anatomical factors, infection.
What is the most common cause of miscarriage?
Chromosomal abnormalities, typically autosomal trisomies.
Why can chromosomal abnormalities cause miscarriage/
Chromosomal abnormalites Can result in failure of development of embryo within gestational sac.
Name two hormonal factors that can lead to miscarriage.
PCOS, hyperprolactinaemia, diabetes, hyper/hypothyroidism.
What autoimmune condition can induce placental thromboses, leading to placental insufficiency?
Antiphospholipid syndrome, factor V Leiden - induces placental thromboses
leading to placental insufficiency
What type of anatomical factors can lead to miscarriage?
Bicornuate uterus, cervical insufficiency
Which infections can lead to miscarriage?
Toxoplasmosis, syphilis
List two risk factors for miscarriage.
Increased maternal age and previous miscarriage.
List some types of miscarriage.
Threatened, incomplete, complete, missed, inevitable
Define a “threatened miscarriage.”
vaginal bleeding in the first 24 weeks of pregnancy (with viable intrauterine pregnancy).
Define a “Incomplete miscarriage”.
non-viable pregnancy, bleeding begun, products of conception in uterus.
Define a “Complete miscarriage”.
: all products of conception passed, bleeding has stopped.
Define a “Missed miscarriage.”
non-viable pregnancy on ultrasound (without pain / bleeding). ○ Mean gestational sac diameter >25mm with no yolk sac or ○ CRL >7mm with no cardiac activity
Define a “Inevitable miscarriage.”
non-viable pregnancy, bleeding begun, cervical os opened, POCs remain in uterus.
What type of miscarriage involves all products of conception being passed and bleeding stopping?
Complete miscarriage.
Fill in the blank: A missed miscarriage is diagnosed by a mean gestational sac diameter of >___ mm without a yolk sac or CRL >___ mm without cardiac activity.
25 mm; 7 mm.
Presentation of miscarriage
pelvic pain, vaginal bleeding
Differentials of bleeding in early pregnancy
The commonest causes of bleeding in early pregnancy are miscarriage, gestational trophoblastic disease, implantation bleeding, ectopic pregnancy, and importantly, bleeding without an identified cause.
How is a miscarriage diagnosed?
Transvaginal ultrasound scan - to identify location, foetal pole and heartbeat
How is a threatened miscarriage managed if there is no history of previous miscarriage?
Conservative management: Advise returning if bleeding persists after 14 days or becomes heavier.
How is a threatened miscarriage managed if there is a history of previous miscarriage?
offer vaginal progesterone until 16 weeks of pregnancy completed.
Once the bleeding has stopped, what should the patient (suspecting miscarriage) do?
Take a pregnancy test 3 weeks after the bleeding has stopped.
If the bleeding is ongoing, offer __ ______ _____.
a repeat scan
First line management of Incomplete/Inevitable Miscarriage
- expectant management (appropriate to 13 weeks gestation): ■ Allow 7-14 days for POCs to pass / bleeding to end
Second line management of Incomplete/Inevitable Miscarriage
- medical management: ■ mifepristone, followed by misoprostol 48 hours later.
Alternative second line management of Incomplete/Inevitable Miscarriage
- surgical management: ■ Vacuum aspiration under local or dilatation and evacuation under GA
For Incomplete/Inevitale Miscarriage when should a pregnancy test be taken?
pregnancy test 3 weeks post-miscarriage
How is missed miscarriage managed differently to Incomplete/inevitable miscarriage?
Exaclty the same except for the second line (medical management) only use misoprostol NOT mifepristone
Contraindications to expectant managment:
- Heavy vaginal bleeding / increased risk of bleeding / increased vulnerability to heavy bleeding (coagulopathy) 2. Previous traumatic experience in pregnancy 3. Evidence of infection
Mechanism of mifepristone
Antiprogesterone; sensitises myometrium to prostaglandins, induces breakdown of decidua basalis.
Mechanism of misoprostol
Prostaglandin E1 analogue; degrades cervical collagen, stimulates uterine contraction.
The 1967 Abortion Act gives four legal grounds for termination of pregnancy (TOP): what are they?
- Pregnancy before 24 weeks - continuation risks injury to physical / mental health of the pregnant woman / her children. 2. Necessary to prevent grave permanent injury to physical / mental health of the pregnant woman. 3. Continuation of pregnancy involves risk to the life of the pregnant woman. 4. Substantial risk of serious physical / mental disability to the child if it were born.
Medical Abortion Procedure
○ Up to 9+6 weeks - single dose mifepristone, followed by single dose PO / PV misoprostol 48 hours later ○ 10+0 to 23+6 weeks - single dose mifepristone, followed by serial misoprostol every 3 hours. ○ Analgesia - NSAIDs, opioids as required.
Surgical Abortion Procedure
○ Up to 13+6 weeks - cervical priming with misoprostol or mifepristone, followed by vacuum aspiration. ○ 14+0 to 24+0 weeks - cervical priming with mifepristone + misoprostol or osmotic dilator, followed by dilatation and evacuation. ○ Plus - oral doxycycline to prevent infection. ○ Analgesia - NSAIDs, local anaesthetic, conscious sedation.
What are the 2 main options for abortion?
Medical or Surgical
Both the medical and surgical abortion methods use misoprostol. How do they differ?
○ Medical - mifepristone plus misoprostol taken 48 hours later ○ Surgical - misoprostol plus vacuum aspiration / dilatation and evacuation.
Anti-D should be offered to Rhesus-negative women after ___ weeks post-abortion.
10
What is the medical regimen for abortion up to 9+6 weeks?
Mifepristone, followed by misoprostol (PO or PV) 48 hours later.
What surgical procedure is used for termination between 14+0 and 24+0 weeks?
Dilatation and evacuation with cervical priming using mifepristone + misoprostol or an osmotic dilator.
What antibiotic is administered post-surgical abortion?
Oral doxycycline.
