Early Pregnancy Pathology Flashcards
How common is hyperemesis gravidarum?
0.1-1% of pregnancies, however general N&V is common and affects >50%
Describe the pathophysiology of hyperemesis gravidarum
Level of hCG is directly related to severity, higher in multiple and molar pregnancy
What is the prognosis of hyperemesis gravidarum?
Usually improves by 12 weeks gestation as hCG levels fall
How does hyperemesis gravidarum present?
N&V
Dehydration
Electrolyte imbalance
Ketonuria
Occasional muscle wasting
How is hyperemesis gravidarum managed?
Fluids
Antiemetics
Potassium replacement
Thromboprophylaxis
Vitamin B1 replacement
Severe cases may require prolonged hospital stay and total parental nutrition
What is first line anti-emetic in pregnancy?
Promethazine
Give complications of hyperemesis gravidarum
Thyrotoxic crisis, as hCG and TSH have similar subunits
Wernicke’s encephalopathy, due to B1 deficiency
Define spontaneous abortion/miscarriage
Loss of pregnancy <24 weeks gestation
Define recurrent miscarriage
Loss of 3 or more consecutive pregnancies
When do miscarriages usually occur?
First trimester
What are the causes of miscarriage?
Uterine abnormality
- Congenital
- Fibroids
- Ashermans Syndrome
Fetal/chromosomal abnormality
Cervical Incompetence, in which cervix opens prematurely
Maternal factors
Idiopathic
What maternal factors can cause miscarriage?
>Age
Hypothyroidism
SLE
Diabetic
Obesity
Acute infections
Anti-phospholipid syndrome
PCOS
What is the most common cause of miscarriage?
Chromosomal abnormality
What are the types of miscarriage?
Threatened
Inevitable
Complete
Incomplete
Septic
Missed
What is a threatened miscarriage?
Viable pregnancy with vaginal bleeding and pain with a closed cervical os, uterus is expected size of dates given
What is an inevitable miscarriage?
Viable pregnancy with pain and bleeding with an open cervical os
What is an incomplete miscarriage?
Evidence of retained products of conception on USS with open cervical os
What is a complete miscarriage?
Expulsion of the products of conception, cervical os closed, bleeding stopped
What is a septic miscarriage?
Following an incomplete abortion, there is risk of ascending infection into the uterus which can spread throughout the pelvis
What is a missed miscarriage?
Pregnancy in which the fetus has died but the uterus has made no attempt to expel the products of conception, so mother has no symptoms
What investigations are used to diagnose miscarriage and the cause?
FSH and LH
Prolactin
- Suppresses FSH
TFT
- Hypothyroidism
Clotting Factors
- Protein S and C
Testosterone
- PCOS
US
- Fibroids
- PCOS
- Crown rump length >7mm with no cardiac activity is diagnostic
Karyotype
- Chromosomal abnormalities
How are threatened miscarriages managed?
Conservative, try get fetus passed 24 weeks so can deliver
Avoid exercise
Weekly US
How are inevitable miscarriages managed?
No point trying to save fetus
Evacuation of uterus if bleeding is heavy
How are missed miscarriages managed?
Conservative in hope uterus will self evacuate
Prostaglandins/misoprostol which will contract the uterus
Surgical (SMM)
What additional management is given in Rh- mothers suffering from miscarriage?
Anti-D for Rh- mothers with spontaneous miscarriage >12 weeks
How are patients with anti phospholipid syndrome managed to prevent further miscarriage?
Aspirin and LMWH after a missed period
What is an ectopic pregnancy?
Pregnancy implanted outside the uterine cavity with invasion into the muscularis layer and subsequent rupture and bleeding into the abdominal cavity
When do ectopic pregnancies usually present?
6-8 weeks
Give the sites of ectopic pregnancies
Tubal
Cervix
Ovary
Fimbria
Abdomen
What is the most common ectopic pregnancy site?
Tubal (cornial region)
What location do ectopic pregnancies have an increased rupture risk?
Isthmus
What is the prognosis of ectopic pregnancies?
60-70% of women will have an intrauterine pregnancy in the future
Give risk factors for ectopic pregnancy
PID
Previous tubal surgery
Previous ectopic pregnancy
Intrauterine contraceptive device (does not increase risk but if an individual with an IUD becomes pregnant, it is likely to be ectopic)
Assisted reproduction
Endometriosis
Smoking
>Age
How do ectopic pregnancies present?
Period of amenorrhoea, with positive pregnancy test
Light vaginal bleeding
Lower abdominal or pelvic pain
Shoulder tip pain in peritonitis/rupture
Signs of haemorrhagic shock
- Hypotension
- Tachycardia
- Syncope
What investigations are used for ectopic pregnancy diagnosis?
US
Serum BHCG levels
- Serially track levels over 48 hour intervals as
- If levels fall, suggests miscarriage
- Slight increase or plataeu, suggests ectopic pregnancy
- Large increase, suggests normal intrauterine pregnancy
- In normal pregnancies beta hCG will double around every two days until it reaches a peak at week 10/40.
Serum progesterone levels
- In viable IU pregnancy high levels > 25ng/ml
Group and save and cross-match if abdominal bleeding suspected
Laparoscopy
What ectopic pregnancy signs are seen on US?
No intrauterine gestational sac/empty uterus
May see adnexal mass
Fluid in pouch of Douglas
What is the management of ectopic pregnancy?
Expectant management
Medical management with IM Methotrexate
Surgical management in those who do not need expectant or medical criteria
What are the surgical options for ectopic pregnancy management?
Laparoscopic salpingectomy of affected tube is first line
Laproscopic salpingotomy in which there is incision and extraction of ectopic, if collateral tube is absent or damaged
When are anti-D immunoglobulins given in ectopic pregnancy management?
Given for rhesus - mothers in surgical management, but not required in medical management
How long are women treated with methotrexate advised not to get pregnant for?
3 months following treatment
What is the criteria for expectnant management of ectopic pregnancy?
Unruptured ectopic
No heartbeat
No pain/asymptomatic
Adnexal mass <35mm
hCG <1000 and declining
What is the criteria for medical management of ectopic pregnancy?
Unruptured ectopic
No pain/asymptomatic
Confirmed absence on US
Adnexal mass <35mm
hcG<1500
What is the criteria for surgical management of ectopic?
Ruptured
Symptomatic
Visible fetal heartbeat
Confirmed absence on US
Adnexal mass >35mm
hcG>1500
When can a pregnancy termination be carried out up to?
24 weeks (20 in scotland)
What drugs are given for medical termination of pregnancy?
Mifepristone
- Switches off pregnancy hormones which are keeping uterus from contracting and allowing pregnancy to grow
Misoprostol
- 48 hours later, initiates uterine contraception, which opens cervix and expels pregnancy
What is a molar pregnancy?
Abnormal placental development, causing overgrowth of abnormal pregnancy tissue/precancer trophoblast
Describe the pathophysiology of molar pregnancy
In a normal ovary, female switches off certain genes in ova by methylating them (adding methyl groups onto DNA), these changes promote baby growth
In normal testis, male switches off different genes in the sperm by methylating them, these changes promote placenta growth by trophoblast proliferation
In molar, two lots of male genes fertilise egg with no chromosomes, resulting in an imbalance in methylated genes and trophoblast overgrowth
What are the two types of molar pregnancy?
Benign: Complete or partial hydatiform mole
Malignant: Choriocarcinoma
How does molar pregnancy present?
Vaginal bleeding in early pregnancy
Hyperemesis
Pelvic mass
Non tender, large for dates uterus
What molar pregnacy sign is seen on US?
Snow storm appearance
What investigations are used in molar pregnancy diagnosis and monitoring?
US
- Snowstorm within endometrial cavity
Surgical evacuation
- To obtain histology
>hCG
- Persistent hCG indicates active disease and warrants chemotherapy
Give differential diagnoses of pelvic pain
Appendicitis
Ovarian cyst
Ovarian torsion
PID
Constipation
UTI
Give complications of termination of pregnancy
Infection, most common
Retained tissue
Haemorrhage
Cervical trauma
Failure
How long can pregnancy tests remain positive after termination?
4 weeks, a positive beyond this point indicates incomplete abortion or persistent trophoblast
What drugs are used in the termination of pregnancy
Methotrexate
Misoprostol, a prostaglandin analogue which is used to promote softening and dilatation of the cervix and uterine contractions
Give features of cervical ectropion
Post coital bleeding
Reddened and irritated cervix
Common in pregnancy and oral contraceptive pill use
