WCS16 Complications Of Early Pregnancy Flashcards
Complications in Early pregnancy
- Miscarriage
- Ectopic pregnancy
- Gestational Trophoblastic Disease
- Hyperemesis gravidarum
- Anxiety state
Common presenting complaints in early pregnancy
- N+V
- unclear mechanism
- ***high level of HCG related —> unknown mechanism affecting the brain
- GI disorder
- psychological cause
- genetics: placental proteins / hormone receptor - Vaginal bleeding
- ectopic pregnancy —> ***endometrium still respond to hormonal changes —> decidual change —> shed if fetus dies - Abdominal pain
- uterine contraction
- distension of cervix
- distension of ***fallopian tube / haemoperitoneum (Ectopic pregnancy) - Shock
- **hypovolaemia due to bleeding
- **vasovagal shock due to cervical distension - Others
- shoulder pain in ectopic pregnancy —> blood irritates diaphragms —> stimulate ***phrenic nerve —> referred pain to shoulder
***1. Miscarriage
Expulsion / extraction of fetus weighing <= 500g
6 types:
1. Threatened: bleeding <24 weeks, cervix **not dilated, fetus alive
2. Inevitable: bleeding <24 weeks, cervix **dilated, pain in uterus
3. Incomplete: part of conceptus expelled but continuing bleeding due to **tissues retained
4. Complete: whole conceptus expelled
5. Silent: pregnancy failure identified **before expulsion of fetal / placental tissues
6. Recurrent: >=2 miscarriages
(Felix Lai:
- Miscarriage: pregnancy loss <20 weeks
- Stillbirth: pregnancy loss >20 weeks
Causes of recurrent miscarriage:
1. **Chromosomal abnormalities
2. **Uterus anatomical defects
3. **Cervical incompetence
4. **Endocrine disturbances
- PCOS
- Poorly-controlled DM
- Thyroid dysfunction
5. ***Autoimmune diseases
- Antiphospholipid syndrome
6. Maternal infection)
***Threatened vs Inevitable vs Incomplete vs Complete vs Silent miscarriage
- Threatened
Abdominal pain: Nil
Cervical Os: Closed
Uterine size: Corresponding - Inevitable
Abdominal pain: **Yes
Cervical Os: **Open
Uterine size: Corresponding / Small (Less than date) (depend on whether tissue mass passed out) - Incomplete
Abdominal pain: +/-
Cervical Os: ***Open
Uterine size: Small (Less than date) - Complete
Abdominal pain: Nil
Cervical Os: Closed
Uterine size: Small (Less than date) - Silent
Abdominal pain: Nil
Cervical Os: Closed
Uterine size: Corresponding / Small (Less than date)
***History, P/E, Investigations in Miscarriage
History:
1. Last menstrual period / Menstrual history
- when did flow stop (start + stop date)
2. Pregnancy test
3. **Vaginal bleeding
4. **Abdominal pain
5. ***Passage of tissue mass
6. Pregnancy planned / unwanted?
P/E:
1. General condition
2. Haemodynamic status
3. Pallor?
4. ***Abdominal tenderness / peritoneal signs
Vaginal examination:
1. Introitus: blood stained
2. Vagina: tissue mass, blood
3. Cervix: tissue mass, vulsellum mark (sign of induced abortion), internal os opened / closed (external os not reliable if given birth before)
4. Uterus: size
5. Fornix: tissue mass
Investigations:
1. Hb, MCV (check for Thalassamia)
2. Rh status
3. **Pelvic sonogram
4. **Tissue mass for histology - decidua, chorionic villi, fetal parts
Recurrent miscarriage (loss of >=2 pregnancies) investigations:
1. **Antiphospholipid antibodies
2. **Thyroid function
3. **Karyotyping
4. **Uterine malformations screening
5. **Thrombophilias for **2nd trimester miscarriage
- Miscarriage: ***Diagnosis of Silent miscarriage (SpC Gynaecological Emergencies)
Transvaginal USG:
- CRL (Crown-rump length) <7mm + No visible heartbeat —> Rescan >=7 days later
- CRL >=7mm + No visible heartbeat —> 2nd opinion / Rescan >=7 days later
- Intrauterine gestational sac with MSD (mean sac diameter) <25mm + No visible fetal pole —> Rescan >=7 days later
- Intrauterine gestational sac with MSD >=25 mm + No visible fetal pole —> 2nd opinion / Rescan >=7 days later
(Fetal pole: normally can be seen at 5-6 weeks (Web))
Transabdominal USG:
- Rescan >=14 days later
Rescan: ***No interval change —> can make diagnosis of Silent miscarriage
NB:
- Private scans with reports done by radiologists / gynaecologists can be accepted as 2nd opinion
- Where there is any doubt about diagnosis / a woman request a repeat scan —> should be performed at an interval of >=1 week from initial scan before treatment
Guidelines for embryonic demise
Guidelines for 1st trimester ultrasound examination:
- Transvaginal ultrasound: Visualisation of decrete embryo >5mm without fetal cardiac activity
RCOG guideline 2011:
- Transvaginal vs Transabdominal
- Gestational sac vs Pseudosac
- Silent miscarriage if:
1. Mean sac diameter (MSD) >=25mm with no evidence of embryo / yolk sac (i.e. fetal pole)
or
2. CRL >=7mm with no evidence of cardiac pulsation
- Need a 2nd scan to make diagnosis (either 2nd opinion / 2nd scan >=7 days later)
Pelvic sonogram of miscarriage
Incomplete miscarriage: ***Thick irregular echoes in the midline of uterine cavity
Complete miscarriage: Thinner well defined regular endometrial line —> beware of ectopic pregnancy
Role of pregnancy test in Miscarriage
- Level of HCG in urine ~ blood
- if negative, can ***rule out pregnancy complication e.g. Abon pregnancy test sensitivity - 25 mIU/ml
- cannot differentiate Complete and Incomplete miscarriage
***Management of Miscarriage
Threatened: Conservative
Silent, Incomplete: Expectant management / Medical treatment / Suction evacuation
Inevitable: Suction evacuation
Complete: Beware of ectopic pregnancy
Medication for Miscarriage:
- **Single dose vaginal misoprostol 800mcg at 8am
- **Reassess in evening round before discharge
- Return next morning for **2nd dose if no bleeding / passage of tissue mass
- Follow up in Early Pregnancy Assessment Clinic (EPAC) **3 weeks after treatment
SpC Gynaecological Emergencies:
1st line: **Expectant management for **7-14 days
—> Resolution of bleeding + pain (i.e. Complete miscarriage)
—> **Pregnancy tests after **3 weeks
—> If negative —> No further action
—> If positive —> USG to guide further management
—> No resolution —> Repeat USG scan
AND
—> **Repeat USG scan —> Incomplete —> Discuss all treatment options (Continued expectant management, medical / surgical management)
- Advise on **pain relief, when to get help in emergency, other treatment options
- Most ***cost-effective + negates risk of intervening + accidentally terminating a viable pregnancy
- Explore management options if:
—> Increased risk of haemorrhage (e.g. late 1st trimester)
—> Previous adverse / traumatic experience associated with pregnancy (e.g. stillbirth, miscarriage, antepartum haemorrhage)
—> Increased risk from effects of haemorrhage (e.g. coagulopathies / unable to have blood transfusion)
—> Evidence of infection
2nd line: **Medical management (next most cost-effective)
- **Vaginal Misoprostol single dose 800mcg
- 8am —> come back next day at 8am for **2nd dose if bleeding not started
—> **Pregnancy test after **3 weeks (1 week if 2nd dose given)
—> If negative —> No further action
—> If positive —> **USG to look for molar / ectopic pregnancy + guide further management
AND
—> **Repeat USG scan after **3 weeks —> Gestational sac present / Incomplete —> Discuss treatment options
- specimen bottle for patient to collect any tissue mass passed —> confirm product of gestation + exclude gestational trophoblastic disease
- expect cramping abdominal pain + vaginal bleeding (2-3 weeks) (paracetamol 1g QID for pain, A/E if heavy bleeding / severe pain)
3rd line:
- Surgical management
- Ectopic pregnancy
- Clinical diagnosis only can be made in 1/2 of patients
Presentation:
1. **Classic triad:
- **Missed period
- **Vaginal bleeding
- **Abdominal pain
2. Shock
3. Syncope, Shoulder pain
4. Abdominal tenderness with varying degree of peritonism
5. Cervical excitation
Risk factors:
1. **Previous ectopic pregnancy (chance of recurrent ectopic 1:10)
2. **Tubal damage from infection / surgery
3. History of infertility
4. **Assisted reproduction techniques
5. **Increased age
6. Smoking
DDx:
1. Miscarriage complications
2. Bleeding corpus luteal cyst
3. Ovarian cyst complications
4. Pelvic inflammatory disease
5. Appendicitis
Types of Ectopic pregnancy (Felix Lai)
- Fallopian tubes (tubal pregnancy) (96%) (MOST common)
- Ampullary (70%)
- Fimbrial (11.1%)
- Isthmus (12%)
- Interstitial / Cornual (2.4%) - Ovaries (3.2%)
- Cervix
- Abdominal (1.3%)
- Uterine ectopic sites
- Caesarean (hysterotomy) scar pregnancy
- Intramural pregnancy
***History, P/E, Investigations in Ectopic pregnancy
History:
1. Pregnancy
2. Risk factors
- PID
- Tubal surgery
- Previous ectopic pregnancy
- IUCD
- C/S (scar pregnancy)
P/E:
1. Abdominal signs (if present —> **Surgical treatment)
2. **Adnexal mass (be gentle, danger of rupture)
3. Bulky uterus (∵ hormonal effect on uterus even though fetus not there)
4. Tender uterus
Investigations:
1. CBC, Hb, Rh, ***Type and Screen —> in case need blood transfusion
- ***Negative pregnancy test —> effectively rule out ectopic pregnancy
-
**Serial HCG assay
- helps decide treatment options
- decision to intervene should not be based solely on single hCG level
- **repeat assay in 48 hours
- cannot differentiate different abnormal pregnancy outcomes
(Discriminatory zone (Felix Lai):
- Threshold = 1500 IU/L
- Level of hCG above which a ***gestational sac should be visualized by TVUS if an intrauterine pregnancy is present
- Suspect ectopic pregnancy when hCG > 1500 IU/L but yet no intrauterine gestational sac is identified) - ***Pelvic USG
- confirm location + viability of pregnancy
- any adnexal mass + size
- any free fluid (see if ruptured) - Diagnostic laparoscopy
- ***Histology of tissue mass (if any)
- confirm product of gestation, molar pregnancy or decidua - Others
***Management of Ectopic pregnancy
Immediate:
1. Fasting
2. IV line of wide gauge (in case need blood transfusion)
3. Close observation
If Symptoms of haemoperitoneum / Haemodynamically unstable:
4. ***Emergency operation
If Stable:
5. Pelvic USG
- **Diagnostic: Adnexal mass moving **separately to ovary, comprising a **gestational sac containing a **yolk sac / fetal pole
- High probability: Adnexal mass moving separately to ovary with an **empty gestational sac (Tubal ring / **Bagel sign) / ***Complex inhomogeneous adnexal mass moving separately to the ovary
- Possible: Empty uterus / Collection of fluid within uterine cavity / Moderate to large amount of free fluid in peritoneal cavity / Pouch of Douglas (suggestive of haemoperitoneum)
- Pseudosac: Endometrial fluid collection surrounded by Endometrial tissue may be mistaken as Gestational sac
USG Result:
- ***Intrauterine pregnancy —> Management according to viability of pregnancy
-
**Features suggestive of ectopic pregnancy
1. **Absent intrauterine pregnancy
2. **Extrauterine gestational sac +/- fetal pole +/- cardiac pulsation
3. **Non-cystic adnexal mass
4. **Free fluid in POD suggestive of haemoperitoneum
—> **Low HCG (<=1000, i.e. early ectopic pregnancy) —> **Expectant management
—> **Intermediate HCG (1500-5000) / Unsuitable for expectant—> **Medical (1st line)
—> **High HCG (>=5000) / Unsuitable for medical —> ***Surgical -
**Uncertain diagnosis (Absent intrauterine pregnancy, NO definite USG evidence of ectopic pregnancy) (i.e. **Pregnancy of unknown location (PUL)) —> **Repeat hCG in **48 hours
—> **>50% drop (i.e. already miscarriage) —> Pregnancy test in 2 weeks —> Positive —> Serum hCG + manage accordingly
—> **50% decline - 63% rise —> Expert opinion (Clinical review at EPAC within 24 hours)
—> ***>63% rise (i.e. normal intrauterine pregnancy) —> Repeat USG 7-14 days later / earlier if hCG >1500
- Expectant management
- For clinical stable women with **minimal symptoms + **pregnancy of unknown location (PUL) - Medical
- IM Methotrexate single dose (Intralesional for C/S ectopic)
—> need close monitoring for ruptured ectopic pregnancy
—> for selected patients with **low hCG + **absence of cardiac activity in fetal pole
—> associated with a saving in treatment costs but with risk of ***persistent ectopic pregnancies - Surgical
- Laparoscopic / Open
- **Total salpingectomy (classical) / **Salpingotomy (conservative, higher risk of **persistent / **recurrent ectopic pregnancy)
- Choice depends on condition of patient + decision of patient (if shock —> salpingectomy) + state of contralateral tube + whether the patient want to follow-up later
- Laparoscopic salpingectomy (Gold standard): preferable to open approach
- ***Laparotomy if haemodynamic unstable - Anti-D Ig
- Non-sensitised Rh negative women should receive
Features suggestive of Ectopic pregnancy
- ***Sliding sign
- Bagel sign / ***Complex, Inhomogeneous adnexal mass moving separately to ovary
- Empty uterus / ***Pseudosac
- Moderate to large amount of ***free fluid in POD (suggestive of haemoperitoneum)
Uncertain diagnosis:
- Absent intrauterine pregnancy
- NO definite USG evidence of ectopic pregnancy
Heterotopic pregnancy
- Co-existing Intrauterine + Extrauterine gestation
- Classical incidence 1 in 30000
- 1-3% following assisted reproduction technique
Early Pregnancy Assessment Clinic
- Streamline management of women with early pregnancy bleeding / pain
- Reduce need for admission
- Need appointment system, appropriate settings, transvaginal US exam, access to laboratory facilities (for Rh Ab + HCG)
- Gestational trophoblastic disease
- ***Complete hydatidiform mole, Partial mole, Invasive mole, Metastatic mole
- ***Choriocarcinoma
- ***Gestational trophoblastic neoplasia: persistently elevated hCG in absence of normal pregnancy + history of antecedent normal / abnormal pregnancy
Hydatidiform mole (+ Felix Lai)
- Complete monospermic: 1 sperm (23) + empty ovum —> 23 —(self duplicate)—> 46
- Complete dispermic: 2 sperm —> 46 —> ***Absent embryonic tissue / fetus
- Partial: 2 sperm + 1 ovum —> 69 —> ***Present embryonic tissue / fetus
Risk factors (Felix Lai + UpToDate):
1. Extremes of age (<=15, >35)
2. Prior molar pregnancy
3. History of prior spontaneous abortion / infertility
4. Vit A deficiency
Presentation:
1. **Vaginal bleeding (~ **Threatened miscarriage, Important DDx)
2. Size of uterus may be **larger than date
3. **Exaggerated pregnancy symptoms (Hyperemesis, Preeclampsia, Hyperthyroidism)
4. Early onset ***pre-eclampsia
Diagnosis:
- USG:
—> **Snowstorm appearance
—> **Lutein cysts of ovary
—> Complex, echogenic, intrauterine mass containing many small **cystic spaces (*clusters of grapes)
(Biopsy are generally NOT performed since GTN lesions are highly vascular and may cause uncontrolled haemorrhage)
Management:
1. **hCG
2. CBP, **Type and Screen
3. **Suction evacuation
4. **Monitor hCG after evacuation
5. **CXR + **TFT —> see if have chest (symptoms of metastasis) / thyroid symptoms (∵ hCG is a thyroid stimulator ∵ homology)
6. Exclude recurrence after any further pregnancies
Gestational trophoblastic disease (Felix Lai)
Pathogenesis:
Aberrant fertilisation
—> Overexpression of paternal genes
—> Abnormal chorionic villi with Trophoblast hyperplasia
GTD:
- Lesions characterised by abnormal proliferation of **trophoblast of placenta
- Comprises of **benign non-neoplastic lesions:
1. **Hydatidiform mole (benign but **premalignant since it can develop into GTN, potential to locally invade uterus and metastasise)
2. Placental site nodule
3. Exaggerated placental site
GTN:
- Group of **malignant neoplasms that consist of abnormal proliferation of **trophoblastic tissues which arises from molar pregnancy (hydatidiform mole) / non-molar pregnancy
1. **Invasive mole
2. **Choriocarcinoma
3. **Placental site trophoblastic tumour (PSTT)
4. **Epithelioid trophoblastic tumour (ETT)
- Diagnosis: ***Persistent elevation of hCG after evacuation of a molar pregnancy
Arise from:
- Molar pregnancy = 50% —> usually Invasive mole / Choriocarcinoma, or rarely PSTT or ETT
- Non-molar pregnancy —> usually Choriocarcinoma, or rarely PSTT or ETT
—> Miscarriage / Tubal pregnancy = 25%
—> Term / Preterm pregnancy = 25%
Treatment:
General:
1. **Contraception
- Reliable contraception during entire interval of hCG monitoring
- **>=1 year after hCG has returned to normal
- ∵ New pregnancy during this period will make it difficult or impossible to interpret hCG results and would complicate management
-
**Follow-up
- Serial monitoring of serum β-hCG until **undetectable level is reached and is maintained for several months
- Regular monitoring to detect relapse which usually occurs within the first 12 months
- Every week until non-detectable for **3 weeks —> **Every month for **6 months for partial mole / Every month for **12 months for complete mole
Medical:
1. ***Prophylactic chemotherapy
- High-risk patients after suction evacuation to decrease the risk of subsequent progression + risk of GTN
—> Pre-evacuation uterine size larger than dates
—> hCG levels >100,000 mIU/mL
—> Bilateral ovarian enlargement due to theca lutein cysts
(2. **Uterotonic (Misoprostol, Oxytocin) **CI ∵ increase the risk of trophoblastic ***embolisation to lungs)
Surgical:
1. **Suction evacuation
2. **Hysterectomy
- Eliminates local invasion and reduce chance of developing GTN but does NOT prevent all cases of metastatic disease due to occult metastasis
GTN:
FIGO Anatomical Staging
- Stage I = Disease confined to the uterus
- Stage II = GTN extends outside of uterus to the adnexa or to the vagina but is limited to genital structures
- Stage III = GTN extend to the lungs, with or without uterine, pelvic or vaginal involvement
- Stage IV = Metastatic disease outside of the lungs, pelvis and vagina
Treatment of GTN:
- Low-risk (RS <= 6) = Single agent
—> **Methotrexate / **Actinomycin D
- High-risk (RS > 6) = Multiple agents
Prognosis:
- Good outcome since GTN is sensitive to chemotherapy
- Hyperemesis gravidarum
Intractable vomiting resulting in hospital admission + Disturbed nutrition
- electrolyte imbalances
- weight loss 5%, ketones
- acetonuria
- ultimate neurological disturbances
- liver damage
- retinal haemorrhage
- retinal damage
Other causes of vomiting:
- multiple pregnancy
- gestational trophoblastic disease
- hyperthyroidism
- upper GI disorder
- hepatitis
- other infection
Investigations of Hyperemesis gravidarum
- No single biomarker to identify / assess severity
- Can only rule out other causes
- CBP, RFT, LFT, TFT
- hCG (***NOT useful)
- ***MSU (for routine analysis, microscopy +/- culture) —> Rule out UTI
- Pelvic USG
- Others
Management of abnormal TFT
If abnormal TFT due to Gestational transient thyrotoxicosis / Hyperemesis gravidarum
—> **Support therapy (Anti-thyroid drugs **NOT recommended)
Complications of Hyperemesis gravidarum
- ***Mallory-Weiss esophageal tear
- ***Mendelson’s syndrome (Aspiration pneumonia)
- Neurological disturbances e.g. ***Wernicke’s encephalopathy, Peripheral neuropathy
Management of Hyperemesis gravidarum
Initial
1. Fasting
2. IV fluid, electrolyte replacement
3. ***Thiamine replacement
4. Intake, Output chart, daily body weight monitoring
Subsequent
1. Dry diet
- small frequent meals
- fairly dry + high in easily digested carbs
- liquids taken between meals
- initial oral fluid intake —> small carb meals —> total avoidance of fatty food
- avoid offensive food / odour
- low protein, low fat, high carb
- ***avoid Fe supplement
- take whichever food appeal when hungry
- little evidence on diet changes to prevent N+V
- Antiemetics
- **H1 antagonist
—> PR / PO Dimenhydrinate (might have increased risk of retrolental fibroplasia in near birth of premature infants)
- **Phenothiazines (Promethazine) - ***Thiamine supplementation
- given to ALL women admitted with prolonged vomiting, esp. before administration of dextrose / parental nutrition
- multi-vitamin?
- Anxiety state
Risk factors for psychiatric morbidity following miscarriage:
- Younger age
- History of infertility
- History of depression
Choice of mode of treatments:
- Ethnomedical beliefs
- Success rates
—> should be individualised
Women’s negative experience:
- Lack of information
- Lack of follow up
- Insensitivity
- Dismissive attitude
- Dishonesty
- Carelessness
- Sonographers
- Lack of understanding of pregnancy journey (e.g. trying for years)
DDx of elevated hCG (Felix Lai)
- Normal pregnancy
- Multiple pregnancy
- Miscarriage (Spontaneous abortion)
- Ectopic pregnancy
- hCG-producing germ cell tumour of ovary
- Ectopic hCG-producing tumour (stomach / liver / pancreas / breast / myeloma / melanoma)
- GTN / GTD
How to ensure a women is NOT pregnant
- Biochemical pregnancy tests
- Highly reliable
- Extremely useful - Pelvic examination
- Reliable at ~8-10 weeks since 1st day of last menstrual period - No S/S of pregnancy + meets any of the following criteria:
- not had intercourse since last normal menses
- has been correctly and consistently using a reliable method of contraception
- within the first 7 days after normal menses
- within 4 weeks postpartum (for nonlactating women)
- within the first 7 days post-abortion / miscarriage
- fully / nearly fully breastfeeding, amenorrhoeic, and <6 months postpartum
