Early Pregnancy Problems

Question 1

Define Miscarriage

Answer 1

The loss of a pregnancy at less than 24 weeks gestation (early if before 12 weeks)

Does not include ectopic or GTD

Question 2

What are the 6 classifications of miscarriage

Answer 2

• Threatened - Viable USS
• Inevitable - likely to proceed to complete/incomplete
• Missed (Early Foetal Demise) - No foetal heart beat when CRL>7cm
• Incomplete - POC partially expelled
• Complete - No POC on USS
• Septic - Infected POC

Question 3

How might a miscarriage present?

Answer 3

Vaginal bleeding (may pass clots or POC)
Suprapubic cramping

May have adnexal masses/collections

Question 4

What imaging would you do to investigate a miscarriage?

Answer 4

Transvaginal Ultrasound

If CRL>7 and Gestation 5.5-6.5 weeks then a foetal heartbeat should be heard

If foetal pole not visible, confirm presence with gestational yolk sac (if yolk sac is greater than 25mm diameter with no foetus - likely miscarriage)

Question 5

What would the bloods of a woman who has just miscarried show?

Answer 5

Declining Serum B-HCG

Low Progesterone

Question 6

Describe the conservative/expectant management of Miscarriage, it’s advantages and disadvantages

Answer 6

Give Anti D and allow POC to pass naturally, repeat scan in two weeks and do a pregnancy test three weeks later

Advantages: can remain at home, no anaesthetic or surgical risk
Disadvantages: unpredictable, heavy bleeding, chance of failure

Question 7

Describe the medical management of Miscarriage, it’s advantages and disadvantages

Answer 7

Use Misopristol (PG Analogue) to stimulate cervical ripening and myometrial contractions

Advantages: can be done at home, avoids anaesthetic and surgical risks
Disadvantages: vomiting, heavy bleeding, chance of requiring op

Question 8

Describe the surgical management of Miscarriage, it’s advantages and disadvantages

Answer 8

If under 12 weeks - manual vacuum under local anaesthetic
If over 12 weeks - evacuation of POC under general anaesthetic

Advantages - planned procedure, unaware during
Disadvantages - anaesthetic risk, perforation, haemorrhage, ashermans

Question 9

When is surgical management of Miscarriage indicated?

Answer 9

Haemodynamically unstable
Infected Tissue
Gestational Trophoblastic Disease

Question 10

Define Recurrent Miscarriage

Answer 10

Occurrence of three or more consecutive pregnancies that end in the miscarriage of the foetus before 24 weeks

Question 11

State 5 causes for recurrent miscarriage

Answer 11

Antiphospholipid Syndrome
Genetic Abnormalities (Robertsonian Translocation)
Endocrine (PCOS, Thyroid, DM)
Anatomical (Uterine Malformations, Ashermans)
Inherited Thrombophilias

Question 12

Give three risk factors for recurrent miscarriage

Answer 12

Advancing maternal age
Number of previous miscarriages
Smoking

Question 13

Name three investigations for recurrent miscarriage

Answer 13

Bloods (Lupus, Anti Cardiolipin, Anti B2 Glycoprotein, Inherited Thrombophilia Screen)
Karyotyping (can test parents if foetus comes back abnormal)
Pelvic USS

Question 14

Describe the genetic counselling given to a woman suffering from recurrent miscarriages

Answer 14

Offers prognosis for future pregnancies

Offers other reproductive options

Question 15

If the cause of the recurrent miscarriage was cervical weakness how would you manage?

Answer 15

Cervical Cerclage

Question 16

If the cause of the recurrent miscarriage was Antiphospholipid Syndrome, how would you manage?

Answer 16

Lose dose Aspirin and Heparin

Question 17

What is an Ectopic Pregnancy?

Answer 17

One occurring anywhere outside the uterus, most commonly ampulla and isthmus

Can coincide with an intrauterine pregnancy (heterotropic pregnancy)

Question 18

What is a Cornual Pregnancy?

Answer 18

Pregnancy in the rudimentary horn of the uterus, technically uterine but ectopic

Question 19

Give five risk factors for ectopic pregnancy

Answer 19

Previous ectopic
PID
Endometriosis
Progesterone only contraception (alters fallopian ciliary motility)
Assisted reproduction

Question 20

How would a NON RUPTURED ectopic pregnancy present?

Answer 20

Pelvic Pain
Vaginal Bleeding (due to reduced HCG)
Shoulder tip pain
Brown vaginal discharge

Question 21

How would a ruptured ectopic pregnancy present?

Answer 21

Haemodynamically unstable
Peritonism
Fullness in PoD during vaginal exam

Question 22

Give three differentials for an ectopic pregnancy

Answer 22

Miscarriage
Ovarian Torsion
Acute PID

Question 23

How would you investigate a suspected Ectopic Pregnancy?

Answer 23

1) Pregnancy Test

2) Pelvic USS (if nothing seen then it is termed PUL - Pregnancy of Unknown Location)

Question 24

What is Pregnancy of Unknown Location and how can you investigate?

Answer 24

Could be an ectopic, a very early intrauterine pregnancy or a miscarriage

If serum hCG>1500IU - offer diagnostic laparoscopy
If serum hCG<1500IU - as long as patient is stable do repeat bHCG (should halve every 48h if miscarriage)

Question 25

How are ectopic pregnancies managed medically?

Answer 25

IM Methotrexate - disrupts folate metabolism causing pregnancy to resolve, may require repeat dose

Remains teratogenic so should not aim to conceive in the following 6 months

Question 26

How are tubal ectopics managed?

Answer 26

Laproscopic Salpingectomy

Question 27

When could you manage ectopics with a conservative approach?

Answer 27

Stable patients with well controlled pain

Low baseline hCG