Early Pregnancy Problems

Question 1

What are the four major causes of bleeding in early pregnancy?

Answer 1

• Ectopic pregnancy (must exclude)
• Miscarriage (most common)
• Implantation bleed
• Cervical/vaginal/uterine pathology

Question 2

In taking a history from a woman with early pregnancy bleeding, what are the important points to cover?

Answer 2

• Characterise the blood
• Passage of tissue?
• Anaemic symptoms?
• Pain?
• Pregnancy symptoms continuing?
• Previous obstetric/gynaecological history

Question 3

A woman in early pregnancy presents with PV bleeding and a low blood pressure and low heart rate. What is this situation likely to be?

Answer 3

Cervical shock

Question 4

What would be some sensible investigations to do for a patient with early pregnancy bleeding?

Answer 4

• FBE (+/- coags)
• Group and hold
• bHCG

Question 5

What is an appropriate course for bHCG levels in an intrauterine pregnancy?

What might falling levels indicate?

A plateau or slow rise?

Answer 5

• Doubling every 48 hours
• Involuting ectopic or non-viable uterine
• Ectopic or abnormal intrauterine

Question 6

At what bHCG level can a intrauterine pregnancy normally be visualised using TVUS?

Answer 6

>1500

Question 7

What are the TVUS criteria for pregnancy non-viability?

Answer 7

• Mean sack diameter > 25mm and no foetal pole OR
• Crown rump length > 7mm and no foetal heart OR
• 2 scans > 1 week apart with no interval growth

Question 8

If a pregnant woman has a positive pregnancy test but a bHCG of < 1500, what is this termed?

Answer 8

• Pregnancy of unknown location
• Generally if a woman presents with early pregnancy complications and this scenario, serial bHCGs will be performed to determine its nature pre-TVUS

Question 9

If you’ve excluded every other cause of early pregnancy bleeding (especially ectopics!), what might be going on?

Answer 9

• Implantation bleeding

Question 10

If, on TVUS, a patient shows an intrauterine gestational sac with no embryonic heartbeat (and no findings of definite pregnancy failure), what is this called?

Answer 10

Pregnancy of uncertain viability

Question 11

What defines a missed miscarriage?

Answer 11

• Death of the foetus < 20 weeks with prolonged retention
• TVUS - intrauterine gestation sac +/- pole, with no cardiac activity

Question 12

How is a missed miscarriage managed?

Answer 12

• Medically (misoprostil) - requires follow-up
• Surgical removal

Question 13

A pregnant woman presents with vaginal bleeding. Her cervix is closed and there’s a detectable pregnancy with cardiac activity on TVUS. What is this situation called?

Answer 13

• Threatened miscarriage

Question 14

How often will threatened miscarriages progress to complete miscarriage? How are they managed?

Answer 14

4% only. Managed expectantly

Question 15

A woman presents with vaginal bleeding and crampy pains. On examination, she has a low HR and BP, an open cervix containing products of conception. What is this situation called? How is it managed?

Answer 15

• Inevitable miscarriage
• Expectantly unless the situation deteriorates (mmay require ergotmetrine and surgical intervention)

Question 16

What is an incomplete miscarriage?

Answer 16

• Ruptured membranes +/- passage of foetus, with significant amounts of placental tissue remaining
• Normally medical or surgical evacuation performed

Question 17

How can a complete miscarriage be distinguished from an ectopic pregnancy?

Answer 17

• Clinically - passage of tissue with subsequent decrease in pain/bleeding
• Direct tissue examination
• Falling bHCG levels

Question 18

What are the risk factors for ectopic pregnancy?

Answer 18

• PHx ectopic
• Increasing age
• OCP or IUD
• PHx of tubal damage (infection, surgery, endometriosis)

Question 19

How is an ectopic pregnancy diagnosed?

Answer 19

• Clinical suspicion AND
• bHCG > 1500 and no pregnancy visible in uterus on TVUS

Question 20

How is an ectopic pregnancy managed medically? What are the contraindications to this?

Answer 20

• Methotrexate (for low risk only)
• Contraindications: unstable, severe pain, >300mL free fluid, bHCG >5000, breastfeeding, abnormal UECs/LFTs, medical comorbidities
• Follow-up: FBE, UEC, LFT, serial bHCG

Question 21

How are ectopic pregnancies managed surgically?

Answer 21

• Stable? - laparoscopy
• Unstable - laparotomy
• Generally (if located here), the Fallopian tube is removed

Question 22

What are complete and partial molar pregnancies? What is the possible serious complication?

Answer 22

• When a sperm (complete) or 2 sperm (partial) fertilise an empty egg.
• Persistent trophoblastic disease (more common in complete disease)

Question 23

What are the clinical features and investigation results that might make you suspect a molar pregnancy?

Answer 23

• Bleeding, passage of vesicles
• Hyperemesis
• Hyperthyroidism (especially later)
• Very high bHCG, suppressed TSH
• Snowstorm TVUS

Question 24

How are molar pregnancies managed?

Answer 24

• CXR (risk of metastatic disease) and FBE, UEC, TFT, x match, coags, bHCG etc.
• Suction curette, hysterectomy if possible
  
  • If former, 10% recurrence in complete disease

Question 25

How is hyperemesis defined? How is it treated?

Answer 25

• Weight loss >5%, non-responsive to normal treatment
• MD team, antiemetics/antacids, consider admission and fluids +/- electrolytes, thiamin, clexane, steroids, NJ tube, TPN, termination