Early pregnancy problems Flashcards
What are the main causes of miscarriage?
-Sporadic chromosomal abnormalities (most common)
–1/3 of Downs Syndrome pregnancies miscarry
-Acute pyrexial illness
-Antiphospholipid antibody syndrome
-Uterine malformations eg bicornuate uterus
How do miscarriages present?
-Vaginal bleeding (amount and type varies)
-Abdo pain
-Regression of pregnancy symptoms
-Incidental finding
How should miscarriages be investigated?
-Pregnancy test (urine or blood)
-USS - possible findings:
–Empty uterus (ectopic, complete miscarriage, very early pregnancy)
–Viable pregnancy
–Non-viable pregnancy
–Too early to confirm
What is a threatened miscarriage?
-Painless vaginal bleeding <24w (typically 6-9 weeks)
-Symptoms suggestive of miscarriage but pregnancy continues
-No long-term harm to baby but complicates up to 25% of pregnancies
What is an inevitable miscarriage?
-Woman presents in the process of a miscarriage and nothing can be done to save the pregnancy
-Heavy vaginal bleeding with clots, pain, open cervical os
What is a complete miscarriage?
-Process has completed without intervention
-Presents with bleeding which has now lessened, closed cervical os
-Still must exclude ectopic pregnancy
What is an incomplete miscarriage?
-Products of conception still remain within the uterus
-Pain and vaginal bleeding
-Open cervical os and mixed debris in uterus seen on USS
-Medical or surgical treatment may be offered
What is a missed or delayed miscarriage?
-Entire gestational sac remains within the uterus containing dead foetus (<20 weeks)
-May have light vaginal bleeding, cervical os is closed
-Uterus and foetus are SGA
-Treat with vaginal misoprostol
When is expectant management offered for miscarriage?
-If not bleeding heavily
-Allows the body to complete miscarriage itself
-Unpredictable and can take weeks to complete
-Repeat TVS to ensure completion at 2 weeks, offer surgical management if unsuccessful
-Offer simple analgesia for pain
What surgical management is offered for miscarriage?
-Evacuation of uterus (under GA, minor)
-Manual vacuum aspiration (under LA, offered to those with excessive bleeding or on patient request)
-Complications = infection, cervical trauma, haemorrhage, uterine perforation
What medical management is offered for miscarriage?
-Prostaglandins / antiprogesterones (induce contractions)
–Mifepristone then misoprostol 2 days later (PO or PV)
-Can cause moderate bleeding and abdo pain
-Good completion rate
What is gestational trophoblastic disease?
-Spectrum of diseases originating from the placenta
-Types:
–Partial and complete hydatidiform mole
–Choriocarcinoma
–Trophoblastic tumour
What risk factors are there for molar pregnancies?
-Maternal age >35
-Prior molar pregnancy
-Asian women
-Long term use of oral contraception
-Dietary deficiency
What is a hydatidiform mole?
-Tumour forms within the uterus at the start of pregnancy
-Consist of proliferating chorionic villi
-Makes lots of hCG –> exaggerated pregnancy symptoms
What is a partial vs complete hydatidiform mole?
PARTIAL
-Dispermy + normal egg
-Triploid karyotype with paternal chromosomes
COMPLETE
-Sperm + empty egg
-Diploid karyotype of paternal origin
How do molar pregnancies present?
-Early pregnancy failure, heavy bleeding
-LGA
-Snowstorm effect seen on US
-May see increased T3/4 and decreased TSH + symptoms of thyrotoxicosis as bHCG can act on thyroid
How do complete and partial molar pregnancies present on US?
PARTIAL = focal cystic spaces in placenta
-Non-viable foetus
COMPLETE = snow-storm appearance without foetus
-No foetus
How are molar pregnancies managed?
-Electric vacuum aspiration (+histology)
-Give anti-D if Rh-
-Monitor bhCG until they are undetectable
-Avoid pregnancy until bhCG at normal levels, hysterectomy if no desire to conceive
What is a choriocarcinoma?
-Complication of molar pregnancy - may present years later with vague symptoms and raised hCG
-Metastases common
What are the most common sites for ectopic pregnancies?
- Ampulla
- Isthmus
- Cornua
More rare = cervix, ovary, peritoneal cavity
>90% are tubal
How are ectopic pregnancies defined?
Any gestation in which implantation occurs at a location other than the endometrial lining
-Leads to 10% of pregnancy-related deaths
What risk factors are there for ectopic pregnancy?
-PID (especially if related to chlamydia)
-Previous ectopic pregnancy
-Tubal damage (surgery, salpingitis)
-Endometriosis
-IVF
-Sterilisation or reversal of sterilisation
-Use of IUD/IUS/POP
How do ectopic pregnancies present?
-Often asymptomatic
-Lower abdo pain usually around 6-7 weeks - constant, unilateral, can be severe
-PV bleeding (dark brown) with Hx of amenorrhoea
-D+V
-Shoulder tip pain and pain on defecation / urination
-Collapse (rupture)
-Cervical motion tenderness and unilateral adnexal tenderness
How should you investigate a ?ectopic pregnancy?
-PREGNANCY TEST (a negative result confidently excludes)
-TV/USS to confirm an intrauterine pregnancy / establish adnexal mass
-If highly suspicious of ectopic:
–Serum progesterone (<20nmol indicates failing pregnancy)
–Serum hCG
-Laparoscopy (if doubtful of diagnosis)
How do serum hCG levels change in pregnancy vs ectopic and miscarriage?
NORMAL
-0-8 weeks = doubles every 48h
-8-10 weeks = doubles every 5 days
ECTOPIC
-Slow rise and/or plateau
MISCARRIAGE
-Rapid fall
When should ectopic pregnancies undergo expectant management?
-If <30mm, unruptured, asymptomatic, no foetal heartbeat
-If hCG <1500IU/L
-Closely monitor for 48h and intervene if hCG levels rise or symptoms present
-Safety net to contact EPAU if severe pain, heavy bleeding, dizziness (rupture)
What medical management is offered for ectopic pregnancies?
-If <30mm, unruptured, asymptomatic, no foetal heartbeat
-If hCG <1500IU/L
-Give methotrexate IM - induces spontaneous termination
–Must not get pregnant for at least 3 months after due to highly teratogenic properties of methotrexate
-Can cause N+V, PV bleeding, abdo pain, and take 4-6 weeks to completely resolve
What surgical management is offered for ectopic pregnancies?
-If >35mm, ruptured, in severe pain, visible foetal heartbeat
-If hCG >1500 or another intrauterine pregnancy is in situ
-Laparoscopic salpingectomy / salpingotomy
