Early Pregnancy Complications

Question 1

Normal pregnancy

Answer 1

• Expected date of delivery is 280 days (40 weeks) from 1st day of LMP
• Fertilisation occurs in tube - transportation of embryo along tube - implantation into endometrium approximately 6 days post fertilisation

Question 2

Miscarriage definitions

Answer 2

• Miscarriage - any pregnancy loss before 24 weks gestation
• Stillbirth - any fetus born dead after 24 weeks gestation
• Livebirth - any fetus which shows signs of life after delivery at any gestation

Question 3

Miscarriage statistics

Answer 3

• Approximately 20% of all pregnancies
• Incidence increases with maternal age
• No increase in recurrence after 1 miscarriage

Question 4

Presentation of miscarriage

Answer 4

• In the presence of a positive pregnancy test:
  
  • Vaginal bleeding (brown spotting to heavy +/- tissue)
  • Pelvic discomfort
  • Asymptomatic

Question 5

Investigation of miscarriage

Answer 5

• Clinical examination
  
  • Haemodynamically stable
  • Assess pain and bleeding
  • Removal of POC (speculum)
• US Scan
  
  • Transabdominal
  • Transvaginal
• Examinatino of the POC (products of conception)
• Serum HCG tracking
• Assess FBC and blood group

Question 6

Ultrasound definitions in miscarriage investigation

Answer 6

• No fetal heart activity >7mm crown-rump length on TV scan
• Empty sac when mean gestational sac diameter >25mm on TV scan
• Retained tissue - if incomplete
• Empty uterus
  
  • Complete passage of tissue
  • Pregnancy too early to visualise on scan
  • Ectopic pregnancy

Question 7

Management of miscarriage

Answer 7

• Expectant - intensive follow-up
• Medical - misoprostol
• Surgical - requires cervical priming, electrical vacuum aspiration or manual vacuum aspiration)

Question 8

Rhesus status and miscarriage

Answer 8

• Anti-D is required if mother Rh negative:
  
  • <12 weeks vaginal bleed and severe pain
  • <12 weeks medical or surgical management
  • Any potentially sensitising event >12 weeks

Question 9

Causes of miscarriage

Answer 9

• Most unexplained
• Higher maternal age
• Fetal chromosome abnormality
• Autoimmune (lupus anticoagulant, antiphospholipid antibodies)
• Endocrine (PCOS, DM)
• Uterine abnormalities (fibroids)
• Infection (pyrexia, CMV, rubella)
• Cervical weakness

Question 10

Ectopic pregnancy nomenclature

Answer 10

Question 11

Risk factors for ectopic pregnancy

Answer 11

• Previous ectopic pregnancy
• Endometriosis
• Pelvic infection
• Pelvic surgery
• Contraception
• Assisted conception techniques
• Cigarette smoking

Question 12

Presentation of ectopic pregnancy

Answer 12

• In the presence of a positive pregnancy test
  
  • Asymptomatic
  • Vaginal bleeding
  • Pelvic discomfort or pain
  • Pain with opening bowels
  • Maternal collapse/hypovolaemic shock