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6. OBSTETRICS > Early Pregnancy Complications > Flashcards

Early Pregnancy Complications Flashcards

1
Q

What is morning sickness?

A

Nausea + vomiting: usually settles 12-16 weeks, some experience none at all. Appears to mirror rise & fall of hCG in maternal serum.

Often retching rather than true vomiting, rarely affects mother’s health.

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2
Q

What are risk factors for hyperemesis gravidarum?

A

Multiple pregnancies + molar pregnancies associated with high hCG & therefore may be more severe symptoms.

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3
Q

What are the complications of hyperemesis gravidarum?

A

Weight loss, dehydration + electrolyte disturbances (e.g. hypochloraemic hypokalaemic alkalosis?).

Very rarely: vitamin B deficiency / polyneuropathy.

Extremely rare: liver failure, renal failure, fetal/maternal death.

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4
Q

How should hyperemesis gravidarum be managed?

A

Admission: urine for ketones + serum renal function (U+Es), LFTs. USS appropriate if not already had pregnancy scan.

IV fluids often sufficient to reduce nausea, antiemetics if not settling (none licensed for pregnancy, but risk of teratogenesis very low with metoclopramide, cyclizine, prochlorperazine).

Very rarely: vitamin B supplementation and/or parenteral feeding

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5
Q

What is gestational trophoblastic disease?

A

Spectrum of disorders originating from placental trophoblast:

Molar pregnancy: complete hydatiform mole or partial hydatiform mole

Malignant conditions of invasive mole: choriocarcinoma or (very rarely) placental site trophoblastic tumour (PSTT)

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6
Q

What is gestational trophoblastic neoplasia?

A

Evidence of persisting GTD - most commonly defined as persistent ↑bhCG.

May develop after a molar pregnancy, a non-molar pregnancy or a livebirth.

Treated with chemotherapy (if partial: lower risk of needing chemo: just 0.5%).

Any woman who develops persistent vaginal bleeding after a pregnancy event (miscarriage, postpartum or following termination) is at risk of GTN and should have urine pregnancy test.

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7
Q

What is a molar pregancy? What are the risk factors?

A

Proliferation of villous trophoblast.

Previous molar pregnancy, age ≤15 or >35, Asian ethnicity.

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8
Q

How is molar pregnancy diagnosed?

A

Urine pregnancy test.

USS helpful in making pre-evacuation diagnosis (more accurate when >14 weeks), however, histological examination of products of conception is definitive.

Majority of confirmed complete moles are associated with USS diagnosis of anembryonic pregnancy or delayed miscarriage. Partial mole diagnosis is more complex: requires multiple soft markers on USS. hCG estimation may also be useful: >2x median.

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9
Q

What are clinical features of a molar pregnancy?

A 
o Irregular vaginal bleeding (1st or early 2nd trimester)
o Hyperemesis
o Early failed pregnancy
o Uterine enlargement
o Very high serum hCG

Rarer: hyperthyroidism e.g. tremor, (hCG can mimic PTH), early-onest pre-eclampsia, abdominal distension due to theca lutein cysts

Very rarely: acute respiratory failure, neurological symptoms e.g. seizures – likely due to metastatic disease

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10
Q

What are the typical features of a COMPLETE mole? (pathophysiology and clinical features)

A

Empty’ ovum by single sperm + duplicates DNA (75-80%) or dispermic fertilisation of ‘empty’ ovum (20-25%)

46 XX or 46 XY (diploid, paternal only)

Fetal tissue/amnion/RBCs absent (2% → choriocarcinoma) and ‘snowstorm’ USS

Diffuse villous oedema (‘grape cluster’ appearance) and diffuse trophoblastic proliferation (slight to severe)

50% large uterus for dates
25-30% theca lutein cysts

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11
Q

What are the typical features of a PARTIAL mole? (pathophysiology and clinical features)

A

Egg by 2 sperm
(10% = tetraploid or mosaic conceptions)

90% triploid: 69 XXX, 69XXY, 69XYY

Fetal tissue often present (fetal parts may be seen), amnion and RBCs usually present

Variable, focal villous oedema and focal trophoblastic proliferation (slight to moderate)

Uterus small for dates
Theca lutein cysts are rare

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12
Q

How is molar pregnancy managed?

A

Evacuation: Suction curettage is method of choice for complete moles (medical evacuation avoided due to theoretical risk of embolising trophoblastic tissue through venous system).

Partial moles: suction curettage EXCEPT when size of fetal parts deters use - medical preferred (also true in twin pregnancies with normal pregnancy + molar pregnancy).

Urine pregnancy test 3 weeks after medical management if PoC are not sent for histological examination. Anti-D required following evacuation of a PARTIAL mole.

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13
Q

How should women be followed up after molar pregnancy?

A

All women with GTD: referred to a GTD-screening centre (including women with atypical placental-site nodules as these may transform into PSTT).

Has high cure (98-100%) and low (5-8%) chemotherapy rates: 6 month follow up if hCG normal 56 days after pregnancy, otherwise follow-up for 6 months from the normalisation

Notify screening centre at the end of any future pregnancy, whatever the outcome: hCG levels are measured 6-8 weeks after the end of the pregnancy to exclude disease (GTN can occur after any GTD event, even when separated by a normal pregnancy, however, probability of developing GTN is very low after hCG levels have normalised).

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14
Q

When are PoC sent for histological assessment?

A

From medical or surgical management of all failed pregnancies (to exclude GTN).

As persistent trophoblastic neoplasia may develop after any pregnancy, all PoC should undergo histological evaluation (including repeat evacuations). However, not necessary after termination of pregnancy provided fetal parts have been identified on prior USS.

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15
Q

What is choriocarcinoma?

A

Malignant trophoblastic tissue made of cytotrophoblasts and syncytiotrophoblasts without villi.

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16
Q

How is GTN managed?

A

15% need chemotherapy after complete mole and 0.5% after partial mole.

FIGO scoring system: scores ≤6 (~100% cure rate) are low risk and are treated with IM methotrexate with folinic acid

Women with scores ≥7 (~95% cure rate) are high risk: IV multi-agent chemotherapy, including combinations of methotrexate, dactinomycin, etoposide, cyclophosphamide + vincristine. Treatment continued until hCG normal, then a further 6 consecutive weeks.

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17
Q

What is an ectopic pregnancy?

A

Implantation of pregnancy outside the endometrial cavity e.g. fallopian tube (98%), cervix, ovary

UK incidence ~1%.

Risk of massive intraperitoneal bleeding, Lining of salpinx very thin, as placenta develops - bleeding into abdominal cavity

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18
Q

What are risk factors for ectopic pregnancy?

A

Anything causing damage to cilia or tube occlusion

  1. Previous sterilisation / tubal surgery / abdominal surgery
  2. Previous tubal infections (STIs) or pelvic adhesions (PID)
  3. IUD in situ
  4. Subfertility / IVF treatment
  5. Smoking
  6. Previous ectopic pregnancy (10% risk of recurrence)

1/3 of all women with ectopic will have no risk factors!

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19
Q

What are symptoms of an ectopic pregnancy?

A

Abdominal / pelvic pain & bleeding (varies in presentation)

Signs of possible rupture:

  1. dizziness / shoulder tip pain (referred from diaphragm – blood is an irritant)
  2. pain on urination/defecation, 3. diarrhoea/vomiting
  3. tenderness +/- rebound,
  4. cervical excitation
  5. signs of shock: pallor, ↑HR (first sign to change in shock), ↓BP.
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20
Q

How would you assess a woman with suspected ectopic and positive pregnancy test (UPT or bHCG)?

A
  1. ABC assessment (always correct haemodynamic instability first)
  2. History: chlamydia/LMP/sexual history/obstetric history/PID, how much bleeding, how much pain
  3. Examine: (gentle to avoid tubal rupture):
    • shock/rebound
    • speculum: os? POC?
    • bimanual: uterus enlarged / cx excitation. do NOT examine for adnexal mass (rupture risk)

If not shocked, transvaginal USS may help distinguish between ectopic, miscarriage & continuing IUP.

Decide: location (uterus, tube or unknown), can we wait or need to go straight to theatre?

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21
Q

Management of unstable woman with suspected ectopic?

A

Grey cannula (16G): antecubital fossa (quickest and easiest)

Bloods: FBC, cross-match 2 units (4 if really worried), HCG

Arrange theatre: SMM/laparoscopy

Examination plus spec / bimanual

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22
Q

Management of stable woman with suspected ectopic? (what are the different options)

A
  1. Expectant management: 50% end spontaneously
  2. Medical (methotrexate): anti-metabolite, prevents growth of rapidly dividing cells by interfering with DNA synthesis: stringent criteria, robust follow up
  3. Surgical (laparoscopic or laparotomy, salpingectomy or salpingostomy)
23
Q

When would you manage suspected ectopic expectantly?

A

If positive pregnancy test, but no pelvic tenderness / cervical motion tenderness / abdominal tenderness.

Clinically stable asymptomatic women with USS diagnosis of ectopic pregnancy + decreasing serum hCG (initially <1500IU/L).

If any of these signs: immediate referral to EPAU & offer USS to aid management.

Also offered for pregnancy of unknown location (PUL).

24
Q

How does bHCG aid diagnosis of ectopic pregnancy?

A

Take immediately & again in 48 hours managed via EPAU.

Likely IUP pregnancy if increases >63% every 48h

Ectopic pregnancy ‘suboptimal rise’

Failing pregnancy: suboptimal rise - plateau then falls

25
Q

When is pregnancy of unknown location diagnosed?

A

Serum hCG <1000IU/L and no pregnancy visible on transvaginal USS (intra or extrauterine).

Using initial upper level of 1000-1500 IU/L to diagnose PUL, women with minimal / no symptoms but risk of ectopic should be managed expectantly with 48h follow up (consider active intervention if rises above 1500IU/L or starts to plateau). Serial measurements until <5 or 15IU/L required.

26
Q

When is diagnostic laparoscopy indicated for ectopic pregnancy?

A

If positive test & clinical signs ectopic (e.g. pelvic tenderness, cervical excitation, shoulder tip pain) with empty uterus on USS

27
Q

When is medical management of ectopic pregnancy indicated?

A

If well with positive urine test and empty uterus on USS- measure serum hCG & repeat 48 hours.

If ectopic likely, but hCG ≤ 3000IU/L & remains asymptomatic: consider medical management (methotrexate single or multiple dose regimen) – must give verbal + written info about possible need for further treatment, need to avoid pregnancy for 3 months after last dose & adverse effects following treatment. Must be able to return easily for assessment at any time during follow-up.

28
Q

What is the preferred treatment for a tubal ectopic

A

If haemodynamically stable tubal ectopic: laparoscopic approach to surgical management preferable. No evidence that salpingotomy is preferable to salpingectomy if healthy contralateral tube, but postoperative tracking of serum hCG needed following salpingectomy to identify small number of cases complicated by persistent trophoblast.

Salpingectomy is offered to women who have had a tubal ectopic unless they have other risk factors for infertility e.g. contralateral tube damage (otherwise, salpingotomy is offered as an alternative)

Inform women having salpingotomy that up to 1 in 5 may need further treatment including methotrexate and/or salpingectomy.

Non-sensitised rhesus negative women with confirmed or suspected ectopic pregnancy should receive anti-D immunoglobulin.

29
Q

What is the preferred approach for a tubal ectopic?

A

If haemodynamically stable tubal ectopic: laparoscopic approach preferable.

Salpingectomy is offered to women who have had a tubal ectopic unless they have other risk factors for infertility e.g. contralateral tube damage (otherwise, salpingotomy is offered as an alternative)

No evidence that salpingotomy preferable to salpingectomy if healthy contralateral tube, but postoperative tracking of serum hCG needed following salpingectomy to identify small number of cases complicated by persistent trophoblast.

Inform women having salpingotomy that up to 1 in 5 may need further treatment (methotrexate and/or salpingectomy).

30
Q

When is surgery considered for ectopic pregnancy?

A
  • adnexal mass >4cm
  • ectopic with positive fetal heart
  • significant free fluid in the Pouch of Douglas
  • serum hCG >3000IU/L (depending on local guideline)
  • symptoms consistent with pain or bleeding from an ectopic pregnanc
31
Q

What is a miscarriage?

A

Loss of intrauterine pregnancy <24 weeks (UK) or expulsion of a foetus or embryo weighing <500g, less than 22/40

Early: when pregnancy loss occurs <12 weeks (1st trim)

Late: when pregnancy loss occurs 12-24 weeks (2nd trim)

32
Q

What is a miscarriage?

A

Loss of intrauterine pregnancy <24 weeks (UK) or expulsion of a foetus or embryo weighing <500g, less than 22/40

Early: when pregnancy loss occurs <12 weeks (1st trim)

Late: when pregnancy loss occurs 12-24 weeks (2nd trim)

33
Q

What is the incidence of miscarriage?

A

Occurs in up to 25% of pregnancies.

Early loss 10-20%.
Once FH seen, risk only 5%.

34
Q

What are the main causes of miscarriage?

A

At least 50% unexplained (both sporadic & recurrent)

  1. Spontaneous chromosomal abnormalities >60%.
    (~50% loss in 1st trimester (of which: 50% autosomal trisomy, ~20% loss in 2nd trimester)
  2. Endocrine factors:
    - poorly controlled diabetes at conception ~45% miscarriage risk (good control: no increased risk)
    - PCOS (high LH in follicular phase)
    - inadequate luteal function
  3. Disorders of placentation (ischaemia, infarction)
  4. Infection (difficult to prove): any serious infection. malaria, trypanosomiasis, mycoplasma, listeria monocytogenes & syphilis: implicated in early pregnancy loss, but unlikely to cause recurrent loss.
  5. Multiple pregnancies: 15% twins reduce to one, 25% triplets reduce to two & 7% reduce to one
  6. Environmental pollutants cigarette smoking (active & passive), high alcohol consumption - slightly higher risk of sporadic & recurrent miscarriage
35
Q

How should you clinically assess a patient with suspected miscarriage?

A

General: pulse, BP, temp

Abdo: masses / uterus, tenderness, guarding + rigidity

Speculum: amount of bleeding, PoC, vulvovaginal or cervical lesions, cervical os (open or closed)

Bimanual: uterine size, cervical excitation, forniceal tenderness + any adnexal mass

Ultrasound scan (EPAU): determines management, irrespective of cervical findings

36
Q

What is a threatened miscarriage?

A

Slight bleeding, sometimes cramping, closed os, IUP on USS

~25% of pregnant women experience 1st trimester bleeding (most cases caused by implantation into endometrium). 15-50% of these lead to foetal demise (compared to just 2-7% in pregnancies which do not threaten to miscarry)

Resolution of bleeding & cramping = favourable prognosis, however, women are at increased risk for subsequent miscarriage.

37
Q

What is an inevitable miscarriage?

A

Heavy bleeding with cramping pain. OPEN internal os & bleeding. Most often, PoC not expelled & intracervical contents present at time of exam (IUP on USS). A sac may be seen low within uterus & progressive migration of sac may be seen on serial scans.

*Shock may be possible.

38
Q

What is a complete miscarriage?

A

Cessation of bleeding with no evidence of retained PoC or a gestation sac in a woman who previously had an USS-confirmed IUP.

(minimal / no bleeding, no pain, closed os, empty uterus).

39
Q

What is an incomplete miscarriage?

Complications?

A

Retained PoC still in the uterus – complications include: endometritis, myometritis, peritonitis, septic shock & diffuse intravascular coagulopathy (DIC).

Bleeding, sometimes pain, os open or closed, PoC on USS, shock possible.

40
Q

What is a delayed / missed miscarriage?

A

Sometimes termed missed abortion - non-viable foetus within the uterus, without symptoms of miscarriage. (or anembryonic pregnancy? i.e. empty sac?)

Minimal / no bleeding, no pain, closed os, IUP but without internal contents or FH, no shock.

41
Q

When is miscarriage conservatively managed?

A

Appropriate if small diameter of retained PoC (e.g. <40mm): repeat scan in 10-14 days (if retained tissue, medical/surgical management required).

42
Q

How is miscarriage managed medically / surgically?

A

Medical: PV misoprostol as outpatient (inpatient if preferred).

Surgical (SMM) aka EPRC (evacuation of retained products of conception):

Group and Save: give Anti-D if Rhesus negative (no practical way of determining fetal blood group in miscarriage).

Confirmed miscarriage: anti-D to all non-sensitised rhesus-negative women who miscarry after 12 weeks, whether complete or incomplete, and those who miscarry <12 weeks when uterus is surgically evacuated

Threatened miscarriage: not given after 12 weeks & not routine if before 12 weeks when fetus is viable, unless bleeding is heavy or associated with abdominal pain (if clinical doubt, give anti-D)

43
Q

How is miscarriage managed (broadly speaking)?

A

Management

  1. Early pregnancy assessment unit
  2. Assess bleeding and haemodynamic stability (stabilise before sending to unit!)
  3. Look for signs of infection
  4. Co-morbidities

Emotional support: at all times should be supported in making informed choices about care + management.

Grief reaction following 1st trimester loss can be as profound as after a stillbirth.

44
Q

What are the features of sepsis following a miscarriage?

How is it managed?

A

Rare: most common after termination where illegal & sometimes after spontaneous miscarriage (especially if retained tissue).

Pyrexia, tachycardia, malaise, abdo pain, marked tenderness & purulent vaginal discharge.

Risk of endotoxic shock which has high mortality (Gram negative bacteria e.g. streptococci [haemolytic & anaerobic] & other anaerobes (e.g. Bacteroides)

Fluid resuscitation, Abx and ensuring uterus is emptied

45
Q

What is recurrent miscarriage?

A

Consecutive loss of ≥3 pregnancies <24 weeks gestation.

Incidence: 1% (greater than expected by chance alone).

46
Q

What are some causes of recurrent miscarriage?

A

Autoimmune

~15% investigated found positive for lupus anticoagulant, anti-phospholipid antibodies or both

Alloimmune disease:

? problem at interface between trophoblastic and maternal cells ? Endometrial NK cells - recent hypothesis suggests role in rejecting abnormal embryos & allowing normal ones to thrive. Inadequate NK function = increased fertility (not uncommon in recurrent miscarriage) but increased loss of embryos due to abnormalities - ? benefit of steroids in future research?

Cervical weakness (internal os unable to retain preg.)

Consider in mid-trimester loss: supported by history of relatively painless cervical dilatation and prior surgery to the cervix. Reliable diagnosis not possible (no single test). 
Cervical suturing (cervical cerclage) may be of benefit, but risks infection developing. Transabdominal cerclage also used if vaginal approach technically impossible (short cervix length) or failure of vaginally placed suture.
47
Q

How is autoimmune disease in recurrent miscarriage managed?

A

If untreated - ~70-80% rate of fetal loss).

Low dose aspirin & LMWH.

Note: the antibodies are also associated with arterial & venous thrombosis, fetal growth restriction, pre-eclampsia & thrombocytopenia (should be noted for later pregnancy management).

48
Q

What investigations are done for recurrent miscarriage?

A
  1. Karyotype from both parents (chromosomal abnormality incidence ~3-5%, genetic referral if abnormality found)
  2. Maternal serum: lupus anticoagulant, anticardiolipin antibodies (for antiphospholipid syndrome
  3. Thrombophilia screen: retrospective studies indicated increased incidence of thrombophilic defects (activated protein C resistance, antithrombin III deficiency, protein C deficiency, protein S deficiency, possibly hyperhomocystinaemia). Lack of effective treatment for this group - ? value of testing
  4. Pelvic USS (uterus & ovaries): for uterine abnormalities but difficult to estimate significance of anatomical abnormalities (surgery more harm than good?) Hysterosalpingogram may also be considered but mainly for 2nd trimester losses and again significance of anomalies is questionable.
49
Q

When can termination of pregnancy (TOP) legally be carried out?

A

Abortion Act 1967(1991)

  1. Continuance of pregnancy would involve risk of life of pregnant woman
  2. Termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman
  3. Pregnancy has not exceeded its 24th week and continuing the pregnancy would involve risk of injury to the physical or mental health of the pregnant woman
  4. The pregnancy has not exceeded its 24th week and continuing it would involve risk of injury to the physical or mental health of the existing child(ren) of the family of the pregnant woman
  5. There is substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped.

95% of TOPs are carried out under clause C (3). Two doctors must agree.

50
Q

What should be done prior to a termination of pregnancy?

A

Counselling: identifies women who will have coping problems and distress and can help identify what went wrong and led to the pregnancy. Timely referral to social worker should be available.

Bloods: Hb, ABO and Rh (if Rh-ve need anti-D afterwards)
HIV / haemoglobinopathies

Confirm gestation (clinical exam or USS)

Prophylactic metronidazole & azithromycin (some clinics give to all women– 10% infection)

Cervical cytology if smear due

Information (types, risk, complications, who to contact if problems).

51
Q

How is TOP carried out medically?

A

If <12 weeks, give mifepristone (blocks progesterone), allow home, return 48 hours, admitted for prostaglandin pv. Bleeding starts within a few hours and usually continues for 10 days.

Mid-trimester medical (13-24 weeks) requires mifepristone + multiple misopristol doses +/- feticide intervention if >22 weeks.

52
Q

How is TOP carried out surgically?

A

Early (<7 weeks): narrow suction curette (4-5mm) under local paracervical block (50ml syringe used to aspirate the pregnancy).

7-14 weeks: suction or vacuum aspiration, flexible suction curette and a mechanical / electrical pump. Curette inserted after cervical dilatation and contents aspirated, usually under GA. Misoprostol 400ug vaginally is often given 3 hours before surgery. Complications increase with gestation: some do not offer surgical > 12 weeks.

Late (15-24): Cervical preparation followed by dilatation and evacuation (D&E), offered by limited amount of doctors in the UK – may be necessary to dilate cervix up to 20mm. Advantage: women are unaware of procedure, however, many medical personnel find the process disturbing.

53
Q

What are the complications of TOP?

A

Retained products of conception (5%): more common after medical termination

Failure: 2.3 / 1000 in surgical termination and 1-14/1000 in medical (critical to advise importance of follow up)

Infection: pelvic infection up to 10%, halved with pre-termination STI screening + prophylactic Abx

Haemorrhage: 1/1000 significant bleeding at time of TOP

Trauma to genital tract: perforated uterus 1/1000, cervical trauma 1/100, small risk of uterine rupture

Future fertility: may be slight increase in subsequent miscarriage and preterm delivery with later termination

No evidence of lasting psychological harm

6. OBSTETRICS (7 decks)

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