Early Pregnancy Complications Flashcards
most common problem in early pregnancy?
bleeding
20% have minimal bleeding
causes of bleeding?
implantation bleeding chorionic haematoma cervical - infection - mlignancy - poly vaginal - infection - malignancy (rare) unrelated - haematuria - PR bleeding
EPAC/EPAU?
early pregnancy assessment clinic/unit
open 24/7
symptoms of miscarriage?
positive pregnancy test varied gestation bleeding (mainly) cramping may have passed products
examination in miscarriage?
scan +/- FH speculum exam - os closed (threatened) - products at open os (inevitable) - products in vagina (complete miscarriage)
what is cervical shock?
cramps/nausea sweating nausea vomiting fainting resolves if products removed from cervix
ho is cervical shock managed?
should resolve when products removed
recuscitation with IVI uterotonics may be needed
causes of miscarriage?
chromosomal abnormality
immune (APS/LAC)
infection (CMV, rubella, toxoplasmosis, listeriosis)
severe stress
iatrogenic after CVS (can cause infection or uterine irritability)
associations (heavy smoking, cocaine, alcohol misuse)
uncontrolled diabetes
pathophysiology of miscarriage?
unclear
bleeding from placental bed or chorion causing hypoxia and villous placental dysfunction is proposed to cause embryonic demise
stages of miscarriage?
threatened (risk to pregnancy)
inevitable miscarriage (cant be saved)
incomplete (cervix dilated and bleeding has began but pregnancy tissue still in uterus)
complete (pregnancy tissue has exited the uterus)
early fetal demise (pregnncy in situ, no heartbeat, MSD>25mm, FP >7mm)
anembryonic pregnancy (no foetus, empty sac
what does a missed miscarriage look like?
irregular gestation sac with some bleeding behind it
investigation in miscarriage?
assess haemodynamic disability bloods - FBC - G&S - bHCG US histology
management in miscarriage?
depends on outcomes of investigation (admit or discharge)
conservative/medical/surgical (vacuum)
anti D administration if surgical intervention needed
emotional support etc
what is recurrent miscarriage?
3 or more losses
what can cause recurrent miscarriage?
antiphospholipid syndrome - (test for LAC, ACA and B2glycoprotein1) thrombophilia - test for (factor V leiden and prothrombin gene mutations, protein C, free protein S and antithrombin) balanced translocation uterine abnormality uterine NK cells are hypothesised independant risk factors
what is given in evidence of APS or thrombophilia when pregnant?
use of LDA and daily fragmin injections after confirmation of viable pregnancy
what may help recurrent miscarriage in future?
progesterone
common site of ectopic pregnancy?
fallopian tube interstitial isthmic ampullary fimbrial can also be in ovary, peritoneum or other organs
presentation of ectopic?
pain bleeding dizziness/collapse shoulder tip pain (blood irritates sub diaphragmatic area when lying flat) short on breath guarding
red flag signs of ectopic pregnancy?
repeated presentation with abdominal and/or pelvic pain or pain requiring opiates in a women known to be pregnant
investigations in ectopic?
FBC
G&S
HCG (2 assessments 48 hrs apart and compare - should double if normal)
US - empty uterus/pseudo sac +/- mass in adnexae, free fluid in POD
management of ectopic?
surgical (if acutely unwell)
medical management = gefitinib + methotrexate (if stable, low HCG and small unruptured ectopic pregnancy)
conservative for well patient
New trial = GEM III trial to enhance medical management of stable and well patient, avoids surgery and can save the tube
- gefitinib + methotrexate
describe molar pregnancy?
gestational trophoblastic disease where non viable egg is fertilized
overgrowth of placental tissue with chorionic villi swollen with fluid giving picture of grape like clusters
can be complete or incomplete
complete mole?
egg without DNA 1 or 2 sperm fertilise causing diploid paternal DNA no fetus overgrowth of placental tissue snowstorm appearance
incomplete?
haploid egg 1 sperm with duplicating DNA or 2 sperm results in triploid foetus overgrowth of placental tissue foetus present but non-viable
issues at presentation of molar pregnancy?
hyperemesis
varied bleeding and passage of grape like tissue
fundus grows faster than it should for age of foetus
occassional shortness of breath
- very dangerous sign as molar tissue can embolise/haemorrhage?
USS can diagnose snowstorm appearence +/- foetus
management of molar pregnancy?
surgical to empty uterus and tissue for histology
- if any is left behind it can turn into choriocarcinoma
follow up with molar pregnancy services
describe implantation bleeding?
normal happens when fertilised egg implants into uterine wall usually around 10 days after ovulation light brownish and limited bleeding signs of pregnancy emerge soon after usually settles
what is a chorionic haematoma?
pooling of blood between endometrium and embryo due to separation - sub-chorionic
features of chorionic haematoma?
bleeding
cramping
threatened miscarriage
symptoms and course follow size and perpetuation
usually self limited and resolve and pregnancy continues normal
large can be source of infection, irritability and miscarriage
cervical causes of bleeding in early pregnancy?
ectopy/ectropion
infection (chlamydia, gonorrhoea, bacteria)
poly
malignancy (growth or generalised angry erosion presentation)
vaginal causes of bleeding?
infection (trichomoniasis, bacterial vaginosis, chlamydia)
malignancy
ulcers
forgotten tampon
management of bacterial vaginosis?
metronidazole 400mg for 7 days
avoid alcohol
option of vaginal gel
chlamydia management?
erythromycin, amoxicillin
TOC 3 weeks later
liase with sexual health, include partner tracing
unrelated bleeding?
bladder infection with haematuria
bowel
- haemorrhoids
- malignancy
pain in miscarriage?
varied intensity, frequency depending onstage
bleeding more than pain
pain in ectopic?
pain main symptom
dull ache to sharp stabbing
peritonism in cases cause rigidity and rebound tenderness
unrelated causes of reproductive pain?
UTI
appendicitis
vaginal infection
rhesus negative women may have what problems in pregnancy?
miscarriage
ectopic pregnancy
molar pregnancy
dosage for anti D?
500 IU
hyperemesis gravidarum?
vomiting in first trimester (usually resolves by 2nd/3rd)
common, limited and mild
start as early as around time of missed period
if excessive, protracted and altering QoL, called hyeperemesis gravidarum
complications of hyperemesis gravidarum?
dehydration ketosis electrolyte and nutritional imbalance weight loss altered liver function (starvation) malnutrition emotional instability/anxiety/depression
principles of amnagement of hyperemesis gravidarum?
rehydration IVI, electrolyte replacement parenteral antiemetic nutritional supplement vitamin supplement (thiamine, pabrinex) NG feeding, TPN steroid use in recurrent, severe cases thromboprophylaxis (high risk of clots due to dehydration and immobility)
first line antiemetics?
cyclizine (50mg Po/IM/IV 8 hourly)
Prochlorperazine (12.5mg IM/IV 8 hourly or 5-10mg po 8 hourly)
2nd line antiemetics?
ondansetron (serotonin inhibitor) - 4-8mg IM 8 hourly for max 5 days metoclopromide - 5-10 mg IM 8 hourly - can cause ucologyric crisis which can be managed with atropine
other medications in antiemetics?
thiamine supplement 50mg tds / pabrinex IV
H2 receptor blocker and PPI
oral steroid - prednisolone 40mg/day in divided doses
