Early Pregnancy Complications Flashcards
Miscarriage is defined as _______
loss of pregnancy before 24 weeks (if after 24 weeks it is stillbirth)
Miscarriage rates decrease with _________
advancing gestation
Pathophysiology of miscarriage is unclear but majority are thought to be related to _________ other factors include ________
majority: random genetic abnormalities in the foetus or embryo
other factors: infections (CMV, rubella, toxoplasma, listeria), severe emotional upset, iatrogenic after sampling, anti-phospholipid syndrome, uncontrolled diabetes, smoking, drugs, alcohol
What is the primary symptom of miscarriage?
Bleeding is primary symptom, pain is mild similar to period pain
Examination of suspected miscarriage?
need speculum exam to assess state of cervix and transvaginal ultrasound to check if anything in the uterus
What is seen if threatened pregnancy on speculum exam?
cervical os is closed
What is seen if inevitable miscarriage on speculum exam?
products sited at open os
What is seen if complete miscarriage on speculum exam?
products in vagina and os closed
Describe a threatened miscarriage and management?
there is PV bleeding with os closed, either the person goes on to miscarry or the pregnancy continues, advice is to rest, no sex, no tampons, sometimes given progesterone supplements
Describe management for an incomplete or completed miscarriage?
4 options
conservative: wait for it to happen
medical: prostaglandins misoprostol induce uterine contractions, this can cause heavy bleeding, pain and sometimes bits left behind
vacuum: done under local anaesthetic
surgery: done under GA carries a risk to the uterus
Describe rhesus positive and negative and what the risk is? How is this related to miscarriage?
Rhesus positive babies born to rhesus negative mothers carry a risk of haemolytic disease of the newborn
this is because if the mother gets in contact with the baby’s blood she will form rhesus antibodies meaning that the mothers blood can start attacking the baby’s RBCs, blood from the mother and baby generally dont mix but there is a chance of mixing if miscarriage particularly if surgery so if mother is rhesus negative and has heavy bleeding, surgery or more than 13 weeks when miscarry they should be given anti D this is so they dont start forming their own antibodies to Rhesus
Define recurrent miscarriage?
loss of 3 or more consecutive pregnancies and affects 1-2% of women trying to conceive
Most causes of recurrent miscarriage __________
remain unexplained
What is the most treatable cause of recurrent miscarriage? What percentage? How is it treated?
Anti-phospholipid syndrome is present in 15-20% of women with recurrent miscarriage and is managed with low dose aspirin and heparin
Define ectopic pregnancy?
implantation of the fertilised ovum outside the uterine cavity, usually in the uterine tube, other sites include ovary, peritoneum, other organs or C section scar
Primary symptom of ectopic pregnancy? What are others?
main symptom is pain
there is less bleeding than there is in a miscarriage, may collapse, SOB, shoulder tap pain
Exam findings on a woman with ectopic pregnancy?
pallor, haemodynamic instability, signs of peritonism, guarding and tenderness
Investigations that should be conducted on a woman with suspected ectopic pregnancy?
FBCs, G and S (to determine blood group), beta HCG, ultrasound
Gold standard test for diagnosis of ectopic pregnancy?
traditionally laparoscopy was gold standard for diagnosis of an ectopic pregnancy but improvements in transvaginal ultrasound mean many people now view that as gold standard
Red flags for ectopic pregnancies?
woman presenting with repeated abdo and/ or pelvic pain or pain requiring opiates when pregnant
Management of ectopic pregnancies?
management depends on presentation
- if mild symptoms and small pregnancy can just do monitoring
- if monitoring is not suitable but woman is stable with low BHCG and no rupture then medical management is done, this involves an injection of methotrexate which blocks enzymes maintaining the pregnancy and stops it growing any bigger
- if patient is acutely unwell they will need surgical management- salpingectomy (removal of tube) or salpingostomy (remove pregnancy only), if rhesus neg they will need antibodies
What are the two types of molar pregnancy?
complete mole, partial mole
Describe a complete mole?
This occurs when an ovum lacking its nucleus is fertilised by 1 or 2 sperm resulting in a diploid cell but only with paternal contribution
There is no fetus
The uterus is filled with grape like cluster of cysts of varying sizes
Describe a partial mole?
This occurs when an ovum is fertilised by 1 sperm (reduplicating its DNA) or 2 sperm resulting in triploidy
There is a malformed/ non viable fetus and overgrowth of the placental tissue
Presentation of a molar pregnancy?
Hyperemesis, hyperthryoidism, early onset pre-eclampsia
varied bleeding and occasional passage of grape like tissue
size of uterus on fundal palpation is bigger than that expected for gestation length
ultrasound shows snowstorm appearance plus or minus a foetus
in rare cases: SOB due to embolisation to lungs, seizures due to metastases to the brain
Snowstorm appearance on ultrasound?
molar pregnancy
A compete mole has a 2.5% risk of developing into a _______
choriocarcinoma
Management of a molar pregnancy?
uterine evacuation surgery is done and the tissue is sent for histology to ascertain the type of mole
registration and follow up with molar pregnancy services
Explain what implantation bleeding is?
normal bleeding that occurs in 1/4 women
occurs when the fertilised egg implants in the endometrial lining
timing about 10 days post ovulation
bleeding is usually light and brownish and self limiting
sometimes bleeding can be mistaken for a period though
signs of pregnancy soon emerge
Implantation bleeding usually occurs ______
10 days post ovulation
Why can implantation bleeding sometimes be mistaken for a period?
timing- occurs 10 days post ovulation so almost lines up with cycle
can sometimes be heavier and more red so looks like period
What is a chorionic haematoma?
a pooling of blood between the chorion (membrane surrounding the embryo) and the endometrium
occurs in 3.1% of all pregnancies
Chorionic haematoma can cause ________
bleeding and cramping
Large chorionic haematomas can be a source of _________
infection, irritability (causing cramping), and miscarriage
Are most chorionic haematomas serious?
no, most are self limiting and resolve
How can chorionic haematomas be picked up?
they can be seen on ultrasound
Management of chorionic haematomas?
reassurance is important but surveillance should remain
What is hyperemesis gravidarum?
vomiting and nausea in the first trimester is common (50-80%) and usually self limiting and mild
if excessive, protractive and alters quality of life it is called hyperemesis gravid arum which occurs in 0.3% - 3% of pregnancies
Presentation of HG?
prolonged and severe nausea and vomiting
dehydration, ketosis, electrolyte and nutritional disturbances
weight loss
hypotension
emotional instability, in severe cases depression
HG is a diagnosis of exclusion as you need to rule out other causes of vomiting first
Management of HG?
Rehydration, IV nutritional and electrolyte replacement
first line anti-emetic= cyclizine or promethazine
thiamine vitamin supplements
steroid used in severe recurrent cases (oral prednisolone)
if weight loss need to monitor baby growth to check HG is not causing fetal growth restriction
may need to do NG feeding or TPN
thromboprophylaxis is needed as increased risk of blood clots
First line anti emetic for HG?
cyclizine or promethazine
Molar pregnancies are very rare but who are they more common in ?
asian populations
