Early Pregnancy Complications Flashcards
what is the marker in a urine pregnancy test
beta hCG
is minimal bleeding common in pregnancy
yes 20%
what can cause bleeding in early pregnancy
minimal bleeding (normal) implantation bleeding cervical causes: infection, malignancy, polyp vaginal causes: infection malignancy unrelated: haematuria, PR bleeding
what is the os
opening of the cervix- has internal and external aspect
what are the possible symptoms of miscarriage
bleeding id the primary symptom
period type cramps, intermittent, varied severity
may have passed products
what does a abdo USS show in miscarriage
either:
pregnancy in situ (+/- fetal HB)
pregnancy in process of expulsion
empty uterus
what do you look for in a speculum exam in miscarriage
is the OS closed (threatened miscarriage)
products are sites at open OS (inevitable)
products in vagina and OS closing (complete)
what are the symptoms of cervical shock
cramps
nausea or vomiting
sweating
fainting
what causes cervical shock
incomplete miscarriage where products are in the cervix/ OS
what is the management for cervical shock
remove products from cervix
resus with IVI
uterotonics maybe required
what are the different causes of miscarriage
embryo abnormality e.g. chromosomal
immunogenic: APS (lupus anticoagulant antibodies bind to form prothrombin)
infections: CMV, rubella, toxoplasmosis, listeriosis
severe emotional upset/ stress
iatrogenic (CVS)
lifestyle: heavy smoking, cocaine or alcohol misuse
uncontrolled diabetes
what is the pathophysiology of a miscarriage
bleeding from placental bed or chorion causes hypoxia and villous/ placental dysfunction resulting in embryonic demise
what is a threatened miscarriage
when there is a risk to pregnancy
what in an inevitable miscarriage
when pregnancy cant be saved
what is an incomplete miscarriage
part of the pregnancy has been lost already
what is a complete miscarriage
all of pregnancy lost, uterus empty
what classifies as early fetal demise
pregnancy in situ, no heart beat, mean sac diameter >25 mm, fetal pole >7cm
what is an anembryonic pregnancy
where there is no fetus, empty sac
what is a missed miscarriage
aka silent
embryo died but it has not been passed and no symptoms
what can all types of miscarriage become
septic
what is the management of a miscarriage
dependent on findings
asses and ensure haemodynamic stability
Ix- FBC, group and save, betahCG, USS< histology (if recurrent miscarriage)
realistic but sensitive discussion, diagrams
wither discharge/ inpatient
treatment: conservative, medical, MVA/ surgical
anti- D if surgical intervention needed
emotional support (for both if couple)
information and support groups (miscarriage association)
what classifies as recurrent miscarriages
3 or more pregnancy losses
what are the antibodies in APS
lupus anticoagulant
ACA
beta2glycoporetein1
what can cause recurrent miscarriage
APS
thrombophilias
balanced translocation
uterine abnormalities (late first trimester losses)
hypothesis of uterine NK cells
independent RF- age, previous miscarriages
what proteins are associated with thrombophilias
factor V leiden prothrombin gene mutations protein C free protein S antithrombin
what can be given after confirmation of IUP in APS or thrombophilia to prevent miscarriage
low dose aspirin and daily fragmin
what may be able to prevent miscarriage in women with bleeding in early pregnancy and previous multiple miscarriage
progesterone
what is the most common site of an ectopic pregnancy
fallopian tube
where can an ectopic pregnancy occur
fallopian tube (interstitial, isthmic, ampullar, fimbrial) ovary peritoneum liver cervix C section scar
where can diaphragmatic pain radiate
shoulder
what is the presentation of an ectopic pregnancy
pain > bleeding dizziness collapse shoulder tip pain SOB pallor haemodynamic instability signs of peritonism guarding and tenderness
what Ix for an ectopic pregnancy
FBC, group and save, betahCG (48hrs apart if haemodynamically stable, expect it to double), USS
what might you see on USS In an ectopic pregnancy
empty uterus/ pseudo sac
+/- mass in adenexa
free fluid in pouch of douglas
what should you do for a patient with suspect EP and deteriorating symptoms
urgent review with senior gynaecologist
what are the management options for an ectopic pregnancy
surgical management (if acutely unwell, will lose tube) medical management (if woman stable, low levels of betahCG and ectopic is small and unruptured give methotrexate) conservative management (well patient who is compliant with follow up visits)
what is a molar pregnancy
gestational trophoblastic disease
non viable fertilised egg
what are the possible SE of methotrexate
vomiting
diarrhoea
hair loss
what does a complete molar pregnancy look like on USS
snow storm / grape clusters
what overgrows in a molar pregnancy
placental tissue with swollen chorionic villi
what cancer is a risk in a molar pregnancy
choriocarcinoma
what is a complete molar pregnancy
egg without DNA with is fertilised with 1/2 sperm
results in diploid (2 paternal contribution only)
no fetus
overgrowth of placental tissue
what is a partial mole
haploid egg 1 sperm (reduplicating DNA material) or 2 sperms fertilising egg (1 maternal 2 paternal) results in triploidy may have fetus overgrowth of placental tissue
what might be seen on USS of a partial molar pregnancy
overgrowth of placenta
may have fetus
can molar pregnancies survive
no
what will be abnormal about serial fundal height in molar pregnancies
more than normal as grow very quickly - needs to be removed
what is a dangerous sing in a molar pregnancy
SOB- molar tissue can embolise and cause PEs
what are the presentations of a molar pregnancies
hyperemesis (due to enlarged placenta creating a lot of hCG)
varied bleeding and passage of grapelike tissue
fundus > dates
occasional SOB
USS can diagnose snow storm appearance +/- fetus
what is the management of a molar pregnancy
surgical
tissue for histology
follow up with molar pregnancy services
what is implantation bleeding
happens when fertilised egg implants
happens 10 days post ovulation
bleeding is light/ brownish and limited
often mistaken for a period
when does a period come after ovulation
2 weeks
what is the management for implantation bleeding
watchful waiting
usually settles and pregnancy continues
sometimes becomes heavier- threatened miscarriage
what is a chorionic haematoma in pregnancy
pooling of blood between endometrium and the chorion (membrane surrounding embryo) due to separation
what are the features of a chorionic haematoma
bleeding, cramps, threatened miscarriage
usually self limited and resolve
large may be source of infection, irritability causing cramping, miscarriage
what are the cervical causes of bleeding in early pregnancy
ectopy/ ectropion (columnar epithelium outwith vaginal portion of cervix)
infections: chlyamdia, gonococcal, bacterial
polyps
malignancy- growth. erosion
what are the vaginal causes of bleeding in early pregnancy
infections: trichomoniasis (strawberry vagina), bacterial vaginosis, chlamydia
malignancy: ulcers (rare)
forgotten tampon
how is bacterial vaginosis treated in pregnancy
metronidazole 400 mg b.d. for 7 days
option of vaginal gel
how is chlamydia treated in pregnancy
azithromycin or erythromycin, amoxycillin
Test of cure 3 weeks later
what can cause unrelated bleeding in early pregnancy
urinary: bladder infection with haematuria
bowel: haemorrhoids, malignancy (rare)
what is miscarriage pain like
varies in severity and
frequency depending on stage of miscarriage
what is the predominant symptom in ectopic pregnancy
pain
dull ache to sharp stabbing
peritonitis in cases causes rigidity, rebound tenderness
what unrelated conditions can cause pain in early pregnancy
UTI
appendicitis
vaginal infections
PID
what dose of anti D is given to rhesus -ve women who have surgical intervention during/ following a pregnancy/ ectopic/ molar
500 IU
what is and what isnt hyperemesis gravidarum
Vomiting in first trimester common, limited and mild. 50-80%
Start as early as around time of missed period - NOT HG
HG= if excessive, protracted and altering QOL
what are the features of hyperemesis gravidarum
Dehydration, ketosis, electrolyte and nutritional disbalance
Weight loss, altered liver function ( up to 50%)
Signs on malnutrition
Emotional instability, anxiety. Severe cases can cause mental health issues e.g. depression.
how do you diagnose hyperemesis G
Diagnosis of exclusion: other causes of vomiting may be UTI, gastritis, peptic ulcer, viral hepatitis, pancreatitis
what is the management for hyperemesis G
Rehydration IVI, electrolyte replacement.
Parenteral antiemetic.
Nutritional supplement
Vitamin supplement : Thiamine / Pabrinex
NG feeding, TPN
Steroid use in recurrent, severe cases (oral Prednisolone 40 mg/ day in divided doses, tapered as per effect)
Thromboprophyaxis
H2 receptor blocker ( Ranitidine) and Proton Pump Inhibitor
(Omeprazole) safe for use in pregnancy.
what antiemetics are used in the management of HG
First line:
Cyclizine ( 50 mg p.o. IM or IV 8hourly)
Prochlorperazine (12.5 mg IM/IV 8 hourly or 5-10 mg p.o. 8 hourly)
Second line:
Ondansetron ( serotonin inhibitor) 4-8 mg IM 8 hourly, max 5/7. Limited safety data
Metoclopramide 5-10 mg IM 8 hourly . Oculogyric crisis : treatable with Atropine
XONVEA UK licensed for pregnancy
why is early resolution of HG important
to avoid delivery of medications for epilepsy, hypertension, diabetes and thyroid
when are steroids used in HG
only in protracted condition with recurrent admissions
can HG extend into 2nd trimester
yes and sometimes present throughout Tx
what might be required in severe cases of HG
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