Early pregnancy complications Flashcards
What are features of a miscarriage
Positive urinary pregnancy test (+UPT)
Bleeding is primary symptom
Period like cramps
may have brought in passed products
What is cervical shock
dilatation of cervix from foetal products passing through
causes N+V, sweating, fainting
resolved by removing products
What are causes of miscarriage
Chromosomal abnormalities Infection Iatrogenic Autoimmune Smoking, alcohol, drugs Emotional upset and stress Uncontrolled diabetes
Define threatened miscarriage
Risk to pregnancy
Define inevitable miscarriage
can no longer save pregnancy
Define incomplete miscarriage
part of pregnancy is already lost
Define complete miscarriage
all pregnancy has been lost, empty uterus
Define early foetal demise
non-viable pregnancy in situ
no foetal heart
mean sac diameter MSD >25mm
foetal pole FP >7mm
Define recurrent miscarriage
3 or more miscarriages
What can cause recurrent miscarriage
antiphospholipid syndrome
thrombophilias
What can be given after confirmation of viable pregnancy in those with APLS or thrombophilia
low dose aspirin and fragmin
How do you manage miscarriage
ABCDE FBC G&S hCG levels USS histology
What are the definitive management options in miscarriage
Conservative
Medical - misoprostol
Surgical - for early foetal demise
manual vaccum evacuation is cervical os is open
What must be given to women who have surgical management of miscarriage
Anti-D 500 IU
What is ectopic pregnancy
implantation of the fertilised egg out with the uterus
List areas where ectopic pregnancy can occur
Fallopian tubes Ovaries Peritoneum C-section scar Cervix
How does (ruptured) ectopic pregnancy present
Abdominal pain is the primary symptom bleeding collapse peritonism subdiaphragmatic irritation --> shoulder tip pain haemodynamic instability
What is the management of ectopic pregnancy
ABCDE FBC G&S hCG levels USS NEWS
What are the definitive management options for ectopic pregnancy
Conservative - really well patients, small ectopic
Medical - methotrexate
Surgical - acutely unwell patients
What is a molar pregnancy
gestational trophoblastic disease where a non-viable fertilised egg implants into the uterus
What happens to the placenta in molar pregnancy
There is placental tissue overgrowth with swollen chorionic villi
What is a complete mole
empty egg fertilised by 1 or 2 sperm
all the genetic material is paternal
no foetus associated
Which type of mole is at increased risk of developing into a choriocarcinoma
Complete mole
What is a partial mole
a haploid egg fertilised by 1 or 2 sperm to give 96 chromosomes in total
triploidy genetic material
foetus can be associated
How does molar pregnancy present
excessive N+V varied bleeding passage of grape like cysts/tissue uterus size is too large for dates of pregnancy pelvic pressure SOB (think PE!)
What is the management of molar pregnancy
Surgical removal
Histology
follow up in molar pregnancy services
What is implantation bleeding
light spotting/bleeding 10 days after ovulation
Is implantation bleeding abnormal
No, it can be normal
what might implantation bleeding be mistaken for
Light period, so women may not realise that they are pregnant
What is a chorionic haematoma
pooling of blood between the placenta and the embryo
How does chorionic haematoma present
bleeding
cramping
threatened miscarriage
How is chorionic haematoma managed
self limiting usually
surveillance
What are cervical causes of bleeding
ectropion
polyp
malignancy
infection
What are vaginal causes of bleeding
infection
malignancy
forgotten tampon
What is hyperemesis gravidarum (HG)
excessive N+V impairing quality of life
HG is more common in 2nd and 3rd trimesters, true or false
FALSE
it is more common in the 1st trimester
may persist into 2nd and 3rd trimesters
What are features of HG
excessive N+V dehydration malnutrition abnormal electrolytes ketosis abnormal LFTs weight loss emotionally unstable
What are differentials of HG
UTI gastritis pancreatitis PUD hyperthyroidism viral hepatitis
What is the management of HG
ABCDE FBC, G&S IV fluids and electrolytes parenteral anti-emetics nutritional supplementation NG tube steroids thromboprophylaxis
What are 1st line anti-emetics in HG
cyclizine
prochlorperazine
What are 2nd line anti-emetics in HG
Ondansetron
metoclopramide
Xonvea
what should be prescribed alongside PV misoprostal
anti-emetic and pain relief
What is a Kleihauer test
test for foetomaternal haemorrhage detecting foetal cells in the maternal circulation and if present allows calculation of giving anti-D prophylaxis
After what gestation would a sensitising event require anti-D
after 20 weeks
indications for anti-D Ig (outwith the normal dosing at 28+34 weeks)
delivery of a Rh+ baby any TOP miscarriage if >12/40 surgical management of ectopic pregnancy external cephalic version antepartum haemorrhage amniocentesis, CVS, Foetal blood sampling abdominal trauma
questions to ask about PV bleeding in early pregnancy
volume of blood - no of pads changed fresh or brown date of +UPT + LMP + cycle length gestation abdominal pain her age previous pregnancies?
> 6/40 with bleeding/pain, do you see her on the same day or not
yes
criteria on TVUSS for diagnosing a miscarriage
intrauterine empty gestational sac with no foetal pole seen or gestational sac with foetal pole MSD >25 CRL >7mm no foetal heart would need 2nd opinion
TV vs TA USS for miscarriage
TVUSS ideally
what is MVA
manual vacuum aspiration
surgical management for miscarriage performed in outpatient setting under LA in the cervix
patient expectations during MVA
misoprostal tablets PV patient will be awake little uncomfortable crampy cope well
how long do you let conservative management for miscarriage
2 weeks
up to which gestation can you do an MVA
10 weeks
medical management of miscarriage
misoprostal tablets PV to expel products of conception
will have heavier than normal bleeding
have someone at home just in case of really heavy bleeding
management of suspected ectopic pregnancy
ABCDE NEWS hCG levels history Abdominal exam !! Speculum FBC, G+S, U+E, LFT arrange for scan
criteria for management of ectopic pregnancy
FBC, U+E, LFT (MTX) state of the patient - pain or pain free size of ectopic (<35mm - MTX, >35mm - surgery) association of foetal pole + heart beat location of ectopic ruptured? free fluid exclude intrauterine pregnancy if giving MTX hCG levels (5000)
what is pregnancy of unknown location
+UPT
no signs of intrauterine pregnancy on scan but equally no signs of extra uterine pregnancy
need to safety net!! in case it is an ectopic
follow up for pregnancy of unknown location
48 hours for hCG
how to break the bad news e.g. molar pregnancy
not a healthy normally developing pregnancy
findings match molar pregnancy
abnormality of placenta
pregnancy hasn’t formed correctly
https://www.nice.org.uk/guidance/ng126/chapter/Recommendations
useful resource
what is the foetal pole
first direct imaging manifestation of the foetus seen as a thickening on the margin of the yolk sac in early pregnancy
used synonymous with embryo
identified at 6/6.5 weeks
should be seen when MSD>25mm
foetal heartbeat should be detected when FP >7mm
