Early pregnancy problems Flashcards
On which day does the oocyte enter the uterus to become a multicellular morula?
Day 4
On which day does the trophoblast invade the enodmetrium (ie implantation)?
Day 6-12
What secretes hCG and when does this peak by?
Trophoblast
Peaks on 12th week
When is placental morphology complete by?
Week 12
When is fetal heart beat present
When is it visible on TVUS?
Weeks 4-5
Visible on TVUS from 6th week onwards
When is the gestational sac visible on ultrasound?
On the 5th week
Definition of early pregnancy miscarriage? When do most occur?
Death of fetus before 24 weeks
<12 weeks
What is the aetiology of miscarriage?
- Implantation- defective trophoblast
- Ovofetal factors- structural chromosomal abnormality
- Maternal factors- Smoking >10 a day, maternal disease eg SLE, and infection (TORCH, parvovirus B19 and Listeria)
Is cervical os open or closed in threatened miscarriage, and what amount of bleeding?
Closed
Mild
Uterus same size as expected
How do you differentiate between completed miscarriage and missed miscarriage?
Both have closed cervical os
Completed will have passage of products of conception, and evidence of prior pregnancy
Missed- no passage of contents and ultrasound will show blighted ovum, and uterus will be smaller for dates than expected
How does septic miscarriage present?
Offensive vaginal discharge
Boggy tender uterus
No fever
What are the investigations for miscarriage?
- Transvaginal ultrasound- fetal pole, heart beat, crown-rump length
- Urinary hcg diagnose pregnancy
- Serum hCG- >50% decrease or slow doubling times then miscarriage
- FBC, coagulation, cross match blood, Rhesus D prophylaxis to rhesus negative women
If a fetal heart beat not present and CRL length >7mm and <7mm what do you do?
Repeat transvaginal ultrasound in 7-14 days, if >7mm then repeat but also get second opinion
When would you expectant management for a miscarriage be suitable?
If bleeding stops with expectant when do you conduct urinary pregnancy tests?
If no pain, minimal blood loss and <6 weeks gestation
>6 weeks gestation, minimal blood loss and no pain
In 3 weeks
What is used in the medical management of incomplete or missed miscarriage? Mifepristone or misoprostol
Mifepristone not indicated anymore- anti-progesterone
Vaginal misoprostol is indicated- is E1 synthetic prostaglandin analogue
When is surgical management indicated for miscarriages?
Excessive bleeding
retained tissue >50mm
suspected gestational trophoblastic disease
infected retained tissue
What is the surgical management of a miscarriage?
Manual vaccum aspiration
Surgical curettage
All tissue sent to histopathology to exclude choriocarcinoma
What is the management of RPOC?
Vaginal examination- speculum-polyp forceps remove products
FBC, coagulation, cross match blood and Anti-D prophylaxis if rhesus negative
ABC and vital signs- give IM Ergometrine (stops bleeding via uterine contraction and vasoconstriction)
If fever- swabs for culture and broad spectrum antibiotics
What are recurrent miscarriages?
> 3 or more consecutive miscarriages
Investigations for recurrent miscarriages?
- Antiphospholipid antibody screen
- Fetal karytoyping
- TFT’s
- Pelvic ultrasound- hysterosalpinogram
Where are the places an ectopic pregnancy can implant?
- fallopian tubes 97%
- Ovaries
- Fimbriae
- Insterstium
- Cervix
- C-section scars
- Abdomen and peritoneum
Aetiology of ectopic?
PID, pelvic infection Endometriosis (adhesions) Pelvic, tubal surgery Assistive reproductive techniques IUS, ICD
Features of ectopic?
Abdo pain first- colicky- then constant- unilateral
Vaginal bleeding- scanty dark
Syncope, light-headedness
Nausea and vomiting
diarrhoea
Shoulder tip pain, collapse, shock- indicate peritoneal blood loss due to rupture. May have absence of vaginal bleeding if this is the case
Examination findings for ectopic?
how does uterus and cervical os appear?
- bimanual pelvic exam: adnexal tenderness pelvic tenderness
- vaginal exam: cervical motion tenderness, cervical os is closed
- Uterus is small for dates
- Adbo exam: rebound tenderness
How is a tubal pregnancy identified and what do you look out for?
Transvaginal ultrasound- look for fetal pole or heart beat
Will show adnexal mass below the level of the internal cervical os
Intrauterine pregnancy may not be able to see if <5 weeks
With serum hCG when diagnosing ectopic how many samples do you take, and what indiciates ectopic pregnancy?
What woud indicate GTD?
2 samples 48 hours apart
If rise of hCG between between >63% increase and >50% decrease
Massively elevated or persistent elevation above >63% increase
How would you stabilise an ectopic patient ie symptomatic?
Hypotensive- IV fluids
FBC, crossmatch blood, coagulation screen
Anti-D prophylaxis to rhesus negative
Which patients should receive conservative management?
Clinically well
Falling hCG levels with initial level <1500 IU
Unruptured ectopic
Location not known
What is medical management of ectopic and when do you use it?
Methotrexate- do LFTS (adequate renal and liver function for this)
No pain
hCG levels <1500 IU
No intrauterine pregnancy on ultrasound
Unruptured ectopic with adnexal mass <35mm
When is surgical management indicated for ectopic and what is surgical?
hCG levels >5000 IU
Adnexal mass >35mm
Fetal heart beat on ultrasound
Significant pain
- Hysterosalpingogram- check condition of other tube
Laproscopic salpingectomy
Laproscopic salpingostomy (if infertility risk factors)
Send all tissue to histopathology to exclude choriocarcinoma
What are complications of ectopic, ie recurrance rate?
Recurrence rate- 10/20%
Rupture- massive haemorrhage- vasovagal shock- DIC-death
