Bleeding in Early Pregnancy Flashcards Preview

Reproductive - Reproductive Gynaecology > Bleeding in Early Pregnancy > Flashcards

Flashcards in Bleeding in Early Pregnancy Deck (96):
1

A foetus is normally carried to what gestation?

40 weeks

2

Describe the trimesters of pregnancy?

1st = up to 13 weeks, 2nd = up to 28 weeks, 3rd = up to 40 weeks

3

What marker is used to detect pregnancy on a urine pregnancy test? What level of this suggests a positive pregnancy test?

Beta hCG / > 20IU

4

Fertilisation occurs where?

In the ampulla of the fallopian tube

5

8-9 days after fertilisation in the ampulla of the fallopian tube, what happens to the blastocyst?

It migrates to and implants in the endometrium of the uterine cavity

6

What is a complication that can arise in early pregnancy due to an abnormal site of implantation?

Ectopic pregnancy

7

What is a complication that can arise in early pregnancy due to an abnormal embryo?

Molar pregnancy

8

What is the most common problem in early pregnancy?

Bleeding

9

Bleeding in early pregnancy is most commonly caused by what? What are some diagnoses you still must exclude?

Miscarriage / ectopic pregnancy, GTD, infection, polyps, trauma or cancer

10

What is implantation bleeding?

A normal, physiological bleed which happens at the time of blastocyst implantation

11

Cervical ectopy can also be a cause of bleeding in early pregnancy, what is this? What makes a diagnosis of this more likely than miscarriage?

A physiological change in pregnancy where the columnar epithelium of the endocervical canal extends onto the ectocervix where it is prone to trauma. If the bleeding comes on after/during intercourse, this is a likely cause.

12

PV bleeding in early pregnancy may be confused for what?

Haematuria or a PR bleed

13

What is a miscarriage?

The spontaneous end of a pregnancy before the foetus has reached the age of viability (24 weeks)

14

How common are miscarriages? Do they become more or less likely as the pregnancy proceeds?

20% of pregnancies / become less likely as the pregnancy proceeds

15

What is the first line investigation of all women of reproductive age presenting with symptoms which could be caused by a miscarriage?

beta hCG urinary pregnancy test

16

If you take repeated beta hCG measurements during a miscarriage, what happens to the levels?

They decrease

17

Describe the main symptoms of miscarriage?

Bleeding is the primary symptom, it may also be associated with crampy abdominal pain similar to a period

18

How is a miscarriage diagnosed in an asymptomatic woman?

US scan showing empty sac

19

What two things are usually diagnostic of a miscarriage?

Empty gestational sac or absence of foetal heartbeat

20

When is the foetal heartbeat usually audible?

After around 12 weeks it should be auscultated with a Doppler

21

If a miscarriage is suspected at < 12 weeks gestation or a foetal heartbeat is not heard, what is the best investigation to do?

Transvaginal ultrasound

22

In a person with suspected miscarriage, what is a transvaginal ultrasound used to assess?

If the pregnancy is in situ, in the presence of expulsion or if there is an empty sac

23

What examination should be performed on someone presenting with suspected miscarriage? What is the purpose of this?

PV / speculum examination to confirm how far the miscarriage has got

24

If there are any products of conception in the cervix, what should be done?

They should be removed to reduce blood loss and pain

25

Name the 4 different types of miscarriage and how they progress?

Threatened, inevitable, incomplete, complete

26

What happens in a threatened miscarriage?

There are symptoms of miscarriage but the cervical os is closed

27

What happens in an inevitable miscarriage?

There are symptoms of miscarriage and the cervical os is open and products may be visualised

28

What happens in an incomplete miscarriage?

There are symptoms of miscarriage and some of the products have been passed into the vagina

29

What happens in a complete miscarriage?

All of the products of the pregnancy are lost to the vagina, symptoms start to settle

30

What is the most common cause of a miscarriage?

Underlying embryonic abnormality

31

What are some immunological causes of a miscarriage?

SLE, APS

32

What are some infective causes of a miscarriage?

CMV, rubella, toxoplasmosis, listeria

33

What are some less common causes of miscarriage?

Structural deformities, iatrogenic, exposure to teratogens, trauma/emotional upset

34

What is an independent risk factor for miscarriage?

Increased parental age (decreased gamete quality)

35

Essentially failure at what stages of embryonic development may result in miscarriage?

Fertilisation, formation of the zygote, implantation, placental support

36

Miscarriage can result in cervical shock. What may this cause? How can it be resolves?

Cramps, N+V, sweats, fainting - will resolve if the products are removed

37

What is the management of a miscarriage with heavy bleeding or significant pain?

Admission for definitive treatment either medical or surgical

38

What is the management of a miscarriage with light or no bleeding?

Conservative outpatient management with a follow up scan after 2-3 weeks to confirm an empty uterus

39

Describe the medical management of a miscarriage?

Repeated doses of prostaglandins (misoprostol) are given orally or vaginally until the miscarriage completes, usually after 6-12 hours

40

Describe the surgical management of a miscarriage?

Dilatation of the cervix and suction evacuation of the uterus to remove the products of conception

41

How should cervical shock be managed?

IV fluids, removal of any products

42

What is the prognosis following a miscarriage?

Most women will go on to have a normal uterine pregnancy in the future, though the risk of subsequent miscarriage increases with every pregnancy loss

43

What defines recurrent miscarriage?

3 or more pregnancy losses

44

What are some causes of recurrent miscarriage?

APS, thrombophilia, balanced translocations, uterine abnormalities

45

Recurrent miscarriages due to uterine abnormalities usually present when?

Late in the 1st trimster

46

What are some investigations for recurrent miscarriage?

Anti-cardiolipin antibody, karyotyping, thrombophilia screen, US of pelvis or hysteroscopy

47

What are some independent risk factors for recurrent miscarriage?

Increased age and previous miscarriages

48

A woman of reproductive age presents with unilateral abdominal pain and a positive pregnancy test is diagnosed with what until proven otherwise?

Ectopic pregnancy

49

What is an ectopic pregnancy?

A pregnancy that has implanted outside the uterus

50

What is the risk if an ectopic pregnancy ruptures?

This is a life threatening emergency that requires urgent surgery

51

What is the most common site of an ectopic pregnancy?

Fallopian tubes

52

What is the most common feature of an ectopic pregnancy?

Unilateral lower abdominal pain

53

Apart from pain, what are some other features of an ectopic pregnancy?

Bleeding, dizziness/collapse, shoulder tip pain, dyspnoea

54

Dizziness/collapse seen in an ectopic pregnancy suggests what?

Significant intra-abdominal bleeding

55

What may be seen on examination of someone with an ectopic pregnancy?

Pallor, tachycardia, hypotension, guarding and tenderness (signs of peritonism)

56

What do tachycardia and hypotension indicate in a woman with an ectopic pregnancy? What is the management?

Haemodynamic instability due to tubal rupture and intra abdominal haemorrhage. Requires immediate resuscitation and surgical intervention

57

What investigations would be done for a suspected ectopic pregnancy?

FBC, G&S, hCG, US

58

What type of pelvic ultrasound is the gold standard in a suspected ectopic pregnancy?

Transvaginal

59

There is a slightly increased risk of ectopic pregnancy with what fertility treatment?

IVF

60

What will an US scan of an ectopic pregnancy show?

Empty uterus, mass in adnexa, free fluid in PoD

61

What will happen with multiple measurements of beta hCG in an ectopic pregnancy?

It will increase slowly or remain static

62

What are some red flag signs for an ectopic pregnancy?

Repeated admissions with abdominal/pelvic pain or pain requiring opiates in a woman known to be pregnant

63

How should an ectopic pregnancy be managed if the woman is unwell?

Surgically

64

How should an ectopic pregnancy be managed if the woman is stable, with low levels of beta hCG and a small, unruptured ectopic?

Medical management with methotrexate

65

How should an ectopic pregnancy be managed if the patient is well, with minimal pain, low beta hCG and a pregnancy not visible on US?

Conservatively, and followed up a while later to ensure hCG levels have normalised

66

What is the key risk factor for ectopic pregnancy?

Tubal damage

67

What is a pregnancy of unknown location?

When the beta hCG is raised but the pregnancy cannot be found anywhere

68

What are some causes of a pregnancy of unknown location?

The pregnancy is still to evolve, there is an ectopic which can't be seen, the patient has had a missed miscarriage and the hCG is still to decrease

69

If a patient with pregnancy of unknown location is haemodynamically stable, how should they be managed?

Take beta hCG levels 48 hours apart to check for doubling which suggests a normal pregnancy

70

What is a molar pregnancy?

A type of gestational trophoblastic disease where a non-viable fertilised egg implants into the uterus

71

Molar pregnancy is more common in who?

Teenagers or women > 45

72

Describe what happens once a molar pregnancy has implanted?

There is overgrowth of placental tissue which grows as a mass

73

Describe a complete mole?

Caused by a single (that duplicates) or two sperm combining with an egg which has lost its DNA

74

How many chromosomes will a complete molar pregnancy have?

46 (diploid)

75

DNA from which parent(s) will be present in a complete molar pregnancy?

The father only

76

Describe a partial mole?

A haploid egg is fertilised by two sperm, or one sperm that duplicates itself

77

How many chromosome will a partial molar pregnancy have?

69 (triploid)

78

DNA from which parent(s) will be present in a partial molar pregnancy?

Both mother and father

79

Will a foetus be present in an a) complete b) partial molar pregnancy?

a) no b) yes, but it will be grossly abnormal

80

How are most partial molar pregnancies diagnosed?

On histology after a miscarriage

81

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

Choriocarcinoma (a malignant tumour of trophoblast cells)

82

What is the most common presentation of a molar pregnancy?

Bleeding in the 1st/2nd trimester +/- the passage of grape like tissue

83

What are some presenting features of a molar pregnancy?

Bleeding, hyperemesis, dyspnoea, fundus > dates

84

What causes hyperemesis in a molar pregnancy?

Excessive beta hCG

85

What will an ultrasound of a molar pregnancy show?

Snowstorm appearance +/- foetus

86

How is a molar pregnancy managed?

Surgical evacuation of the pregnancy and tissue samples for histology, as well as follow up at a molar pregnancy service until hCG levels are undetectable

87

After a molar pregnancy, what happens with regards to future pregnancies?

They are monitored for molar pregnancy, but recurrence is unlikely

88

When does implantation bleeding usually occur?

About 10 days after ovulation

89

How would you describe the bleeding seen in implantation bleeding? What can it be mistaken for?

Light, brownish and limited, can be mistaken for a period

90

What is the management and outcomes of implantation bleeding?

Watchful waiting, usually settles and pregnancy continues

91

What is a chorionic haematoma?

A pooling of blood between the endometrium and the embryo due to separation

92

What may a chorionic haematoma cause?

Bleeding, cramping and threatened miscarriage

93

What is the management and outcomes of chorionic haematoma?

Reassurance and surveillance, usually self-limited and resolve

94

What are some vaginal causes of bleeding that may be mistaken for PV bleeding in early pregnancy?

Infections, malignancy, forgotten tampon

95

What are some urinary causes of bleeding that may be mistaken for PV bleeding in early pregnancy?

Haematuria from a UTI

96

What are some bowel related causes of bleeding that may be mistaken for PV bleeding in early pregnancy?

Haemorrhoids, cancer