Early pregnancy complications Flashcards
When is a pregnancy considered full term and what is the average length of pregnancy ?
Full term = 37-42 weeks, average length is 40 weeks
Define the duration of each of the 3 trimesters of pregnancy
- 1st trimester = 0-12 weeks
- 2nd trimester = 13-27 weeks
- 3rd trimester = 28-birth
What marker do pregnancy tests test for ?
Levels of βHCG
What is the normal outcome of ferilisation ?
A developing embryo in the normal location with development on-going
List the main abnormal outcomes of pregnancy
- Misscardige (embryo is normal)
- Ectopic pregnancy (abnormal site of implantation)
- Molar pregnancy (abnormal embryo)
Note all of these can cause vaginal bleeding
How common is PV bleeding in early pregnancy ?
Very - occurs in about 20% of pregnancies
Other than the 3 main abnormal outcomes of pregnancy list some of the other causes of PV bleeding in early pregnancy
- Implantation bleeding
- Chorionic haematoma
- Cervical causes - infection, malignancy, polyps, ectopy/ectropion
- Vaginal causes - infection, malignancy (rare)
- Unrelated bleeding in pregnancy - haematuria, PR bleeding
If a women in early pregnancy presents with any symptoms of bleeding, pain (cramps), hyperemesis (nausea, vomiting, WL), dizziness/fainting, where should they be assessed?
The early pregnancy assessment clinic/unit (EPAC/EPAU)
Define what miscarridge is and what a stillbirth is
Miscarriage = loss of pregnancy up to 23+6 weeks, after this known as stillbirth
What percentage of pregnancies miscarry ?
20-40%, mainly in the 1st trimester
Pregnancy tests remain +ve for several days after a fetal death - T or F?
True
What are the general symptoms of miscarriage ?
- Vaginal bleeding
- Abdo cramps - period like
- Passage of tissue through the vagina
- +ve urine pregnancy test
How is miscarriage diagnosed ?
Initially assess if haemodynamically stable, if not then admit to hospital immediately, if they are stable then investigate as follows:
- Confirm pregnancy with UPT
- Carry out abdo exam & transvaginal U/S to assess location and viability of pregnancy - U/S will show if there is a FH, if they are in the process of expulsion or if they have an empty uterus
- Speculum examination then used to assess if cervical os closed (threatened miscarriage), if products (tissue) are sited at the os (miscarriage inevitable) or if products/tissue in vagina (complete)
Describe the features of a threatened miscarriage
- Mild symptoms (bleeding often less than menstruation & painless) and the cervical os is closed
- It typically occurs between 6-9 weeks
- The fetus is still seen on scan
Describe the features of a inevtiable miscarriage
- Severe symptoms (heavy bleeding, clots & pain)
- The cervical os is open
Describe the features of a incomplete miscarriage
- Most but not all products of conception have been expelled but there are some remaining
- Pain and vaginal bleeding
- Cervical os is open
Describe the features of a complete miscarriage
Empty uterus - Products may be in the vagina
Describe what a Missed (delayed) miscarriage (also called early fetal demise) is
- A gestational sac which contains a dead fetus before 20 weeks without the symptoms of expulsion
- Mother may have light vaginal bleeding / discharge and the symptoms of pregnancy which disappear. Pain is not usually a feature
- Cervical os is closed
Define what a anembryonic pregnancy is
When the gestational sac is > 25 mm and no embryonic/fetal part can be seen it is sometimes described as a ‘blighted ovum’ or ‘anembryonic pregnancy’
What is the management of miscarriage ?
- Ensure haemodyanmically stable
- Emotional support, ensure routine antenatal care cancelled & ensure if required that anti-D is given
- If no tissue left in the womb the no treatment given
If incomplete or missed miscarriage then:
- 1st line = expectant management (for 7-14 days)
- 2nd line = medical management - vaginal or oral misoprostol
- 3rd line = surgical intervention with manual vacuum aspiration or surgical management
When is medical or surgical treatment of incomplete or missed miscarriages preferred rather than expectant ?
- If increase risk of haemorrhage
- Had previous adverse/traumatic experience
List some of the potential causes of miscarriage
- Embryonic abnormality
- Anti-phospholipid syndrome
- Infection
- Severe emotional upsets
- Environmental
- Iatrogenic after CVS or amniocentesis
- Smoking, cocaine, alcohol use
All women who have had surgical management/intervention for miscarriage should have what?
Anti-D immunoglobulin
Define what recurrent miscarriage is
This is 3 or more consecutive spontaneous abortions.
What should be done for someone with recurrent miscarriages ?
They should be referred for investigations:
- Assessment for anti-phospholipid syndrome & possibly other immunological abnormalities
- Investigate for genetic abnormalities in both partners
- Investigate for fetal genetic abnromalities if fetal tissue available
- Pelvic U/S for uterine abnormalities
What is the prognosis for someone with recurrent miscarriages even if no underlying cause is found ?
75% chance of a future successful pregnancy
If the mother is found to be anti-phospholipid syndrome +ve what should she be treated with during pregnancy and the postpartum period ?
Aspirin + heparin
Define what an ectopic pregnancy is
This is implantation and development of the fetus outwidth the uterus
State the most common site of ectopic pregnancy and also the additional other areas it can occur
Most common site is the fallopian tubes (in particular the ampulla of the fallopian tubes)
Other sites include:
- Ovary
- Peritoneum
- Organs e.g. liver, cervix
- C-section scar
What are the signs/symptoms of ectopic pregnancy ?
- Missed period & other signs of pregnancy
- Strong cramps or lower abdo/pelvis pain
- Vaginal bleeding
- Shoulder tip pain
- Dizziness/ collapse
- SOB
A typical history is a female with a history of 6-8 weeks amenorrhoea (longer past 10wks suggests other cause) who presents with lower abdominal pain and later develops vaginal bleeding
How is ectopic pregnancy diagnosed ?
Firstly assess is haemodynamically stable or not. If not stable then transfer to hospital immediately
If haemodynamically stable then:
- 1st line = confirm pregnacy using betaHCG pregnancy test + followed by Transvaginal U/S to determine locaiton of pregnancy
- 2nd line = serial serum HCG test (2 tests 48hrs apart) if transvaginal U/S doesn’t confirm pregnancy
State the management of ectopic pregnancy
There are 3 ways to manage ectopic pregnancies:
- Expectant management - For low risk, hemodynamically stable, asymptomatic patients (or with minimal pain) with a plateau or decrease in human chorionic gonadotrophin (hCG) levels. RCOG recommends it as an option when there is a decreasing hCG level which was initially <1500 IU/L. Or in patients with an initial hCG <200 IU/L
- Medical management (methotrexate) - reserved for haemodynamically stable patients who have a confirmed or high clinical suspicion of ectopic pregnancy, an unruptured mass, and no absolute contraindications to methotrexate. RCOG recommends that hCG levels patients need a hCG ideally <1500 and no fetal cardiac activity on an U/S with certainty that there is no intrauterine pregnancy
- Surgical management (laproscopy + salpingectomy or salpingotomy) - If a patient shows signs of haemodynamic instability, symptoms of a ruptured ectopic mass, or signs of intraperitoneal bleeding then surgical intervention is required.
After management of an ectopic pregnancy what do almost all women need followed up with and who is the exception
All women (except those who have had a salpingectomy) need to be followed up with serum betahCG tests to ensure it is decreasing at an acceptable rate until non-pregnant levels reached which may take up to 6 weeks
What do all Rhesus -ve women undergoing surgical management of an ectopic pregnancy require ?
Anti-D
Define what gestational trophoblastic disease is
This is a group of disorders spanning the conditions of complete & partial molar pregnancies through to the malignant conditions of invasive mole, choriocarcinoma & the very rare placental site trophoblastic tumour (PSTT)
Define what a molar pregnancy is
- This is an abnormal form of pregnancy in which a non-viable ferilised egg implants in the uterus & will fail to come to term, it grows into a mass in the uterus & has swollen chorionic villi which resemble grapes
- The growth is called a ‘hydatidform mole’ which can either be a complete or partial mole
Describe how a complete mole forms
An empty ovum ‘egg without DNA’ is ferilised by 1 or 2 sperm resulting in diploidy. No fetus develops (makes sense as only DNA from father), there is then an overgrowth of placental tissue
Describe how a partial mole forms
A haploid egg (ovum) is fertilised by 1 or 2 sperm (usually 2) resulting in triploidy. There may be evidence of an abnormal fetus (cant survive or develop into a baby) and an overgrowth of abnormal placental tissue
(makes sense as there is maternal and paternal DNA to contribute to actually makking the fetus albeit abnormal)
What does a complete mole carry a risk of ?
A 2.5% risk of developing into a choriocarcinoma
Describe the presentation of a molar pregnancy
- The hydatidiform mole makes a lot of betaHCG causing exaggerated pregnancy symptoms & strongly +ve pregnancy tests
- Hypermesis gravidarum - servere nausea, vomiting, weight loss, feeling faint
- PV bleeding
- Passage of ‘grapelike tissue’
- Fundus height > than gestational dates
- SOB
- Snow storm appearance on U/S +/- an abnormal fetus
How is molar pregnancy diagnosed ?
U/S is useful in making pre-evacuation diagnosis but definitive diagnosis is made by histological examination of the products of conception
What is the management of molar pregnancies
- 1st line = Surgical curratage for complete & partial molar pregnancies
- 2nd line = medical evacuation for partial molar pregnancies when the size of the fetal parts doesn’t allow for surgical curretage
Following this send tissue to histology, carry out regular pregnancy tests until acceptable levels reached & follow-up with molar pregnancy services
Describe what implantation bleeding is
- This is PV bleeding which occurs after the fertilised egg implants into the uterine wall
- It occurs roughly 10 days post ovulation
- The PV bleeding is light/brownish & limited/spotting
- Signs of pregnancy soon then emerge
- Occasionally mistake as a period
What is the management of implantation bleeding ?
Watchful waiting
Define what a chorionic haematoma is
This is pooling of blood between the endometrium (uterine wall) & the outer fetal membrane (covering embryo)
Describe the presentation of a chorionic haematoma
- PV bleeding ranging from spotting to heavier bleeding +/- clots
- Cramping
- If bleeding is excessive enough then may get a prognosis of threatened miscarriage
- Usually is self-limiting & resolve
- U/S is used to monitor them
How is a chorionic haematoma diagnosed ?
U/S
What is the treatment of a chorionic haematoma ?
Reassurance & surveillance with U/S
