Early pregnancy Complications Flashcards
What percentage of women have bleeding in early pregnancy?
20%
What are the abnormal pregnancy outcomes?
- Miscarriage (normal embryo)
- Ectopic pregnancy (abnormal site of implantation)
- Molar pregnancy (abnormal embryo)
What are the causes of bleeding in pregnancy?
- Implantation bleeding
- Chorionic haematoma
- cervical causes
- infection
- malignancy
- polyp
- vaginal causes
- infection
- malignancy (rare)
- unrelated : haematuria, PR bleeding
What are the other common symptoms in early pregnancy?
Pain (cramps)
Hyperemesis
Dizziness/fainting
What are the symptoms of miscarriage?
- bleeding
- cramping
What is used to diagnose miscarriage?
ultrasound Scan
Speculum exam
What is determined in US scan of miscarriage?
Confirm pregnancy in situ (+/- foetal heart), in process of expulsion, empty uterus
What is seen on speculum exam in miscarriage?
Closed os (threatened)
Products sited at open os (inevitable)
Products in vagina and os closing (complete)
How does cervical shock present?
Cramps, nausea/vomiting, sweating, fainting
When does cervical shock resolve?
When products are removed from cervix
How should patients with cervical shock be resuscitated?
IVI, uterotonics
What are the causes and pathophysiology for miscarriage?
Embryonic abnormality
Immunologic
Infections
Severe emotional upset, stress
Iatrogenic after CVS (infection or uterine irritability)
Uncontrolled diabetes
What Embryonic abnormality causes miscarriage?
Chromosomal
What immunologic issues cause miscarriage?
APS (LAC)
What infections cause miscarriage?
CMV, rubella, toxoplasmosis, listeriosis
What lifestyle choices are associated with miscarriage?
Heavy smoking, cocaine, alcohol misuse
What is a proposed pathophysiology of miscarriage?
Bleeding from placental bed or chorion causing hypoxia and villous/placental dysfunciton
Causes embyronic demise
Define threatened miscarriage
There is a risk to pregnancy
Define inevitable miscarriage
Pregnancy can’t be saved
Define incomplete miscarriage
Part of pregnancy lost already
Define complete miscarriage
All of pregnancy lost, uterus is empty
What is early foetal demise?
Pregnancy in-situ, no heartbeat: MSD > 25mm, FP >7mm
MSD: mean gestational sac diameter
What is an anembryonic pregnancy?
No foetus, empty sac
How is management of miscarriage dictated?
Dictated by findings
What are the treatment options for miscarriage?
Conservative, medical, MVA/surgical
What is recurrent miscarriage?
3 or more pregnancy loses
What are the causes of recurrent miscarriage?
- 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
When would uterine abnormality be suspected as cause for miscarriage?
Recurrent miscarriages in late first trimester
What can be done for women with recurrent miscarriages?
Use of low dose aspirin (LDA) and daily fragmin injections after confirmation of viable IUP in evidence of APS or thrombophilia
What are the common sites for ectopic pregnancy?
Fallopian tube; interstitial, isthmic, ampullary or fimbrial
What are sites of ectopic pregnancy other than fallopian tube?
Ovary, peritoneum, other organs e.g. liver, cervix, c-section scar
Describe presentation of ectopic pregnancy
Pain > bleeding, dizziness/collapse/shoulder tip pain, short on breath
Describe findings in ectopic pregnancy
Pallor
Haemodynamic instability
Signs of peritonism
Guarding and tenderness
What is the commonest site of ectopic pregnancy?
Ampullary
What is recommended for a woman with a suspected ectopic pregnancy and deteriorating symptoms?
Urgently reviewed by a senior gynaecologist
What are the red flag signs for ectopic pregnancy?
- Repeated presentation with abdominal and/or pelvic pain
- pain requiring opiates
What are the investigations for ectopic pregnancy?
FBC, G&S, bHCG, USS
What may be seen on USS of ectopic pregnancy?
Empty uterus/pseudo sac
Mass in adnexa
Free fluid in pouch of douglas
Describe assessment of hCG in ectopic pregnancy
Comparative assesment 48hours apart if haemodynamically stable, to assess doubling
What is the management of ectopic pregnancy?
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)
What is the standard treatment for medically managed ectopic pregnancy?
Methotrexate
What is molar pregnancy?
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’
What are the types of molar pregnancy?
Complete and partial
________ mole has a 2.5% risk of ___________
Complete mole has a 2.5% risk of choriocarcinoma
What is a complete mole?
- egg without DNA
- 1 or 2 sperm fertilise, result in diploid (paternal contribution only)
- no foetus
- overgrowth of placental tissue
What is a partial mole?
- haploid egg
- 1 sperm (reduplicating DNA material) or 2 sperms fertilising egg, result in triploidy
- may have foetus
- overgrowth of placental tissue
What creates the snowstorm appearance of complete moles?
Multiple placental vesicles
What are the important issues at presentation suggesting molar pregnancy?
- hyperemesis
- varied bleeding and passage of ‘grapelike tissue’
- fundus > dates
- occasional SOB
What is the management of molar pregnancy?
Surgical and tissue for histology
Follow up with molar pregnancy services
What is implantation bleeding?
Bleeding when egg implants into uterine wall
About 10 days post-ovulation
Bleeding is light/brownish and limited
Ocassionally mistaken as period
What is chorionic haematoma?
Pooling of blood between endometrium and the embryo due to separation: sub-chorionic
How does chorionic haematoma present?
Bleeding, cramping and threatened miscarriage
What is the prognosis of chorionic haematoma
If small pregnancy usually continues
If large may be source of infection, irritability causing cramping and miscarriage
What are the cervical causes of bleeding in early pregnancy?
Ectopy/ectropion
Infections: chlamydia, gonococcal or bacterial
Polyp
Malignancy- growth or generalised angry erosion
What are the vaginal causes of bleeding in early pregnancy?
- infections
- trichomoniasis (strawberry vagina)
- bacterial vaginosis
- chlamydia
- malignancy
- ulcers
- rare cause of bleeding in reproductive age
- forgotten tampon
How is BV treated in pregnancy?
Metronidazole 400mg b.d. 7 days
Can have vaginal gel
How is chlamydia treated during pregnancy?
Erythromycin, amoxicillin
test of clearance 3 week later
What are the causes of pain in pregnancy?
- 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
What is the dose of Anti-D for rhesus negative women who have a surgical miscarriage?
500 IU
What is hyperemesis gravidarum?
Excessive, protracted vomiting altering the quality of life beyond the 1st trimester
What can hyperemesis gravidarum result in?
- dehydration, ketosis, electrolyte and nutritional disbalance
- weight loss, altered liver funciton (50%)
- malnutrition
- emotional instability, anxiety, depression
What must be excluded before HG is diagnosed?
UTI, gastritis, peptic ulcer, viral hepatitis, pancreatitis
What is the managment of HG?
- rehydration IVI, electrolyte replacement
- parenteral antiemetic
- nutritional supplement
- vitamin supplement : thiamine/pabrinex
- NG feeding, TPN
- steroid use in recurrent, severe cases
- thromboprophylaxis
What are the 1st line antiemetics for HG?
- cyclizine (50mg p.o. IM or IV 8hourly)
- prochloperazine (12.5mg IM/IV 8 hourly or 5-10mg p.o. 8 hourly)
What are the second line antiemetics for HG?
- 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
What medications aside from anti-emetics should be given in HG?
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
