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Reproductive & Sexual Health > Early pregnancy Complications > Flashcards

Early pregnancy Complications Flashcards

1
Q

What percentage of women have bleeding in early pregnancy?

A

20%

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2
Q

What are the abnormal pregnancy outcomes?

A
  • Miscarriage (normal embryo)
  • Ectopic pregnancy (abnormal site of implantation)
  • Molar pregnancy (abnormal embryo)
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3
Q

What are the causes of bleeding in pregnancy?

A
  • Implantation bleeding
  • Chorionic haematoma
  • cervical causes
    • infection
    • malignancy
    • polyp
  • vaginal causes
    • infection
    • malignancy (rare)
  • unrelated : haematuria, PR bleeding
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4
Q

What are the other common symptoms in early pregnancy?

A

Pain (cramps)

Hyperemesis

Dizziness/fainting

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5
Q

What are the symptoms of miscarriage?

A
  • bleeding
  • cramping
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6
Q

What is used to diagnose miscarriage?

A

ultrasound Scan

Speculum exam

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7
Q

What is determined in US scan of miscarriage?

A

Confirm pregnancy in situ (+/- foetal heart), in process of expulsion, empty uterus

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8
Q

What is seen on speculum exam in miscarriage?

A

Closed os (threatened)

Products sited at open os (inevitable)

Products in vagina and os closing (complete)

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9
Q

How does cervical shock present?

A

Cramps, nausea/vomiting, sweating, fainting

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10
Q

When does cervical shock resolve?

A

When products are removed from cervix

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11
Q

How should patients with cervical shock be resuscitated?

A

IVI, uterotonics

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12
Q

What are the causes and pathophysiology for miscarriage?

A

Embryonic abnormality

Immunologic

Infections

Severe emotional upset, stress

Iatrogenic after CVS (infection or uterine irritability)

Uncontrolled diabetes

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13
Q

What Embryonic abnormality causes miscarriage?

A

Chromosomal

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14
Q

What immunologic issues cause miscarriage?

A

APS (LAC)

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15
Q

What infections cause miscarriage?

A

CMV, rubella, toxoplasmosis, listeriosis

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16
Q

What lifestyle choices are associated with miscarriage?

A

Heavy smoking, cocaine, alcohol misuse

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17
Q

What is a proposed pathophysiology of miscarriage?

A

Bleeding from placental bed or chorion causing hypoxia and villous/placental dysfunciton

Causes embyronic demise

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18
Q

Define threatened miscarriage

A

There is a risk to pregnancy

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19
Q

Define inevitable miscarriage

A

Pregnancy can’t be saved

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20
Q

Define incomplete miscarriage

A

Part of pregnancy lost already

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21
Q

Define complete miscarriage

A

All of pregnancy lost, uterus is empty

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22
Q

What is early foetal demise?

A

Pregnancy in-situ, no heartbeat: MSD > 25mm, FP >7mm

MSD: mean gestational sac diameter

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23
Q

What is an anembryonic pregnancy?

A

No foetus, empty sac

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24
Q

How is management of miscarriage dictated?

A

Dictated by findings

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25
Q

What are the treatment options for miscarriage?

A

Conservative, medical, MVA/surgical

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26
Q

What is recurrent miscarriage?

A

3 or more pregnancy loses

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27
Q

What are the causes of recurrent miscarriage?

A
  • antiphospholipid syndrome APS (LAC, ACA, B2 Glycoprotein1)
  • thrombophilia (factor V leiden) and prothrombin gene mutations (protein c, free protein S and antithrombin)
  • balanced translocation
  • uterine abnormality
  • uterine natural killer cells
28
Q

When would uterine abnormality be suspected as cause for miscarriage?

A

Recurrent miscarriages in late first trimester

29
Q

What can be done for women with recurrent miscarriages?

A

Use of low dose aspirin (LDA) and daily fragmin injections after confirmation of viable IUP in evidence of APS or thrombophilia

30
Q

What are the common sites for ectopic pregnancy?

A

Fallopian tube; interstitial, isthmic, ampullary or fimbrial

31
Q

What are sites of ectopic pregnancy other than fallopian tube?

A

Ovary, peritoneum, other organs e.g. liver, cervix, c-section scar

32
Q

Describe presentation of ectopic pregnancy

A

Pain > bleeding, dizziness/collapse/shoulder tip pain, short on breath

33
Q

Describe findings in ectopic pregnancy

A

Pallor

Haemodynamic instability

Signs of peritonism

Guarding and tenderness

34
Q

What is the commonest site of ectopic pregnancy?

A

Ampullary

35
Q

What is recommended for a woman with a suspected ectopic pregnancy and deteriorating symptoms?

A

Urgently reviewed by a senior gynaecologist

36
Q

What are the red flag signs for ectopic pregnancy?

A
  • Repeated presentation with abdominal and/or pelvic pain
  • pain requiring opiates
37
Q

What are the investigations for ectopic pregnancy?

A

FBC, G&S, bHCG, USS

38
Q

What may be seen on USS of ectopic pregnancy?

A

Empty uterus/pseudo sac

Mass in adnexa

Free fluid in pouch of douglas

39
Q

Describe assessment of hCG in ectopic pregnancy

A

Comparative assesment 48hours apart if haemodynamically stable, to assess doubling

40
Q

What is the management of ectopic pregnancy?

A

Manage as per presentation;

  • surgical management (if patient is acutely unwell)
  • medical management (if woman is stable, low levels of BhCG and ectopic is small and unruptured)
  • conservative management (for the ‘well patient’ who is compliant with follow up)
41
Q

What is the standard treatment for medically managed ectopic pregnancy?

A

Methotrexate

42
Q

What is molar pregnancy?

A

Gestational trophoblastic disease

A non-viable egg is fertilised and there is overgrowth of placental tissue with chorionic villi swollen with fluid giving a picture of ‘grape like structures’

43
Q

What are the types of molar pregnancy?

A

Complete and partial

44
Q

________ mole has a 2.5% risk of ___________

A

Complete mole has a 2.5% risk of choriocarcinoma

45
Q

What is a complete mole?

A
  • egg without DNA
  • 1 or 2 sperm fertilise, result in diploid (paternal contribution only)
  • no foetus
  • overgrowth of placental tissue
46
Q

What is a partial mole?

A
  • haploid egg
  • 1 sperm (reduplicating DNA material) or 2 sperms fertilising egg, result in triploidy
  • may have foetus
  • overgrowth of placental tissue
47
Q

What creates the snowstorm appearance of complete moles?

A

Multiple placental vesicles

48
Q

What are the important issues at presentation suggesting molar pregnancy?

A
  • hyperemesis
  • varied bleeding and passage of ‘grapelike tissue’
  • fundus > dates
  • occasional SOB
49
Q

What is the management of molar pregnancy?

A

Surgical and tissue for histology

Follow up with molar pregnancy services

50
Q

What is implantation bleeding?

A

Bleeding when egg implants into uterine wall

About 10 days post-ovulation

Bleeding is light/brownish and limited

Ocassionally mistaken as period

51
Q

What is chorionic haematoma?

A

Pooling of blood between endometrium and the embryo due to separation: sub-chorionic

52
Q

How does chorionic haematoma present?

A

Bleeding, cramping and threatened miscarriage

53
Q

What is the prognosis of chorionic haematoma

A

If small pregnancy usually continues

If large may be source of infection, irritability causing cramping and miscarriage

54
Q

What are the cervical causes of bleeding in early pregnancy?

A

Ectopy/ectropion

Infections: chlamydia, gonococcal or bacterial

Polyp

Malignancy- growth or generalised angry erosion

55
Q

What are the vaginal causes of bleeding in early pregnancy?

A
  • infections
    • trichomoniasis (strawberry vagina)
    • bacterial vaginosis
    • chlamydia
  • malignancy
    • ulcers
    • rare cause of bleeding in reproductive age
  • forgotten tampon
56
Q

How is BV treated in pregnancy?

A

Metronidazole 400mg b.d. 7 days

Can have vaginal gel

57
Q

How is chlamydia treated during pregnancy?

A

Erythromycin, amoxicillin

test of clearance 3 week later

58
Q

What are the causes of pain in pregnancy?

A
  • miscarriage
    • usually more bleeding than pain
  • Ectopic pregnancy
    • predominant symptom
    • dull ache to sharp stabbing
    • peritonism cases cause rigidity and rebound tenderness
  • ​Unrelated
    • UTI, Appendicitis
  • vaginal infections, PID
59
Q

What is the dose of Anti-D for rhesus negative women who have a surgical miscarriage?

A

500 IU

60
Q

What is hyperemesis gravidarum?

A

Excessive, protracted vomiting altering the quality of life beyond the 1st trimester

61
Q

What can hyperemesis gravidarum result in?

A
  • dehydration, ketosis, electrolyte and nutritional disbalance
  • weight loss, altered liver funciton (50%)
  • malnutrition
  • emotional instability, anxiety, depression
62
Q

What must be excluded before HG is diagnosed?

A

UTI, gastritis, peptic ulcer, viral hepatitis, pancreatitis

63
Q

What is the managment of HG?

A
  • rehydration IVI, electrolyte replacement
  • parenteral antiemetic
  • nutritional supplement
  • vitamin supplement : thiamine/pabrinex
  • NG feeding, TPN
  • steroid use in recurrent, severe cases
  • thromboprophylaxis
64
Q

What are the 1st line antiemetics for HG?

A
  • cyclizine (50mg p.o. IM or IV 8hourly)
  • prochloperazine (12.5mg IM/IV 8 hourly or 5-10mg p.o. 8 hourly)
65
Q

What are the second line antiemetics for HG?

A
  • Ondansetron ( serotonin inhibitor) 4-8 mg IM 8 hourly, max 5/7. Limited safety data
  • Metoclopramide 5-10 mg IM 8 hourly . Oculogyric crisis : treatable with Atropine
  • XONVEA UK licensed for pregnancy
66
Q

What medications aside from anti-emetics should be given in HG?

A

Thiamine supplement (50mg tds)/ pabrinex IV

H2 receptor blocker (ranitidine) and PPI (Omeprazole)]

Steroid: oral prednisolone 40mg/day in divided doses, tapered as per effect

Reproductive & Sexual Health (54 decks)

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