Early Pregnancy Care (miscarriage, ectopic, molar, hyperemesis)

Question 1

What are the most common causes for bleeding during early pregnancy?

Answer 1

Miscarriage, ectopic pregnancy, benign lesions in the lower genital tract

Question 2

What is miscarriage and what causes it?

Answer 2

Pregnancy loss less than 24 weeks gestation, caused by:

• spontaneous
• chromosomal abnormalities
• endocrine factors (failure of progesterone and corpus luteum eg. in PCOS)
• maternal illness and infection
• maternal lifestyle and drug history (smoking, obesity, alcohol)
• uterine abnormalities (eg. bicornuate uterus)
• cervical incompetence
• autoimmune factors
• thrombophilic defects

Question 3

What is threatened miscarriage?

Answer 3

Vaginal bleeding but no miscarriage occurs

Question 4

What is inevitable/incomplete miscarriage?

Answer 4

Abdo pain and increasing vaginal bleeding, but with the products of conception remaining in the cervix or vagina

Question 5

What is complete miscarriage?

Answer 5

Complete expulsion of the products of conception, accompanied by vaginal bleeding and pain, which subsides on complete expulsion

Question 6

What is missed miscarriage?

Answer 6

No symptoms of miscarriage, but foetus has died or never developed, which can be shown on the 12 week scan

Question 7

What is recurrent miscarriage?

Answer 7

Three or more successive pregnancy losses prior to viability (24 weeks)

Question 8

How should an incomplete miscarriage be managed?

Answer 8

Conservative: wait for products to pass (expectant)
Medical: prostaglandin analogue (misoprostol) causing passage of products within 48-72 hours (but bleeding may continue up to 3 weeks)
Surgical: dilatation of the cervix and suction curettage to remove the products, which are then sent to histology

Question 9

What is ectopic pregnancy?

Answer 9

Pregnancy occurring outside the uterine cavity..this can occur in the fallopian tubes, cervix, ovaries, abdomen

Question 10

What are the risk factors for ectopic pregnancy?

Answer 10

• Previous history of PID
• Previous tubal surgery
• Failed sterilisation
• IUD
• Previous ectopic pregnancy

Question 11

What is the classical presentation of an ectopic?

Answer 11

Amenorrhoea for 6-8 weeks, followed by lower abdo pain and uterine bleeding, and shoulder tip pain if severe

Question 12

How is an ectopic pregnancy managed?

Answer 12

Conservative: None
Medical: Administer methotrexate
Surgical: Salpingectomy or salpingotomy

Question 13

What is trophoblastic disease (AKA molar pregnancy)?

Answer 13

Replacement of fetus by hydatidiform mole (grapelike vesicles) due to abnormal development of placental tissue. It causes excessive secretion of hCG.

Types:

• Hydatidiform moles (complete or partial)
• Invasive mole
• Choriocarcinoma (metastasis)

It is thought to be caused by fertilisation with two sperm

Question 14

How does molar pregnancy present?

Answer 14

Early pre-eclampsia, heavy vaginal bleeding, hyperemesis gravidarum and spontaneous miscarriage at 20 weeks (exaggerated symptoms of pregnancy due to elevated hCG)

USS shows ‘snowstorm’ appearance

Question 15

How is molar pregnancy managed?

Answer 15

Termination of pregnancy by suction curettage, but it may require chemotherapy

Question 16

What is hyperemesis gravidarum?

Answer 16

Persistent pregnancy-related vomiting associated with weight loss of more than 5% of body mass, severe hydration and electrolyte disturbance

Question 17

What are the risk factors for hyperemesis gravidarum?

Answer 17

• Multiple pregnancy
• Hydatidiform mole

NB both of these conditions involve high levels of hCG

Question 18

How is HG managed?

Answer 18

Conservative: diet, powdered ginger, vitamin supplements (thiamine), MONITOR bloods
Medical: anti-emetics (antihistamines), fluids, steroids (if severe)

Question 19

What is the risk of leaving HG untreated?

Answer 19

Wernicke’s encephalopathy (due to thiamine/B12 deficiency), renal and hepatic failure

Question 20

How can early pregnancy problems be investigated?

Answer 20

Bedside: urine pregnancy test
Bloods: serum beta-hCG
Imaging: pelvic ultrasound (abdo/transvaginal), laparoscopy

Question 21

Why do some women collapse in early pregnancy?

Answer 21

Progesterone causes vasodilatation and postural hypotension that can lead to syncope

Question 22

What could be the causes of elevated levels of hCG if the patient is not pregnant?

Answer 22

• Ectopic pregnancy
• Miscarriage
• Molar pregnancy
• Testicular/ovarian cancer

Question 23

What are the risk factors for molar pregnancy?

Answer 23

• Extremes of reproductive age
• Asian ethnicity
• Previous molar pregnancy