Early Pregnancy Complications Flashcards
Define miscarriage
Pregnancy loss before 24 weeks
What are the symptoms of a miscarriage?
Positive pregnancy test, bleeding with period cramps
What can help to identify a miscarriage?
Ultrasound
Speculum examination to assess stage
What are the symptoms of cervical shock?
Cramps, nausea/vomiting, sweating, fainting
How is cervical shock managed?
Remove products from cervix, occasionally IV resuscitation is required
Name the causes of miscarriage
Embryonical abnormality Immune cause - anti phospholipid syndrome Infection - CMV, rubella, listeria Severe emotional upset/stress Iatrogenic Uncontrolled diabetes Alcohol/drugs
What are the four types of miscarriage?
Threatened
Inevitable
Incomplete
Complete
Describe a threatened miscarriage
Closed os and no product can be seen, risk to pregnancy
Describe an inevitable miscarriage
Pregnancy cannot be saved, open os but nothing in the vagina
Describe an incomplete miscarriage
Part of pregnancy is lost already, os is open and pregnancy can be seen
Describe a complete miscarriage
All of pregnancy is lost and the uterus is empty
On a scan what counts as a non-viable pregnancy
Sac diameter >25mm and foetal pole >7mm with no heartbeat
What is the name given to the presence of a sac but no foetus?
Anmbryonic pregnancy
Describe the different management options in a miscarriage
Conservative
Medical (miepristone and misoprostol)
Manual Vacuum Aspiration
Surgical Evacuation
What investigations should be done on a patient with a suspected miscarriage?
FBC, group and save, serum hCG, ultrasound and histology
What should be given in patients who require surgical intervention for miscarriage?
Anti-D
What counts as recurrent miscarriage?
3 or more pregnancy losses
State the causes of recurrent miscarriage
Antiphospholipid syndrome Thrombophilia Balanced translocations Uterine abnormality Age Previous miscarriage
How is anti phospholipid syndrome managed?
Low dose aspirin
Daily frogmen
What treatment can be given in recurrent miscarriages?
Progesterone pessary if >35 and more than two miscarriages
Define ectopic pregnancy
Normal embryo implanted out with the uterine cavity
What are sites for ectopic pregnancy?
Fallopian tube - interstitial, isthmus, ampulla or fibrial part
Ovary
Peritoneum
Other organs - liver, cervix, C-section scar
How will an ectopic pregnancy present?
Pain, bleeding, dizziness, collapse, shoulder tip pain, SOB, pallor, peritonism, haemodynamically unstable, guarding and tenderness
What are the red flags in early pregnancy?
Repeated presentation with abdominal +/- pelvic pain or pain requiring opiates
Describe the investigations for ectopic pregnancy
FBC, blood group and save, beta HCG, transvaginal ultrasound
What may be seen on transvaginal ultrasound in an ectopic pregnancy?
Empty uterus, pseudo sac, mass outside of cavity, free fluid in the pouch of douglas
What is the use of serum hCG?
It can be used to show a comparison and if decreasing conservative treatment can be used
What are the risk factors for an ectopic pregnancy?
Previous ectopic pregnancy, pelvic inflammatory disease (chlamydia), tubal surgery, C-section
How are ectopic pregnancies managed?
Conservative
Medical if woman is stable and low levels of beta HCG
Surgery
Describe the medical management of an ectopic pregnancy
Small un-ruptured ectopic pregnancy, beta HCG<5000 methotrexate given in one or two doses
What guides the progress of an ectopic pregnancy?
Progesterone levels
What is the surgical management of an ectopic pregnancy?
Laparoscopic salpingectomy
Define molar pregnancy
Non-viable fertiliser egg part of gestational trophoblastic disease
Describe a molar pregnancy histologically
Overgrowth of placental tissue with chorionic villi swollen with fluid in grape like clusters
What are the two types of molar pregnancy?
Complete
Partial
What is the DNA difference between complete and partial?
Complete - only paternal 46 chromosomes
Partial - Triploidy 69 chromosomes
Describe the classic ultrasound appearance of a molar pregnancy
Snowstorm created by multiple placental vesicles in complete mole
May be theca lutein cysts
What are important warning signs of a molar pregnancy?
Hyperemesis Hyperthyroidism Early onset pre-eclampsia Varied bleeding and passage of grape like tissue Uterus size > gestational age SOB or seizures are rare
How is a molar pregnancy managed?
Uterine evacuation and biopsy
What is the risk of a complete molar pregnancy?
Choriocarcinoma
Describe implantation bleeding and how it is managed
Occurs when the fertilised egg implants in the endometrial lining - 10 days post ovulation
Light brown often mistaken as a period as it can be similar - watchful waiting
What is a chorionic haematoma?
Pooling of blood between endometrium and embryo due to separation (sub-chorionic)
What does a chorionic haematoma cause?
Bleeding, cramping, threatened miscarriage
How are chorionic haematomas managed?
Usually self limiting and resolve
Larger - source of infection, irritability or miscarriage so follow up is important
What are the cervical causes of bleeding?
Polyps, ectopy, infection, malignancy
What are the vaginal causes of bleeding?
Infection (trichomaniosis, bacterial vaginosis, chlamydia)
Malignancy
Forgotten tampon
How is vaginosis treated in pregnancy?
Metronidazole 400mg BD 7 days
How is chlamydia treated in pregnancy?
Erythromycin/amoxicillin with cure test 3 weeks later
What is the aim of an anti-D injection?
Neutralise anti-D antigen and prevent sensitisation of immune system from forming anti-D antibody in rhesus negative women
Define Hyperemesis Gravidarum
Vomiting excessively altering quality of life
How does Hyperemesis Gravidarum present?
Dehydration, ketosis, electrolyte/nutritional disturbance, weight loss, altered liver function, emotional instability
How is Hyperemesis Gravidarum managed?
Diagnosis of exclusion
IVI rehydrate and electrolyte replacement
Antiemetic (cyclizine, prochloperazine, metaclopromide)
Vitamin supplement
Nutritional support
Thromboprophylaxis
What is given in Hyperemesis Gravidarum if severe and recurrent?
Steroids
In very extreme circumstances where a woman’s life is at risk in Hyperemesis Gravidarum what may be required?
Termination of Pregnancy
