Early Pregnancy Problems

Question 1

explain how βHCG levels correlate to the progression of normal and abnormal pregnancy in the first trimester

Answer 1

Normal Pregnancy: B-hCG doubles every 48hrs between 4-8wks (around 1500 at 5wks)

Abnormal Pregnancy: may be plateauing, falling or rising (but not doubling) every 48hrs

Question 2

describe the pathophysiology, diagnosis and management of hyperemesis gravidarum

Answer 2

Pathophys- rising B-hCG levels, from 4-10wks, usually T1

Dx- of exclusion (NTBM: meningitis/brain occupying lesion, DKA, thyroid storm)

Mx- NON-PHARM = ginger, acupuncture, avoid triggers, small high-carb/low-fat meals
PHARM = Phrenegan (anti-Ch/anti-hist), motility drugs, steroids, anti-emetics (Ondansetron); Support = IV fluids/dextrose + Mg/K/PO4 + anti-emetic; TPN severe

Question 3

describe the pathophysiology, diagnosis and management of miscarriage

Answer 3

Pathophys - spontaneous loss of pregnancy before 20wks, most due to extra copy or missing copy of chromosome (aneuploidy)

Dx - B-hCG falling or not doubling every 48hrs

  - US: CRL >7mm with no fetal heart beat, or gestational sac >25mm with no fetal pole - TVUS should show gestational sac <5wks (B-hCG 1500), gestational sac + yolk sac 5-6wks (B-hCG 1500-3500), fetal heart beat 7wks (B-hCG 20,000) 

Mx-

a) counselling / education
b) EXPECTANT (pass naturally next 1-2wks, falling B-hCG, measure every 48hrs until 0), MEDICAL (Misoprostol), SURGICAL (D&C)
c) follow-up, check B-hCG down to 0
d) greif counselling, future preg planning

Question 4

describe the pathophysiology, diagnosis and management of molar pregnancy

Answer 4

Pathophys- Complete = egg w no DNA + sperm; Incomplete = egg + 2 sperm

Dx- vesicles in underwear or on examination, bulky uterus large for gestational date, US (vesicular or honeycomb pattern), confirm with histopath

Mx- wide bore suction

Question 5

describe the pathophysiology, diagnosis and management of ectopic pregnancy

Answer 5

Pathophys - implantation of egg outside uterine cavity. RF’s include prev ectopic, PID, IUD

Dx - abnormal B-hCG + US (showing no intra-uterine or sx of extra-uterine pregnancy)

Mx - EXPECTANT (if low B-hCG <1500 & confirmed no intra-uterine preg or strongly suggests extra-uterine) - wait for ectopic to resolve, need to monitor B-hCG every 48hrs until 0
MEDICAL- Mtx injection (+ monitor B-hCG to prove success, 3 injections otherwise move to surg)
SURGICAL - salpingectomy or salpingostomy

Question 6

compare and contrast the basic diagnostic capabilities and limitations of ultrasonography in the first trimester of
pregnancy

Answer 6

<5wks: (B-hCG <1500) - TVUS shows gestational sac, TAUS - no sx

5-6wks: (B-hCG 1500-3000) - TVUS gestational sac + yolk sac, TAUS gestational asc

7wks: (B-hCG 20,000) - TVUS 5-10mm embryo with heart beat, TAUS embryo