Early Pregnancy Complications

Question 1

most common problem in early pregnancy?

Answer 1

bleeding

20% have minimal bleeding

Question 2

causes of bleeding?

Answer 2

implantation bleeding
chorionic haematoma
cervical
- infection
- mlignancy
- poly
vaginal
- infection
- malignancy (rare)
unrelated
- haematuria
- PR bleeding

Question 3

EPAC/EPAU?

Answer 3

early pregnancy assessment clinic/unit

open 24/7

Question 4

symptoms of miscarriage?

Answer 4

positive pregnancy test
varied gestation
bleeding (mainly)
cramping
may have passed products

Question 5

examination in miscarriage?

Answer 5

scan +/- FH 
speculum exam
- os closed (threatened)
- products at open os (inevitable)
- products in vagina (complete miscarriage)

Question 6

what is cervical shock?

Answer 6

cramps/nausea
sweating
nausea
vomiting
fainting
resolves if products removed from cervix

Question 7

ho is cervical shock managed?

Answer 7

should resolve when products removed

recuscitation with IVI uterotonics may be needed

Question 8

causes of miscarriage?

Answer 8

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

Question 9

pathophysiology of miscarriage?

Answer 9

unclear
bleeding from placental bed or chorion causing hypoxia and villous placental dysfunction is proposed to cause embryonic demise

Question 10

stages of miscarriage?

Answer 10

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

Question 11

what does a missed miscarriage look like?

Answer 11

irregular gestation sac with some bleeding behind it

Question 12

investigation in miscarriage?

Answer 12

assess haemodynamic disability
bloods 
- FBC
- G&S
- bHCG
US
histology

Question 13

management in miscarriage?

Answer 13

depends on outcomes of investigation (admit or discharge)
conservative/medical/surgical (vacuum)
anti D administration if surgical intervention needed
emotional support etc

Question 14

what is recurrent miscarriage?

Answer 14

3 or more losses

Question 15

what can cause recurrent miscarriage?

Answer 15

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

Question 16

what is given in evidence of APS or thrombophilia when pregnant?

Answer 16

use of LDA and daily fragmin injections after confirmation of viable pregnancy

Question 17

what may help recurrent miscarriage in future?

Answer 17

progesterone

Question 18

common site of ectopic pregnancy?

Answer 18

fallopian tube
interstitial
isthmic ampullary
fimbrial
can also be in ovary, peritoneum or other organs

Question 19

presentation of ectopic?

Answer 19

pain
bleeding
dizziness/collapse
shoulder tip pain (blood irritates sub diaphragmatic area when lying flat)
short on breath
guarding

Question 20

red flag signs of ectopic pregnancy?

Answer 20

repeated presentation with abdominal and/or pelvic pain or pain requiring opiates in a women known to be pregnant

Question 21

investigations in ectopic?

Answer 21

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

Question 22

management of ectopic?

Answer 22

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

Question 23

describe molar pregnancy?

Answer 23

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

Question 24

complete mole?

Answer 24

egg without DNA
1 or 2 sperm fertilise causing diploid paternal DNA
no fetus
overgrowth of placental tissue
snowstorm appearance

Question 25

incomplete?

Answer 25

haploid egg
1 sperm with duplicating DNA or 2 sperm
results in triploid foetus
overgrowth of placental tissue
foetus present but non-viable

Question 26

issues at presentation of molar pregnancy?

Answer 26

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

Question 27

management of molar pregnancy?

Answer 27

surgical to empty uterus and tissue for histology
- if any is left behind it can turn into choriocarcinoma
follow up with molar pregnancy services

Question 28

describe implantation bleeding?

Answer 28

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

Question 29

what is a chorionic haematoma?

Answer 29

pooling of blood between endometrium and embryo due to separation - sub-chorionic

Question 30

features of chorionic haematoma?

Answer 30

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

Question 31

cervical causes of bleeding in early pregnancy?

Answer 31

ectopy/ectropion
infection (chlamydia, gonorrhoea, bacteria)
poly
malignancy (growth or generalised angry erosion presentation)

Question 32

vaginal causes of bleeding?

Answer 32

infection (trichomoniasis, bacterial vaginosis, chlamydia)
malignancy
ulcers
forgotten tampon

Question 33

management of bacterial vaginosis?

Answer 33

metronidazole 400mg for 7 days
avoid alcohol
option of vaginal gel

Question 34

chlamydia management?

Answer 34

erythromycin, amoxicillin
TOC 3 weeks later
liase with sexual health, include partner tracing

Question 35

unrelated bleeding?

Answer 35

bladder infection with haematuria
bowel
- haemorrhoids
- malignancy

Question 36

pain in miscarriage?

Answer 36

varied intensity, frequency depending onstage

bleeding more than pain

Question 37

pain in ectopic?

Answer 37

pain main symptom
dull ache to sharp stabbing
peritonism in cases cause rigidity and rebound tenderness

Question 38

unrelated causes of reproductive pain?

Answer 38

UTI
appendicitis
vaginal infection

Question 39

rhesus negative women may have what problems in pregnancy?

Answer 39

miscarriage
ectopic pregnancy
molar pregnancy

Question 40

dosage for anti D?

Answer 40

500 IU

Question 41

hyperemesis gravidarum?

Answer 41

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

Question 42

complications of hyperemesis gravidarum?

Answer 42

dehydration
ketosis
electrolyte and nutritional imbalance
weight loss
altered liver function (starvation)
malnutrition
emotional instability/anxiety/depression

Question 43

principles of amnagement of hyperemesis gravidarum?

Answer 43

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)

Question 44

first line antiemetics?

Answer 44

cyclizine (50mg Po/IM/IV 8 hourly)

Prochlorperazine (12.5mg IM/IV 8 hourly or 5-10mg po 8 hourly)

Question 45

2nd line antiemetics?

Answer 45

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

Question 46

other medications in antiemetics?

Answer 46

thiamine supplement 50mg tds / pabrinex IV
H2 receptor blocker and PPI
oral steroid - prednisolone 40mg/day in divided doses