early pregnancy complications Flashcards
how is a miscarriage defined? (include early and late miscarriage
loss of pregnancy <24 weeks gestation
early: <13 weeks gestation
late >13 weeks gestation
what are the causes of a miscarriage?
chromosomal abnormalities,
congenital abnormalities
uncontrolled maternal disease - e.g. infection, diabetes, uterine anomalies, thrombophilia
what increases the risk of having a miscarriage?
maternal age >35 - chromosomal abnormalities
paternal age >45
chromosomal abnormalities in mother or father
uterine abnormalities - adhesions, fibroids
low BMI/ obese
folate deficiency
antiphospholipid syndrome / coagulopathy
smoking, alcohol, drugs (NSAIDs, aspirin)
previous miscarriage
consanguinity
if a pregnancy test is positive does this rule out a miscarriage?
a pregnancy test can be positive for several days post miscarriage
what are the clinical features of a miscarriage?
vaginal bleeding - passing clots/ products of conception
- if excessive can lead to dizziness, pallor, SoB
subrapubic cramping pain
significant number are found incidentally
what should you look for on examination if you suspect a miscarriage?
speculum examination - cervical os diameter, any products of conception or areas of bleeding
bimanual examination - assess for uterine tenderness or adnexal masses
what are the differentials to a miscarriage
implantation bleeding
ectopic pregnancy
hydatidiform mole
cervical/uterine malignancy
how does a threatened miscarriage present?
mild bleeding +/- pain, cervical os is closed
transvaginal USS - viable pregnnacy
what is meant by an inevitable miscarriage?
heavy bleeding, clots, pain
cervix os is open
TVUS - open os, viable/nonviable preg
what is meant by a missed miscarriage?
asymptomatic
TVUS - no fetal HR found, crown rump length >7mm
what is meant by an incomplete miscarriage
bleeding clots/ products of conception.
partially expelled
TVUS shows retained products of conception, AP endometrial diameter >15mm, proof there was a previous intrauterine pregnancy
what is meant by a complete miscarriage
bleeding, clots, POC , cervix now closed
TVUS - closed os, AP endometrial diameter <15mm, proof of previous intrauterine pregnancy (otherwise could be ectopic)
what is a septic miscarriage?
POC infection
fever, rigors, intrauterine tenderness
bleeding, discharge
raised WCC and CRP
how is a miscarriage investigated?
assessment in early pregnancy unit
use Transvaginal USS for definitive diagnosis:
1. look for fetal HR (usually first picked up around 6 weeks) - if present, no miscarriage
2. if fetal HR absent, look for fetal pole and measure crown rump length
- if >7mm = confirm miscarriage, with second opinion
- if < 7mm = wait 7 days and re-assess for fetal HR
3. if no fetal pole, measure gestational sac
- if >25mm = confirm miscarriage with second opinion
- if <25 mm = repeat scan in 7 days.
bloods:
- serial bHCG - for ectopic
- FBC, blood group and rhesus antigen
- triple swab and CRP is pyrexic
why is crown rump length and gestational sac measured In process of confirming miscarriage?
if crown rump is <7mm or gestational sac is <25 mm then measurement of fetal HR is inaccurate and cannot confirm a miscarriage based on the absence of fetal HR (may just not be visible at this point)
what are the 3 management options for miscarriage?
expectant/ conservative
medical
surgical
what is the expectant/conservative way to manage a miscarriage?
conservative - wait and see
allow products of conception to pass naturally over 2-3 weeks
must have 24 hour access to gynae services
repeat scan in 2 weeks or pregnancy test in 3 weeks.
indicated when <6 weeks and no pain
what is the medical way to manage a miscarriage?
Vaginal misoprostol (prostaglandin analogue) is given - cervical ripening and myometrial contractions are stimulated. (oral version also available)
Do not give misopristone
pregnancy test 3 weeks later
what is the surgical way to manage a miscarriage?
manual vacuum aspiration with local anaesthetic if <12 weeks - quicker, safer and less painful
if >12 weeks then evacuation of POCs under general anaesthetic - speculum inserted and suction of POC
need to screen for chlamydia before undergoing surgery
what are the advantages and disadvantages of conservative management of miscarriage?
no side effects of surgery/ medicine. can be managed at home
but takes longer and thus at increased risk of heavy bleeding. also unpredictable timing and more pain. higher chance of being unsuccessful
what are the contraindications of using a conservative method for managing miscarriage?
at risk of haemorrhage e.g. coagulopathy
what are the advantages and disadvantages of medical management of miscarriage?
advantage - quicker than conservative, at home, surgery avoided
disadvantage - side effects from medication (N+V, diarrhoea)
what are the indications for surgical management of miscarriage?
infection
gestational trophoblastic disease
haemodynamically unstable
what are the advantages and disadvantages of surgical management of miscarriage?
advantages - quick, planned time
disadvantage - damage to bowel, bladder, nerves, uterine rupture, ashermans (adhesions), infection (endometritis), anaesthetic risk
when is Anti-D prophylaxis recommended in miscarriage?
any surgical removal of miscarriage or ectopic DO NOT NEED if: - complete miscarriage - threatened miscarriage - medically managed miscarriage - pregnancy of unknown location
how is a septic miscarriage managed?
Abx, anti pyretics, IV fluids, surgical evacuation
define recurrent miscarriage
3 or more consecutive miscarriage (loss of fetus <24 weeks) with the same partner
what is the aetiology behind recurrent miscarriages?
systemic disease
- antiphospholipid, inherited thrombophilias (factor V leiden, protein S, C or ATIII deficiency) - risk of uteroplacental thrombosis
- infection - especially if pyrexia e.g. bacterial vaginosis in T1 can lead to miscarriage in T2
- endocrine factors: PCOS, diabetes, thyroid
anatomical defects
- uterine malformations - bicornate or septate uterus
- cervical weakness - dilates before pregnancy reaches erm
- adhesions and fibroids
chromosomal abnormalities
- balanced translocations or robertsonian translocation I leads to increased risk of unbalanced chromosomal rearrangements.
what are the risk factors for recurrent miscarriage?
same as risk factors for miscarriage
the number of previous miscarriages is an independent risk factor for future miscarriage
what investigations can be done in someone presenting with recurrent miscarriages?
anti phospholipid syndrome - ab screening: lupus anticoagulant testing, anti cardiolipin Ab, anti B2 glycoprotein Ab (need 2 positive tests, 12 weeks apart)
inherited Thrombophillia screen
pelvic USS to assess uterine anatomy
if abnormality found can do laparoscopy or hysteroscopy
karyotyping:
- cytogenetic analysis of products of conception for any chromosomal abnormalities
- if chromosomal abnormalities are found then can karyotype parental peripheral blood
how is recurrent miscarriages managed if a genetic abnormality is identified?
refer to clinical specialist to discuss gamete donation, adoption or just trying again
offer IVF and pre-implantation testing
genetic counselling
support and counselling for psychological distress.
how is recurrent miscarriage managed if cervical weakness was found to be cause of previous miscarriage?
cervical weakness - offer cervical cerclage = sutures used to close and hold cervix. If the patient decides to not have this then instead can offer cervical surveillance by USS.
what are the complications of cervical cerclage?
bleeding
membrane rupture
stimulation of uterine contractions
when is cervical cerclage indicated?
cervix shortening on USS
history of cervical weakness
symptomatic women with premature cervical dilation and exposed fetal membranes in vagina
how are recurrent miscarriages managed if thrombophilia/ antiphospholipid syndrome is identified as the cause?
low dose aspirin and LMWH
counselling and support for any psychological distress
How is infertility defined? (include primary and secondary)
inability to conceive after 12 months of regular unprotected intercourse.
this may be primary - never previously conceived
or secondary - previous children.
what are the causes of infertility ?
age - maternal age (as mum gets older, reduced number of oocytes)
ovulation defections:
- ovarian failure/ PCOS
- hyperprolactinaemia
- high / low BMI
genetic : turners, CF
male factors
chromosomal problems
uterine adhesions (ashermans ) / previous PID endometriosis
unexplained
what questions should you ask in history both men and women presenting with infertility?
age
previous successful pregnancies
regularity of intercourse and any problems
when did they stop contraception and what method
PMH / systemic disease
drug history
social history - stress, excessive exercise , weight loss, drugs/alcohol/smoking?
what questions should you ask in history just women presenting with infertility?
menstrual history - regularity, menorrhagia/oligomenorrhea etc,
any previous STIs - particularly PID / chlamydia
last cervical smear
previous tubal surgery
specific:
galactorrhoea - hyperprolactinaemia
any PCOS? (ask about acne and hirsituism)
any endometriosis - (ask about dysmenorrhoea)
what questions should you ask in history just men presenting with infertility?
ejaculation difficulties?
history of Mumps, torsion, trauma or STIs?
history of undescended testes?
previous surgery e.g. hernial repair
how can you examine a women presenting with infertility ?
BMI - high or low
look for features of turners or PCOS or galactorrhoea
feel for any mass - ovarian cysts
tenderness - PID, endometriosis
how would you examine a women presenting with infertility?
feel testis for softness and size (hypogonadism) or absence (undescended)
look for features of gynacomastia , absence of axillary hair etc - indicating hypogonadism
check penis for structural abnormalities
how would you investigate a woman presenting with infertility?
LH, FSH on day 2 of cycle
progesterone on day 21 of cycle
TFTs and prolactin
SHBG and testosterone levels
test for chlamydia and rubella
USS of uterus and ovaries
hysteroscopy
test tubal patency - hysterosalpingogram or laparoscopy and dye
how would you investigate a man presenting with infertility?
LH, FSH and progesterone levels.
USS of prostate and seminal vesicles
semen analysis x2
- constituent and sperm count
- if sperm count low can do chlamydia test
- sampled 2 days post but <7days since last ejaculation
how is infertility managed?
give general advice: gain/loose weight, healthy diet, stop smoking, alcohol, drugs. start taking folic acid, regular intercourse (every 2-3 days), reduce stres
depends on the cause:
e. g. tubal disease - may require surgery to unblock tubes
e. g. endometriosis - surgery
e. g. hyperprolactinaemia - dopamine agonists
otherwise can help with ovulation by giving certain medications
- clomifene citrate: inhibits oestrogen receptors at hypothalmus to reduce negative feedback and thus more LH to stimulate ovulation
- gonadotrophins if resistant to clomifene citrate
what are the methods of assisted conception?
Intrauterine insemination Intracytoplasmic sperm injections - if sperm count is very low IVF donor insemination donor oocyte
what are the complications of assisted conception?
ovarian hyperstimulation syndrome (OHSS) - bloating, oedema, tense ascites, N+V, oliguria, VTE and respiratory distress
ectopic pregnancy
multiple pregnancy
increased cancer risk
increased infection risk.
IVF increases risk of pre-eclampsia
Define an ectopic pregnancy?
An implantation of pregnancy outside of the uterine cavity. This may be in fallopian tubes, cervix, interstitium or peritoneal cavity
where is the most common site for an ectopic pregnancy? where are the less common sites?
most commonly in isthmus or ampulla of fallopian tube
less commonly in cervix or peritoneal cavity
what are the past medical risk factors for ectopic pregnancy?
PID - resulting in adhesions and destruction of cilia
previous ectopic pregnancy
endometriosis
motility disorders of cilia
what are the contraception risk factors for ectopic pregnancy?
Intrauterine device or intraunterine system
progesterone only pill - reduces ciliary motility
tubal ligation or occlusion
remember contraception reduces chance of getting pregnant - so still less of a risk than no contraception
what are the iatrogenic risk factors for ectopic pregnancy ?
tubal surgery
embryo transfer in IVF
what are the clinical features of an ectopic pregnancy?
pain - lower abdominal/ pelvic pain
bleeding
- usually intraperitoneal - results in shoulder tip pain because blood irritates diaphragm (innervated by C3,4,5) and referred to shoulder
- can result in vaginal bleeding due to decidua (endometrium) breaking down because of insufficient BhCG
- can lead to dizziness, collapse
brown vaginal discharge - break down of decidua
what are the clinical features of an ectopic pregnancy?
pain - lower abdominal/ pelvic pain
bleeding
- usually intraperitoneal - results in shoulder tip pain because blood irritates diaphragm (innervated by C3,4,5) and referred to shoulder
- can result in vaginal bleeding due to decidua (endometrium) breaking down because of insufficient BhCG
- can lead to dizziness, collapse
brown vaginal discharge - break down of decidua
history of amenorrhea = pregnancy
what do you expect to find on examination in someone with an ectopic pregnancy?
pelvic/ abdominal tenderness
cervical excitation or adnexal tenderness
if ruptured ectopic pregnancy:
- haemodynamic instability - pallor, low BP, prolonged cap refil, tachycardia
- signs of peritonism
- fullness in pouch of douglas on vaginal examination
how can an ectopic pregnancy be investigated?
- pregnancy test - if positive …
- transabdominal/ pelvic USS to look for intrauterine pregnancy … if this cant be found…
- offer a transvaginal USS
if no intrauterine pregnancy can be identified but pregnancy test is positive = pregnancy of unknown location
- measure BHCG
- if >1500iU then confirmed ectopic and offer diagnostic laparoscopy
- if <1500 iU and stable then repeat in 48 hours
- in normal pregnancy it should double
- in miscarriage it should half
- anything inbetween treat as ectopic
what are the differentials for pregnancy of unknown location (i.e. positive pregnancy test but cant be identified on USS)?
ectopic
miscarriage
early intrauterine pregnancy
how is an ectopic pregnancy managed? (in broad terms)
ABCDE
definitive treatment: choose between medical and surgical management
what is the medical management of an ectopic pregnancy?
IM methotrexate - inhibits folate dependant cell division and thus stops developing fetus and pregnancy will gradually resolve
re-check BHCG to ensure level is declining and if not repeat methotrexate dose.
give 24 hour access to gynae services and inform symptoms of rupture and when to seek help.
what is the surgical management of an ectopic pregnancy ?
surgical removal of ectopic pregnancy e.g. removal of ectopic and tube its implanted in. however in some women this may be the only viable tube and thus try to salvage the tube whilst removing ectopic
follow up BhCG - measure after 7 days and then weekly until <5iU
give anti D prophylaxis (250IU) to any rhesus negative mother.
when is medical management offered over surgical management?
medical management: no fetal HR, stable, no pain, adnexal mass <35mm , bHCG < 1500, not ruptured
surgical management: pain, fetal HR, bHCG >5000, adnexal mass >35mm
if bHCG is between 1500 and 500 and no pain, HR or adnexal mass is <35mm then offer surgical OR medical
what are the advantages and disadvantages of medical management of an ectopic pregnancy ?
no surgical complications, can occur at home
however methotrexate has side effects - abdo pain, myelosuppression, renal toxicity, hepatitis, teratogenesis (advised not to get pregnant for 3-6 months after use)
what are the advantages and disadvantages of surgical management of ectopic pregnancy?
advantages: high success rate
disadvantage - damage to bowel, bladder, anaesthetic risk, DVT, P.E, haemorrhage , infection
what is the conservative management of an ectopic pregnancy?
watchful waiting of stable patient while allowing ectopic to naturally resolved.
monitor bHCG every 48 hours to ensure it is falling >/= 50%
used when BhCG is rapidly falling
when is the conservative management of ectopic pregnancy preferred?
when rupture is unlikely , pain is well controlled, B-hCG basaline is low and small unruptured ectopic on USS
what are the advantages and disadvantages of the conservative management of ectopic pregnancy?
advantages - avoids risk of medical/ surgery, can be done at home
disadvantages - risk of failure or complications (rupture)
what is gestational trophoblastic diseases? how are they categorised?
group of pregnancy related tumours.
divided into 2 groups
- pre-malignant conditions (more common) - parital molar pregnancy and complete molar pregnancy
- malignant conditions - invasive molar pregnancy, placental trophoblastic site tumours, choriocarcinoma, and epithelioid trophoblastic tumour
what is the pathophysiology behind molar pregnancies?
occurs when abnormal contribution of chromosomes in pregnancy
e. g. partial molar - 2 sperm and 1 egg - results in 69 chromosomes. both placenta and fetus may be triploidy or may have mosaism where placenta is but fetus isn’t
e. g. complete molar pregnancy - oocyte has no chromosomes and is fertilised by one sperm which duplicates chromosomes or 2 sperms. thus chromosomes are both paternal but 46 all together.
usually benign but can become malignant (invasive molar pregnancy) and invade uterine myometrium and disseminate around the body
what is the pathophysiology behind choriocarcinoma?
a malignancy of the trophoblastic cells of the placenta
commonly co-exists with molar pregnancy
commonly metastasises to the lung
what is the pathophysiology of a placental site trophoblastic tumour?
malignancy of intermediate trophoblasts which are normally responsible for anchoring the placenta to the uterus
these can occur after a normal pregnancy (more common), molar pregnancy or miscarriage
what is the pathophysiology behind an epitheloid trophoblastic tumour?
malignancy of trophoblastic placental cells
difficult to distinguish from a choriocarcinoma
similar features to squamous cell carcinoma
what are the risk factors for gestational trophoblastic disease?
previous gestational trophoblastic disease
age <20 or >35 yrs
previous miscarriage
oral contraceptive pill
what are the clinical features of gestational trophoblastic disease?
pain and vaginal bleeding in early pregnancy
hyperemesis
hyperthyroidism
anaemia
how will the uterus appear on examination of someone with gestational trophoblastic disease ?
larger uterus, boggy and soft.
why may..
a) hyperemesis
b) hyperthyroidism
develop in gestational trophoblastic disease?
hyperemesis due to high BhCG
hyperthyroid because BhCG mimics TSH
what investigations could be done if gestational trophoblastic disease is suspected?
urine and blood BhCG (elevated at diagnosis and used to monitor)
USS
- complete molar pregnancy has a characteristic appearance but not all of them do
histological examination of products of conception
- performed post treatment to confirm diagnosis for follow up
if metastatic - need MRI or staging CT CAP or Pelvic USS
how are gestational trophoblastic diseases managed?
any women diagnosed is referred to GTD centre for follow up and monitoring in future pregnancies.
molar pregnancies:
- suction curettage - complete and non-viable partial moles
- however if partial mole is greater gestation then medical evacuation should be performed
- monitoring BhCG 3 weeks post treatment
- anti D prophylaxis if rhesus negative
some require chemotherapy
what is hyperemesis gravidarum?
excessive/ prolonged nausea and vomiting in early pregnancy
what is the normal pattern of nausea and vomiting in pregnancy?
normal pregnancy N+V starts around weeks 4-7 and peaks at weak 9 and then usually settles by week 20. affects 80% of pregnancy
what are the features of hyperemesis gravidarum?
dehydration
nutritional deficiency
excessive vomiting and nausea
what are the complications of hyperemesis gravidarum
dehydration / malnutrition / weight loss
- B12 defieicney - periepheral neuropathy and anaemia
- B1 deficiency - wernickes
ketosis / acidosis
deranged electrolytes - hypo NA, hypoK
- lethargy, seizures, arrhtyhmias
- hypoNa can lead to central pontine myelinosis
without treatment can lead to nervous system complications:
- wernickes encephalopathy - central pontine myelinosis
AKI liver failure oesophageal rupture / Mallory Weiss tear pneumothorax retinal haemorrhage splenic avulsion
what is the pathophysiology behind hyperemesis gravidarum?
BhCG can bind receptors in chemoreceptor trigger zone in brain
BHCG can also induce T4 release - thyrotoxicosis leads to hyperemesis
high progesterone and oestrogen - reduce gut motility and increase liver enzymes and oesophageal sphincter pressure.
psychological
who is N+V more common in pregnancy in?
younger and obese women
what are the first factors for hyperemesis gravidarum?
first pregnancy HG present in previous pregnancy multiple pregnancy raised BMI hydatidiform mole
what is a hydatidiform mole?
same name for molar pregnancy
how is hyperemesis gravidarum diagnosed?
objective scoring: scoring system can be used to classify severity = pregnancy unique quantification of emesis (PUQE) score.
history of hyperemesis in previous pregnancy
exclude other causes - infection, graves, Addison’s, tumours (hydatidiform mole)
what scoring system is used to grade hyperemesis gravidarum and how is it used?
pregnancy unique quantification emesis score (PUQE)
6 = mild
7-12 = moderate
13-15 - severe
what investigations can be carried out for suspected hyperemesis gravidarum ?
weight and urine dipstick (ketouria)
blood tests: UES, LFTs, blood glucose, FBC (infection, anaemia, haemocrit) , amylase (pancreatitis excluded) , TFT
USS - exclude GTD/ multiple pregnancy
midstream urine
how is hyperemesis gravidarum managed?
small frequent meals, low in fat
referred for fluid, vitamin replacement and nutritional support
rehydrate - not with glucose (could precipitate wernickes), replace K
give thiamine and folic acid
antiemetics:
- first line: cyclizine, prochlorperazine, promethazine
- second line: metoclopramide, domperidone, ondansetron
- third line: hydrocortisone IV
ranitidine for reflux
consider thromboprophylaxis
level of care depends on how severe
when does hyperemesis gravidarum usually resolve?
16 to 20 weeks
what are the differentials for hyperemesis gravidarum?
UTI gastroenteritis pancreatitis drug induced raised ICP metabolic disturbance pre-eclampsia
