Early Pregnancy Problems Flashcards
What is the definition of early pregnancy?
- anything <12 weeks gestation
A 26 year old women G2P0 12weeks nuchal translucency - empty gestational sac or blighted ovum
a 36 year old G2P1 pregnant with a confirmed twin pregnancy after IVF, ongoing vomiting despite ondasetron wafers, maxalon, and complimentary therapies
A 34 year old women G2P0 who is 6 weeks pregnant has been followed through EPAS with abnormally rising beta-HCG levels. She is well
A 28 year old G3P0 presents with heavy bleeding.
Early Pregnancy Problems Divisons?
- Symptoms
- bleeding
- pain
- other
- Diagnoses
- miscarriage
- ectopic
- hyperemesis
- GTD
- Clinical Presentations:
- missed period/amenorrhea
- N/V
- Breast tenderness
Diagnosis of Pregnancy?
Hx
- important - ask all the questions.
- Could you pregnant?
- Last period. Was it normal? very few will say exactly
- ectopic will get some bleeding from endometrium (brown or prune coloured)
- breast tender
- N/V
Ix: - confirm history
What test do you order in early pregnancy? How do you track normal pregnancy? Symptoms? No symptoms?
- Quantitative beta-HCG (qualitative is a pregnancy test +/- only)
- produced by trophoblast cells
- First Trimester. doubles every 48hrs in a normal pregnancy, ectopic it will not double normally. Until 8-9weeks.
- every 48 hours for 3 readings.
- does not correlate to number of weeks, only trophoblast tissue.
Ultrasound:
- no symptoms: <1500 don’t expect to see anything on US.
- symptoms: severe pain and 600 still do US looking for ectopic.
- 1500 - see fetus on transvaginal scan (not transabdominal)
- 1500-3500 gestational sac + yolk sac
Morning sickness vs hyperemesis gravidarum?
hyperemesis gravidarum
- presistent vomiting with weightloss, dehydration and ketonuria
- onset usually 4-10wks
- 1 in 200 pregnancies
- might persist - reason it gets better. Plateaus.
- Dx of exclusion
- repoductive age group (space occupying lesion)
- Hx and Ex
Morning sickness - common
- related to beta-HCG - more related to mass of fetus
- molar pregnancy, twin pregnancy
What would you examine for morning sickness?
- weight
- orthostatic BP
- free T4 concentration/TSH
- UECs
- FBE
- LFTs
Non-pharmacological interventions for morning sickness? Some questions to ask?
- trigger removal
- stuffy rooms
- odours
- heat
- humidity
- noise
- avoid brushing teeth after eating
- accupressure
- ginger
- diet
- high carb, low fat small meals -
- eliminate spicy food.
- avoid iron supplements
- psychological
- emotional support
- mood
- domestic violence
- psychiatric history
Pharmacological Management of Morning sickness?
Pyridoxine
- Doxylamine - antihistamine (vitamin B6)
Antihistamines:
- Phenergan - can be sedating (promethazine)
Antiemetic:
- ondansetron - Zofran (serotonin receptor antagonist)
- highly constipating which is bad in pregnancy anyway.
Motility Drugs:
- dopamine antagonists - increase LES pressure, speeds up transit
Corticosteroids
- refractory
IV fluids if needed
Enteral nutrition if needed
What is miscarriage? What are some statistics surrounding it? How common is it?
- loss of pregnancy <20weeks (definitions vary)
- sponteanous - on its own
- complete - all products passed (scan with empty uterus)
- incomplete -might need suction currete or stimulation
- septic - more common in NT, tropical, infections
- missed. Very sick.
- blighted ovum - gestational big but no crown rump, genetic abnormality
- recurrent miscarriage - 3 in a row go searching.
- inevitable - products sitting in cervix
- 5-10 years ago changed the terminology to classify it as different to abortion.
- 50% threatened miscarriage have continuing pregnancy - 15-20% clinically diagnosed pregnancy.
Causes of Miscarriages?
- chromosomal abnormalities = 85%
- maternal illness (increasing - older women)
- DM,
- phospholipid/ SLE
- Thyroid
- advanced maternal age (>35, >40)
- lifestyle factors
- smoking, drugs, alcohol, caffeine, extremes of weight
- Others: (2nd trimester) mid-term
- uterine abnormalities
- trauma (iatrogenic, other, DV)
- progesterone deficiency
- cervical incompetence
A women comes in with pregnancy, what history and examination should you perform?
- planned/unplanned? not the same as wanted and unwanted
- where do you live?
- social implications
- LNMP - period Hx
- pregnancy symptoms
- last eat?
Examination
- general appearance/abdo exam
- vital signs
- cervical shock - products in the os. Innervated by vagus nerve.
- speculum exam
- cerivcal appearance
- amount of blood
- products of conception
- vaginal examination NOT indicated
WHat service should you refer them to? What investigations will they perform?
refer to EPAS -
- US
- measure serum beta-HCG
- Rhesus group and blood
- FBC, Group and save vs group and hold?
- psychological support
Criteria for Diagnosing a miscarriage?
- crown rump length >7mm with no cardiac activity
- empty gestational sac with a mean diameter >25mm (does not mean yolk sac or fetal pole)
- see fetus around 6.5weeks transabdominally 5.5 transvaginally
Management of miscarriage?
- expectant
- inevitable/incomplete
- missed = 70% success in 14 days
- medical
- misoprostol
- not everyone is respoonsive
- indicated if there are products of conception in uterus
- 80% success rates in 3-4days
- misoprostol
- surgical
- 1% uterine perforation rate/repeat procedure
- IV antibiotics
- anti-D required if rhesus negative
- resus
- emergency
- expectant vs medical vs surgical
- Rh negative give anti-D
- psychological support
