Early Pregnancy Complications

Question 1

Miscarriage is defined as _______

Answer 1

loss of pregnancy before 24 weeks (if after 24 weeks it is stillbirth)

Question 2

Miscarriage rates decrease with _________

Answer 2

advancing gestation

Question 3

Pathophysiology of miscarriage is unclear but majority are thought to be related to _________ other factors include ________

Answer 3

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

Question 4

What is the primary symptom of miscarriage?

Answer 4

Bleeding is primary symptom, pain is mild similar to period pain

Question 5

Examination of suspected miscarriage?

Answer 5

need speculum exam to assess state of cervix and transvaginal ultrasound to check if anything in the uterus

Question 6

What is seen if threatened pregnancy on speculum exam?

Answer 6

cervical os is closed

Question 7

What is seen if inevitable miscarriage on speculum exam?

Answer 7

products sited at open os

Question 8

What is seen if complete miscarriage on speculum exam?

Answer 8

products in vagina and os closed

Question 9

Describe a threatened miscarriage and management?

Answer 9

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

Question 10

Describe management for an incomplete or completed miscarriage?

Answer 10

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

Question 11

Describe rhesus positive and negative and what the risk is? How is this related to miscarriage?

Answer 11

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

Question 12

Define recurrent miscarriage?

Answer 12

loss of 3 or more consecutive pregnancies and affects 1-2% of women trying to conceive

Question 13

Most causes of recurrent miscarriage __________

Answer 13

remain unexplained

Question 14

What is the most treatable cause of recurrent miscarriage? What percentage? How is it treated?

Answer 14

Anti-phospholipid syndrome is present in 15-20% of women with recurrent miscarriage and is managed with low dose aspirin and heparin

Question 15

Define ectopic pregnancy?

Answer 15

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

Question 16

Primary symptom of ectopic pregnancy? What are others?

Answer 16

main symptom is pain

there is less bleeding than there is in a miscarriage, may collapse, SOB, shoulder tap pain

Question 17

Exam findings on a woman with ectopic pregnancy?

Answer 17

pallor, haemodynamic instability, signs of peritonism, guarding and tenderness

Question 18

Investigations that should be conducted on a woman with suspected ectopic pregnancy?

Answer 18

FBCs, G and S (to determine blood group), beta HCG, ultrasound

Question 19

Gold standard test for diagnosis of ectopic pregnancy?

Answer 19

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

Question 20

Red flags for ectopic pregnancies?

Answer 20

woman presenting with repeated abdo and/ or pelvic pain or pain requiring opiates when pregnant

Question 21

Management of ectopic pregnancies?

Answer 21

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

Question 22

What are the two types of molar pregnancy?

Answer 22

complete mole, partial mole

Question 23

Describe a complete mole?

Answer 23

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

Question 24

Describe a partial mole?

Answer 24

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

Question 25

Presentation of a molar pregnancy?

Answer 25

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

Question 26

Snowstorm appearance on ultrasound?

Answer 26

molar pregnancy

Question 27

A compete mole has a 2.5% risk of developing into a _______

Answer 27

choriocarcinoma

Question 28

Management of a molar pregnancy?

Answer 28

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

Question 29

Explain what implantation bleeding is?

Answer 29

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

Question 30

Implantation bleeding usually occurs ______

Answer 30

10 days post ovulation

Question 31

Why can implantation bleeding sometimes be mistaken for a period?

Answer 31

timing- occurs 10 days post ovulation so almost lines up with cycle
can sometimes be heavier and more red so looks like period

Question 32

What is a chorionic haematoma?

Answer 32

a pooling of blood between the chorion (membrane surrounding the embryo) and the endometrium
occurs in 3.1% of all pregnancies

Question 33

Chorionic haematoma can cause ________

Answer 33

bleeding and cramping

Question 34

Large chorionic haematomas can be a source of _________

Answer 34

infection, irritability (causing cramping), and miscarriage

Question 35

Are most chorionic haematomas serious?

Answer 35

no, most are self limiting and resolve

Question 36

How can chorionic haematomas be picked up?

Answer 36

they can be seen on ultrasound

Question 37

Management of chorionic haematomas?

Answer 37

reassurance is important but surveillance should remain

Question 38

What is hyperemesis gravidarum?

Answer 38

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

Question 39

Presentation of HG?

Answer 39

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

Question 40

Management of HG?

Answer 40

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

Question 41

First line anti emetic for HG?

Answer 41

cyclizine or promethazine

Question 42

Molar pregnancies are very rare but who are they more common in ?

Answer 42

asian populations