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Early Pregnancy Complications Flashcards

1
Q

What is measured in a urine pregnancy test?

A

hCG = human chorionic gonadotrophin

High sensitivity = can detect pregnancy as early as 20 IU

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2
Q

Where does fertilisation occur?

A

In the fallopian tubes

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3
Q

Where does the morula/blastocyst migrate to after fertilisation?

A

The uterine cavity = implantation occurs

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4
Q

What are the normal outcomes of fertilisation?

A

Embryo, normal in location and development, live birth

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5
Q

How common in minimal bleeding in early pregnancy?

A

Common issue = 20%

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6
Q

What are some abnormal pregnancy outcomes?

A

Miscarriage, ectopic pregnancy, molar pregnancy

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7
Q

What are some symptoms that commonly accompany bleeding in early pregnancy?

A

Pain (cramps), hyperemesis, dizziness/fainting

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8
Q

How may a miscarriage present?

A

Positive pregnancy test with varied gestation
Bleeding is most common symptom
May bring in passed products

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9
Q

What will a speculum exam help confirm in a miscarriage?

A

Is os closed (threatened), products sited at open os (inevitable) or in vagina and os closing (complete)?

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10
Q

What will a scan help confirm in a miscarriage?

A

Helps confirm pregnancy in-situ, expulsion or empty uterus

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11
Q

What are the symptoms of cervical shock?

A

Cramps, nausea/vomiting, sweating, fainting

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12
Q

When does cervical shock resolve?

A

If products are removed from cervix

May need IV infusion and uterotonics

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13
Q

What are some causes of miscarriage?

A 
Embryonic abnormality or antiphospholipid syndrome
CMV, rubella, toxoplasmosis or listeria
Severe emotional upset or stress
Following chorionic villus sampling
Heavy smoking, alcohol abuse or cocaine
Uncontrolled diabetes
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14
Q

What is the pathophysiology of a miscarriage?

A

Bleeding from placental bed or chorion leads to hypoxia and villous/placental dysfunction = causes embryonic demise

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15
Q

What are the types of miscarriage?

A 
Threatened = risk to pregnancy
Inevitable = pregnancy can't be saved
Incomplete = part of pregnancy lost already
Complete = all of pregnancy lost, uterus is empty
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16
Q

What is early foetal demise?

A

Type of miscarriage = pregnancy in-situ, no heartbeat, mean sac diameter >25mm, foetal pole >7mm

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17
Q

What is an anembryonic pregnancy?

A

Type of miscarriage = no foetus and empty sac

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18
Q

What investigations may be done for a miscarriage?

A

FBC, group and save, hCG, USS, histology

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19
Q

How are miscarriages managed?

A

Assess and ensure haemodynamic stability

May discharge or admit as inpatient

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20
Q

How are miscarriages treated?

A

Conservative, medical, manual vacuum aspiration, surgery = begin anti-D if surgery needed
Emotional support, info leaflets and support groups

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21
Q

What is recurrent miscarriage?

A

3 or more pregnancy losses

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22
Q

What are some causes of recurrent miscarriage?

A

Antiphospholipid syndrome or balanced translocation
Thrombophilia = factor V leiden or prothrombin mutations, protein C, free protein S, antithrombin
Uterine abnormality = 1st trimester losses

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23
Q

What are the independent risk factors for recurrent miscarriage?

A

Age, previous miscarriage

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24
Q

What was the PRISM trial?

A

Showed that progesterone may prevent miscarriage in women with bleeding in early pregnancy

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25
Q

What is an ectopic pregnancy?

A

Implantation outwith the uterine cavity

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26
Q

What are some common sites for ectopic pregnancy to occur?

A

Fallopian tubes, interstitium, isthmus, ampulla, fimbriae

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27
Q

What are some other sites an ectopic pregnancy may occur?

A

Ovary, peritoneum, other organs (e.g liver, cervix)

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28
Q

How do ectopic pregnancies present?

A

Pain. bleeding, dizziness/collapse, shoulder tip pain, SOB, pallor, haemodynamic instability, signs of peritonism, guarding and tenderness

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29
Q

How should a woman with suspected ectopic pregnancy and deteriorating symptoms be managed?

A

Urgent reviewal directly by senior gynaecologist

30
Q

What are the red flags for ectopic pregnancy?

A

Repeated presentation with abdominal pain and/or pelvic pain, or any pain requiring opiates in a woman known to be pregnant

31
Q

What investigations can be done for ectopic pregnancy?

A

FBC, group and save, USS, serum hCG

32
Q

What may an USS of an ectopic pregnancy show?

A

Empty uterus or pseudo-sac +/- mass in adnexa

Free fluid in pouch of Douglas

33
Q

How is serum hCG measured in a suspected ectopic pregnancy?

A

Comparative assessment 48hrs apart if haemodynamically stable = to assess doubling

34
Q

How is ectopic pregnancy managed?

A 
Surgical = if patient acutely unwell
Medical = if stable, low levels of hCG and ectopic is small and unruptured
Conservative = well patient who is compliant with follow up visits
35
Q

What is molar pregnancy?

A

Gestational trophoblastic disease = non-viable fertilised egg

36
Q

What occurs in molar pregnancy?

A

Overgrowth of placental tissue with chorionic villi swollen with fluid = grape-like clusters

37
Q

What are the types of molar pregnancy?

A

Complete or partial

38
Q

What malignancy do complete molar pregnancies carry a risk of?

A

Have 2.5% risk of choriocarcinoma

39
Q

What are the features of a complete molar pregnancy?

A

Egg without DNA
1 or 2 sperm fertilise = results in diploid with only parental DNA present
No foetus

40
Q

What are the features of a partial molar pregnancy?

A

Haploid egg
1 sperm reduplicates DNA or 2 sperm fertilise egg = results in triploidy
Foetus may be present

41
Q

How can molar pregnancy present?

A

Hyperemesis
Varied bleeding and passage of grape-like tissue
Fundus is bigger than dates
Occasional SOB

42
Q

What does a USS of a molar pregnancy show?

A

Snow storm appearance +/- foetus

43
Q

What is the management of molar pregnancy?

A

Surgical and tissue sampling for histology

Follow up with molar pregnancy service

44
Q

When does implantation bleeding occur?

A

Timing is about 10 days post ovulation = occurs when fertilised egg implants into uterine wall

45
Q

What is the blood that passes during implantation bleeding usually like?

A

Light/brown and limited

46
Q

Why might implantation bleeding be mistaken for a period?

A

Can occur 2 weeks post ovulation

May be heavier bleed of bright red blood

47
Q

How is implantation bleeding managed?

A

Watchful waiting = usually settles and pregnancy continues

48
Q

What is a chorionic haematoma?

A

Pooling of blood between endometrium and embryo due to separation

49
Q

What are the symptoms of a chorionic haematoma?

A

Bleeding, cramping, threatened miscarriage

50
Q

How are chorionic haematomas managed?

A

Usually self limiting and resolves on its own = surveillance is needed

51
Q

What may large chorionic haematomas cause?

A

Infection, irritability and miscarriage

52
Q

What are some cervical causes of bleeding in early pregnancy?

A

Ectopy/ectopion and polyps
Infection = chlamydia, gonococcal, bacteria
Malignancy = growth or generalised erosion

53
Q

What may be present in the history of a patient with a cervical cause to their bleeding?

A

Missed attendance at colposcopy

Never had a cervical smear

54
Q

What are some vaginal causes of bleeding in early pregnancy?

A

Infection = trichomoniasis, bacterial vaginosis, chlamydia
Malignancy = ulcers, tends to be rare
Forgotten tampon

55
Q

How is bacterial vaginosis treated in pregnancy?

A

Metronidazole 400mg twice daily for 7 days
Avoid alcohol when taking medication
Option of vaginal gel

56
Q

How is chlamydia treated in pregnancy?

A

Erythromycin or amoxicillin
Test for resolution 3 weeks later
Include partner tracing

57
Q

What are some causes of bleeding unrelated to the reproductive tract?

A 
Urinary = bladder infection with haematuria 
Bowel = haemorrhoids, malignancy (rare)
58
Q

What is the character of the pain felt during a miscarriage?

A

Varied intensity and frequency

Bleeding tends to be more common than pain

59
Q

What is the character of the pain felt with an ectopic pregnancy?

A

Pain is predominant symptom
May range from dull ache to sharp stabbing
Peritonism may cause rigidity or rebound tenderness

60
Q

What are rhesus negative women at risk of?

A

May miscarry of develop ectopic/molar pregnancy

61
Q

When is anti-D given?

A

To women being managed with surgery = dose is 500 IU

62
Q

How common is vomiting in the first trimester?

A

Common = 50-80%, tends to be limited and mild, starts as early as around time of missed period

63
Q

What is hyperemesis gravidarium?

A

Excessive and protracted vomiting during pregnancy = damaging to quality of life, occurs in 0.3-3%

64
Q

What effects can hyperemesis gravidarium have?

A

Dehydration, ketotsis, electrolyte/nutritional disbalance, weight loss, altered liver function (up to 50%), signs of malnutrition

65
Q

What mood disturbances can occur in hyperemesis gravidarium?

A

Emotional instability and anxiety

Severe cases can cause mental health issues

66
Q

What must be ruled out before you diagnose hyperemesis gravidarium?

A

Diagnosis of exclusion = rule out UTI, gastritis, peptic ulcer, viral hepatitis, pancreatitis

67
Q

What is the management for hyperemesis gravidarium?

A

Replacement with IV fluids and electrolytes
Parenteral anti-emetics and nutritional support
Thiamine and vitamin supplement
Steroids if recurrent or severe
Thromboprophylaxis

68
Q

What are the first line anti-emetics used to treat hyperemesis gravidarium?

A

Cyclizine 50mg

Prochlorperazine 12.5 mg IM/IV or 5-10mg orally

69
Q

What are the second line anti-emetics used to treat hyperemesis gravidarium?

A

Ondansetron 4-8mg

Metoclopramide 5-10mg

70
Q

What are some other medications given for hyperemesis gravidarium?

A

H2 receptor blocker (ranitidine) and PPI
Omeprazole
Oral prednisolone 40mg/day

71
Q

Why is early symptom resolution in hyperemesis gravidarium important?

A

Avoids need for medications for epilepsy, hypertension, diabetes and thyroid

72
Q

What is the outcome of hyperemesis gravidarium?

A

Can rarely extend to 2nd trimester or throughout pregnancy

Termination of pregnancy may be required in severe cases

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