Early Pregnancy Complications Flashcards
What is the classic appearance of a molar pregnancy?
Snow storm appearance
What are the abnormal pregnancy outcomes?
Miscarriage (normal embryo) Ectopic pregnancy (abnormal site of implantation) Molar pregnancy (abnormal embryo)
What are the causes of bleeding in early pregnancy?
Implantation bleeding Chorionic haematoma Cervical (infection, malignancy, polyp) Vaginal (infection, malignancy) Unrelated (haematuria, PR)
What are the symptoms of a miscarriage?
Positive UPT
Varied gestation
Bleeding primary symptom (> cramping)
Period type cramps
What can help confirm a miscarriage?
Scan; intrauterine (+/- FH)
In process of expulsion
Empty uterus
What is the function of a speculum exam in miscarriage?
Is os closed (threatened)
Products of sites at open os (inevitable)
Products in vagina and os closing (complete)
What is cervical shock?
Cramps
N+V
Sweating
Fainting
Resolves if products are removed from cervix
IF required; resuscitation with IVI and uterotonic (oxytocin)
What are the causes for miscarriage?
Embryonic; chromosomal Immunologic; APS (lupus anticoagulant) Infection: CMV, rubella, toxoplasmosis, listeriosis Severe emotional upset, stress Iatrogenic after chorionic villus sampling (infection or uterine irritability) Heavy smoking Cocaine Alcohol misuse Uncontrolled diabetes
What is the proposed pathophysiology of miscarriage?
Bleeding from placental bed or chorion resulting in hypoxia and villus/ placental dysfunction
Embryonic demise
What are the different types of miscarriage?
Threatened Inevitable Incomplete Complete Early foetal demise Anembryonic pregnancy Missed
What is early foetal demise?
Pregnancy in situ
No heartbeat
Mean Sac Diameter > 25mm
Foetal pole > 7mm
What is an anembryonic pregnancy?
No foetus
Empty sac
What is the management for a miscarriage?
Assessing and ensuring hemodynamically stable
FBC, G+S, bhCG, USS, histology
Mx; conservative, medical (misoprostol), LA with MVA if cervical os open or surgical
Anti-D if surgical intervention
What is a recurrent miscarriage?
3 or more pregnancy losses
What are common causes for recurrent miscarriages?
APS (lupus anticoagulant, anticardiolipin antibody, B2 glycoprotein 1) Thrombophilia Balanced translocation Uterine abnormality Age Previous miscarriages
What are the different forms of thrombophilia?
Factor 5 Leiden Prothrombin Protein C Free protein S Antithrombin
What is the management for APS or thrombophilia in recurrent miscarriages?
Use low dose aspirin and daily fragmin after conformation of viable IUP
What is the PRISM trial?
Progesterone to prevent miscarriage in women with recurrent miscarriages who experience bleeding
What is an ectopic pregnancy?
Implantation outwith the uterine cavity
What are common sites for ectopic pregnancy?
Fallopian tube( interstitial isthmus, ampullary or fimbria) Ovary Peritoneum Liver Cervix C-section scar
What is the presentation of ectopic pregnancy?
Pain > bleeding Dizziness Collapse Shoulder tip pain (C5,6) SOB
What are the findings of an ectopic pregnancy?
Pallor
Hemodynamically unstable
Signs of peritonism
Guarding and tenderness
What are the recommendations for ectopic pregnancy?
Review by senior gynaecologist
Repeated presentation with abdo pain that requried opiates in a women known to be pregnant: RED FLAG
What investigations should be done for suspected ectopic pregnancy?
FBC
G+S
bhCG
USS
What can be seen on USS of an ectopic pregnancy?
Empty uterus
Pseudosac
Mass in adenexa
Free fluid
How can hCG be used to monitor ectopic pregnancy?
Comparative assessment 48 hours apart if hemodynamically unstable, to assess doubling
What are the management options for ectopic pregnancies?
Surgical; salpingectomy
Medical; if low bhCG and small ectopic, can manage with methotrexate
Conservative; if well, follow up visits
What is a molar pregnancy?
Gestational trophoblastic disease
Non-viable fertilised egg
Overgrowth of placental tissue with swollen chorionic villi
What are the types of molar pregnancy?
Complete; egg without DNA fertilised by a sperm
Partial; 1 egg and 2 sperm = triploid
Is there a foetus in a complete or partial molar pregnancy?
Complete; no foetus
Partial; non viable foetus
What is the danger with a complete molar pregnancy?
Can transform to choriocarcinoma
How can molar pregnancies present?
Hyperemesis (trophoblastic cells produce hCG)
Varied bleeding and passage of “grape like tissue”
Fundus > date
Occasional SOB
USS; snow storm appearance
Why can you get SOB in a molar pregnancy?
Can throw off ectopic resulting in PE
What is the management of a molar pregnancy?
Surgical and tissue for histology
Follow up with serial bhCG to ensure no malignant transformation
What is implantation bleeding and when does it tend to occur?
Fertilised egg implants onto uterine wall
Timing around 10 days post ovulation
Light/ brown bleeding
What is a chorionic haematoma?
Pooling of blood between endometrium and embryo due to separation: subchorionic
Can result in bleeding, cramping and a threatened miscarriage
Is a chorionic haematoma self-limiting?
Tends to be
Large haematomas may be a source of infection, irritability or miscarriage
What are the cervical causes of bleeding in early pregnancy?
Ectopy/ ectropion
Infections; chlamydia, gonococcal, bacteria
Polyp
Malignancy; growth or generalised angry erosion
What are the vaginal causes of early bleeding in pregnancy?
Trichomoniasis Bacterial vaginosis Chlamydia Ulcers Forgotten tampon
How should bacterial vaginosis be treated in pregnancy?
Metronidazole 400mg b.d. 7 days
Option of vaginal gel
AVOID alcohol
How should chlamydia be treated in pregnancy?
Erythromycin
Amoxicillin
TOC 3 weeks later
Partner tracing
What is the pain like in a miscarriage?
Varied intensity, depending on stage
Bleeding > pain
What is the pain like in an ectopic?
Pain predominant sy
Dull ache to sharp stabbing
Peritonism can result in rebound tenderness
What is hyperemesis gravidarum?
Diagnosis of exclusion characterized by: Prolonged and severe nausea and vomiting Dehydration Electrolyte Imbalance Ketonuria Body weight loss of more than 5% of pre-pregnancy weight
What are the other diagnoses that need to be considered when diagnosing hyperemesis gravidarum?
UTI Gastritis Peptic ulcer Viral hepatitis Pancreatitis
What are the principles of treatment for hyperemesis?
Rehydration, electrolyte replacement Vitamin supplementation: thiamine/ pabrinex Nutritional support If required; NG or TPN Steroid use in recurrent, severe cases Thromboprophylaxis
In what conditions can hyperemesis be dangerous?
Pre-existing epilepsy, hypertx, diabetes and thyroid disease
Which one is which in terms of molar pregnancy;
Diploidy
Triploidy
Diploid; complete
Triploid; partial
What medications are 1st line for HG?
Cyclizine (50 mg PO IM or IV 8 hourly)
Prochlorperazine (12.5mg IM/IV 8 hourly or 5-10 mg PO 8 hourly)
What medications are 2nd line for HG?
Ondansetron (serotonin inhibitor) 4-8 mg IM 8 hourly
metoclopramide 5-10mg IM 8 hourly
How is an oculogyric crisis treated in HG?
Atropine
What other medications aside from antiemetics are used in HG?
Thiamine
H2 recetpro blocker and PPI (omeprazole safe in pregnancy)
Steroid; 40mg prednisolone in divided doses
When is anti-D given in miscarriage?
Rh neg women who receive surgical management
Surgical management is 1st choice for molar
