Early Pregnancy Problems Flashcards
DIAGNOSIS OF PREGNANCY
history
- Menstrual history - Describe menstrual pattern, Date of onset of last menses, duration, flow, frequency, Atypical last menstrual period, contraceptive use, irregular menses
- Rising hCG, empty uterus, abdominal pain, vaginal bleeding – ectopic
- Classic presntation – amenorhoea, nausea, vomiting, generalised malaise, breast tenderness
- Examination – enlarged uterus, brast changes, softening and enlargement of cervix (hegar sign at 6 weeks)/ chadwick sign (blue discolouration of cervix) / uterus may be palpable low in abdomen if progressed far enough by 12 weeks
DIAGNOSIS OF PREGNANCY
laboratory evaluation
- hCG
- corticotropin-releasing hormone, gonadotropin-releasing hormone, thyrotropin-releasing hormone, somatostatin, corticotropin, human chorionic thyrotropin, human placental lactogen, inhibin/activin, transforming growth factor-beta, insulinlike growth factors 1 and 2, epidermal growth factor, pregnancy-specific beta-1 glycoprotein, placental protein 5, and pregnancy-associated plasma protein-A.
- progesterone – evaluating abnormal early pregnancy, produced by corpus luteum, viable pregnancy diagnosed with levels grater than 25ng/mL
- early pregnancy factor – earliest available marker to indicate fertilisation detectable 36-48 hours after fertilisaion
DIAGNOSING PREGNANCY
describe serum hCG monitoring
- detectable in 98% of patients after day 11
- at 4 weeks the hCG double every 2 days, levels peak at 10-12 weeks, then falls and then rises again from 22 weeks
- low false positive rates
DIAGNOSING PREGNANCY
describe ultrasonography
- earliest structure identified is gestational sac at 4-5 weeks
- yolk sace – 4-5 weeks and seen until 10 weeks gestation (larger thn 7mm with no fetal pole suggests nonviable pregnancy
- embryonic pole – 5-6 weeks
- 5-6 weeks – HR=100-115 which rises to 140 by 9 weeks gestational age
DIAGNOSING PREGNANCIES
multiple pregnancies
- hcg levels higher
- uterus larger thn expected for dates
- more morning sickness
- greater appetite
- too much weight gain
- foeta moveements in different parts of abdomen at same time
- alpha-fetoprotein levels higher
- ultrasound
BLEEDING IN PREGNANCY
benign causes
Infection -cervix, vagina, STI
Cervical changes – progesterone influence, sexual intercourse
Implantation bleed
BLEEDING IN PREGNANCY
serious causes
Miscarriage
Ectopic pregnancy
Gestational trophoblastic diseases
what is miscarriage?
Spontaneous loss of the pregnancy before fetus reaches viability
Up to 20% of all clinically recognised pregnancies (80% 1st trimester)
UK viability – 23+6 weeks
MISCARRIAGE
classification
Threatened
Inevitable
Complete/incomplete
Missed miscarriage – anembryonic pregnancy
missed miscarriage
Failure of an embryo or fetur to develop in pregnancy
Death of fetus in utero – no cardiac activity
Gestational sac continue to grow, no fetal parts seen
Diagnosis with USS
aetiology of miscarriage
foetal chromosomal abnormalities hormonal factors immunological causes uterine anomalies infections environmental factors unexplained
AETIOLOGY OF MISCARRIAGE
examples of foetal chromosomal abnormalities
- trisomy 21-downs
- trisomy 13 – patau
- trisomy 18 - edwards
AETIOLOGY OF MISCARRIAGE
examples of hormonal factors
- PCOS
- Inadequate luteal function
- Diabetes
- Thyroid dysfunction
AETIOLOGY OF MISCARRIAGE
immunological causes
- Autoimmune
* alloimmune
AETIOLOGY OF MISCARRIAGE
uterine anomalies
- septated
- asherman syndrome
- fibroid
AETIOLOGY OF MISCARRIAGE
environmental factors
- alcohol
* smoking
CONSERVATIVE MANAGEMENT OF MISCARRIAGE
confirmed incomplete, missed or inevitable miscarriage?
- first line expectant management 7-14 days if accepted by women
- exclude complicated factors
- reassess after 14 days if no bleeding
CONSERVATIVE MANAGEMENT OF MISCARRIAGE
complete miscarriage
- pregnancy test at home in 3 weeks and return for assessment if positive
- anti-d if required
CONSERVATIVE MANAGEMENT OF MISCARRIAGE
when can retained products of conception by managed conservatively
if small and minimal bleeding
MEDICAL MANAGEMENT OF MISCARRIAGE
Misoprostol – synthetic prostaglandin E1 (PGE1) – orally or vaginally usually with antiprogesterone priming (mifepristone) 24-28hr prior
Bleeding may continue for up to 3 weeks after medical uterine evacuation but completion rates upto 80-90% expected after 9 weeks
Warn women that passage of pregnancy tissue may be associated with pain and heavy bleeding and 24hr telephone advice and facilities for emergency admission should be available
SURGICAL MANAGEMENT OF MISCARRIAGE
Evaluation of retained products of conception
General anaesthesia/sedation, Theatre, Suction evacuation
Local anaesthesia / outpatient department/manual vacuum aspiration
Complications – infection, haemorrhage, uterine performation, retained products of conception, intrauterine adhesions, cervical tears, intra-abdominal trauma, uterine and cervical trauma can be minimised by administering prostaglandin before the procedure
ECTOPIC PREGNANCY
- what is it
- incidence
- risk factors
- Any implantation outside the uterine cavity
- Incidence 1 in 100 all pregnancies / 1 in 30 high risk population
- pelvic infection, previous ectopic pregnancy, previous surgery, endometriosis, IVF. 50% with no predisposing risk factors
what is a heterotropic pregnancy
(combined intrauterine and ectopic) is rare
ECTOPIC PREGNANCY
clinical presentation
no symptoms, abdominal pain, PV bleeding, intra-peritoneal bleeding (signs of peritonism, shoulder tip pain), bowel, urinary symptoms, maternal collapse, positive pregnancy test
ECTOPIC PREGNANCY
diagnosis and management
clinical presention, examination, serum beta HCG, TV USS
ECTOPIC PREGNANCY
management
- conservative – clinically stable, low declining levels of serum HCG, no symptoms.
- HCG declines
- Methotrexate
- Surgical laparoscopy
RECURRENT MISCARRIAGE
- what is it
- risk factors
- causes
- risk factors
- Loss of 3 or more consecutive pregnancies, occurring in the first trimester with the same biological father
- advanced maternal age
- antiphospholipid syndrome, genetic, foetal chromosomal abnormalities, anatomical abnormalities, fibroids, thrombophilic disorders, infectioin, endocrine disorders, cervical weakness, immune dysfunction
- maternal age, number of previous loss
RECURRENT MISCARRIAGE
antiphospholipid syndrome
- Treatable
- 15% of cases
- Presence of anticardiolipin antibodies or lupus anticoagulant antibodies on 2 separate occasions with any of the folloing
- 3 or more consecutive foetal losses before 10th week
- 1 or more births or morphologically normal fetus at <34 weeks associated with severe pre-eclampsia or placental insufficieny
RECURRENT MISCARRIAGE
genetic causes
- Robertsonian translocation
* Carrier is phenotypically normal but 50-75% of gametes will be unbalanced
RECURRENT MISCARRIAGE
foetal chromosomal abnormalities
- Incompatible with life
- As number of pregnancies increase, prevelance of chromosomal abnormality decrease and chance of recurring maternal cause increase
RECURRENT MISCARRIAGE
anatomical abnormailities?
- Uterine septae
* Bicornuate uterus
RECURRENT MISCARRIAGE
thrombophilic disorders
Gene mutations in factor V leiden and factor II prothrombin G20210A associated with recurrent miscarriage
RECURRENT MISCARRIAGE
infection
- Inconsistnent link to bacterial vaginosis with 1st trimester loss
- Recurrent 2nd trimester stronger association
RECURRENT MISCARRIAGE
endocrine disorders?
Well controlled diabetes and thyroid disease not risk factor
RECURRENT MISCARRIAGE
cervical weakness
History of late miscarriage preceded by painless cervical dilatation cause of recurrent mid trimester loss but does not appear to have association with frst trimester miscarriage
RECURRENT MISCARRIAGE
immune dysfunction
Excessive uterine natural killer cell activity – hypothetical and no link between peripheral and uterine NK activity is proven
RECURRENT MISCARRIAGE
investigations
- Antiphospholipid antibodies
- Cytogenetic analysis – POC (unbalanced chromosome abnormality / parental blood karyotyping)
- USS- uterine anatomy
- Inherited thrombophilias
- Lupus anticoagulant
- Bacterial vaginosis
RECURRENT MISCARRIAGE
treatment
- Low dose aspirin and heparin
- Genetic counselling
- Assised conception – pigd
- Surgery – for intrauterine abnomaliries or fibroids
- Cervical cerclage
- lifestyle - bed rest, smoking cessation, alcohol, weight loss
what is the role of the early pregnancy assessment unit?
Diagnosis and care in early pregnancy
Managing complications
Early diagnosis and management of ectopic pregnancies
Emotional support during pregnancy loss
ANTI-D PROPHYLAXIS
Given to all non-sensitised rhesus negative patients in following circumstances –
• <12 weeks (250IU IM) – uterine evacuation/ectopic pregnancies
• >12 weeks – all women with bleeding (250IU IM before 20weeks and 500IU IM after 20 weeks)
HYDATIFORM MOLE
- vaginal bleeding
- uterus size greater than expected for gestational age
- abnormally high serum hCG
- ultrasound: ‘snow storm’ appearance of mixed echogenicity
- type of gestational trophoblastic disease
- can be complete or partial
HYDATIFORM MOLE
complete mole
- consists of diffuse hydropic vili with trophoblastic hyperplasia
- diploid, derviced from sperm duplicating its own chromosome following fertilisation of an ‘empty’ ovum. Mostly 46xx with no evidence of fetal tissue
HYDATIFORM MOLE
partial mole
- hydropic and normal villi
- triploid 69XXX, XXY, XYY with one maternal and 2 paternal haploid sets
- due to 2 sperms fertilising an ovum and fetus may be present
HYDATIFORM MOLE
signs and symptoms
- irregular first trimester vaginal bleeding
- uterus large for dates
- pain from large theca lutein cysts resulting from ovarian hyperstimulation by high hCG levels
- vaginal passage of vesicles containing products of conception
- exaggerated pregnancy symptoms – hyperemesis, hyperthyroidism, early pre-eclampsia
- serum hCG excessively high with complete moles
HYDATIFORM MOLE
risk factors
- age - >40 and <15 in complete but not partial
- ethnicity – X2 in east asia
- previous molar pregnancies
HYDATIFORM MOLE
maagement
- Complete mole – surgical evacuation, risk of uterine perforation and haemorrhage. Oxytocin to reduce haemorrage
- Partial mole – surgical evacuation unless size necessitates medical evaluation
- chemotherapy
- Barrier contraception until hcg normal
HYDATIFORM MOLE
prognosis and follow up
- Specialist follow up for molar pregnancy
- Registered at one of 3 specialist centres (Sheffield, Dundee, London)
- Serum hCG checked fortnightly until levels are normal
- Urine hcg requested at 4 weekly intervals until 1 year post evaculation then 3 months in 2nd year follow up
- If normalises follow up to 6 months
- No normal within 8 weeks 2 yr follow up
THREATENED MISCARRIAGE
- clinical features
- USS findings
- management
- bleeding +/- abdominal pain, closed cervic
- intrauterine gestation sac, foetal pole, foetal heart activity
- anti-D if >12 weeks or heavy bleeding or pain
COMPLETE MISCARRIAGE
- clinical features
- USS findings
- management
- bleeding and pain cease, closed cervix
- empty uterus, endometrial thickness <15mm
- anti-D if >12 weeks, serum hcg to exclude ectopic, review if bleeding persists >2 weeks and consider endometritis or retained products of contraception
INCOMPLETE MISCARRIAGE
- clinical features
- USS findings
- management
- bleeding +/- pain, possible open cervix
- heterogenous tissues +/- gestation sac. endometrial thickness
- expectant generally preferable/medical/surgical. anti-D if >12 weeks or heavy bleeding or pain or medical/surgical management
MISSED MISCARRIAGE/EARLY FOETAL DEMISE
- clinical features
- USS findings
- management
- +/- bleeding, +/- pain, +/- loss of pregnancy symptoms, closed cervix
- foetal pole >7mm with no foetal heart activity. mean gestation sac diameter >25mm with no foetal pole or yolk sac
- expectant/medical/surgical. anti-D if >12 weeks or medical/surgical management
INEVITABLE MISCARRIAGE
- clinical features
- USS findings
- management
- bleeding +/- pain. open cervix
- intrauterine gestation sac +/- foetal pole +/- heart activity
- expectant/medical/surgical
anti-D if >12 weeks or heavy bleeding or pain or medical/surgical management
PREGNANCY OF UNCERTAIN VIABILITY
- clinical features
- USS findings
- management
- +/- bleeding, +/- pain, closed cervix
- intrauterine gestation sac <25mm with no foeta pole or yolk sac, foetal echo with CRL <7mm with no foetal heart activity
- rescan in 1 week. anti-d if heavy bleeding or pain
PREGNANCY OF UNKNOWN LOCATION
- clinical features
- USS findings
- management
- +/- bleeding, +/- pain, closed cervix
- positive pregnancy test, empty uterus, no sign of extrauterine pregnancy
- serial serum hcg assay with initial serum progesterone level to exclude ectopic pregnancy/failing PUL . anti-D if heavy bleeding
