2: Care in early pregnancy

Question 1

How long does an average pregnancy last?

Answer 1

40 weeks

Question 2

Pregnancy is split into three trimesters.

When does each trimester start?

Answer 2

First trimester starts on day after last period

Second trimester starts at 13 weeks

Third trimester starts at 28 weeks

Question 3

How is gestation (i.e the length of time a woman has been pregnant) estimated?

Answer 3

Simple timing using date of last period, current date

Ultrasound scan - distinct appearances during each trimester

Question 4

Which hormonal marker confirms pregnancy?

Answer 4

ßhCG

Question 5

What is the sample taken to test for pregnancy?

Answer 5

Urine sample

Question 6

What is the most common symptom complained about at the beginning of pregnancy?

Answer 6

PV bleeding

Usually an implantation bleed (benign)

Question 7

What are three abnormal outcomes of pregnancy?

Answer 7

Miscarriage

Ectopic pregnancy

Molar pregnancy

Question 8

What is the difference between miscarriage and molar pregnancy?

Answer 8

Miscarriage - natural death of a viable embryo in early pregnancy

Molar pregnancy - implantation and subsequent death of non-viable embryo

Question 9

What symptoms can accompany bleeding in pregnancy?

Answer 9

Pain (abdominal cramps)

Hyperemesis (vomiting)

Dizziness / Syncope

Question 10

What is the presentation of a miscarriage?

Answer 10

Bleeding +/- passed products

Abdominal/back pain - may be mistaken as period cramps

Question 11

Which scan is used to check for an implanted embryo in suspected miscarriage?

Answer 11

Transvaginal ultrasound

Question 12

In miscarriage, what is the initial abdominal pain compared to?

Answer 12

Period cramps

Must ask when last period was and do a urine pregnancy test

Question 13

What is a rare complication of miscarriage which causes bradycardia and hypotension?

Answer 13

Cervical shock

Stimulation of the uterus by retained products causes vagal (parasympathetic) stimulation, causing a similar presentation to haemorrhagic or septic shock

Question 14

What is the pathophysiology of miscarriage?

Answer 14

Bleeding > Impaired oxygen / nutrient supply to foetus > Foetal death

Question 15

What is the os?

Answer 15

Passage between the vagina and the neck of the cervix

Question 16

Women who have had a miscarriage should be scanned to check for which abnormal pregnancy?

Answer 16

Ectopic pregnancy

Because it’s possible that they have an implanted embryo elsewhere and a ruptured ectopic is a medical emergency

Question 17

What should you measure if a patient has been bleeding profusely e.g in miscarriage?

Answer 17

FBC

BP

HR

haemodynamics

Question 18

In which four ways can a miscarriage be managed?

Answer 18

Conservative - watch and wait; natural expulsion

Medical - mifepristone > misoprostol to induce an abortion

MVA (manual vacuum aspiration)

Surgical removal of contents

Question 19

Which autoantibody disease causes increased risk of thrombotic events and recurrent miscarriages?

Answer 19

Antiphospholipid syndrome

Question 20

Which antibodies are raised in APS?

Answer 20

Anti-Lupus anticoagulant

Anti-cardiolipin

Anti-glycoprotein

Question 21

How many miscarriages must a patient have to describe them as recurrent?

Answer 21

3+

Question 22

What is an ectopic pregnancy?

Answer 22

Implantation of a fertilised egg outwith the uterus

Question 23

Where do ectopic pregnancies most commonly occur?

Answer 23

Fallopian tubes

Question 24

What is the presentation of an ectopic pregnancy?

Answer 24

Pain

+/- bleeding, dizziness, dyspnoea (due to internal bleeding)

Question 25

Which form of **referred pain** may women with an **ectopic pregnancy** experience?

Answer 25

**Shoulder tip pain** Unusual, cause not known

Question 26

Recurrent **pain** in a pregnant women should be a red flag for which disease?

Answer 26

**Ectopic pregnancy**

Question 27

Which **imaging** should be done for patients with suspected ectopic pregnancy?

Answer 27

**USS**

Question 28

Which view is used in USS of pregnant women?

Answer 28

**Transvaginal view**

Question 29

Which hormone should be tested for in any women who may be pregnant?

Answer 29

**ßhCG**

Question 30

What is a **pregnancy of unknown location**? Is it a definite diagnosis?

Answer 30

**Elevated bhCG but can't find the embryo using ultrasound** No - wait and try again later

Question 31

How is **ectopic pregnancy** managed **surgically**?

Answer 31

**Minimal access** (keyhole) **surgery** or **Laparotomy**

Question 32

Is every ectopic pregnancy managed surgically?

Answer 32

No - if small ectopic and not acutely unwell, watch and wait

Question 33

What is a **molar pregnancy**? What is the difference between molar pregnancy and ectopic pregnancy?

Answer 33

**Non-viable fertilised egg which has implanted in the uterus (i.e wrong egg in the right place)** **Results in OVERGROWTH OF PLACENTAL TISSUE around dodgy egg ("mole")** Ectopic - right egg in the wrong place

Question 34

In **molar pregnancy**, a non-viable egg (or **mole**) implants in the uterus and the **placenta grows excessively** **around it.** What classic appearance does this tissue have?

Answer 34

**"Bunch of grapes"** **"Snowstorm appearance"** **Also called a hydratidiform mole** Either on ultrasound scan, gynae exam or actively being expelled

Question 35

What are the two types of **abnormal egg** which can cause a **molar pregnancy?**

Answer 35

**Complete mole** **Partial mole**

Question 36

Describe a a) **complete mole** b) **partial mole** and how their fertilisations by sperm cells cause **molar pregnancy**.

Answer 36

**a) Complete mole** - egg without DNA, fertilisation by 1 sperm produces a non-viable haploid zygote, and fertilisation by 2 sperm produces a paternal diploid zygote which still isn't viable **b) Partial mole** - haploid egg which is for some reason unviable (i've asked), fertilisation by 1 sperm creates an unviable zygote, fertilisation by 2 sperms creates an unviable triploid zygote

Question 37

What happens around the **implanted mole** in **molar pregnancy**?

Answer 37

**Overgrowth of placental tissue** With a characteristic "bunch of grapes" appearance

Question 38

**The tissue created by a molar pregnancy** **has a classical** **"bunch of grapes" appearance.** ## Footnote **What appearance does it have on ultrasound?**

Answer 38

**"Snowstorm"**

Question 39

What is the **presentation** of molar pregnancy?

Answer 39

**Hyperemesis** **Bleeding** **Passage of "grape-like" tissue** **Dyspnoea**

Question 40

What is the presentation of **complete molar pregnancy** on USS?

Answer 40

**"Snowstorm"**

Question 41

What is a **normal** sign of pregnancy which mimics period bleeding?

Answer 41

**Implantation bleeding**

Question 42

When does **implantation bleeding** occur? What does it look like?

Answer 42

**10 days after ovulation** Light brown, spots (i.e it shouldn't be profuse)

Question 43

What is a **collection of blood** between the **endometrium** and the **embryo** called?

Answer 43

**Chorionic haematoma**

Question 44

What is a differential diagnosis for bleeding in pregnant women?

Answer 44

**Abnormal pregnancy** - miscarriage, ectopic, molar **Infection** **Polyps / malignancy** --- Renal - UTI other ones

Question 45

In **miscarriage**, **(bleeding / pain)** is the predominant symptom.

Answer 45

**bleeding**

Question 46

In **ectopic pregnancy**, **(bleeding / pain)** is the predominant symptom.

Answer 46

**pain**

Question 47

What is **Rhesus disease**? How is it treated?

Answer 47

**Production of antibodies targeting a foetus's red blood cells** Occurs when a mother is Rhesus-positive and baby is Rhesus-negative Rx: **anti-D immunoglobulin** injections

Question 48

What is the medical name for **morning sickness**? Is "morning sickness" accurate?

Answer 48

**Hyperemesis gravidarum** No - can occur at any time

Question 49

What metabolic disturbances can **excessive vomiting** cause?

Answer 49

**Dehydration** **Ketosis** **Electrolyte imbalance** (e.g hypokalaemia)

Question 50

What must be excluded before you can diagnose a pregnant women with hyperemesis gravidarum?

Answer 50

**Infection** e.g UTI, viral hepatitis ## Footnote **Peptic ulcer disease** **Pancreatitis**

Question 51

How is **hyperemesis gravidarum** managed?

Answer 51

**Replace losses** - water, nutrition, vitamins ## Footnote **Antiemetics**

Question 52

Which **drug** may be used in **recurrent, severe morning sickness?**

Answer 52

**Steroids**