Early Pregnancy Complications Flashcards
Describe the clinical findings, USS findings and management of a threatened miscarriage
Bleeding and abdominal pain with a closed cervix
Intrauterine pregnancy with heart activity
Watch and wait, rescan in 10 days. Anti-D if appropriate
Describe the clinical findings, USS findings and management of a complete miscarriage
Bleeding and pain ceased with a closed cervix
Empty uterus and endometrial thickness <15mm
Anti-D if appropriate
If bleeding persists for >2 weeks consider RPOC or endometritis
Describe the clinical findings, USS findings and management of an incomplete miscarriage
Bleeding and pain. Cervix open (can be closed)
Heterogenous tissue +/-gestational sac
Anti-D if appropriate
Describe the clinical findings, USS findings and management of a missed miscarriage/early foetal demise
Bleeding
Pain
Loss of pregnancy symptoms
Closed cervix
Foetal pole >7mm with no heart activity OR
Mean gestation sac diameter >25 mm with no foetal pole or yolk sac
Expectant, medical or surgical
Anti-D if appropriate
Describe the clinical findings, USS findings and management of an inevitable miscarriage
Bleeding
Pain
Open cervix
Intrauterine gestation sac, foetal pole and foetal heart activity
Expectant, medical or surgical
Anti-D if appropriate
Describe the clinical findings, USS findings and management of a pregnancy of unknown viability
Bleeding
Pain
Closed cervix
Foetal echo with CRL <7mm with no heart activity OR
Mean gestation sac diameter <25 mm with no foetal pole or yolk sac
Rescan in 1 week
Anti-D if appropriate
Describe the clinical findings, USS findings and management of a pregnancy of unknown location
Bleeding
Pain
Closed cervix
Positive pregnancy test
Empty uterus
No sign of extrauterine pregnancy
Serial hCG 48 hours apart and serum progesterone level
Anti D if appropriate
What can cause a miscarriage
Usually genetic issues in the foetus
Maternal disease – poorly controlled diabetes, acute illness/infection, uterine anomalies and Thrombophilia’s/Antiphospholipid syndrome
Placental problems and multiple pregnancies
High pyrexia e.g. Malaria
Advanced maternal age – mother and father germ cell quality
Drugs, alcohol and smoking
What are the risk factors for miscarriage?
Advance maternal age Previous miscarriage Smoking Alcohol Drugs – NSAIDs and Aspirin, Narcotics Folate deficiency Consanguinity Always check for abnormal smears – bleeding and weakened cervix
How should a women who has come into the early pregnancy assessment unit with a suspected miscarriage be investigated?
- Abdominal Examination
- Speculum
- Bimanual Examination
- Urine Pregnancy test
- USS either TA (trans abdominal) or TV (trans vaginal)
- Serum BhCG
- Group and Save
- Serum progesterone - <20nmol indicates a failing pregnancy
How should a pregnancy of unknown location be investigated?
Could be ectopic pregnancy, complete miscarriage, or early uterine pregnancy. After confirming there is nothing in the uterus distinguish between these differentials with a serum beta hCG
>1500IU = ectopic pregnancy
<1500IU then repeat in 48 hours
• Viable pregnancy BhCG will increase by 63% every 48 hours
• Miscarriage BhCG will decrease by 63% every 48 hours
• If the change is outside these limits ectopic cannot be excluded
Describe the conservative/expectant management of a miscarriage and describe its advantages and disadvantages?
Can take 2 weeks for all tissue to pass – especially if intact sac. Access to Gynae services 24h, follow up scan after 2 weeks.
Offer medical if unsuccessful (or surgical if urgent)
Advantages Avoids risks of surgery/medication and can be at home
Disadvantages: Pain and bleeding is unpredictable, worrying at home is not nice, takes longer and may be unsuccessful.
Describe the medical management of a miscarriage and its advantages and disadvantages
Use of drugs to empty the uterus. Drugs used: Misoprostol (prostaglandins) – 1 dose if less than 9 weeks. Increase the dose if 9 weeks or greater. Given orally or Vaginally
Advantages: Avoids Surgery, high patient satisfaction if successful and can be done as outpatient or day case.
Disadvantages: pain and bleeding may be unpleasant and last many weeks; side effects of the drugs used and need for surgical management in about 5% of cases
Describe the surgical management of a miscarriage and its advantages and disadvantages?
If haemodynamically unstable or at patient’s choice. Highest complication rates. Use of a suction curette to empty the uterus – ERPC (evacuation of retaind product of conception. Takes around 5 minutes under general anaesthetic or can be done under local in a MVA (manual vacuum aspiration) – both done as day cases. Will feel normal after 24 hours but can bleed for 1-2 weeks. Uterine and cervical trauma minimised by administering prostaglandin before procedure.
Advantages: planned procedure and absolute closure
Disadvantages: complications: infection, haemorrhage, surgical damage to uterus, bowel or cervix. RPOC, adhesions, cervical tears and also anaesthetic risk.
Describe what women should be aware of if they chose to pass the POC at home?
Passing the POC may be painful and last up to 2 hours with bleeding. If excessive they need to come to hospital. Always send products to Histology to confirm they are POC and rule out trophoblastic disease.
Who should receive Anti-D prophylaxis
Should be given to all women <12 weeks with a uterine evacuation (medical or surgical) or with ectopic pregnancies. Should be given to all women >12 weeks with bleeding.
What is the definition of recurrent miscarriage?
Definition – loss of 3 or more consecutive pregnancies <24 weeks with the same partner.
What are the common causes of recurrent miscarriage?
Common causes:
• Antiphospholipid syndrome – treatable
• Parental genetics balanced rearrangements – IVF may be an option
• Foetal Genetic disorders – related to age
• Endocrine – poorly controlled diabetes or thyroid disease and PCOS
• Maternal anatomical abnormalities e.g. Cervical weakness, adhesions and fibroids
• Thrombophilic disorders
• Infection – bacterial vaginosis (rare)
What are the risk factors for recurrent miscarriage?
Advancing maternal age
Number of previous miscarriages
Lifestyle factors: smoking, drinking, obesity
How should recurrent miscarriages be investigated?
Antibodies – antiphospholipid
Thrombophilia screen
Karyotyping – parents and POC
USS of the uterus
How should recurrent miscarriages be managed?
Test for possible causes but keep trying – may just be bad luck
Lifestyle changes – very important
Genetic counselling
Antiphospholipid – low dose aspirin for primary prevention and LMWH therapy during pregnancy or for secondary prevention
Thrombophilia’s – heparin therapy
Surgical intervention in uterine abnormalities in very specific cases
What is gestational trophoblastic disease and what are the different types?
Spectrum of disorders of trophoblastic development arising from abnormal fertilisation
Pre-malignant
Hydatidiform mole/molar pregnancy
• Complete Mole (empty egg and 1 sperm) – benign tumour. Very high hCG
• Partial mole (egg and 2 sperm – more common and less likely to develop into malignancy). Can be normal hCG. Foetus may be present.
Malignant
Invasive Mole, Choriocarcinoma, placental trophoblastic site tumour and epithelioid trophoblastic tumour
What are the risk factors for Gestational trophoblastic disease?
Extremes of reproductive age
Ethnicity – east Asia
Previous molar pregnancy
What are the signs and symptoms of gestational trophoblastic disease?
Asymptomatic – USS diagnosis
Irregular vaginal bleeding in 1st trimester and anaemia
Uterus large for dates
Large theca lutein cysts from high BhCG stimulation
Exaggerated pregnancy symptoms: N and V, early pre-eclampsia and hyperthyroidism
How should gestational trophoblastic disease be investigated?
USS – suspicion but not confirmation
Confirmation by histology
Bloods – BhCG, TSH and Thyroxine (BhCG acts like TSH causing a thyrotoxicosis type presentation)
How is confirmed gestational trophoblastic disease managed? (when would chemotherapy be indicated?)
Surgical – SERPC (surgical evacuation of the products of conception)
Indications for Chemotherapy: • Serum hCG >20000IU • Static or rising hCG after SERPC • Persistent symptoms • Evidence of metastases • Histological diagnosis of choriocarcinoma
Once confirmed they are then registered at national centres where they have 6 months postal follow ups of urine and serum samples to monitor levels. Must not fall pregnant again in this time so contraception
What are choriocarcinomas and when are they seen?
50% preceded by hydatidiform mole. Also seen following ectopic pregnancies and miscarriages. Highly malignant with metastases to the lung. Treated with chemotherapy and has a 90% cure rate.
What are the symptoms of choriocarcinomas?
Symptoms
Similar to GTD
Lung symptoms due to metastasis
Intrabdominal bleeding due to invasion
How should choriocarcinomas be investigated?
Investigations
Chest X-ray and CT abdomen and chest
USS and serum hCG
What is hyperemesis gravidarum?
Excessive nausea and vomiting in early pregnancy. Diagnosis of exclusion.
Diagnosis - persistent 1st trimester Intractable vomiting (inability to keep solids or liquids down). Weight loss (5% baseline), muscle wasting, dehydration, hypovolaemia, electrolyte imbalance and haematemesis.
RCOG triad diagnostic guidelines
5% baseline weight loss
Electrolyte disturbance
Dehydration
What alternative differentials should be excluded before a diagnosis of hyperemsis gravidarum is made?
Must exclude:
Infections: UTI, gastroenteritis, appendicitis, pancreatitis etc.
Metabolic: Biochemical thyrotoxicosis, Graves’ disease, Addison’s and DKA
Tumours: Trophoblastic disease, islet cell or germ cell tumours.
80% of pregnant women will have N and V. True Hyperemesis affects only 0.1%
What can cause hyperemesis gravidarum?
Elevated hCG levels – more common in twins and molar pregnancies.
Elevated oestrogen and progesterone – decreased gut motility, increased liver enzymes and decreased cardiac sphincter pressure of the stomach.
Helicobacter pylori – subclinical infection activated by altered immunity in pregnancy
Psychological – difference in incidence in different populations and cultures
What are the risk factors for hyperemesis gravidarum?
Hyperthyroidism
Nulliparity
Multiple pregnancy
Obesity
What are the signs and symptoms of hyperemesis gravidarum?
Persistent and intractable excessive vomiting
Alpha subunit of hCG is the same as TSH so can present as a thyrotoxicosis
Usually no abdominal pain
Weight loss and muscle wasting (5% pre pregnancy)
Dehydration and electrolyte imbalance
Symptoms of dehydration and hypovolaemia
Raised ketones
How should hyperemesis gravidarum be investigated?
To assess level of vomiting – PUQE score (pregnancy unique quantification of emesis)
Urine dip for infections and ketones FBC – haematocrit for dehydration U and E especially looking at Potassium LFT (gall stones) and Amylase (ALT usually rises in excessive vomiting in pregnancy check again once vomiting stops) TFT – can be difficult to interpret USS exclude GTD/multiple pregnancies
How should hyperemesis gravidarum be managed?
Rehydration (NOT Glucose due to Wernicke’s encephalopathy – thiamine used up in glucose metabolism)
Control potassium levels
NBM for 24hours then introduce light diet as tolerated
Thiamine and folic acid replacement. Thiamine levels drop rapidly in pregnancy when not eating and can lead to Wernicke’s encephalopathy and Korsakoff’s Psychosis.
Antiemetics –
1st line: promethazine or Cyclizine. Route PO/IV/IM
2nd line: Prochlorperazine IM/IV or Metoclopramide PO/IV/IM
3rd line: ondansetron or graniestron (not actually licensed for pregnancy)
Consider thromboprophylaxis if severely dehydrated.
Rarely Steroids to stimulate appetite. Alternative routes of nutrition.
TOP if mother becomes very ill.
What complications can occur from hyperemesis gravidarum?
Liver and Renal failure Hyponatraemia Thiamine deficiency Foetal growth restriction Mallory Weiss tear
How should someone with bleeding before 6 weeks of gestation be managed?
If bleeding after 6 weeks gestation refer to early pregnancy assessment unit for investigation. If less than 6 weeks, with no pain or risk factors for ectopic pregnancy then manage expectantly. Return if bleeding continues or pain develops or is pregnancy test still positive after 7-10 days.
