Early pregnancy disorders

Question 1

What is the definition of early pregnancy?

Answer 1

First half of pregnancy:

Up to about 20 weeks

Question 2

What are some common problems in early pregnancy?

Answer 2

Miscarriage
Ectopic pregnancy
Hyperemesis

Question 3

What are some common symptoms of miscarriage?

Answer 3

Bleeding
Pain

May not know - may have to be told secondary to ultrasound scan

Question 4

How do you tell the difference between miscarriage or ectopic pregnancy?

Answer 4

ultrasound scan

Question 5

What service exists for women to go if they have pain and bleeding?

Answer 5

Early pregnancy unit

GATU - if referred to by doctor

Question 6

What is the first thing you would do if a ‘pregnant’ woman presents with pain and bleeding

Answer 6

pregnancy test - if -ve, definite miscarriage (or were never pregnant)

Pregnancy test +ve - need to do US scan

Question 7

Why does a transvaginal USS need to be done to a woman with ?miscarriage?

Answer 7

Better image

won’t disturb or put the pregnancy at risk

Question 8

What are the two things you want to know from a USS in ?miscarriage, ?ectopic pregnancy?

Answer 8

Location

Viability

Question 9

What sorts of things might you be able to see in a transvaginal USS?

Answer 9

intrauterine sac, 5 weeks after LMP 10-15 mm
5+ weeks: sac + yolk sac
6 weeks: foetal pole/baby (baby is 5mm at this stage)
6+ weeks: Foetal heart sounds (needs to be 7mm size)

(move all of these forward by one week if you scan abdominally - 6 weeks = intrauterine sac, 6+ weeks = yolk sac etc.)

Question 10

If you see a foetus that is AT LEAST 7mm without any heart sounds, what does this indicate?

Answer 10

pregnancy not continuing

Question 11

If a baby is less than 7mm in size, what do you have to tell the mother re. diagnosing miscarriage/ectopic etc.?

Answer 11

they have to wait

Question 12

What is the cut off for being confident about viability of foetus? why?

Answer 12

7mm

needs to be this size to see heart

Question 13

What might be the case if there’s a positive pregnancy test but an empty uterus on transvaginal USS?

Answer 13

ectopic pregnancy
complete miscarriage (foetus has already gone)
too small to be seen

Question 14

How do you differentiate between whether a woman has an: ectopic pregnancy
complete miscarriage (foetus has already gone)
too small to be seen?

Answer 14

there might be free fluid in the push of douglas or in pelvis

Question 15

How do you differentiate between whether a woman has an: ectopic pregnancy
complete miscarriage (foetus has already gone)
too small to be seen?

Answer 15

USS: there might be free fluid in the push of douglas or in pelvis (due to rupture)

beta hCG (levels in blood): in early pregnancy, quantity will increase rapidly
in miscarriage, quantity will decrease rapidly
in ectopic, ‘sub-optimal rise’ - rise of less than 50%

Laparoscopy - only definitive diagnosis of ectopic

Question 16

What proportion of ectopic pregnancies resolve spontaneously?

Answer 16

1/3

Question 17

How can you manage a non-viable early stage pregnancy?

Answer 17

conservative (can take months to sort itself out, depending on circumstances)

Medical: prostaglandin eg. misoprostol (encourages uterine activity). CAN’T GIVE IN SEVERE ASTHMA
miscarriage usually complete between 48hrs-7days

Surgical: surgical management of miscarriage (inpatient, under GA) aka. evacuation of retained products of conception
OR
MVA - manual vacuum aspiration (Outpatient, under local)

Question 18

What is the most common form of termination with a pregnancy of less than 7 weeks?

Answer 18

MVA

Question 19

What is the benefit of MVA over surgical management of miscarriage?

Answer 19

quicker and less complications

Question 20

When would you only offer conservative or medical management of miscarriage?

Answer 20

when baby gets over a 12 week size

Question 21

How long should women wait (treat conservatively) before being offered medical or surgical management of miscarriage? (technically, locally this isn’t done)

Answer 21

14 days

Question 22

How long do women need to wait before trying for a baby again?

Answer 22

After next period

Question 23

How would you manage an ectopic pregnancy?

Answer 23

Medical: methotrexate - singular IM injection

Question 24

How would you manage an ectopic pregnancy?

Answer 24

Medical: methotrexate - singular IM injection

Surgical: laparoscopic salpingectomy (most common treatment)

Question 25

Why is laparoscopy the most common treatment for ectopic pregnancy?

Answer 25

only definitive diagnosis of ectopic pregnancy

can only give methotrexate if you’re CERTAIN it’s an ectopic pregnancy, therefore there is a risk of giving this when the pregnancy isn’t ectopic

therefore, better in terms of risk, as needs to be done for diagnosis anyway

Question 26

What is one of the benefits of methotrexate?

Answer 26

Tube not as damaged (doesn’t necessarily have to be removed)

Only as damaged as it was prior to methotrexate

Question 27

When might you especially consider methotrexate for ectopic pregnancy?

Answer 27

if woman has already had tube removed

Question 28

Where can you recommend women (and men) go post-miscarriage?

Answer 28

miscarriage association