Implantation and Early Pregnancy Flashcards
What is the main hormone produced by the corpus luteum after ovulation?
PROGESTERONE
What is the function of progesterone?
Prepare the endometrium to support the pregnancy
When does the blastocyst implant in the endometrium?
7-11 days post fertilisation
What is the blastocyst made up of?
Inner cell mass > foetus
Trophoblast > placenta
What does the trophoblast secrete?
hCG
What is the function of hCG?
To maintain the corpus luteum, thereby continuing progesterone secretion
How long does the corpus luteum maintain the pregnancy for?
Up to 8-9 weeks
Then the placenta takes ov r
When does a urine pregnancy test first detect prgegnancy?
1-2 days before the expected date of menstruation
When does a TVUSS first detect pregnancy=?
at 5 weeks
When is the foetal heartbeat first visible on USS?
6 weeks
When is gestational age calculated from?
From the last menstrual period (LMP)
How fast do serum hCG concentration increase in pregnancy?
DOUBLE every 48h
When does hCG peak in pregnancy?
at 9 weeks
What happens to hormonal sercretion when the placenta takes over at 9 weeks?
Synctitiotrophoblasts produce
- progestogen
- estriol
- hCG
- Human placental lactogen
What is the purpose of Human placental lactogen?
To counter the effect of maternal insulin, ensuring sufficient glucose
What is a miscarriage?
Pregnancy that ends spontaneously before 24 week gestation
What is the clinical presentation in a threatened miscarriage?
Vaginal bleeding and abdominal pain
Speculum: closed cervical os
What is the clinical presentation in an inevitable miscarriage?
Vaginal bleeding and abdominal pain
Speculum: open cervical os
What is the clinical presentation in an incomplete miscarriage?
vaginal bleeding and abdominal pain
Speculum: cervical os open, product of conception in cervical os
What is the clinical presentation in a complete miscarriage?
Empty uterus (need serum hCG to exclude extopic)
Pain and bleeding has resolved
Speculum: cervical os closed
What is the clinical presentation in a missed miscarriage?
Asymptomatic, often diagnosed at booking USS
What is the management for a threatened miscarriage?
If confirmed intrauterine pregnancy with foetal heartbeat
Tell woman to return for assessment if bleeding gets worse/persists beyond 14 days
Continue routine antenatal care if bleeding stops
How can you manage miscarriage=
Expectant
Medical
Surgical
What is first line treatment for confirmed miscarriage?
EXPECTANT
Tell woman bleeding should stop in 7-14 days
Then take a pregnancy test after 3 weeks, should be negative
What is medical management for a miscarriage?
Vaginal / PO misoprostol
+ pain relief / anti emetics
What are symptoms of a medical management of miscarriage?
Vaginal bleeding, pain, diarrhoea, vomiting
When should a lady take a pregnancy test after miscarriage?
3 weeks
What is surgical management of miscarriage?
Manual vacuum aspiration OR surgical evacuation in theatre
What medications must you give for surgical management of miscarriage?
- MISOPROSTOL (to ripen cervix)
- ANTI-D PROPHYLAXIS (to all RhD- women)
What is a recurrent miscarriage?
Loss of 3+ consecutive pregnancies
How many couples are affected by recurrent miscarriage?
1%
What are risk factors for recurrent miscarriage=
Advancing age
obesity
Uterine structural abnormalities
antiphospholipid syndorme
How do you screen for APS?
Lupus anticoagulant
Anti-cardiolipin antibodies
What is management of APS?
Low dose ASPIRIN + LMWH
What is an ectopic pregnancy?
Implantation of a pregnancy outside the womb
What are locations for an ectopic pregnancy=
Fallopian tube (98%) Rarer sites: ovary, cervix, abdominal cavity, C section scar
What is a heterotopic pregnancy ?
Simultaneous development of 2 pregnancies, 1 within and one outside the uterus
What are RF for ectopic pregnancy
Prior ectopic
Prior abdo surgery
Fallopian tube damage
- PID, prior ectopic, prior tubal surgery
Functional alterations to Fallopian tube
- Smoking
- Advanced maternal age
Sufertility
Endometriosis
IUD, conception on OCP/morning after pill
IVF
What is the clinical presentation of an ectopic?
Abdominal pain and / or vaginal bleeding in early pregnancy
How does a rupture of an ectopic pregnancy present?
MASSIVE INTRAPERITONEAL BLEEDING
- massive abdominal pain (ACUTE ABDOMEN)
- Hypovolaemic shock
- shoulder tip pain (due to Diaphragmatic irritation)
- Dysuria, diarrhoea (due to impingement of other organs)
what is hCG like in ectopic pregnancy=
LOW, increases slightly but does not double every 24h
So taking 2 separate hCG measurements 48h apart will show this
How do you manage ectopic pregnancy?
EXPECTANT
MEDICAL
SURGICAL
Who is expectant management of an ectopic appropriate for?
Some ectopics resolve without treatment
Suitable if patient is haemodynamicaly stable, asymptomatic, pain free, ectopic <35mm, no visible heartbeat, hCG <1500IU/L
What is expectant management of ectopic?
serial hCG measurements
What is medical management of ectopic’
Methotrexate IM
What are criteria for methotrexate in ectopic management
No significant pain
Unruptured ectopic with adnexal mass <35 mm and no visible heartbeat
no intrauterine pregnancy
Serum b hCG <1500 iU/L
What are criteria for surgery in ectopic?
Significant pain
adnexal mass >35 mm and visible heartbeat
Serum b hCG >5000 iU/L
What kinds of surgery are used for ectopic?
Salpingectomy
Salpingostomy (creating an opening in FT)
How do you follow up a salpingectomy?
urine hCG at 3 weeks
How do you follow up a salpingostomy?
1 serum hCG every week until negative result
When do you offer choice between methotrexate and surgery?
If beta hCG is between 1500-5000
and no significant pain
Unruptured ectopic with adnexal mass <35 mm and no visible heartbeat
No intrauterine pregnancy
How do you investigate an ectopic?
ABCDE Abdominal and pelvic exam Vaginal (bimanual + speculum) Urine hCG Bloods - Serum hCG, Hb, G&S (or XM if urgent) TVUSS
Why do you need to do both urine and serum bhCG?
urine hCG is rapid and immediately tells you if she is pregnant
serum hCG gives precise level and allows you to track it rise/drop in hCG
What commonly happens in 40% of ectopics at first presentation? How do you investigate them?
40% of ectopics are pregnancy of unknown location
Shows an empty uterus with no evidence of an adnexal mass + positive pregnancy test
Investigate with consecutive measurements of serum hCG
What must you do about RhD in ectopic pregnancy?
Offer 250iU of anti-D Ig to all RhD negative women who have surgical management of ectopic
DO NOT do Keihauer
When is there no need to offer anti-D prophylactic with ectopic / miscarriage?
Solely medical management of ectopic
Threatened / complete miscarriage
Pregnancy of unknown origin
What are symptoms of a molar pregnancy?
Light PV bleed May be asymptomatic Large for date uterus Hyperemesis (due to large placenta releasing hCG) Hyperthyroidism (due to high hCG) Anaemia
What are the types of gestational trophoblastic disease (molar pregnancy)
- Partial mole: ovum fertilised by 2 sperm > 69 chr
- Complete mole: ovum has no chromosomes, so sperm chromosomes double
- Choriocarcinoma
- Invasive mole
What is a choriocarcinoma
Malignancy of trophoblastic cells, which can co-exist with molar pregnancy
Where does a choriocarcinoma metastasise to’
To the lungs
Haematogeneously
What are Ix for Gestational Trophoblastic Disease?
- urine beta hCG
- serum hCG
- TVUSS
What is Gestational Trophoblastic Disease like on USS?
Snowstorm appearance
How do you manage Gestational Trophoblastic Disease
Evacation of POC (partial curettage) + histology
Monitor hCG > give chemo if it does not fall
