Early Pregnancy Complications Flashcards
It is normal to have minimal bleeding occur during early pregnancy? TRUE/FALSE?
TRUE
- around 20% of females have this
What abnormal pregnancy outcomes may arise?
Miscarriage (Normal Embryo)
Ectopic (Abnormal Implantation)
Molar (Abnormal Embryo)
What are the most common causes of abnormal bleeding in pregnancy?
- chorionic haematoma
- Cervical pathology
- vaginal causes
Miscarriage usually present with what symptoms?
- BLEEDING
- menstrual-type cramping (intermittent, varying intensity)
How is a miscarriage investigated and diagnosed?
- Positive urinary pregnancy test?
- Abdominal Examination
- Speculum examination (is Os opened/closed?)
- US Scan to look for pregnancy in situ
What symptoms would indicate a patient is in cervical shock?
- cramping
- nausea and vomiting
- sweating
- fainting
What causes cervical shock?
Dilatation of the cervix when products of miscarriage are passing through
What is the most common cause of miscarriage in older mothers?
Chromosomal problems
- this is because they are ovulating less suitable eggs as they get older and closer to the menopause
What immune condition may cause recurrent miscarriage?
Antiphospholipid syndrome
What are the main causes of miscarriage?
- chromosomal
- Immune conditions
- Infection
- Severe stress
- Iatrogenic (e.g. after chorionic villus sample OR amniocentesis)
What is thought to be the pathophysiology of a miscarriage?
- bleeding from placental bed/ chorion
=> causes hypoxia and placental dysfunction
What are the different stages or types of miscarriage?
Threatened = Risk to pregnancy
Inevitable = pregnancy cannot be saved
Incomplete = part of pregnancy lost already
Complete = uterus is empty
Early Foetal Demise = Pregnant but no foetal heartbeat
Anembryonic = no foetus present, empty sac
Missed = irregular sac with bleeding behind
How can we treat a patient who is going through a miscarriage?
- Conservative management if patient is well, no SEPSIS risk and pregnancy is <12 weeks
- Medical (misoprostol) or surgical approach may also be used
- Anti-D injection required if mother is Rhesus Neg. and is taken to theatre for surgical removal of miscarriage
- Emotional Support = IMPORTANT (Miscarriage Assoc.)
What does “recurrent” pregnancy loss mean?
- 3 or more pregnancy losses
What conditions may cause recurrent pregnancy loss?
- Antiphospholipid
- Thrombophilias (Factor V Leiden)
- Chromosome based translocation
- Uterine abnormality
What treatment is recommended for patients with antiphospholipid syndrome or thrombophilias once they know that they have a viable pregnancy?
Aspirin and Fragmin recommended
Where can an ectopic pregnancy potentially implant?
- Fallopian tubes (Most common)
- Ovary
- Peritoneum/Intra-abdominal
- Cervix
- C-section scar
What are the main symptoms of an ectopic pregnancy?
- PAIN
- bleeding
- dizziness/collapse
- Shoulder tip pain (due to blood pooling in subdiaphragmatic recess when lying down => irritates diaphragm)
What presenting patient would make you suspicious of an ectopic pregnancy?
- known pregnant woman
- abdominal or pelvic pain requiring opiates to control
What can be seen on US scan if a patient has an ectopic pregnancy?
- Empty uterus
- Pseudo sac
- Free fluid may be seen
- Known as “Pregnancy of Unknown Location” (PUL) as foetus may not be seen on scan
If a patient has an Ultrasound where the foetus is not found (PUL) then what other test can be done to check if this IS an ectopic pregnancy?
- Retest HCG every 48 hours
- it should DOUBLE in this time
How can an ectopic pregnancy be treated?
- Conservative management if pt is well
- If HCG levels are low and ectopic is unruptured = give methotrexate
- if patient is unstable/ acutely unwell => surgery
What is involved in the GEM III trial which is currently taking place for ectopic pregnancy treatment?
- combination of methotrexate and Gefitinib (small cell lung cancer drug)
- HCG falls faster and ectopic shrinks faster
=> less need for surgery and less complications
A molar pregnancy is a disease of which part of the developing foetus?
Trophoblastic disease
Describe the difference in genetic makeup between a Complete and Partial mole
Complete = 2 copies of paternal DNA and NO maternal DNA (46 chromosomes)
Partial = 2 copies of paternal DNA AND a copy of maternal DNA (69 chromosomes)
Describe the difference in outcome between a Complete and Partial mole
Complete - overgrowth of placental tissue (looks like snowstorm on US)
Partial - overgrowth of placental tissue AND small foetus forms
How do mother’s with a molar pregnancy usually present?
- hyperemesis
- Varied bleeding (and passing “grape-like” structures)
- may cause PE => present with SOB
- tissue grows rapidly => fundal height is often large for gestation
How are molar pregnancies normally managed?
- surgery to remove
- tissue sent for histology
- follow up at Molar Pregnancy Services (due to small choriocarcinoma risk)
Patients who have had a molar pregnancy cannot have a normal pregnancy in the future. TRUE/FALSE?
FALSE
What bleeding can occur in normal pregnancy that patients often mistake as a period?
Implantation bleeding
- occurs around 10 days post ovulation
- light bleeding
How can a chorionic haematoma complicate pregnancy?
it may grow above placenta and obscure transfer of blood from mother -> baby
How do patients usually present with a chorionic haematoma?
- bleeding
- cramping
- threatened miscarriage
What may cause cervical bleeding in early pregnancy?
- cervical ectopy/ectropion
- infection - chalmydia, gonorrhoea etc
- Polyp
- malignancy
What is cervical ectopy/ectropion?
- Soft glandular cells from inside the cervical canal are present on the outside surface of the cervix
- Caused by hormones, pregnancy and the pill
- not linked to the development of cervical cancer
What vaginal causes of bleeding can occur in pregnancy?
- infection - BV, Chalamydia, Trichomoniasis
- Malignancy
- Forgotten tampon
What bleeding in pregnancy may come from other non-reproductive tract causes?
- haematuria (e.g. UTI)
- Haemorrhoids/ rectal bleeding (IBD/malignancy etc)
What type of pain is felt in a ruptured ectopic pregnancy?
- dull ache which converts to sharp pain
- rigidity of abdomen common
- rebound tenderness
What other differential diagnoses are there for ectopic pregnancy abdominal pain?
UTI
Appendicitis
What constitutes a diagnosis of Hyperemesis Gravidarum when a pregnant woman has morning sickness?
- if it is altering her quality of life
=> this is only diagnosed in 0.3-3%
What severe symptoms can occur as a result of hyperemesis gravidarum?
- dehydration
- ketosis
- electrolyte disturbance
- weight loss
- abormal LFTs
- Malnutrition
- Mental health problems as a result
Hyperemesis gravidarum is a diagnosis of exclusion. What other differentials should you consider?
- UTI
- gastritis
- peptic ulcer
- viral hepatitis
- pancreatitis
How is Hyperemesis gravidarum managed?
- rehydrate
- parenteral antiemetic
- nutritional supplements
- Thiamine supplement (IV Pabrinex)
- NG feeding
- Thromboprophylaxis (as patient’s not moving much)
What anti-emetics are 1st and 2nd line in the treatment of Hyperemesis gravidarum?
1st Line
- Cyclizine
- Prochlorperazine
2nd Line
- Ondansetron
- Metocloperamide
Which drugs are licensed to combat heartburn/acid reflux in pregnancy?
Ranitidine (H2 receptor antagonist)
Omeprazole (PPI)
What is a Manual Vacuum Aspiration and in what two ways can it be carried out?
Manual Vacuum Aspiration (MVA)
- surgical suction method to remove products of miscarriage
- Can be carried out under GA in theatre
- If lack of space in theatre, can be carried out under LOCAL anaesthetic in clinic (if cervical Os is open)
