Disorders of early pregnancy

Question 1

When is a heartbeat established?

Answer 1

It is established at 4-5 weeks and is visible on TVS a week later

Question 2

What is the definition of spontaneous miscarriage?

Answer 2

The fetus dies or delivers dead before 24 complete weeks of pregnancy

Question 3

What are the different types of miscarriage?

Answer 3

Threatened miscarriage
Inevitable miscarriage
Incomplete miscarriage
Complete miscarriage
Septic miscarriage
Missed miscarriage

Question 4

What is a threatened miscarriage?

Answer 4

There is bleeding but the fetus is still alive, the uterus is the size expected from the dates and the os is closed. Only 25% will go on to miscarry.

Question 5

What is an inevitable miscarriage?

Answer 5

Bleeding is usually heavier than threatened miscarriage. Although the fetus may still be alive, the cervical os is open. Miscarriage is about to occur

Question 6

What is an incomplete miscarriage?

Answer 6

Some fetal parts have been passed, but the os is usually open.

Question 7

What is a complete miscarriage?

Answer 7

All fetal tissue has been passed. Bleeding has diminished, the uterus is no longer enlarged and the cervical os is closed.

Question 8

What is a septic miscarriage?

Answer 8

The contents of the uterus are infected, causing endometriosis. Vaginal loss is usually offensive, the uterus is tender, but a fever can be absent. If pelvic infection occurs, there is abdominal pain and peritonism

Question 9

What is a missed miscarriage?

Answer 9

The fetus has not developed or died in utero, but this is not recognised until bleeding occurs or US is performed. The uterus is smaller than expected from the dates and the os is closed.

Question 10

What are the clinical features of spontaneous miscarriage?

Answer 10

Bleeding is usual unless a missed miscarriage is found incidentally at US. Pain from uterine contractions can cause confusion with an ectopic pregnancy.

Question 11

What would you find on examination of a spontaneous miscarriage?

Answer 11

Uterine size and the state of the cervical os are dependent on the type of miscarriage. Severe tenderness is usual.

Question 12

What investigations would you perform for a spontaneous miscarriage?

Answer 12

US will show if a fetus is in the uterus and if it is viable, and it may detect retained fetal tissue products. If in doubt, repeat in a week. hCG in the blood normally increases by 66% in 48h with a viable intrauterine pregnancy.

Question 13

How would you manage a spontaneous miscarriage?

Answer 13

IM ergometrine will reduce bleeding by the contracting uterus, but is only used if the fetus is non-viable.

Question 14

What are the options for a non-viable intrauterine pregnancy?

Answer 14

Expectant management (as long as no infection); medical management (prostaglandin, potentially folloed by mifepristone); surgical management (ERPC).

Question 15

What is recurrent miscarriage?

Answer 15

When three or more miscarriages occur in succession

Question 16

What investigations do you need to do in recurrent miscarriage?

Answer 16

Antiphospholipid antibody screen (repeat after 6 weeks if positive)
Karyotyping of both parents
Pelvic ultrasound.

Question 17

What are the risk factors for recurrent miscarriage?

Answer 17

Obesity, smoking, PCOS, excess caffeine intake and higher maternal age

Question 18

What are the statutory grounds for termination of pregnancy in England (long answer, sorry!)?

Answer 18

A: continuance of pregnancy would involve more risk to woman’s life than termination
B: termination is necessary to prevent physical or mental harm to the woman
C: pregnancy before 24 weeks and continuance would involve risk of physical or mental harm to existing children or family
D: there is a substantial risk that the child would be born with physical or mental abnormalities as to be seriously handicapped

Question 19

What are the surgical methods of abortion?

Answer 19

Suction curettage

Dilatation and evacuation

Question 20

When is surgical curettage performed?

Answer 20

Usually between 7 and 13 weeks.

Question 21

When is dilatation and evacuation performed?

Answer 21

Above 13 weeks.

Question 22

What are the medical methods of abortion before 22 weeks?

Answer 22

The antiprogesterone mifepristone, plus prostaglandins (misoprostol) 36-48h later. Can be performed between 7 and 24 weeks gestation.

Question 23

What are the medical methods of abortion after 22 weeks?

Answer 23

Beyond 22 weeks, feticide is performed first to prevent live birth, using KCl into the umbilical vein or fetal heart. Such later terminations are usually only performed where a fetal abnormality is present.

Question 24

What are the complications of an abortion?

Answer 24

Haemorrhage, infection, uterine perforation, cervical trauma and failure. Multiple abortions are associated with an increased risk of subsequent preterm delivery.

Question 25

What is an ectopic pregnancy?

Answer 25

When the embryo implants outside the uterine cavity and occurs in 1 in 60-100 pregnancies.

Question 26

In which women is ectopic pregnancy more common?

Answer 26

Advanced maternal age and lower socioeconomic class.

Question 27

Where are the most common sites of ectopic pregnancy?

Answer 27

The most common side is in the fallopian tube (95%), although implantation can occur in the cornu, the cervic, the ovary and the abdominal cavity.

Question 28

What are some risk factors for ectopic pregnancy?

Answer 28

PID, assisted conception and pelvic, particularly tubal, surgery are additional risks as is having a previous ectopic and being a smoker.

Question 29

What are the clinical features of an ectopic pregnancy?

Answer 29

Usually, lower abdominal pain is followed by scanty, dark vaginal bleeding. One may be present without the other. The pain is variable in quality, often initially colicky as the tube tries to extrude the sac and then constant. Syncopal episodes and shoulder tip pain suggest intraperitoneal blood loss.

Question 30

What would you find on examination of an ectopic pregnancy?

Answer 30

tachycardia suggests blood loss, and hypotension and collapse occur only in extremis. There is usually abdominal and often rebound tenderness. On pelvic examination, movement of the uterus may cause pain (cervical excitation) and either adnexum may be tender. The uterus is small than expected from the gestation and the cervical os is closed.

Question 31

What investigations would you perform when investigating an ectopic pregnancy?

Answer 31

A pregnancy test (urinary hCG), US (doesn’t always detect ectopic but can see if it is intrauterine), quantitive serum hCG

Question 32

What pattern of serum hCG would suggest an ectopic pregnancy?

Answer 32

Declining or slower rising levels (plateauing).

Question 33

How would you manage a suspected ectopic pregnancy?

Answer 33

NBM
FBC and cross-match
Pregnancy test
US
IV access
Potential laparoscopy or medical management

Question 34

What would be performed during a laparoscopy due to ectopic pregnancy?

Answer 34

The ectopic is either removed from the tube (salpingostomy) or a salpingectomy is performed.

Question 35

What medical management would be used to treat an ectopic pregnancy?

Answer 35

If the ectopic pregnancy is enraptured with no cardiac activity and an hCG level <3000IU/mL, systemic single-dose methotrexate can be used. A second dose or surgery may be required.

Question 36

What is hyperemesis gravidarum?

Answer 36

When nausea and vomiting in early pregnancy are so severe as to cause severe dehydration, weight loss or electrolyte disturbance.

Question 37

How long does hyperemesis gravidarum usually last for?

Answer 37

It rarely persists beyond 14 weeks

Question 38

Is hyperemesis gravidarum more common in nulliparous or multiparous women?

Answer 38

Multiparous

Question 39

How do you treat hyperemesis gravidarum?

Answer 39

IV rehydration. Antiemetics such as metoclopramide.

Question 40

What is gestational trophoblastic disease?

Answer 40

Trophoblasts proliferate in a more aggressive way the. normal. hCG is normally secreted in excess.

Question 41

What is a hydatidiform mole?

Answer 41

Trophoblast proliferation is localised and non-invasive

Question 42

What is a complete mole?

Answer 42

A mole entirely from paternal origin, usually when one sperm fertilises an empty oocyte and undergoes mitosis. There is no fetal tissue, merely a proliferation of swollen chorionic villi.

Question 43

What is a partial mole?

Answer 43

Usually triploid, derived from two sperms entering one oocyte. There if variable evidence of a fetus.

Question 44

What is an invasive mole?

Answer 44

Invasion is locally within the uterus

Question 45

What is choriocarcinoma?

Answer 45

An invasive mole that has metastasised

Question 46

What are the clinical features of gestational trophoblastic disease?

Answer 46

Vaginal bleeding is usual and may be heavy. Severe vomiting may occur.

Question 47

What would you find on examination of gestational trophoblastic disease?

Answer 47

The uterus is often large. Early PE and hyperthyroidism may occur

Question 48

What would you find on US of gestational trophoblastic disease?

Answer 48

A ‘snowstorm’ appearance of the swollen villi with complete moles, but the diagnosis can only be confirmed histologically.

Question 49

How do you treat gestational trophoblastic disease?

Answer 49

Suction curettage and the diagnosis is confirmed histologically. Follow up of repeated hCG levels to check for persisting malignancy

Question 50

What are the complications of gestational trophoblastic disease?

Answer 50

Recurrence of molar pregnancy occurs in about 1 in 60 subsequent pregnancies. Gestational trophoblastic neoplasia, as an invasive mole or choriocarcinoma may follow.

Question 51

How is gestational trophoblastic neoplasia diagnosed?

Answer 51

Persistently elevated or rising hCG levels, persistent vaginal bleeding or evidence of blood-borne metastasis, commonly to the lungs.

Question 52

How do you treat gestational trophoblastic neoplasia?

Answer 52

The tumour is highly malignant, but is normally sensitive to chemotherapy.