Bleeding in Early Pregnancy

Question 1

To how many weeks is a foetus usually carried?

Answer 1

40 weeks

Question 2

When is trimester 1 completed?

Answer 2

13 weeks

Question 3

When is trimester 2 completed?

Answer 3

28 weeks

Question 4

When is trimester 3 completed?

Answer 4

40 weeks

Question 5

What is gestation estimated by?

Answer 5

Dates + USS

Question 6

When is there a focus on bleeding?

Answer 6

1st trimester

Question 7

What is the marker of pregnancy?

Answer 7

hbCG

Question 8

What is the sensitivity of the urine pregnancy test like?

Answer 8

High – can detect pregnancy as early as 20IU

Question 9

Where does fertilisation occur?

Answer 9

In the fallopian tube

Question 10

Where does implantation occur?

Answer 10

In the uterine cavity

Question 11

What migrates to the uterine cavity?

Answer 11

Blastocyst

Question 12

What can ‘house’ the pregnancy?

Answer 12

Uterine wall

Question 13

List the 3 potential abnormal pregnancy outcomes.

Answer 13

Miscarriage – normal embryo.
Ectopic pregnancy – abnormal site of implantation.
Molar pregnancy – abnormal embryo.

Question 14

What % of women experience bleeding in early pregnancy?

Answer 14

20%

Question 15

Aside from miscarriage, give examples of other causes of bleeding in early pregnancy.

Answer 15

• Implantation bleeding.
• Chronic haematoma.
• Cervical causes
• Vaginal causes
• Unreleated e.g haematuria

Question 16

List some cervical causes of bleeding in early pregnancy.

Answer 16

• Infection
• Malignancy
• Polyp

Question 17

List some vaginal causes of bleeding in early pregnancy.

Answer 17

• Infection

* Malignancy

Question 18

Outline the key features of a miscarriage.

Answer 18

• Positive UPT.
• Varied gestation.
• Bleeding is primary symptom (> cramping).
• ‘Period cramps.’
• Passed products may be brought in.

Question 19

What will a scan of someone having a miscarriage show?

Answer 19

A pregnancy in situ (+/- FH), in the process of expulsion or an empty uterus.

Question 20

What is a speculum exam used for during investigations of someone with a miscarriage?

Answer 20

To confirm if:

• the os is closed (threatened).
• products are sited at open os (inevitable).
• or in vagina (complete).

Question 21

What is the most common contributing factor to a lady having a miscarriage?

Answer 21

Chromosomal abnormality

Question 22

What causes embryological demise?

Answer 22

Bleeding from placental bed or chorion causing hypoxia and villous/placental dysfunction.

Question 23

Outline the 5 different categories of miscarriage.

Answer 23

1 – Threatened Miscarriage.

• risk to pregnancy due to bleeding and cramping, but pregnancy is still in situ.

2 – Inevitable Miscarriage.

• pregnancy can’t be saved.

3 – Incomplete Miscarriage.

• part of pregnancy lost already.

4 – Complete Miscarriage.

• all of pregnancy lost, uterus is empty.

5 – Early Foetal Demise.

Question 24

What is meant by ‘early foetal demise’?

Answer 24

Pregnancy in-situ, but no heartbeat: MSD >25mm, FP >7mm

Question 25

What should always be given to a women following a miscarriage? Why?

Answer 25

Anti- D injection To prevent antibody-antigen interaction from the products crossing with the maternal blood

Question 26

Outline the 5 investigations that must be done in someone having a miscarriage.

Answer 26

``` FBC G&S ẞhCG USS histology ```

Question 27

What should you suspect if a lady presents with recurrent late first trimester loss?

Answer 27

Uterine abnormality

Question 28

What is recurrent miscarriage defined as?

Answer 28

3 or more pregnancy losses

Question 29

Give 3 examples of causes of recurrent pregnancy loss.

Answer 29

1. APS 2. Thrombophilia 3. Balanced translocation

Question 30

What are the 2 independent risk factors for recurrent pregnancy loss?

Answer 30

1. Age | 2. Previous miscarriage

Question 31

What is an ectopic pregnancy?

Answer 31

Implantation outwith the uterus

Question 32

Where is the most common site for an ectopic pregnancy to occur?

Answer 32

In the fallopian tube

Question 33

List some sites (except the fallopian tube) where an ectopic pregnancy may occur.

Answer 33

Ovary, peritoneum, other organs (i.e. liver, cervix, CS scar).

Question 34

How does an ectopic pregnancy present?

Answer 34

``` Pain > bleeding. Dizziness. Collapse. Shoulder tip pain. Short on breath. ```

Question 35

What is the primary symptom of a miscarriage?

Answer 35

Bleeding

Question 36

What is the primary symptom of an ectopic pregnancy?

Answer 36

Pain

Question 37

What are the common findings of an ectopic pregnancy?

Answer 37

Pallor, haemodynamic instability, signs of peritonism, guarding and tenderness.

Question 38

What may an US of an ectopic pregnancy show?

Answer 38

* Empty uterus/pseudo sac. * +/- mass in adenexa. * Free fluid POD.

Question 39

What is serum hCG used for in the assessment of ectopic pregnancy?

Answer 39

For comparative assessment 48 hours apart if haemodynamically stable, to assess doubling.

Question 40

What are the 3 treatment options for someone with an ectopic pregnancy?

Answer 40

1. Conservative 2. Medical 3. Surgery

Question 41

When is conservative management of an ectopic pregnancy done?

Answer 41

In the 'well patient'

Question 42

When is medical management done for an ectopic pregnancy?

Answer 42

* Woman is stable. * Low levels of ẞhCG. * Ectopic is small and unruptured.

Question 43

What is a molar pregnancy?

Answer 43

* A gestational trophoblastic disease. | * Non-viable fertilised egg.

Question 44

Describe the appearance of a molar pregnancy and why it looks like this.

Answer 44

Overgrowth of placental tissue with chorionic villi swollen with fluid give a picture of ‘GRAPE-LIKE CLUSTERS.’

Question 45

GRAPE LIKE CLUSTERS

Answer 45

Molar pregnancy

Question 46

What are the 2 types of molar pregnancy?

Answer 46

Complete OR Incomplete

Question 47

With complete mole, what is there a 2.5% risk of?

Answer 47

Choriocarcinoma

Question 48

On US, what has a snowstorm appearance due to placental vesicles?

Answer 48

Complete mole

Question 49

Describe a complete molar pregnancy.

Answer 49

* Egg WITHOUT DNA * 1/2 sperms fertilise * Results in diploidy * No foetus * Overgrowth of placental tissue

Question 50

Describe a partial molar pregnancy.

Answer 50

* Haploid egg * 1 sperm (reduplicating DNA material) or 2 sperms fertilising egg, result in triploidy * May have foetus * Overgrowth of placental tissue

Question 51

Molar tissues grow rapidly, so the size of the uterus is much greater than what it should be for actual gestation

Answer 51

TRUE

Question 52

What does the management of a molar pregnancy involve?

Answer 52

* Surgical mx, and retrieval of tissue for histology. | * Follow-up with Molar Pregnancy Services.

Question 53

When does implantation bleeding occur?

Answer 53

When the fertilised egg implants into the uterine wall, about 10 days post-ovulation

Question 54

What does implantation bleeding look like?

Answer 54

Light/brownish and limited.

Question 55

What occurs after implantation bleeding?

Answer 55

Signs of pregnancy

Question 56

What is implantation bleeding occasionally mistaken as?

Answer 56

A period (2 weeks post ovulation, heavier, bright red like a normal period usually).

Question 57

What is a chorionic haematoma?

Answer 57

Pooling of blood between the endometrium and the embryo due to separation: sub-chorionic. i.e blood between chorion (foetal sac) and uterine wall

Question 58

Outline the key features of a chorionic haematoma?

Answer 58

Bleeding, cramping, threatened miscarriage

Question 59

A chorionic haematoma is usually self-limiting and will resolve

Answer 59

TRUE

Question 60

What may large chorionic haematomas be a source of?

Answer 60

Infection, irritability (causing cramping) and miscarriage.