Early Pregnancy Complications Flashcards by raniya robb

what does a missed miscarriage look like at 8 weeks gestation?

an irregularly shaped gestation sac containing a small amniotic cavity and no foetal pole

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minimal bleeding is a very common problem in early pregnancy - true or false?

true (20%)

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what are the three different types of abnormal pregnancy outcomes?

miscarriage (normal embryo)
ectopic pregnancy (abnormal site of implantation)
molar pregnancy (abnormal embryo)

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what are other causes of bleeding during early pregnancy?

implantation bleeding

chorionic haematoma

cervical causes (infection, malignancy, polyp)

vaginal causes (infection, malignancy)

unrelated (haematuria, PR bleeding etc)

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what are the symptoms of a miscarriage?

bleeding (> cramping)

period type cramps described
passed products may be brought in

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how can a miscarriage be diagnosed?

scan - help confirm a pregnancy in situ (+/- FH), in process of expulsion and empty uterus

speculum exam - is the os closed (threatened), products sighted at open os (inevitable) or in vagina and os closing (complete)

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what are the symptoms of cervical shock?

cramps
nausea / vomiting
sweating
fainting

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how is cervical shock treated?

resolves if products removed from cervix

resuscitation with IVI, uterotonics may be required

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what are thought to be the different causes of miscarriage?

embryonic abnormality = chromosomal 
immunologic = APS
infections = CMV, rubella, toxoplasmosis, listeriosis 
severe stress
iatrogenic after CVS 
heavy smoking, cocaine, alcohol misuse
uncontrolled diabetes

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the pathophysiology of miscarriage is unknown but what is thought to occur?

bleeding from placental bed or chorion causing hypoxia and villous / placental dysfunction

this causes embryonic demise

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what is early foetal demise?

pregnancy in situ

no heartbeat: MSD >25mm, FP >7mm

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what is an anembryonic pregnancy?

no foetus, empty sac

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when in a miscarriage would anti-D be given?

if surgical intervention needed

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what is defined as recurrent miscarriage?

3 or more pregnancy losses

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what are thought to be the potential causes of recurrent miscarriage?

APS (LAC, ACA, B2glycoprotein1)

thrombophilia (factor V leiden and prothrombin gene mutation, protein C, free protein S and antithrombin)

balanced translocation

uterine abnormality - late first trimester losses

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what are the independent risk factors for recurrent miscarriage?

age and previous miscarriages

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what is thought to decrease the chance of miscarriage in those with APS or thrombophilia?

use of LDA and daily fragmin injection after confirmation of viable IUP

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what is thought to be a way we could minimise pregnancy loss in future?

progesterone vaginal pessary use

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what is an ectopic pregnancy?

implantation is out with the uterine cavity

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what are the common and uncommon sites of an ectopic pregnancy?

common - fallopian tube: interstitial, isthmic, ampullary or fimbrial

other - ovary, peritoneum, other organs eg liver, cervix, C-section scar

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what are the common presentations of an ectopic pregnancy?

pain (dull ache to sharp stabbing) > bleeding

dizziness / collapse / shoulder tip pain, SOB

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what are the common findings in an ectopic pregnancy?

pallor
haemodynamic instability
signs of peritonism
guarding and tenderness

what are considered to be “red flag” signs of an ectopic pregnancy?

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

what investigations should take place in an ectopic pregnancy?

FBS

G&S

BhCG = comparative assessment 48 hours apart if haemodynamically stable, to assess doubling

USS = empty uterus / pseudo sac +/- mass in adenexa, free fluid POD

what are the different types of management for ectopic pregnancy?

surgical management = if acutely unwell medical management = if women is stable, low levels of BhCG and ectopic is small and unruptured conservative management = for well patient who is compliant with follow-up visits

what is a molar pregnancy?

gestational trophoblastic disease non-viable fertilised egg with overgrowth of placental tissue with chorionic villi swollen with fluid giving picture of "grape like clusters"

what are the two different types of molar pregnancy?

complete - egg without DNA - 1 or 2 sperm fertilise, result in diploid (paternal contribution only) - no foetus and overgrowth of placental tissue partial - haploid egg - 1 sperm (reduplicating DNA material) or 2 sperms fertilising egg, resulting in triploidy - may have foetus and overgrowth of placental tissue

a complete molar pregnancy has a 2.5% risk of what?

choriocarcinoma

what are the important issues at presentation of a molar pregnancy?

hyperemesis varied bleeding and passage of "grapelike tissue" fundus > dates occasional SOB

how can molar pregnancy be diagnosed?

USS - snow storm appearance +/- foetus

what is the management of a molar pregnancy?

surgical and tissue for histology follow-up with molar pregnancy services (3 centres in UK: London, Sheffield, Dundee)

what is implantation bleeding?

bleeding when fertilised egg implants into the uterine wall

what are the characteristics of implantation bleeding?

timing is about 10 days post-ovulation bleeding is light / brownish soon signs of pregnancy emerge occasionally mistaken as period *watchful waiting and being aware of entity, usually settles and pregnancy continues

what is a chorionic haematoma?

pooling of blood between endometrium and the embryo due to separation

what are the symptoms of a chorionic haematoma?

bleeding cramping threatened miscarriage

what could be the consequences of a large chorionic haematoma?

infection irritability (causing cramping) miscarriage

how is a chorionic haematoma managed?

usually self limited and resolve | reassurance important but surveillance should remain

what are the different cervical infections which can cause bleeding in early pregnancy?

chlamydia gonococcal bacteria

what are the different vaginal infections which can cause bleeding in early pregnancy?

trichomoniasis (strawberry vagina) bacterial vaginosis chlamydia

how is bacterial vaginosis treated in early pregnancy?

metronidazole 400mg bd 7 days avoid alcohol during medication option of vaginal gel

how is chlamydia treated in early pregnancy?

erythromycin, amoxycillin TOC 3 weeks later liaise with sexual health

what can be a cause of urinary bleeding in early pregnancy?

bladder infection with haematuria

what can be the cause of bowel bleeding in early pregnancy?

haemorrhoids | rarely: a malignancy

what should be given in those who receive surgical treatment for molar pregnancy?

anti-D (500 IU)

what is hyperemesis gravidarum (HG)?

excessive morning sickness which is protracted and alters quality of life

what are the complications of HG?

dehydration, ketosis, electrolyte and nutritional disbalance weight loss, altered liver function (up to 50%) signs of malnutrition emotional instability and anxiety

what other causes of vomiting must be excluded before diagnosis of HG?

``` UTI gastritis peptic ulcer viral hepatitis pancreatitis ```

what are the principles of management in HG?

rehydration IVI, electrolyte replacement parenteral antiemetic nutritional supplement vitamin supplement (thiamine 50mg tds, pabrinex IV) NG feeding, TPN steroid use in recurrent, severe cases thromboprophylaxis

what are the first line antiemetics for HG?

cyclizine (50 mg PO, IM or IV 8 hourly) prochlorperazine (12.5mg IM/IV 8 hourly or 5-10mg PO 8 hourly)

what are the second line antiemetics for HG?

ondansetron (serotonin inhibitor) 4-8mg IM 8 hourly, max 5/7 metoclopramide 5-10mg IM 8 hourly

what is a severe side effect of metoclopramide and how is this treated?

oculogyric crisis treatable with atropine

what PPI is safe for use in pregnancy?

omeprazole

what steroids are used in pregnancy for HG?

prednisolone 40mg/day in divided doses, tapered as per effect *only used in protracted condition with recurrent admissions

HG can extend into second trimester - true or false?

true - rarely into 2nd trimester or even throughout pregnancy in severe cases, TOP may be required