Problems with early pregnancy Flashcards
Early pregnancy pain and PV bleed Hx?
SQITARS
Bleeding - how long, how much (spotting v light v heavy period - how many pads)
Past gynae Hx: LMP, cycle, previous ectopic/miscarriage, planned/unplanned/unwanted pregnancy, previous STIs
PMH, surgery
Drugs Hx: teratogenic drugs, allergies, POP (RF for ectopic)
Social - consanguineous, smoker, alcohol, drugs
Family history – any inheritable diseases?
early pregnancy pain and PV bleed exam?
- General – collapsed, unwell, clinically shocked
- Abdo – distension, scars
- Per speculum – Internal os open? (important if establishing if miscarriage happening) – also quantify amount of bleeding patient is having
- Bimanual exam – uterus enlarged? (DDx: fibroids, adenomyosis)
early pregnancy pain and PV bleed Ix?
- Urine pregnancy test
- USS – Trans-abdo (fine after 8wks gestation) or TV
o By 6weeks – can detect fetal heartbeat
o First sign is gestational sac, 2nd yolk sac, 3rd is fetal pole - If excluding ectopic – serum BHCG
o If >1500 and nothing in uterus increased risk of ectopic
o If BHCG low – repeat in 48hrs (if >63% rise – likely to be IU pregnancy)
If <63% rise – ectopic or non-viable IU pregnancy - G+S – for future transfusion and if require anti-D
Causes of miscarriage?
- Never established in most cases
- Chromosomal abnormalities
- Congenital abnormalities
- Maternal disease: Poorly controlled diabetes, Acute illness / infection, Uterine anomalies, Thrombophilia/Antiphospholipid Syndrome
RFs for miscarriage?
- Advanced maternal age (>/= 40)
- Previous miscarriage
- Smoking
- Alcohol (moderate to heavy) and drug use
o NSAIDs and Aspirin
o Street drugs - Folate deficiency
- Consanguinity
Define threatened miscarriage?
Bleeding and or pain up to 24/40 with a viable ongoing pregnancy. Cervix closed.
Define inevitable miscarriage?
Open cervix but products of conception have not yet passed but inevitably will.
- Features: Heavy bleeding, clots, pain
- TV: Fetus can be viable or non-viable
- Offer conservative/medical/surgical options. Likely to proceed to incomplete/complete miscarriage
Define missed miscarriage?
where the baby has died or not developed, but has not been physically miscarried
- Features: Asymptomatic or hx of threatened miscarriage, on-going discharge, small for dates uterus
- TV: No fetal heart pulsation in a fetus where crown rump length is >7mm
o Crown rump length must be greater than 7mm before you can accurately comment on fetal heart pulsation
- May want to rescan and second person to confirm
Define incomplete miscarriage?
Some POC have been passed, however some tissues and blood clot remain within uterus. Cervix stays open and bleeding and pain usually persist
- TV: Retained POC, with A/P endometrial diameter >15mm AND proof that were was a intrauterine pregnancy previously present
Define complete miscarriage?
All POC been passed. Cervix now closed and Bleeding and pain reducing. Complete sac (Pale – colour of raw chicken) may be identifiable. - TV: No POC seen in uterus, with endometrium that is <15 mm diameter AND previous proof of intrauterine pregnancy - Mx: Anti-D if >12wks Serum hCG to exclude ectopic if any doubt Review if bleeding persists >2wks and consider endometritis or retained products of conception
What does a blighted ovum/anembryonic pregnancy look like on TVUSS?
Failed pregnancy with empty gestation sac i.e. no fetus present
Mx for all types of miscarriage?
If >12 weeks & rhesus negative: Anti-D
Define septic miscarriage?
If POC infected → septic patient. Rare where Termination of pregnancy (TOP) is legal
- fever, rigors, uterine tenderness, bleeding/discharge, pain
- TV: Leucocytosis, raised CRP + can be features of complete or incomplete miscarriage
- Mx: IV antibiotics and fluids
Whats the conservative Mx of miscarriage? CIs? Advs? Disadv? follow up>
Waiting for all POC to pass naturally usually over 2 weeks, but can be longer
o Require access to 24hr gynae service (EPAU)
o CIs: Infection, high risk of haemorrhage ie. Coagulopathy, haemodynamic instability.
o Advantages:
Avoid risks of surgery / medication
Can be at home
o Disadvantages
Pain and bleeding can be unpredictable
Worries re: being at home
Takes longer
May be unsuccessful – still requiring active management
A repeat TVS should be offered at 2wks to ensure complete
miscarriage—can be repeated after another 2wks if a woman wishes to
continue with conservative management.
Whats the medical Mx of miscarriage? Adv disdv? follow up?
o Misoprostol (prostaglandin analogue) to stimulate cervical ripening and myometrial contractions
usually preceded by mifepristone 24-48 hours prior to administration.
o Advantages:
Can be at home if patient desires ( with 24/7 access to gynaecology services)
Avoid anaesthetic and surgical risk.
o Disadvantages:
Pain and bleeding may be unpleasant and/or severe - bleeding may continue for up to 3 wks
s/e of drugs: vomiting/diarrhoea, heavy bleeding and pain during passage of POC
Need for emergency surgical management (SERPC) < 5%
o Follow up pregnancy test 3wks later
DDx for bleeding in early pregnancy?
iscarriage. • E ctopic pregnancy. • G estational trophoblastic disease. • R arely gynaecological lower tract pathology (e.g. Chlamydia, cervical cancer, or a polyp).
Define miscarriage?
expulsion of a pregnancy, embryo, or fetus at a stage of
pregnancy when it is incapable of independent survival - includes all pregnancy losses before 24wks
When to give anti-D prophylaxis in miscarriage?
< 12wks (250IU IM):
• u terine evacuation (medical and surgical)
• e ctopic pregnancies.
• > 12wks: all women with bleeding (250IU IM before 20wks and 500IU
IM after 20wks).
Describe surgical Mx of miscarriage? Complications? Advs, disadvs?
A n ERPC should be performed in patients who have excessive or persistent bleeding or request surgical management.
• Suction curettage should be used.
Complications: infection. • H aemorrhage. • U terine perforation (and rarely intraperitoneal injury). • R etained products of conception. • I ntrauterine adhesions. • C ervical tears. • I ntra-abdominal trauma.
o Return to normal physically 24 hours - Bleeding 1-2 weeks
o Advantages: Planned procedure, closure
o Disadvantages:
Surgical risks: perforation, bowel/bladder damage, damage to cervix, Asherman’s, Cervical weakness
Anaesthetic risks
Ectopic pregnancy symptoms?
o ften asymptomatic, e.g. unsure dates
• a menorrhoea (usually 6–8wks)
• p ain (lower abdominal, often mild and vague, classically unilateral)
• v aginal bleeding (usually small amount, often brown)
• d iarrhoea and vomiting should never be ignored
• d izziness and light-headedness
• s houlder tip pain (diaphragmatic irritation—haemoperitoneum)
• c ollapse (if ruptured).
Ectopic pregnancy signs?
o ften have no specifi c signs
• u terus usually normal size
• c ervical excitation and adnexal tenderness occasionally
• a dnexal mass very rarely
• p eritonism (due to intra-abdominal blood if ectopic ruptured).
ectopic pregnancy Ix?
TVUSS - establish location of pregnancy, adnexal mass presence or free fluid
serum progesterone - to distinguish whether a pregnancy is failing: <20nmol/L is highly suggestive of this, whether ectopic
pregnancy (EP) or intrauterine pregnancy (IUP).
Serum hCG - >1500 - IUP should be seen on TVUSS
repeated 48h later:a rise of ≥ 66% suggests an IUP - a suboptimal rise is suspicious, but not diagnostic of an EP.
Laparoscopy - gold standard
RFs for ectopic pregnancy?
H istory of infertility or assisted conception. • H istory of PID. • E ndometriosis. • P elvic or tubal surgery. • P revious ectopic (recurrence risk 10–20%). • I UCD in situ. • A ssisted conception, especially IVF. • S moking.
When to do medical or expectant Mx for ectopic?
C linically stable.
• A symptomatic or minimal symptoms.
• h CG, initially <3000IU (can be tried >3000IU but less successful).
• E P <3cm and no fetal cardiac activity on TV USS.
• N o haemoperitoneum on TV USS.
• F ully understand symptoms and implications of EP.
• L anguage should not be a barrier to understanding or communicating
the problem to a third party (such as phoning an ambulance).
• L ive in close proximity to the hospital and have support at home.
• Y ou deem the patient will not default on follow-up.
do expectant over medical if falling hCG level
Describe expectant Mx of ectopic?
requires serum hCG initially every 48h until repeated fall in level; then weekly until <15IU.
Describe medical Mx of ectopic?
M ethotrexate is given intramuscularly as a single dose of 50mg/m2 .
• h CG levels should be measured at 4 and 7 days, and another dose of methotrexate given (up to 25% of cases) if the d in hCG is <15% on
days 4–7.
- should use reliable contraception for 3mths after, as methotrexate
is teratogenic.
Describe surgical Mx of ectopic? Advs diadvs?
Laparoscopy is preferable to laparotomy as it has shorter operating times
and hospital stays, reduced analgesia requirements, and reduced blood loss.
o Advantages: Reassurance about when the definitive treatment can be provided, high success rate.
o Disadvantages: General anaesthetic risk, risk of damage to neighbouring structures like the bladder, bowel, ureters, DVT/PE, haemorrhage, infection. With salpingotomy, there is also a risk of treatment failure – as some of the pregnancy may remain within the tube.
Describe Tx of haemodynamically unstable ectopic?
Resuscitation
• T wo large-bore IV lines and IV fl uids (colloids or crystalloids).
• C ross-match 6U blood.
• C all senior help and anaesthetic assistance urgently.
Surgery
• Laparotomy with salpingectomy once the patient has been resuscitated.
SEs of methotrexate?
Conjunctivitis.
Stomatitis.
Gastrointestinal upset.
Define recurrent miscarriage
The loss of ≥ 3 CONSECUTIVE pregnancies with SAME partner
Three causes of recurrent miscarriage?
- Balanced (Robertsonian) translocations
- Uterine anomalies
- Antiphospholipid syndrome
Define trophoblastic disease
A spectrum of disorders of trophoblastic development (therefore placental) arising from abnormal fertilisation
Name the pre-malignant and malignant types of trophoblastic disease
pre-malignant: Hydatidiform Mole / Molar pregnancy
- Complete Mole (empty egg, 1sperm)
- Partial Mole (egg and 2 sperm) – more common
Malignant: Invasive mole, Choriocarcinoma
presentation of trophoblastic disease?
- Asymptomatic – USS diagnosis
- Bleeding / haemorrhage
- Severe nausea and vomiting
- Uterus large for dates
Dx of trophoblastic disease?
- Suspected on USS: snowstorm appearance due to vesicles in uterus; and large theca lutein cysts
- Has to be confirmed with histology
Mx of trophoblastic disease? Indications for different type of Mx?
- Surgical (SERPC)
- Register with one of 3 national GTD centre
- Postal follow-up of serum and urine Serial ßhCG – as directed by the centre
May require chemo if:
- Serum hCG levels >20 000IU/L at 4wks after uterine evacuation.
• Static or rising hCG after uterine evacuation in absence of new pregnancy.
• Persistent symptoms, e.g. uterine bleeding and/or abdominal pain.
• Evidence of metastases.
• Histological diagnosis of choriocarcinoma.
Types of hydatidiform mole?
Complete mole
• Consists of diffuse hydropic villi with trophoblastic hyperplasia.
• This is diploid, derived from sperm duplicating its own chromosome
following fertilization of an ‘empty’ ovum. This is mostly 46XX with no
evidence of fetal tissue.
Partial mole
• Consists of hydropic and normal villi.
• T his is triploid (69XXX, XXY, XYY) with one maternal and two
paternal haploid sets. Most cases occur following two sperms fertilizing
an ovum, and a fetus may be present.
RFs for hydatidiform mole?
Age: extremes of reproductive life (>40yrs and <15yrs of age) in complete moles, not partial moles.
• Ethnicity: x2 higher in east Asia, particularly Korea and Japan.
• P revious molar pregnancy: x10 higher risk of developing future molar pregnancy.
Guidance on contraception use with hydatidiform mole?
B arrier contraception should be used until serum hCG is normal.
• T he COCP and HRT are safe to use after hCG levels have returned
to normal.
When does hyyperemesis gravidarum usually occur?
6-12wks
Features of hyperemesis gravidarum?
- Severe dehydration
- Deranged bloods
- Marked ketosis
- Weight loss
- Nutritional deficiency
PPx of hyperemesis?
- Elevated hCG – hCG has same α subunit as thyroid stimulating hormone (TSH) → Thyrotoxicosis
- Elevated oestrogen/progesterone
o ↓ Gut motility
o ↑ Liver enzymes
o ↓ Cardiac sphincter pressure - Helicobacter pylori: Sub-clinical infection activated by altered immunity in pregnancy
- Psychological: Difference in incidence in different populations and cultures
DDx of hyperemesis?
o Infections: UTI, gastroenteritis, appendicitis, pancreatitis etc
o Metabolic: Biochemical thyrotoxicosis, Graves disease, Addisons, DKA
o Drugs: Antibiotics, iron preparations
o Tumours: hydatidiform mole formation, Choriocarcinoma, teratoma with elements of choriocarcinoma, germ cell tumors, islet cell tumor
Ix for hyperemesis?
- Urine (exclude UTI, measure Ketones)
- FBC: Haematocrit (dehydration)
- U+Es: dehydration and ?hyperkalaemia
- LFT (possible gallstones) and amylase (pancreatitis) - Raised ALT is common – recheck when rehydrated and vomiting stopped
- TFTs
- USS – exclude GTD and multiple pregnancy
Mx of hyperemesis?
- Rehydration: NOT with glucose (precipitates Wernicke’s), replace K
- Thiamine replacement and folic acid: Thiamine deficiency –> Wernicke’s and korsakoff’s
- Antiemetics: parenteral route initially
- Ranitidine – esp. if MW tear
- Consider thromboprophylaxis
- Rarely:
o Steroids – stimulate appetite
o TPN/JEG
o Termination – if vomiting wont stop
What are the 5 categories for termination to be allowed?
A: continuance of the pregnancy would involve risk to life of pregnant woman greater than if pregnancy were terminated.
• B: termination is necessary to prevent grave permanent injury to physical or mental health of pregnant woman.
• C: pregnancy has not exceeded 24th week and continuance of
the pregnancy would involve risk, greater than if pregnancy were
terminated, of injury to physical or mental health of pregnant
woman.
• D: pregnancy has not exceeded 24th week and continuance of
pregnancy would involve risk, greater than if pregnancy were
terminated, of injury to physical or mental health of any existing
child(ren) of family of pregnant woman.
• E: there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped.
Clauses A, B, and E have no time limit. Clauses C and D have a legal limit of 24 wks.
whats the law about TOP for doctors?
D octors must ensure their personal beliefs do not prejudice patient
care.
• D octors have the right to refuse to participate in TOPs on grounds
of conscientious objection. If so, they must always refer the patient to another doctor who will help.
Methods of TOP? What does cervical preparation involve?
<7wks: conventional suction termination should be avoided.
• 7–13wks: conventional suction termination is appropriate
• >13wks: dilatation and evacuation following cervical preparation;
The greater gestation, the higher the risk of bleeding, incomplete evacuation, and perforation.
C ervical preparation is highly beneficial:
• it reduces diffi culties with cervical dilation
• particularly if patient is <18yrs or gestation is >10wks.
Can use misoprostol, gemeprost or mifepristone prior to surgery
Describe medical TOP?
< 9wks: using mifepristone priming plus a prostaglandin regime is the most effective method of TOP in gestations <9wks.
• 9–13wks: medical TOP is an appropriate, safe, and effective alternative to surgery (incomplete procedure rates increase after 9wks).
• 13–24wks: medical TOP as above is also appropriate, safe, and effective in this group. Feticide should be considered in advanced gestations
(>20wks).
medical TOP medications MOA?
Mifepristone: antiprogesterone ( given 24–48h prior), which results in uterine contractions, bleeding from the placental bed, and sensitization of uterus to prostaglandins.
Misoprostol: prostaglandin E1 analogue, used off-licence in medical
TOP and for cervical preparation prior to surgical TOP. It stimulates
uterine contractions.
Gemeprost: prostaglandin E1 analogue. It is licensed for softening and
dilatation of the cervix before surgical TOP in the first trimester and
for therapeutic TOP in the second trimester
What should be done before TOP?
counselling/support
blood tests: Hb, blood group and abx, if indicated - HIV, HBV, HCV, haemoglobinopathies
USS - give accurate
gestation and identify already non-viable pregnancies and occasional ectopic pregnancies
prevention of infection: May include screening for lower genital tract
infections, such as Chlamydia + prophylactic abx
What should be done following TOP?
Anti-D should be given to all Rh –ve women undergoing medical or
surgical TOP (250IU ≤ 20wks; 500IU >20wks).
• Provide written patient information, which should include: symptoms that may be experienced following TOP, symptoms requiring further medical attention, contact numbers.
• Follow-up within 2wks of TOP.
• Refer for further counselling if required.
• Discuss and prescribe/provide ongoing contraception.
What are the complications of TOP?
S ignifi cant bleeding (1:1000).
• G enital tract infection (5– 10%).
• U terine perforation (surgical TOP: 1–4:1000).
• U terine rupture .
• C ervical trauma
• F ailed TOP
• R etained products of conception (1:100).
• Nausea, vomiting, diarrhoea due to PGs: occasional, but transient.
• Psychological sequelae: short - term anxiety and depressed mood.
• Long- term regret and concern about future fertility has been shown
to be common.
