Early pregnancy Problem

Question 1

What cells are beta HCG produced by?

Answer 1

Trophoblasts

Question 2

Describe the quantitative increase in beta HCG over time if pregnant?

Answer 2

Beta HCG doubles every 48 hours, for the first 4-8 weeks of pregnancy

Question 3

What does falling or plateauing beta HCG indicate? What other investigation could help?

Answer 3

Falling or plateauing beta HCG may indicate but is not diagnostic of a poor outcome, it cannot differentiate between an ectopic or a miscarriage. The addition of ultrasound gives the most useful information about the status of a pregnancy.

Question 4

What is morning sickness? At which gestational age is it most common? When does it peak? How prevalent is it?

Answer 4

• Nausea with or without vomiting
• Typically occurs between 5-6 weeks of gestation
• Peaks at weak 9
• It occurs in 50-90% of all pregnancies

Question 5

What is Hyperemesis Gravidarum? When is the usual onset? How prevalent is it?

Answer 5

• persistent vomiting accompanied by weight loss exceeding 5 % of body weight, dehydration, ketonuria unrelated to other causes
• Most prevalent between 4-10 weeks of gestational age
• N/V after 10 weeks unlikely due to hyperemesis gravidarum

Question 6

Name some investigations to consider if Hyperemesis Gravidarum is suspected?

Answer 6

• Weight , BP (orthostatic), serum free T4, TSH, serum electrolytes, urine ketones, FBE. LFTS
• Ultrasound to exclude trophoblastic disease, or multiple pregnancy or molar pregnancy, it also allows the confirmation of gestational age
• Do a midstream urine for micro/culture/sensitivity to exclude urinary tract infection

Question 7

What are some non pharmacological interventions for hyper-emesis Gravidarum?

Answer 7

• Ginger, acupressure, diet: frequent meals, low in fat, avoid triggers, address psychology

Question 8

What are the pharmacological approaches to treat hyper-emesis Gravidarum?

Answer 8

• Pyroxidine (Vitamin B6) is useful for morning sickness
• Antihistamines/ Anticholinergics (promethazine- Phenergan)
• Antiemetics: First line in doxylamine or metoclopramide (both category A), if persists take category B Ondansetron
• Motility drugs (dopamine antagonists): Procloperazine , Droperidol
• Coticosteroids: Oral prednisolone, dose minimised to prevent maternal side effects
• IV fluids - NS or LR; dextrose; give thiamine (risk of Wernicke’s) replete mag, phos, potassium +/- anti-emetic
• Enteral/ Parenteral Nutrition - TPN is the last resort; gastric or duodenal intubation; parental via PICC

Adjuvant therapy: Ranitidine

Question 9

What are the clinical features of hyperemesis Gravidarum?

Answer 9

• Severe dehydration
• Electrolyte disturbances
• Vitamin deficiency
• Specifically a thiamine deficiency, resulting in Wernickes encephalopathy ( opthalmoplegia, ataxia, confusion)

Question 10

What is the definition of miscarriage?

Answer 10

Miscarrige = loss of pregnancy at < 20 weeks of gestation. Approximately 30% of pregnancies will experience bleeding in in early pregnancy. Miscarrige occurs in 15-20% of clinically diagnosed pregnancies.

Question 11

What is a threatened miscarriage?

Answer 11

uterine bleeding at anytime in the first half of pregnancy, in the presence of an embryo with cardiac activity. Admission is generally not necessary, bleeding is seldom sufficient to require transfusion or IV fluids. Cervix closes, no products passed, US is viable

Question 12

What is a complete miscarriage

Answer 12

Usually a history of significant bleeding, pain and complete passage of all products of conception. It is defined as endometrial thickness less than 15 mm. The cervix is closed and the Ultrasound shows an empty uterus. Must consider ectopic pregnancy and weekly beta HCG’s to document return to non pregnant beta HCG levels, ask patients to return if worsening symptoms.

Question 13

Incomplete Miscarrige

Answer 13

• Pain & PV bleeding
• Cervix is open or closed
• Some products passed out but on US some retained products.

Question 14

Missed miscarrige

Answer 14

Minimal or absent bleeding, with gestation sac diameter of greater than or equal to 25 mm with no fetal pole or yolk sac OR fetal pole greater than or equal to 7 mm with no cardiac activity.

• Non viable pregnancy with no symptoms/ signs
• Cervix is closed
• US is non viable IUP

Question 15

Inevitable Miscarrige

Answer 15

Bleeding in the presence of a dilated cervix, indicated passage of the conceptus is unavoidable.

• Pain or PV bleeding ongoing
• US is non viable
• Expectant and medical management, curette offered if bleeding is very heavy

Question 16

What is a spontaneous and early spontaneous miscarriage?

Answer 16

It is the involuntary loss of a pregnancy within the first 20 weeks. if it is early it means it is prior to 12 weeks of gestational age

Question 17

What is a septic miscarriage?

Answer 17

Incomplete miscarriage associated with ascending infection of the endometrium, parametrium , adenexae or peritoneum. There pain &/or bleeding ongoing, symptoms and signs of infection, cervix may be open or closed, On ultrasound may be present or absent.

Question 18

Recurrent Miscarrige

Answer 18

three or more consecutive miscarriges

Question 19

What the causes of a miscarriage?

Answer 19

• Chromosomal abnormalities
• Uterine abnormalities (congenital or acquired)
• Cervical incompetence
• Maternal illness: diabetes, thyroid disease, phospholipid/ lupus - 15% of recurrent miscarriges
• Advanced maternal age
• Lifestyle factors: smoking, drugs, medications, alcohol, caffeine, extremes of weight
• Progesterone deficiency
• Trauma ( Iatrogenic/ DV/ Other)
• Unexplained

Question 20

Clinical Presentation of miscarrige

Answer 20

• Bleeding, need to gauge amount

Question 21

What are the appropriate investigations if miscarriage is suspected?

Answer 21

• Ultrasound (once Beta HCG is 1500)
• Measurement of serum Beta HCG
• Determination of blood and rhesus group
• FBC, G& s and admit if significant bleeding
• Psychological support

Question 22

What is the ultrasound criteria for diagnosing miscarriage?

Answer 22

• You expect to see viable fetus from around 6.5 weeks trans abdominally, 5.5 weeks tranvaginally
• CRL greater than or equal to 7 mm with not fetal cardiac activity
• Empty Gestational sac with a mean diameter of greater than or equal to 25 mm ( does no contain a yolk sac or fetal pole)

Question 23

Management of Miscarrige?

Answer 23

Medical - Misprostolol
Surgical Dilatation and curettage - give IV antibiotics prior

Resucitation as required
Rhesus negative give anti D, not required for threatened miscarriage

Psychological support

Question 24

What is recurrent miscarriage?

Answer 24

-It is the loss of 3 or more consecutive pregnancies requires investigation and referral

Question 25

What is the aetiology of recurrent miscarriage?

Answer 25

Idiopathic - In 50% of couples
Genetic - balanced translocation or robertsonian translocation of one of the parents
Antiphopholipid syndrome
- anticardiolipin, lupus anticoagulant, b2 macroglobulin antibodies
- Treat with aspirin + heparin (Unfractioned or LMW)
- Structural anomalies - Uterine septum, US recommended
- Hypothyroidism: especially antibody positive disease
- Uncontrolled diabetes
- Thrombophilia

Question 26

What investigations need to carried out in a recurrent miscarriage?

Answer 26

Pelvic US, Thrombophilia screen/ APLS, Parental karyotype

Question 27

What is GTD?

Answer 27

Gestational trophoblastic disease encompasses a range of conditions charaterised by a proliferative disorder of trophoblastic cells which can be broadly classified into benign or malignant via histopathology.

Question 28

What is a molar pregnancy?

Answer 28

A molar pregnancy also known as a hydatidiform mole, is a non cancerous tumour in the uterus. A molar pregnancy starts when an egg is fertilised but instead of a viable pregnancy, the placenta develops into an abnormal mass of cysts.

Question 29

What is a choriocarcinoma?

Answer 29

Choriocarcinoma is a malignant disease characterised by abnormal trophoblastic hyperplasia and anaplasia, absence of chorionic villi, haemorrhage and necrosis. Follows a hydatidiform mole in 50% of cases, normal pregnancy in 25% and miscarriage or ectopic pregnancy in 25%.
Eg. Invasive mole, choriocarcinoma, placental site trophoblastic tumour (PSTT)

Question 30

What are the clinical features of Molar Pregnancy?

Answer 30

Mole:
Hydatidiform mole characterised by oedematous, avascular villi with trophoblastic proliferation. Initially diagnosed following US after vaginal bleeding in early pregnancy.
Other features include:
Hyperemesis gravidarum, theca lutein cysts, pre-eclampsia (potentially <20/40), hyperthyroidism, vaginal passage of hydropic vesicles
Symptoms from metastatic spread may occur – eg. haemoptysis
- You can get torsion rupture or bleeding
- trophoblastic embolization
- Thyrotoxicosis
- bHCG > 200, 0000
- Vaginal bleeding
- uterus larger than dates

Question 31

What is the management of Molar pregnancies?

Answer 31

Dilation and curettage, with regular monitoring of beta HCG afterwards.

Question 32

WHAT a pregnancy of unknown location?

Answer 32

Pregnancy of unknown location is a positive pregnancy test, with no signs of intrauterine or extrauterine pregnancy on transvaginal sonography

Management should be expectant if stable with an intitial serum progesterone less than 20, initial beta hcG ratio of Oh/48h of <0.87

Question 33

What is an ectopic pregnancy?

Answer 33

Occurs with implantation of the conceptus outside the uterine cavity, usually in the fallopian tube and rarely in the ovary, abdominal cavity or cervix.
~1% of pregnancies

Most dangerous ectopics are in the isthmus, this where the blood supply anastomoses and rupture can occur

Question 34

What are the risk factors for an ectopic pregnancy?

Answer 34

Risk factors of an ectopic pregnancy:
Previous ectopic pregnancy
Progesterone only or emergency hormonal contraception
IUD
IVF
Tubal damage or adhesions (eg. pelvic surgery/curettes)
Kinking or narrowing of the tube prevents the fertilised ovum making its way from the ampulla to the uterine cavity.
Apart from mechanical effect of the narrowing, damage to the cilia will impede transport of fertilised ovum
Affected by salpingitis, appendicitis, endometriosis, congenital abnormalities and previous tubal surgery
STIs

previous ectopic pregnancy

Question 35

What is the clinical presentation of an ectopic pregnancy?

Answer 35

Acute presentations:
Amenorrhea, lower abdominal pain, vaginal bleeding

• Lower abdominal pain (90%), peritoneal irritation
  And/or
• Vaginal bleeding (50%) - shedding of decidua may be present or absent. May be brown or prune coloured or red
• Adnexal tenderness
• Acute abdomen
• Shoulder tip pain referred from diaphragm
• Fainting hypovolaemia, shock/ collapse

Atypical

• Assymptomatic
• Gastrointestinal symptoms
• Incidental finding on ultrasound

Question 36

How is the clinical diagnosis of ectopic pregnancies made?

Answer 36

= Clinical diagnoses with collapsed patient in early pregnancy until otherwise proven

• Ultrasound findings: Empty uterus, adnexal mass, tubal ring, free fluid, adnexal gestational sac
• Serial beta HCG, if not rising normally and / or symptoms or beta hcg above 1500, refer for USS
• FBE, Group and hold and antibodies
• UEC/ LFT’s if considering methotrexate
• Diagnostic laparaoscopy

Question 37

Management of Ecoptic pregnancies medically?

Answer 37

MTX – inhibits DNA synthesis in rapidly dividing cells
Success in the absence of contraindications is 90%
Contraindications:
Haemodynamic instability or evidence of rupture
ß-hCG >5000 or tubal mass >3.5cm
Fetal heartbeat
Lack of access to timely assistance in the event of ectopic rupture
Patient not able to comply with post medical treatment follow up
Contraindication to MTX (eg. renal disease, hypersensitivity, breastfeeding)
Side effects:
N/V, diarrhoea, stomatitis, gastritis
Pneumonitis, abnormal liver function and bone marrow suppression
Note:
There remains a risk of rupture. Return of ßhCG may take weeks and a delay of 3 months recommended before conceiving.
Patients must be willing to present weekly for serum ß-hCG measurements to ensure resolution of the ectopic pregnancy

Question 38

What is the surgical treatment of ectopic pregnancies?

Answer 38

Laparoscopy or laparotomy:
Laparoscopy is appropriate for most ectopics except those with significant haemodynamic compromise
Salpingectomy or salpingostomy:
Laparoscopic salpingectomy is the standard treatment. Salpingostomy is occasionally performed with a view to increase future intrauterine pregnancy rates. Evidence suggests only greater in those with contralateral tubal disease.