Week 1 - C - Bleeding in early pregnancy

Question 1

When is the end of each of the trimesters?

Answer 1

First trimester ends at 13 weeks

Second trimester ends at 28 weeks

Third trimester ends at 40 weeks

Question 2

When are the normal ultrasound scans carried out in pregnancy?

Answer 2

First ultrasound scan carried out at 11-13 weeks to check for the when the due date of the baby will be

Second ultrasound scan carried out at roughly 18 weeks to check for the gender of the baby

Question 3

When a preganncy test, tests positive, what hormone causes this?

Answer 3

This is beta-Human chorionic gonadotrophin

Question 4

Where in the fallopian tubes does fertilisation normally occur? Name different parts of the fallopian tube from ovary to uterus?

Answer 4

Fertilisation normally occurs in the ampulla of the fallopian tube

Fimbrae, infundibulum, ampulla, isthmus

Question 5

When the egg becomes fertilized, what day does it divide to become the morula then blastocyst and what day does the egg implant into the uterus wall?

Answer 5

• The morula is usually seen on day 4 of development
• And the blastocyst formation is normally seen on day 5
• The egg implants onto the uterus wall at day 6/7 after ovulation has occured

Question 6

When their is bleeding in early pregnancy, what other symptoms may arise?

Answer 6

Bleeding

Hyperemesis,

dizzyness/fainintg,

pain (cramps)

Question 7

When is light vaginal bleeding normal during pregnancy and therefore miscarriage is not always thought of?

Answer 7

Light vaginal bleeding is normal during the first trimester (the first twelve weeks - up to the 13th week)

Question 8

What is a miscarriage?

Answer 8

A miscarriage is a loss of preganncy in the first 23 weeks of gestation

Question 9

What are the symptoms of a miscarriage?

Answer 9

Bleeding is the primary symptoms with increased cramp like pains

There may also be passed products (foetal tissue)

Question 10

Is the pregnancy test positive or negative in a miscarriage? What can a speculum confirm when a miscarriage has been thought of? What does an open or closed os mae you think?

Answer 10

urine pregnancy test (UPT) is normal in a miscarriage

Speculum can confirm if the os is closed (threatned or complete miscarriage) or if it is open (inevitable or incomplete miscarriage)

Question 11

Is the majority of miscarriages due to the mother?

Answer 11

Majority of miscarriages is down to their most likely being a chromosomal abnormality in the developing foetus

Question 12

Embryonic abnromality due to chromsomal abnormality is a reason for miscarriage Name another it has the lupin-anticoagulant antibody? Name the ther two antibdoies in this conditon?

Answer 12

This is Ant-phospholipid syndrome

Anti-cardioplin and anti-beta2 glycoprotein 1 antibodies are the others

Question 13

What are the features of anti-phosopholipid syndrome?

Answer 13

Recurrent pregnancy losss

Migrraine and

venous thrombosis

Question 14

What social and dietary issues can increase the risk of miscarriage?

Answer 14

Smoking, alcohol and too much caffeine have an increased association with miscarriages

Question 15

Describe a threatened miscarriage? decribe the os?

Answer 15

This is where there is a lot of bleeding and cramping in the pregnancy

The cervical os remains closed

Question 16

Describe an inevitable and an incomplete miscarriage? Describe the os?

Answer 16

Inevtiable miscarriage - a lot of bleeding and cramps - usually the os is open and only a matter of time until the foetus passes through

Incomplete miscarriage - part of the pregnancy is lost already and some pregnancy tissue remains in the uterus hence the uteral cramping and bleeding to get ris of it - cervical os is open

Question 17

What is the difference between a complete miscarriage and early foetal demise? What is EFD also known as?

Answer 17

In a complete micarriage - all of the pregnancy is lost and the uterus is empty

In an early feotal demise - the foetus has died but the body has not recognized the loss and has not tried to expel the tissue and therefore placenta continues to grow until a scan shows it

EFD - aka missed miscarriage, missed abortion, silent abortion

Question 18

Describe each picture?

Answer 18

• Red box shows a threatened miscarriage - there is bleeding but the sac is intact and the foetus remains alive in the uterus
• Green box - this is an inevitable miscarriage - bleeding is occurring and the sac is open
• Yellow box - this is an incomplete miscarriage - there is some foetal tissue left
• Blue box - missed abortion - foetus has died inside the womb

Question 19

Management is as per findings: Emotional support - a very important aspect of couple care Assessing and ensuring hemodynamic stability Investigations : FBC, G&S, ẞhCG, USS, histology What are the different management options of a miscarriage?

Answer 19

Conservative management

Medical management

Surgical management

Question 20

What are the advantages and disadvantages of conservative mnagement of a miscarriage?

Answer 20

Advantages - can happen at home

Disadvantages - can take up to 3 weeks but after 7-14 days would state medical or surigcal management

Question 21

Medical management and surgical management of an abortion pros and cons? What is the medication taken in medical management?

Answer 21

medical management – take medication that causes the tissue to pass out of your womb - misoprostol is taken

Surgical management - know exactly when the operation to remove the miscarriage will take place

Both are usually offered should it be 14 days after expected management and the foetal products remain uterine bound

Question 22

What is rhesus disease and what is it also known as?

Answer 22

Rhesus disease is a condition where the mothers antibodiesdestroyed her babies blood cells

It is also known as hameolytic disease of the foetus and newborn (HDFN)

Question 23

Are most people rhesus positive or negative?

Answer 23

Most people are rhesus positive

Question 24

If a mother is rhesus negative, what does this mean potentially for the baby?

Answer 24

If a mother is rhesus negative, this means the baby has likely inherited the rhesus positive from the father and therefore the mothers antibodies may try to attack the babies blood cells

A protective injection known as Anti-D immunoglobulin can be given to prevent this

Question 25

When does sensitisation to rhesus positive blood occur in a rhesus negative mother?

Answer 25

Sensitisiation only occurs wheen the mother has been exposed to a child rhesus positive blood and therefore forms antibodies that recognise the foreign cells - this therefore means on next exposure (ie a second child), if exposed to blood the antbodies then attack the next baby upon exposure

The aim of Anti-D is to stop the antibodies forming in the first place

Question 26

What classifies as recurrent miscarriages? What is a syndrome that can cause this?

Answer 26

3or more miscarriages i srecurrent miscarriages

Anti-phospholipid syndrome can cause this

Question 27

What is an ectopic pregnancy and what is the most common site?

Answer 27

An ectopic pregnancy is implantation of a fertilized egg anywhere outside of the uterus

Most common site is the ampulla of the fallopian (uterine) tube (oviducts)

Question 28

Ampulla is the most common site for an ectopic pregnancy Name other sites where this type of pregnancy can occur?

Answer 28

Ampulla most common

Isthmus - fimbrae, ovary, abomdinal organ eg liver, CS (caesaren section) scar

Question 29

Ectopic pregnancies found in the ampulla can grow here for a few weeks longer than implantations in the isthmus can grow before rupture usually, why is this?

Answer 29

This is cause the isthmus of the uterine tube is usually thinner than the ampulla

Question 30

What are the symptoms of ectopic pregnancy? What are signs of a rupture? WHat STD can scar the uterine tube lining narrowing it and making it more susceptible to ectopic pregnancy?

Answer 30

Symptoms - Pain (on one side usually)>bleeding, dizziness, shortness of breath, shoulder pain

Signs of a rupture - can include pallor, haemodynamic instability, guarding and tenderness

Chalmydia can scar the tubes

Question 31

Where can the pain radiate to in a ruptured ectopic preganncy?

Answer 31

The pain can radiate to the shoulder - exact mechanism is not well understood

guessed to be involved w phrenic nerve => inflammation of diaphragm results in referred pain to shoulder via phrenic nerve

Question 32

What is the management of an ectopic pregnancy? Ie what medication can be given as medical management? What surgery can be carried out if the patient is acute unwel?

Answer 32

Can give methotrexate - a folate antagonist which will stop growth of the foetus

Usually surgical management if a ruptured ectopic preganancy where salpingectomy (removal of the fallopian tube and ruptured fertilized egg) occur vie lapaoroscopy

Question 33

Egg is fertilised, comes to the uterus and implants in the right place Overgrowth of the placental tissue What is this known as?

Answer 33

This is a molar pregnancy - hyaditidiform mole

Question 34

What are the cells that experience abnormal growth in a molar pregnancy?

Answer 34

These are the gestational trophoblastic tissue that experiences abnormal growth

Question 35

Overgrowth of placental tissue with chorionic villi swollen with fluid giving picture of “grape like clusters”. What are the two types of molar pregnancy and what is the risk of which type of cancer?

Answer 35

There are partial and complete molar pregnancies

Hydatidiform mole has a 2.5% chance of becoming a choriocarcinoma

Question 36

What is the difference between partial and complete moles?

Answer 36

Complete mole - the egg has none of its own DNA and instead has only paternal contribution

1or2 sperms fertilise resulting in diploidy

There is no feotus and instead a growth of only abnoormal placental tissue

Partial mole

1o2sperm fertilise egg resulting in triploidy

Sometimes feotal growth and abnormal placental tissue

Question 37

Why is it if one sperm fertilises an egg with no DNA, there is still a diploidy zygote in the complete mole? Why is it if one sperm fetilises the egg, there is a triploid partial mole?

Answer 37

Complete mole - sperm reduplicates if one sperm to result in diploidy (no baby here and instead huge cystic mass (tonnes of vesicles))

Partial mole - sperm reduplicates & its DNA + haploid egg form triploidy (foetus has formed but overgrown placenta )

Question 38

What is the classic appearance on ultrasound described as on ultrasound? What is seen here?

Answer 38

Classic snowstorm appearance created by the multiple placental vesciles

Partial mole - can see foetus and placental vesicles also

Question 39

Molar tissue really grow rapidly and size of uterus is a lot greater than should be for their pregnancy time What is used to estimate the gestation time? (it is a measurmeent from a bony landmark) What is the presentation of a molar pregnancy?

Answer 39

The fundal height

MEasure from the superior apsect of the uterus (fundus) to the pubic symphysis - centimetres measured is weeks of gestation

Molar pregancy presents with hyperemesis, varied bleeding and passage of grape like tissue, increased fundal>gestation, can have SOB

Question 40

What is the management of a molar pregnancy?

Answer 40

Management would be suction removal usually - with tissue for biopsy to confirm a molar pregnancy

Question 41

What is implantation bleeding?

Answer 41

This is when the fertilised egg implants into the uterus

Normally bleeding occurs about 10 days post ovulation and is occasionally mistaken as a period

Question 42

What is the difference in the blood in implantation bleeding and period bleeding?

Answer 42

IMpknatation bleeding - usually occurs day 10 after ovulation and bleeding is a light brownish and limited

Period - usually 14 days post ovulation and bleeding is heavier and light reddish

Question 43

Pooling of blood between endometrium and the embryo due to separation : subchorionic What is this known as? What is the chorion?

Answer 43

This is a chorionic haematoma

The chorion + amnion together make up the amniotic sac

The chorion is the outer layer and seaparates the foetus from the mother

Question 44

Chorionic haematomas usually self limit Why can they lead to miscarriage?

Answer 44

Chorionic haematomas have the potenital to cut off the placenta from the blood supply of the mother leading to a miscarriage

Ie if the haematoma in the picture extended down left- no placenta to mother exchange

Question 45

Different STIs can cause bleeding also It is always important to take a history as other causes such as UTIs can also cause bleeding which means the bleeding is unrelated Which STI can cause a strawberry vagina? (very red vagina due to capillary dilatation due to inflammatory response)

Answer 45

This would be trichomoniasis