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
