Gynaecology: Early Complications of Pregnancy Flashcards
What are the most common problems of early pregnancy?
- Miscarriage
- Ectopic pregnancy
- Gestational trophoblastic disease
- Hyperemesis Gravidarum
What are the four/five kinds of miscarriage?
- Threatened
- Inevitable
- Incomplete
- Complete
(can also have a Septic miscarriage)
Define a threatened miscarriage?
Bleeding and/or pain up to the 24th week with a viable ongoing pregnancy
Define an inevitable miscarriage?
Open cervix, but products of conception have not yet been passed, but they inevitably will
What is an incomplete miscarriage?
When some POC have been passed but some tissue and/or blood clots remain within the uterus.
Cervix remains open.
USS definition = Echogenic mass of blood clot and tissue within the uterine cavity >20 mm
How does a Septic miscarriage occur?
Incomplete miscarriage where the POC have become infected (rare as tend to get removed quickly).
When is a miscarriage complete?
If all products of conception have been passed. Bleeding and pain begin to reduce, cervix begins to close.
Uterine cavity = empty, AP <20m
What is the term for a failed pregnancy with no cardiac pulsations on USS?
Missed miscarriage/ Early fetal demise
What do you call a failed pregnancy with empty gestation sac?
Blighted ovum/ Anembryonic pregnancy.
How will a woman with a miscarriage present?
Vaginal bleeding +/- abdominal pain.
She may or may not know about pregnancy.
What examination signs point towards suspicion of miscarriage?
- Blood from cervical os
- Intense bleeding
- Presence of clots or tissue fragments
- Internal cervical os can be open (as in incomplete or inevitable MC) or closed (as in threatened MC)
For a missed miscarriage, the only sign may be lack of foetal heart sounds on CTG.
When are miscarriages most common, what is normally the cause?
- First trimester (before 13th week)
- Normally foetal abnormality (chromosomal, congenital)
- However aetiology is rarely established.
2T miscarriages are more commonly maternal factors e.g. SLE or APLS, infection,, poorly controlled diabetes,
What are the risk factors for miscarriage?
- Advanced maternal age
- Previous miscarriage
- Smoking
- Alcohol (moderate to heavy)
- NSAIDs, ASPIRIN
- Folate deficiency
- Consanguinity
What are the conservative management options for a woman miscarrying?
- Just wait for all POC to pass naturally, usually over a 2 week span.
- Must have 24 hour access to gynae services
What are the pros and cons of conservative management for miscarriage?
Pros:
- Avoids risk of surgery and medication
- Allows women to be at home during an incredibly difficult time
Cons:
- Pain and bleeding are unpredictable, risk of rapid escalation
- Being at home may be more worrying
- Takes longer
- May be unsuccessful and still require active management
What maternal factors can lead to miscarriage?
- Uncontrolled diabetes
- SLE
- Antiphospholipid syndrome
- Thrombophilia
- Acute illness/ infection
- Uterine anomalies
Outline the medical management of miscarriage?
MERPC
- Drugs are used to empty the uterus
- 85%+ successful
- On day 1 give Mifepristone (anti-progesterone)
- On day 3 give Misoprostol (prostaglandin)
What classes of drugs are given in miscarriage?
Anti-progesterone (Mifepristone) + Prostaglandins (Misoprostol)
What are the pros and cons of managing miscarriage medically?
Pros:
- Avoids surgery
- High satisfaction if successful
- Can be done as outpatient in some centres
Cons:
- Pain and bleeding may be unpleasant and/or severe
- Drugs can have side effects
- Need for emergency surgical management isn’t negligible (around 5%)
How can miscarriage be managed surgically?
SERPC:
- Suction curette used to empty uterus
- Takes 5 minutes, performed under GA
- Day case
- Return to physiological norm within 24 hours
- Bleeding for 1-2 weeks
What are the pros and cons of surgical management of miscarriage?
Pros:
- Planned procedure so gives degree of closure
- Takes 5 minutes
- Return to phys norm within 24 hours
Cons:
- Surgical RFs e.g. perforation of the bowel, bladder damage, cervical damage, Asherman’s, cervical weakness
- Anaesthetic RFs
What is Asherman’s Syndrome?
An acquired uterine condition that occurs when adhesions form inside the uterus and/or the cervix.
No singular cause but common after trauma e.g. SERPC in the West, in other countries can occur due to infections e.g. TB
Can lead to menstrual disturbances, placental abnormalities and infertility.
When can a patient be said to have recurrent miscarriages?
Loss of 3+ CONSECUTIVE pregnancies with SAME partner.
Affects 1% of women, however 75% will achieve ongoing pregnancy with supportive care only
What are some causes of recurrent miscarriages?
- Robertsonian translocations
- Uterine anomalies
- Antiphospholipid syndrome
What are some causes of ectopic pregnancy?
Essentially anything that would slow the movement of an ovum throught the Fallopian tubes:
- PID
- PRevious surgery/scar tissue
- IUCD
- Smoking
- Previous ectopic
- Endometriosis
Where are ectopic pregnancies most commonly located?
97% are tubal (mostly in ampullas, sometimes in isthmus).
Other locations include:
- Ovaries
- Abdomen
- Cervix
- CS scar
What are the signs and symptoms of ectopic pregnancy?
Can be none, but suspect ectopic in any sexually active women presenting with: - Abdo pain - PV bleeding - Fainting - Diarrhoea or Vomiting \+/- no periods in last 6 weeks
Rarer symptoms include; shoulder tip pain (blood in peritoneum causing irritation of diaphragm), Peritonism, Dizzyness
What investigations and exams are required in a suspected ectopic pregnancy?
- Pregnancy test
- Vaginal exam
- Speculum exam
- FBC, Group and Save
- Serum progesterone and b-HCG
- TVUS is the only reliable way of distinguishing where the pregnancy is
What are the three management options in ectopic pregnancy?
- Expectant
- Medical (methotrexate)
- Surgical (laparoscopic or salpingectomy)
When is expectant management of ectopic pregnancy offered?
If hCG is falling rapidly and below 1500, and the patient has 24 hour access to gynae services.
Plateauing or slowly rising b-HCG sent to consultant.
Outline the medical management of ectopic pregnancy?
- Methotrexate, 50mg, IM, single dose.
- hCG monitoring is required on days 4 and 7
- If fallen by less than 15% give a second dose
- Contraception required for next 3 months (teratogens)
- Warn of SEs: Conjunctivitis, Stomatitis, Diarrhoea, Abdo pain
Outline the surgical options for ectopic pregnancy?
- Laparoscopic management (ideal as less risk)
- Salpingotomy (incision of the tube to remove the ectopic)
- Salpingectomy (removal of the tube)
Removal > Incision if the contra-L tube is healthy
How can you attempt to manage the BPS elements of miscarriages/ ectopics?
- Choose your wording carefully: say pregnancy not baby/POC
- Offer support
- Refer to miscarriage association
- Provide written information and leaflets
- Offer counselling and support
What is Gestational Trophoblastic Disease/ Molar pregnancy?
A spectrum of disorders of trophoblastic development arising from abnormal fertilisation. Egg becomes fertilised but grows into a tumour rather than a baby.
Essentially an abnormality in the egg/sperm causes an abnormal growth process into a Hydatidiform mole (partial or complete), which can then become cancerous (invasive mole/ choriocarcinoma)
What are the fourtypes of molar pregnancy?
Pre-malignant:
- Complete mole (empty egg + 1 sperm)
- Partial mole (1 egg + 2 sperm)
Malignant:
- Invasive mole
- Choriocarcinoma
How do women with a molar pregnancy present?
- May be asymptomatic (USS diagnosis)
- Bleeding or haemorrhage
- Severe morning sickness
- 1st trimester pre-eclampsia
- Severe nausea, vomiting
- Abdominal pain
- Enlarged uterus vs dates
How are molar pregnancies diagnosed?
- Suspicion raised on scan, frog spawn or snow storm effects
- Confirmation on histology
How are molar pregnancies managed?
Hydatidiform moles:
- Molar tissue removed from uterus, sent for histology (SERPC)
- Anti-D if Rh negative
- Register patient at GTC centre (Sheffield, Charing Cross or Dundee)
- Monitor b-HCG, pregnancy should be avoided until 6 months normal.
- If b-HCG does not drop within 6 months, consider invasive mole or choriocarcinoma
Choriocarcinoma:
- Very responsive to chemo, based on methotrexate
What is Hyperemesis Gravidarum?
- Excessive nausea and vomiting in early pregnancy.
- Exists on a scale with the normal morning sickness experienced by 80% of pregnant women
What separates HG from normal sickness?
HG –>
- Severe dehydration
- Deranged bloods
- Marked ketosis
- Weight loss
- Nutritional deficiency
- Complications of all of the above
which in turn –> Complications
How is HG diagnosed?
Diagnosis of exclusion so look for:
- History of hyperemesis in previous pregnancies
- No abdo pain (rare)
- No infections (rule out UTI, gastroenteritis, appendicitis, pancreatitis…)
- No metabolic dysfunction such as thyroid, Addisons or DKA
- No drug reactions (e.g. antibiotics, iron preparations)
- No mole tumours
How should a woman with HG be investigated?
- Urine dipped for ketonuria, UTI
- FBC (raised haematocrit)
- Us and Es (K!!!)
- LFTs and Amylase
- TFTs
- USS to exclude GTD or multiple pregnancies
How should you manage a woman with HG?
Initially; ginger and acupuncture can be helpful
If still not able to keep things down admit for…
- Rehydration w/ Hartman’s (NOT with glucose can lead to Wernicke)
- Replace K
- Replace thiamine and folic acid
- Antiemetics; parenteral route only
- Ranitidine
- Consider thromboprophylaxis
- Can give steroids to stimulate appetite (prenisolone)
What anti-emetic interventions are used in pregnancy?
Non-pharm: Ginger and acupuncture
Pharm:
- 1st line = Cyclizine or Promethazine
- 2nd line = Metaclopromide or Ondansetron
What battery of products could you consider for a woman admitted to hospital with HG?
- Hartman’s solution
- Cyclizine, Metaclopromide
- Thiamine
- Folic acid
- Prednisolone
- Enoxaparin
How do you define a pregnancy of unknown location
- Woman dips positive for pregnancy OR b-hcg greater than 5
- TVUS shows no ectopic, no pregnancy within uterus
- And you haven’t removed any pregnancy products
What could a PUL be?
- Very early intrauterine pregnancy (too small to see on scan)
- Ectopic
- Complete miscarriage w/o previous scan to confirm
- Failing PUL (will never be big enough to see on scan but will selfresolve)
- b-HCG secreting hormone (very rare)
- Persistent PUL
How do you manage a PUL?
Complicated management, but influenced by symptoms:
- If in pain/hemoperitoneum, manage as an ectopic pregnancy (think surgical- laparotomy)
- If not then measure Progesterone and hCG on day of presentation then again 48 hours later
- Progesterone fall suggests failing pregnancy
- hCG rise suggests ectopic
- If hCG levels plateau, keep monitoring and consider for senior review
How can you use b-hCG to spot ectopic pregnancy?
b-HCG > 1500 confirms pregnancy.
Measure it twice 48 hours apart, a rise in b-hCG of less than 66% is suggestive of ectopic pregnancy.
