Early Pregnancy Problems Flashcards
What are the four major causes of bleeding in early pregnancy?
- Ectopic pregnancy (must exclude)
- Miscarriage (most common)
- Implantation bleed
- Cervical/vaginal/uterine pathology
In taking a history from a woman with early pregnancy bleeding, what are the important points to cover?
- Characterise the blood
- Passage of tissue?
- Anaemic symptoms?
- Pain?
- Pregnancy symptoms continuing?
- Previous obstetric/gynaecological history
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?
Cervical shock
What would be some sensible investigations to do for a patient with early pregnancy bleeding?
- FBE (+/- coags)
- Group and hold
- bHCG
What is an appropriate course for bHCG levels in an intrauterine pregnancy?
What might falling levels indicate?
A plateau or slow rise?
- Doubling every 48 hours
- Involuting ectopic or non-viable uterine
- Ectopic or abnormal intrauterine
At what bHCG level can a intrauterine pregnancy normally be visualised using TVUS?
>1500
What are the TVUS criteria for pregnancy non-viability?
- 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
If a pregnant woman has a positive pregnancy test but a bHCG of < 1500, what is this termed?
- 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
If you’ve excluded every other cause of early pregnancy bleeding (especially ectopics!), what might be going on?
- Implantation bleeding
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?
Pregnancy of uncertain viability
What defines a missed miscarriage?
- Death of the foetus < 20 weeks with prolonged retention
- TVUS - intrauterine gestation sac +/- pole, with no cardiac activity
How is a missed miscarriage managed?
- Medically (misoprostil) - requires follow-up
- Surgical removal
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?
- Threatened miscarriage
How often will threatened miscarriages progress to complete miscarriage? How are they managed?
4% only. Managed expectantly
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?
- Inevitable miscarriage
- Expectantly unless the situation deteriorates (mmay require ergotmetrine and surgical intervention)
What is an incomplete miscarriage?
- Ruptured membranes +/- passage of foetus, with significant amounts of placental tissue remaining
- Normally medical or surgical evacuation performed
How can a complete miscarriage be distinguished from an ectopic pregnancy?
- Clinically - passage of tissue with subsequent decrease in pain/bleeding
- Direct tissue examination
- Falling bHCG levels
What are the risk factors for ectopic pregnancy?
- PHx ectopic
- Increasing age
- OCP or IUD
- PHx of tubal damage (infection, surgery, endometriosis)
How is an ectopic pregnancy diagnosed?
- Clinical suspicion AND
- bHCG > 1500 and no pregnancy visible in uterus on TVUS
How is an ectopic pregnancy managed medically? What are the contraindications to this?
- 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
How are ectopic pregnancies managed surgically?
- Stable? - laparoscopy
- Unstable - laparotomy
- Generally (if located here), the Fallopian tube is removed
What are complete and partial molar pregnancies? What is the possible serious complication?
- When a sperm (complete) or 2 sperm (partial) fertilise an empty egg.
- Persistent trophoblastic disease (more common in complete disease)
What are the clinical features and investigation results that might make you suspect a molar pregnancy?
- Bleeding, passage of vesicles
- Hyperemesis
- Hyperthyroidism (especially later)
- Very high bHCG, suppressed TSH
- Snowstorm TVUS
How are molar pregnancies managed?
- 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
How is hyperemesis defined? How is it treated?
- Weight loss >5%, non-responsive to normal treatment
- MD team, antiemetics/antacids, consider admission and fluids +/- electrolytes, thiamin, clexane, steroids, NJ tube, TPN, termination
