Early Pregnancy Problems Flashcards
What puts women higher risk of ectopic pregnancy?
Hx of chlamydia or ectopic pregnancy Adhesions Tubal surgery Infertility Conceiving whilst on progesterone only pill or IUD Smoking Maternal age >40yrs
But not present in all - c.50-75% have no risk factors
What are some symptoms and signs of ectopic pregnancy?
Symptoms: Abdo/pelvic pain Amenorrhoea or missed periods Vaginal bleeding +/- clots Also - breast tenderness, GI upset, urinary symptoms, dizziness/syncope, shoulder tip pain
Signs:
Pelvic tenderness
Cervical motion tenderness/cervical excitation
Adnexal tenderness
Abdominal tenderness
Also - rebound tenderness, pallor, distension, tachycardia, hypotension
How should you investigate ectopic pregnancy?
Pregnancy test - in any sexually active woman of childbearing age presenting with these symptoms, even if non-specific as can mimic other conditions
Refer ASAP to early pregnancy assessment service or OOH gynae if:
+ve pregnancy test with bleeding or pelvic tenderness or cervical motion tenderness
Transvaginal (or if not wanted, transabdominal) USS:
Intrauterine vs extrauterine? (Only intrauterine is viable)
Foetal heartbeat? If visible then still viable
If not visible but visible foetal pole - crown rump length - if <7mm then repeat scan at 7+ days to check for heartbeat before making Dx
How do you investigate the possibility of tubal ectopic pregnancy?
TV USS signs for tubal ectopic include:
Adnexal mass moving separate to the ovary comprising a gestational sac containing a yolk sac
OR
Adnexal mass moving separate to ovary containing gestational sac and foetal pole +/- foetal heartbeat
Other signs that might mean tubal ectopic is likely:
Bagel sign = separate adnexal mass with empty gestational sac
Complex separate adnexal mass
Empty uterus
How do you use serum hCG levels in the investigation of pregnancy of unknown location on USS?
2x serum levels as near as possible to 48hrs apart to determine subsequent management:
Increase in serum hCG >63% after 48hrs = likely intrauterine pregnancy (though can not exclude ectopic - other symptoms are important indicators e.g. pain) - TV USS to determine location between 7-14days later
Decrease in hCG >50% after 48hrs = pregnancy unlikely to continue (though again not confirmed) - take pregnancy test after 14days - if negative no further action necessary, if positive then return to centre for review in 24hrs
If a decrease in hCG <50% (inappropriate decrease) or increase <63% (suboptimal rise) then return to centre for review
How do you manage threatened miscarriage?
Possible miscarriage where PV bleeding + confirmed intrauterine pregnancy + foetal heartbeat
If bleeding worse or persists beyond 14days then return for review, if settles - continue with antenatal care
What is expectant management of confirmed miscarriage?
7-14 days of watchful waiting and explaining what is going to happen, provide literature, advise a home pregnancy test in 3wks time, review at 14 days minimum
For low risk patients
Consider other management if:
Woman at risk of haemorrhage (e.g. if in later first trimester)
Increased risk of consequences of haemorrhage e.g. coagulopathy or refusing blood transfusion
Previous traumatic experience with pregnancy
Evidence of infection
What is the medical management of miscarriage?
(Mifepristone - PO - few days before misoporstol to prepare the uterus for evacuation of products of conception - GIVEN IN THE CASE OF TOP)
Misoprostol - PO or PV - 800micorgrams - bleeding should start within 24hrs
Is a prostaglandin - stimulates uterus and opens cervix - expels pregnancy
Pregnancy test after 4wks and return to services if positive
What is the surgical management of miscarriage?
Offer choice of:
Manual vacuum aspiration under local in clinic OR
Surgical removal under general in theatre (risk of uterine adhesions and subsequent negative effects on fertility)
What is expectant management of confirmed tubal ectopic pregnancy?
Indicated if:
Clinical stable + no pain + pregnancy <35mm with no visible heartbeat on TV USS + serum hCG <1000IU/L + can return to follow up
Repeat hCG on days 2, 4 and 7 after original test:
Decrease by >15% each day = repeat weakly until -ve
Do not do the above = review condition and senior review
Expectant management not at an increased risk of:
Tubal rupture
Need for additional treatment (though this may be necessary)
Poor mental health outcomes
What is the medial and surgical management of tubal ectopic pregnancy?
Methotrexate - IM - when:
No significant pain + unruptured ectopic with adnexal mass <35mm with no heartbeat + hCG <1500 + no intrauterine pregnancy + can return to follow up
Surgery - laparoscopic - when: Unable to return to follow up for Medical management Significant pain Ectopic with adnexal mass >35mm Ectopic with visible heartbeat on USS Ectopic with hCG >5000
What other treatment might be needed?
Anti-D rhesus prophylaxis - 50micrograms - in rhesus -ve women undergoing surgery for ectopic pregnancy or miscarriage
What are molar pregnancies?
Molar pregnancy = a form of gestational trophoblastic disease, 1/600 pregnancies - non-viable fertilised egg implants into uterus, aka a hyadatidiform mole; partial moles are triploid (2x sperm + 1x egg that doubles - 69XXY), complete moles are diploid (empty ovum, 1x sperm that then doubles - 46XX) - most are complete moles
Can also become invasive/malignant e.g. choriocarcinoma - tissue of a molar pregnancy does not die off as normal but proliferates into endometrium like a cancer (can also metastasise) -
More common in: <20yrs, >35yrs, Asian ethnicities
Presentation:
Vaginal bleeding most commonly, may be painless
Uterus large for dates
Hyperemesis gravidum - because high levels of bHCG
Would be particularly concerned about this in patients who have a positive pregnancy test after the end of management for miscarriage or ectopic
Investigations:
High beta hCG
(+ low TSH + high thyroxine - because bhCG is structurally similar to LH+FSH+TSH so stimulates thyroid gland to produce T4 (+T3) resulting in a thyrotoxicosis picture w/-ve feedback to the pituitary gland to stop TSH production)
USS - snowstorm appearance (if complete mole)
Management:
Molar pregnancy treated surgically - don’t want to embolise potentially cancerous cells into maternal circulation
Once is cancerous, is treated with chemotherapy e.g. methotrexate which is usually highly successful
What is the epidemiology of miscarriage an ectopic pregnancies?
Miscarriage:
1/4 pregnancies - most within 1st trimester (1-12wks), late = 13-24 and is much less common
Ectopic:
11/1000 pregnancies
Still can be fatal (following rupture) but death rate has dropped
What is hyperemesis gravidum? What are some risk factors?
Troubling nausea and vomiting in pregnancy outside the normal
Most common in weeks 8-12 (rare beyond 20wks)
Thought to be related to raise beta hCG levels thus increased risks with increased placental mass - molar pregnancies and multiple pregnancies
Also may relate to - in oestrogen, nutritional deficits (B6), gastric smooth muscle relaxation due to high progesterone etc
Other risk factors:
Hyperthyroidism
Nulliparity
Obesity
Smoking is linked to a deceased incidence…
