early pregnancy complications DONE Flashcards
implantation bleeding
few days of light bleed at point of implantation happens when they expect to see period
examination in early pregnancy
general - collapsed, pain, clammy
per abdomen - abdominal distension, scars
speculum - cervix - neck of womb internal os open, quantify bleeding
bimanual ex - uterus enlarged - fibroids, adenomyosis can also cause it
Ix for early pregnancy
- urine pregnancy test
USS - Transabdominal fine afteer 8 weeks gestation therefore do transvaginal
US inconclusive - serum BHCG level
above 1500 - nothing in uterus then ectopic more likely
serial measurement fails to rise by 60%
Group and save - collapse need transfusion, anti D
threatened miscarriage
Bleeding and or pain up to 20/40
closed cervical os
viable ongoing pregnancy fetal heart seen
incomplete miscarriage
PV bleeding cervix open Some POC have been passed Some tissues and blood clot remain within the uterus on US youll see POC in uterus
septic miscarriage
Septic Miscarriage
If POC infected → septic patient
Rare where Termination of pregnancy (TOP) is legal
IV ABx
complete miscarriage
- All products of conception have been passed
- Complete sac may be identifiable
- Bleeding and pain reducing
- Cervix now closed
- Cannot diagnose with USS – this can be helpful but no strict cut offs Caution required if no previous USS
US classification of miscarriages
- Missed miscarriage / Early fetal demise
- Failed pregnancy with no cardiac pulsations on USS - Blighted ovum / Anembryonic pregnancy
- Failed pregnancy with empty gestation sac i.e. no fetus present, fetus too small to see - Incomplete miscarriage / Retained products of conception
- Echogenic mass of blood clot and tissue within the uterine cavity >20mm in Anterior-posterior (AP) diameter - Complete miscarriage
Empty uterine cavity – Rough guide AP <20mm
MUST have seen an Intrauterine pregnancy (IUP) on scan before or Pregnancy of unknown location (PUL)
aetiology of miscarriage
- Never established in most cases (no need)
- Chromosomal abnormalities
- Congenital abnormalities
- Maternal disease
- – Poorly controlled diabetes
- – Acute illness / infection
- – Uterine anomalies
- – Thrombophilia/Antiphospholipid Syndrome
- age
- obesity or really low weight
RFs of miscarriage
Advanced maternal age (>/= 40)
Previous miscarriage 2 or more higher risk
OBESITY
Smoking
Alcohol (moderate to heavy) and drug use
NSAIDs and Aspirin
Street drugs
Folate deficiency
Consanguinity
Opportunity for health promotion
Certain uterine abnormalities (Mullerian duct anomalies, large cervical cone biopsies)
expectant Mx of miscarriage
when to take pregnancy test
Waiting for all POC to pass naturally usually over 2 weeks, but can be longer
take pregnancy test after 3 weeks
Must have 24 hour access to gynae service
advantages of conservative Mx
Avoid risks of surgery / medication
Can be at home
if they are <6 weeks gestation
disadva of conservative Mx
Pain and bleeding can be unpredictable
Worries re: being at home
Takes longer
May be unsuccessful – still requiring active management
Medical Mx if miscarriage
- Vaginal misoprostol
Prostaglandin analogue, binds to myometrial cells to cause strong myometrial contractions leading to the expulsion of tissue
+ antiemetics and pain relief
advantages of medical Mx of miscarriage
Avoids surgery
High patient satisfaction if successful
Can be done as outpatient in some centres
disadvantages of medical Mx of miscarriage
Pain and bleeding may be unpleasant and/or
severe
s/e of drugs
Need for emergency surgical management (SERPC) < 5%
surgical Mx of miscarriage
Use of suction curette to empty uterus
5 minute procedure under general anaesthetic (GA)
Vacuum aspiration is done under local anaesthetic as an outpatient
Day case
Return to normal physically 24 hours
Bleeding 1-2 weeks
advantages of surgical Mx
planned procedure, closure
Disadvantages of surgical Mx
Surgical (perforation, (bowel/bladder damage) damage to cervix, Asherman’s, Cervical weakness) and anaesthetic risk
define recurrent miscarriage
The loss of ≥ 3 CONSECUTIVE pregnancies with SAME partner
causes of recurrent miscarriage
- advancing maternal age
- Balanced (Robertsonian) translocations
- Uterine anomalies - 2nd trimester more
- Antiphospholipid syndrome
- cervical weakness
RFs of ectopic pregnancy
- failed IVF or IVF
- Anything which could affect tubal function
- Previous ectopic pregnancy
- pelvic/Tubal surgery (sterilization or reversal )
- Tubal pathology
- Previous pelvic inflammatory disease (PID)/endometriosis
- Mirena (IUS) or copper coil (IUD) in situ
- smoking
symptoms & signs of ectopic pregnancy
- > Unilateral pain RIF / LIF
- > Irregular PV spotting/bleeding - prune juice
- > amenorrhoea or missed period
- > Shoulder tip pain - heamaperitoneum
-> Fainting, dizziness
-> (N&V)(vomiting usually not prominent - low βhCG )
breast tenderness
gastrointestinal symptoms
dizziness, fainting or syncope
shoulder tip pain
urinary symptoms
passage of tissue
rectal pressure or pain on defecation.
SIGNS -> pelvic/abdominal/adnexal tenderness or examination - cervical motion tenderness pthers - rebound tenderness or peritoneal signs - pallor - abdominal distension - enlarged uterus - tachycardia (more than 100 beats per minute) or hypotension (less than 100/60 mmHg) - shock or collapse - orthostatic hypotension.
when to offer expectant mx for ectopic
- asymptomatic no evidence of rupture - less than 35mm w no visible heartbeat on transvaginal US - hCG is low <1000 and falling - increasingly offered
when to offer medical Mx of ectopic
what is prescribed
how is it monitored
- no significant pain
- unruptured ectopic pregnancy w an adnexal mass smaller than 35 mm with no visible heartbeat
- hCG<1500
- do not have an intrauterine pregnancy (as confirmed on an US scan)
- methotrexate
- may rupture
- must avoid pregnancy 3 - 6 months
For women with ectopic pregnancy who have had methotrexate, take 2 serum hCG measurements in the first week (days 4 and 7) after treatment and then 1 serum hCG measurement per week until a negative result is obtained
surgical Mx of ectopic
2 large bore cannulae IV fluids routine bloods obtain consent keep NBM
> 5000
pt choice
Laparoscopic / Laparotomy
Salpingectomy / Salpingotomy
an ectopic pregnancy and significant pain
an ectopic pregnancy with an adnexal mass of 35 mm or larger
an ectopic pregnancy with a fetal heartbeat visible on an ultrasound scan
an ectopic pregnancy and a serum hCG level of 5000 IU/litre or more.
trophoblastic disease
A spectrum of disorders of trophoblastic development arising from abnormal fertilisation
Potentially pre-malignant
Hydatidiform Mole / Molar pregnancy
Complete Mole (empty egg, 1sperm)
Partial Mole (egg and 2 sperm) – more common
Malignant
Invasive mole
Choriocarcinoma
presentation of trophoblastic disease
- Asymptomatic – USS diagnosis
- Bleeding / haemorrhage
- Severe nausea and vomiting
- severe very early pre-eclampsia 2nd trimester -> similar to TSH
- Uterus large for dates
how to confirm trophoblastic disease
histology
on US snowstorm appearnace
Mx of trophoblastic disease
Surgical mx (SERPC)
Register with one of 3 national GTD centre
Sheffield
Charing Cross
Dundee
Postal follow-up of serum and urine Serial ßhCG – as directed by the centre
follow up for 3 months they cant get pregnant
hyperemesis gravidarum
excessive nausea and vomiting in pregnancy
true hyperemesis gravidarum
Severe dehydration Deranged bloods Marked ketosis Weight loss Nutritional deficiency Complications of all of above
possible pathology for hyperemesis gravidarum
Elevated hCG
More common in twin / molar pregnancies
Same α subunit thyroid stimulating hormone (TSH) → Thyrotoxicosis
Elevated oestrogen/progesterone
↓ Gut motility
↑ Liver enzymes
↓ Cardiac sphincter pressure
Helicobacter pylori
Sub-clinical infection activated by altered immunity in pregnancy
Psychological
Difference in incidence in different populations and cultures
diagnosis of exclusion for hyperemesis
History of hyperemesis in previous pregnancies
Usually no abdominal pain
Infections
UTI, gastroenteritis, appendicitis, pancreatitis etc
Metabolic
Biochemical thyrotoxicosis
Graves disease - HCG activating thyroid
Addisons, DKA
Drugs
Antibiotics, iron preparations
Tumours hydatidiform mole formation, Choriocarcinoma, teratoma with elements of choriocarcinoma germ cell tumors islet cell tumor negative pregnancy test
Ix of hyperemesis gravidarum
Urine: PT / ketonuria / urinary tract infection (UTI) Full blood count (FBC): Haematocrit U&E (esp K) hypokalaemia LFT and Amylase TFT – can be difficult to interprete USS: exclude GTD/Multiple pregnancy
Mx of hyperemesis gravidarum
- Rehydration: NOT with glucose (precipitates Wernicke’s), replace K
- Thiamine replacement and folic acid - psychosis, wernicke maybe irreversible
- Antiemetics: parenteral route initially
- Ranitidine - evidence of mallory weiss tear
- Consider thromboprophylaxis - dehydrated
Rarely - Steroids – stimulate appetite - TPN/JEG - Termination stomach cancer mistaken for hyperemesis gravidarum
when is expectant Mx contraindicated
increased risk of haemorrhage
- late in the first trimester
- coagulopathies or is unable to have a blood transfusion
- previous adverse and/or traumatic experience ass w pregnancy
- evidence of infection
when to do BHCG in ectopic pregnancy woman
day 2, 4, 7
Ix for ectopic pregnancy
pregnancy test
transvaginal US to identify the location of the pregnancy
- fetal pole and heartbeat
Consider a transabdominal ultrasound scan for women with an enlarged uterus or other pelvic pathology, such as fibroids or an ovarian cyst.
how to diagnose tubal ectopic pregnancy
- > an adnexal mass, moving separate to the ovary (sometimes called the ‘sliding sign’), comprising a gestational sac containing a yolk sac, or
- > an adnexal mass, moving separately to the ovary (sometimes called the ‘sliding sign’), comprising a gestational sac and fetal pole (with or without fetal heartbeat).
- > empty uterus
- > collection of fluid within the uterine cavity
when to measure serum hCG level in ectopic pregnancy
they have had methotrexate
- take 2 serum hCG measurement between days 4 and 7 after treatment
- 1 serum hCG measurement per week until a negative result is obtained
when do we offer surgery as first line Mx in ectopic pregnancy
- unable to return for follow-up after methotrexate
- ectopic pregnancy and significant pain
- ectopic pregnancy with a fetal heartbeat visible fetal heartbeat visible on an US scan
- an ectopic pregnancy and serum hCG >5000
laparoscopy
offer salpingectomy if they have nor other RFs for infertility
salpigotomy to those who are infertile
when do u offer women anti D prophylaxis in ectopic pregnancy
Offer anti-D rhesus prophylaxis at a dose of 250 IU (50 micrograms) to all rhesus negative women who have a surgical procedure to manage an ectopic pregnancy or a miscarriage.
what is the abortion act 1967
- That the pregnancy has not exceeded its 24th week and that the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman or any existing children of her family; or
- That the termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman; or
- That the continuance of the pregnancy would involve risk to the life of the pregnant woman, greater than if the pregnancy were terminated; or
- That there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped.
Mx of ectopic pregnancy
offer methotrexate
- have no significant pain and
- have an unruptured ectopic pregnancy with an adnexal mass smaller than 35 mm with no visible heartbeat and
- have a serum hCG level less than 1500 IU/litre and
- do not have an intrauterine pregnancy (as confirmed on an ultrasound scan) and
- are able to return for follow-up.
hCG monitoring in pts who used methotrexate
take 2 serum hCG measurements in the first week (days 4 and 7) after treatment and then 1 serum hCG measurement per week until a negative result is obtained. If hCG levels plateau or rise, reassess the woman’s condition for further treatment.
Ix for pregnancy unknown location
Take 2 serum hCG measurements as near as possible to 48 hours apart (but no earlier) to determine subsequent management of a pregnancy of unknown location
decrease in HCG of more than 50% after 48hrs
inform her that the pregnancy is unlikely to continue but that this is not confirmed and
provide her with oral and written information
ask her to take a urine pregnancy test 14 days after the second serum hCG test, and explain that:
- if the test is negative, no further action is necessary
- if the test is positive, she should return
increase in hCG of more than 63%
Inform her that she is likely to have a developing intrauterine pregnancy (although the possibility of an ectopic pregnancy cannot be excluded).
Offer her a transvaginal ultrasound scan to determine the location of the pregnancy between 7 and 14 days later. - Consider an earlier scan for women with a serum hCG level greater than or equal to 1500 IU/litre.
Ix for recurrent miscarriage
antiphospholipid antibodies
karyotyping
- Cytogenetic analysis should be performed on products of conception of the third and
subsequent consecutive miscarriage(s).
- Parental peripheral blood karyotyping of both partners should be performed in
couples with recurrent miscarriage where testing of products of conception reports
an unbalanced structural chromosomal abnormality
- All women with recurrent first-trimester miscarriage and all women with one or
more second-trimester miscarriages should have a pelvic ultrasound to assess uterine
anatomy. - Suspected uterine anomalies may require further investigations to confirm the
diagnosis, using hysteroscopy, laparoscopy or three-dimensional pelvic ultrasound. - screened for thrombophilias factor V lieden, factory II genen mutation, protein S
Mx for recurrent miscarriage
specialist clinic
antiphospholipis -> low-dose aspirin plus heparin
geneticist
IVF
TOP Mx
comp
follow up
medical mx
1. mifepristone - anti-progestorone - vaginal buccal or sublingual
- followed by misoprostol - PG analogue
>10 weeks on misoprostol
> 14 weeks
manual vacuum aspiration before 14 weeks -> increased risk of failure before 7 weeks can be done under local
vacuum aspiration using large bore cannulae
dilation and surgical evacuation after 14 weeks
cervical preparations to reduce trauma
we should not use sharp curettage use suction cannula
comp
- failure to end the pregnancy
- need for further intervention
- haemorrhage requiring transfusion
- uterine rupture
surgical comp
cervical trauma
uterien perforation
follow up
• how much bleeding to expect in the next few days and weeks
• how to recognise potential complications, including signs of ongoing pregnancy
• when they can resume normal activities (including sexual intercourse)
• how and where to seek help if required
Women who want to try again to conceive should be advised to wait until after having at least one normal menstrual period, longer if chronic health problems (e.g. anaemia) require treatment
AND CONTRACEPTION
what is pregnancy if uncertain viability
transvaginal ultrasound demonstrating a crown-rump length <7mm with no cardiac activity
inevitable miscarriage
open cervical os
PV bleeding
pain
