Early Pregnancy and Complications Flashcards
Implantation bleed
Spotting at time of missed bleeding
Harmless
Miscarriage
Early - < 13 weeks
Late - 13-24 weeks
Stillbirth - > 24 weeks
Bleeding - examination
ABC - pallor? vital signs? cool peripheries? cap refill etc
Abdo exam - peritonism?
Speculum - open cervix? assess quantity of bleeding?
Bimanual - cervical excitation? adnexal tenderness?
Bleeding - investigations
Transvaginal USS - gestational sac, yolk sac, fetal pole, fetal heart sounds
FBC, group and save
RF for miscarriage
> 35 Smoking Excess alcohol Low pre-pregnancy BMI Paternal age > 45 Illicit drug use Uterine surgery /abnormalities CTD Uncontrolled DM Stress / anxiety
DDx
ECTOPIC - MUST EXCLUDE!!!! Implantation bleed Cervical polyp Cervical ectropion Cervicitis / vaginitis
Serum hCG (48 hours apart)
> 63% increase suggests ongoing pregnancy
50% decrease suggests pregnancy unlikely to continue
If inbetween then review in EPAU in 24 hours
Consider rare causes of increased BhCG e.g, germ cell tumour, gestational trophoblastic disease
Expectant management
Urinary pregnancy test in 7-14 days
Retest 3 weeks after symptom resolvement
Other options should be considered if infection, increased risk of haemorrhage, previous adverse / traumatic experience associated with pregnancy, increased risk from the effects of haemorrhage
Medical management
Vaginal misoprostol for missed / incomplete (oral suitable alternative)
Not mifepristone for incomplete
Symptoms may continue for up to 3 weeks. Take pregnancy test after 3 weeks. If symptoms worsen - need to exclude ectopic or molar
Surgical management
Clinical indications - persistent excessive bleeding, haemodynamic instability, evidence of infected retained tissue, suspected gestational trophoblastic disease
Screening for infection, tissue sample sent for analysis
Less likely to lead to emergency intervention, shorter duration of SE, less GI SE
Ectopic RF
Assisted conception Hx of pelvic infection Endometriosis Previous tubal surgery Intrauterine contraceptive device Becoming pregnant when on progesterone only contraception Hx of ectopic pregnancy
Interstitial Pregnancy
Interstitial rather than extrauterine part of tube
Can be misdiagnosed as normal intrauterine pregnancy
Often catastrophic haemorrhage
Rare but dangerous type of ectopic
Symptoms of Ectopic
Abdo pain, pelvic pain, amenorrhoea / missed period, vaginal bleeding
Dizziness, fainting, syncope, breast tenderness, shoulder tip pain, urinary symptoms, GI symptoms, rectal pain / pressure on defaecation
Examination signs (ectopic)
Common - pelvic or abdominal tenderness, adnexal tenderness
Others - rebound tenderness, cervical tenderness, pallor, abdominal distention, enlarged uterus, tachycardia, hypotension, shock, collapse
Refer to EPAU for urgent assessment
Positive pregnancy test, plus any of: Pain and abdominal tenderness Pelvic tenderness Cervical motion tenderness Vaginal bleeding
