Early Pregnancy Complications Flashcards
What is measured in a urine pregnancy test?
hCG = human chorionic gonadotrophin
High sensitivity = can detect pregnancy as early as 20 IU
Where does fertilisation occur?
In the fallopian tubes
Where does the morula/blastocyst migrate to after fertilisation?
The uterine cavity = implantation occurs
What are the normal outcomes of fertilisation?
Embryo, normal in location and development, live birth
How common in minimal bleeding in early pregnancy?
Common issue = 20%
What are some abnormal pregnancy outcomes?
Miscarriage, ectopic pregnancy, molar pregnancy
What are some symptoms that commonly accompany bleeding in early pregnancy?
Pain (cramps), hyperemesis, dizziness/fainting
How may a miscarriage present?
Positive pregnancy test with varied gestation
Bleeding is most common symptom
May bring in passed products
What will a speculum exam help confirm in a miscarriage?
Is os closed (threatened), products sited at open os (inevitable) or in vagina and os closing (complete)?
What will a scan help confirm in a miscarriage?
Helps confirm pregnancy in-situ, expulsion or empty uterus
What are the symptoms of cervical shock?
Cramps, nausea/vomiting, sweating, fainting
When does cervical shock resolve?
If products are removed from cervix
May need IV infusion and uterotonics
What are some causes of miscarriage?
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
What is the pathophysiology of a miscarriage?
Bleeding from placental bed or chorion leads to hypoxia and villous/placental dysfunction = causes embryonic demise
What are the types of miscarriage?
Threatened = risk to pregnancy Inevitable = pregnancy can't be saved Incomplete = part of pregnancy lost already Complete = all of pregnancy lost, uterus is empty
What is early foetal demise?
Type of miscarriage = pregnancy in-situ, no heartbeat, mean sac diameter >25mm, foetal pole >7mm
What is an anembryonic pregnancy?
Type of miscarriage = no foetus and empty sac
What investigations may be done for a miscarriage?
FBC, group and save, hCG, USS, histology
How are miscarriages managed?
Assess and ensure haemodynamic stability
May discharge or admit as inpatient
How are miscarriages treated?
Conservative, medical, manual vacuum aspiration, surgery = begin anti-D if surgery needed
Emotional support, info leaflets and support groups
What is recurrent miscarriage?
3 or more pregnancy losses
What are some causes of recurrent miscarriage?
Antiphospholipid syndrome or balanced translocation
Thrombophilia = factor V leiden or prothrombin mutations, protein C, free protein S, antithrombin
Uterine abnormality = 1st trimester losses
What are the independent risk factors for recurrent miscarriage?
Age, previous miscarriage
What was the PRISM trial?
Showed that progesterone may prevent miscarriage in women with bleeding in early pregnancy
What is an ectopic pregnancy?
Implantation outwith the uterine cavity
What are some common sites for ectopic pregnancy to occur?
Fallopian tubes, interstitium, isthmus, ampulla, fimbriae
What are some other sites an ectopic pregnancy may occur?
Ovary, peritoneum, other organs (e.g liver, cervix)
How do ectopic pregnancies present?
Pain. bleeding, dizziness/collapse, shoulder tip pain, SOB, pallor, haemodynamic instability, signs of peritonism, guarding and tenderness
How should a woman with suspected ectopic pregnancy and deteriorating symptoms be managed?
Urgent reviewal directly by senior gynaecologist
What are the red flags for ectopic pregnancy?
Repeated presentation with abdominal pain and/or pelvic pain, or any pain requiring opiates in a woman known to be pregnant
What investigations can be done for ectopic pregnancy?
FBC, group and save, USS, serum hCG
What may an USS of an ectopic pregnancy show?
Empty uterus or pseudo-sac +/- mass in adnexa
Free fluid in pouch of Douglas
How is serum hCG measured in a suspected ectopic pregnancy?
Comparative assessment 48hrs apart if haemodynamically stable = to assess doubling
How is ectopic pregnancy managed?
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
What is molar pregnancy?
Gestational trophoblastic disease = non-viable fertilised egg
What occurs in molar pregnancy?
Overgrowth of placental tissue with chorionic villi swollen with fluid = grape-like clusters
What are the types of molar pregnancy?
Complete or partial
What malignancy do complete molar pregnancies carry a risk of?
Have 2.5% risk of choriocarcinoma
What are the features of a complete molar pregnancy?
Egg without DNA
1 or 2 sperm fertilise = results in diploid with only parental DNA present
No foetus
What are the features of a partial molar pregnancy?
Haploid egg
1 sperm reduplicates DNA or 2 sperm fertilise egg = results in triploidy
Foetus may be present
How can molar pregnancy present?
Hyperemesis
Varied bleeding and passage of grape-like tissue
Fundus is bigger than dates
Occasional SOB
What does a USS of a molar pregnancy show?
Snow storm appearance +/- foetus
What is the management of molar pregnancy?
Surgical and tissue sampling for histology
Follow up with molar pregnancy service
When does implantation bleeding occur?
Timing is about 10 days post ovulation = occurs when fertilised egg implants into uterine wall
What is the blood that passes during implantation bleeding usually like?
Light/brown and limited
Why might implantation bleeding be mistaken for a period?
Can occur 2 weeks post ovulation
May be heavier bleed of bright red blood
How is implantation bleeding managed?
Watchful waiting = usually settles and pregnancy continues
What is a chorionic haematoma?
Pooling of blood between endometrium and embryo due to separation
What are the symptoms of a chorionic haematoma?
Bleeding, cramping, threatened miscarriage
How are chorionic haematomas managed?
Usually self limiting and resolves on its own = surveillance is needed
What may large chorionic haematomas cause?
Infection, irritability and miscarriage
What are some cervical causes of bleeding in early pregnancy?
Ectopy/ectopion and polyps
Infection = chlamydia, gonococcal, bacteria
Malignancy = growth or generalised erosion
What may be present in the history of a patient with a cervical cause to their bleeding?
Missed attendance at colposcopy
Never had a cervical smear
What are some vaginal causes of bleeding in early pregnancy?
Infection = trichomoniasis, bacterial vaginosis, chlamydia
Malignancy = ulcers, tends to be rare
Forgotten tampon
How is bacterial vaginosis treated in pregnancy?
Metronidazole 400mg twice daily for 7 days
Avoid alcohol when taking medication
Option of vaginal gel
How is chlamydia treated in pregnancy?
Erythromycin or amoxicillin
Test for resolution 3 weeks later
Include partner tracing
What are some causes of bleeding unrelated to the reproductive tract?
Urinary = bladder infection with haematuria Bowel = haemorrhoids, malignancy (rare)
What is the character of the pain felt during a miscarriage?
Varied intensity and frequency
Bleeding tends to be more common than pain
What is the character of the pain felt with an ectopic pregnancy?
Pain is predominant symptom
May range from dull ache to sharp stabbing
Peritonism may cause rigidity or rebound tenderness
What are rhesus negative women at risk of?
May miscarry of develop ectopic/molar pregnancy
When is anti-D given?
To women being managed with surgery = dose is 500 IU
How common is vomiting in the first trimester?
Common = 50-80%, tends to be limited and mild, starts as early as around time of missed period
What is hyperemesis gravidarium?
Excessive and protracted vomiting during pregnancy = damaging to quality of life, occurs in 0.3-3%
What effects can hyperemesis gravidarium have?
Dehydration, ketotsis, electrolyte/nutritional disbalance, weight loss, altered liver function (up to 50%), signs of malnutrition
What mood disturbances can occur in hyperemesis gravidarium?
Emotional instability and anxiety
Severe cases can cause mental health issues
What must be ruled out before you diagnose hyperemesis gravidarium?
Diagnosis of exclusion = rule out UTI, gastritis, peptic ulcer, viral hepatitis, pancreatitis
What is the management for hyperemesis gravidarium?
Replacement with IV fluids and electrolytes
Parenteral anti-emetics and nutritional support
Thiamine and vitamin supplement
Steroids if recurrent or severe
Thromboprophylaxis
What are the first line anti-emetics used to treat hyperemesis gravidarium?
Cyclizine 50mg
Prochlorperazine 12.5 mg IM/IV or 5-10mg orally
What are the second line anti-emetics used to treat hyperemesis gravidarium?
Ondansetron 4-8mg
Metoclopramide 5-10mg
What are some other medications given for hyperemesis gravidarium?
H2 receptor blocker (ranitidine) and PPI
Omeprazole
Oral prednisolone 40mg/day
Why is early symptom resolution in hyperemesis gravidarium important?
Avoids need for medications for epilepsy, hypertension, diabetes and thyroid
What is the outcome of hyperemesis gravidarium?
Can rarely extend to 2nd trimester or throughout pregnancy
Termination of pregnancy may be required in severe cases
