Early pregnancy

Question 1

Define miscarriage and foetal demise

Answer 1

Miscarriage spontaneous termination of pregnancy before 20 weeks Foetal demise – demise after 20 weeks of gestation or when the foetus is more than 500g

Question 2

What percentages of early pregnancy end in miscarriage How many women will experience bleeding in first trimester and how many of these will miscarry What is the chance of miscarriage in a viable foetus seen on POCUS

Answer 2

20-30 25% of women will experience some bleeding – of these 50% will miscarry When viable foetus is seen on ultrasound miscarriage occurs in 3-6%

Question 3

Discuss risk factors for miscarraige

Answer 3

Increasing maternal age Increasing paternal age, alcohol use, increased parity, history of prior miscarriage, Alcohol use poorly controlled DM Thyroid disease obesity low maternal BMI Maternal stress history of PV bleeding

Question 4

Discuss pathophysiology of miscarriage

Answer 4

Most miscarriages are due to foetal malformation or chromosomal abnormalities In most miscarraige the foetal death of preceeds symptoms of miscarriage by several weeks

Question 5

Discuss terminology associated with miscarriage

Answer 5

Broadly divided into three categories

1: threatened miscarriage: bleeding but with closed cervical os – risk of miscarriage in this population is 35-50% -inevitable miscarraige – cervical os is open
2: incomplete miscarriage – products of conception are present at the cervical os or in the vaginal canal
3: Completed miscarriage – the uterus has expelled all of the products of conception, the cervic is closed and the uterus is contracted

Question 6

Discuss ultrasound finding and gestational stage

What is the discrimatory zone

Answer 6

Gestational sac –

5 weeks Discrimninatory zone –

5-6 weeks Yolk sac –

6 weeks Upper discriminatory zone

6-7 weeks Foetal pole

7 weeks Foetal heart beat 7 weeks

The discrimnatory zone is the level of BHCG in which bedside ultrasound should be able to identify foetal structures – 6500 for transabdominal 1000 -2000 for transvaginal

Question 7

Name the structures seen on the following early pregnancy ultrasound

Answer 7

Question 8

Discuss DDX of early pregancny bleeding

Answer 8

Miscarriage

Molar pregnancy

Ectopic

Question 9

Discuss management of threatened miscarraige in the ED

Answer 9

If HD stable and ectopic has been excluded minimal further management is needed.

Those women who are resus -ve should be given anti D

Although more than 50% of women who present with early pregancny bleeding treatment to prevent miscarraige is not useful as foetal demise has likley occured several weeks prior to presentation.

In most cases miscarige is the bodies way of expelling an abnormal or underdevloped foetus

Advise should be given that moderate daily activities do not affect preganancy. Tampons, intercourse and other activities that might introduce infection should be avoided

Re-assure patient that they have done nothing wrong – minor falls, injuries or stress do not effect

Question 10

Discuss management of incomplete miscarraige

Answer 10

Includes expectant management, medical management with misoprostol or surgical evacuation.

When miscarriage is incomplete the uterus may be unable to contract fully to limit bleeding. Gental removal of tissue form the cervical os can drastically reduce slow bleeding

Question 11

Discuss misoprostol

Answer 11

Prostoglandin analouge- binds to myometrial cells to cause strong myometrial contractions leading to expulsion of tissue. Acts on EP2-4 receptors not EP1 limiting toxicity

Useful in treatment of, incomplete miscarraige, termination of pregnancy, PPH, induction of labor, ulcer prevention

Question 12

Discuss epidiemiology and risk factors of ectopic pregnancy

Answer 12

Third leading cause of maternal death, responsible for 4% -10%

Estimated to account for 2% of all pregancny

Incidence is highest in women aged 25-34,

Hetrotropic pregnancy historically rare 1 in 4000 becoming more common in IVF assisted pregnancy

Risk factors

High: Previous ectopic, previous tubal surgery, tubal pathology, IUD, sterilization previous IVF

Moderate: Current use of OCP, PID, STI, smoking, previous spont abortion,

Mild: Infertility, >40, vaginal douching, age at first intercourse <18, previous appendectomy

Question 13

Discuss pathophysiology of ectopic pregnancy

Answer 13

Ovum implants arround day 8-9

Risk factors for an abnormal site of implantation include

• prior tubal infection (PID)
• Anatomical abnormalities in the fallopian tube
• Assisted reproduction
• Abnormal endometrium
• Previous ectopic – risks of subsequent ectopic is 22%
• IUD
• Smoking
• Advanced age

When abnormal implanation occurs foetal development is slow which can result in low or declining BHCG – cannot exclude on 1 BHCG

Three outcomes of an ectopic are possible

1. spontaneous involution
2. Tubal abortion into the peritoneal cavity or vagina
3. Rupture of the preganncy with internal or vaginal bleeing

Implantation in the uterine horn is particularly dangerous becuase the growing embryo can use the myometrial blood supply to grow larger (12-14 weeks) before rupture

Question 14

Discuss clinical signs and symtpoms

Answer 14

Delayed menses, followed by abdominal paina and bleeding – very varied

Risk factors are absent in 15-20% of ectopic cases

Abdominal pain is very severe peritonitic in nature, shoulder tip pain indicates rupture and diaphragm irritation

Signs include – vaginal bleeding, tender abdomen, tender adenexa, adenexal mass in 10-20% of patient

Question 15

Discuss ultrasound finding in patient with suspected ectopic pregnancy

Answer 15

Diagnostic of intrauterine pregnancy

• Double gestational sac – see pciture
• Intrauterine feotal pole or yolk sac
• Intrauterine foetal heart activity

Diagnostic of ectopic gestation

• Ectopic in fallopian tube
• extopic feotal heart activity
• ectopic foetal pole

Suggestuive of ectopic gestation

• moderate or large cul-de-sac fluid without intrauterine pregnancy
• adnexal mass without intrauterine pregnancy

Question 16

Discuss hormonal assays in management of ectopic pregnancy

Answer 16

Serves two roles

• Serial levels can be taken in stable patients – normally doubles every 1.8-3 days in the first 6-7 weeks of pregnancy – serial levels can be taken 72 hours apart and if they fall or rise slowly suggestive of abnormality
• Can be used to estimate whether foetus should be identified on ultrasound

Question 17

Discuss management of ectopic pregnancy

Answer 17

In HD unstable – fluid/blood resuscitation urgent laporotomy, all patient who are RH -ve should be given antiD

In stable patients - methotrexate is the most commonly used medical management – tubal mass should be smaller than 3.5 cm to be treated medically – increasing HCG levels have been shown to be associated with failure of methotrexate management

Best candidates for medical managements are: HD stable, nil feotal heart rate, bhcg <5000

Contraindications to methotrexate: viable intrauterine, comorbidities in which methotrexate would be unwise, sensitivity to same, breast feeding

Question 18

Discuss rupture corpus luteum cyst

Answer 18

A luteum cyst occurs after an egg has been released from a follicle

The ruptured follicle begins producing large quantities of estrogen and progesterone in preparation for conception

If pregnancy does not occur normal degrade however has the possible to bleed into themselves causing sharp abdominal pain – may lead to ovarian torsion

Can occur in pregnancy

Question 19

Define complete and incompete molar pregancy

Answer 19

Complete mole –> caused by ferilization of an ovum without maternal DNA and subsequent duplication of the haploid genome

Incomplete mole –> normal ovum fertilized by two sperm. The duplication of the triploid

Question 20

Discuss clinically features of molar pregnancy

Answer 20

Major risk factor is advanced maternal age –

Patients present with abdominal pain, nausea and vomiting, or vaginal bleeding- if miscarraige does occur it is usually in the 2nd trimester and the patient or physician may note the passage of grapelike hydatid vesciles

The characteristic snowstorm appearance on ultrasound showing hyropic vesicles

Question 21

Discuss complications of molar pregnancy

Answer 21

Complications of molar preganncy include pre-eclampsia or eclampsia which can develop before 24 weeks of gestation, respiratory failure or distress from PE or trophoblastic cells, hyperemesis gravidarum and significant uterine bleeding

Following evacuation of a molar pregnancy patient must be mopnitored in the OPD for trophoblastic sequelae. Patients are at increased risk of an invasive mole, a benign tumor that invades the uterine wall and metastasizes to the lungs or vagina

Also at risk of choriocarcinoma a malignant tumor that invades the uterine wall and disseminates to the lungs, brain and liver via vasculature route

Question 22

Discuss bleeding in later pregnancy

Answer 22

Occurs in only approximatley 4% of pregnancy with 20% of miscariages occuring after the first trimester.

The most important DDX is placental abruption and placentae previa

Question 23

Discuss abruptio pacentae

Answer 23

Seperation of the placenta from the uterine wall is believed to account for appoximatly 30% of episodes of bleeding during the second half of pregnancy

In non trauamtic abrutpion spontaneous haemorryhage into the decidua basalis occurs causing separation and comparession of the adjacent planentae

Abruption i smost clearly associated with maternal hypertension and pre-eclampsia. It is also more common with maternal age younger than 20 or greater than 35, parity of 3 or more, unexplained infertility, history of smoking, thrombophilia, prior miscarriage, prior abruption and cocaine

Question 24

Discuss clinical features abruption

Answer 24

Vaginal bleeding occurs in 70% of cases. Blood is characteristically dark and amount is often insignificant but can range to life threatening haemorrhage

Uterine tenderness or pain is seen in approxiamtly 2/3rds of women, with uterine irritabiliy or contraction seen in 1/3

With significant seperation there is evident foetal distress and the maternal coagulation cascade is triggered leading to DIC

Wide range of symptoms from asymptomatic to tetanic contraction, foetal distress, DIC and maternal tachycardia in sever. Severe abruption is associated with significant pain and maternal hypotension from conealed or evident haemorrhage.

Question 25

Discuss placenta pravia

Answer 25

Implantation of the placenta over the cervical os

Risk is increased with maternal age, smoking, multiparity, c-section, prior miscarriage or induced abortions and preterm labour

Bleeding occurs when marginal placental vessels implanted in the lower uterine segment are tone either as the lower uterine wall elongates or with cervical dilation near the time of delivery

Question 26

Discuss clinical features of placenta previa

Answer 26

Painless fresh vaginal bleeding is the most common symtpom.

in 20% of cases there is some degree of uterine irritbailty- this is usually mild. Vaginal examination usually reveals bright red blood from the cervical os. -All patients with painless second trimester bleeding should be assumed to have placenta previa

Digital or instrumental probing of the cervix should be avoided yuntil the diagnosis is exclude via ultraosund. Injudicious vaginal examination can precipitate severe hamerrohage

Most cases of placenta praevia identified during the mid trimester resolve by time of delivery as the lower uterine segment elongates and the placenta no longer overlaps the os

Question 27

Discuss management of abpruption and praevia

Answer 27

ABCD

If RH -ve should receive anti D 300 mic

O&G input

Foetal monitorign

Question 28

Discuss Rhesus (Anti D) immunization in pregnancy

Answer 28

Occurs when a Rh -ve women is exposed to RH psotive foetal blood

Small amount of feotal cells enter the maternal circulation throughout pregnancy - bute the maternal immune system is triggered only by sgnificant laods fo foetal cells

Sensitization occurs in yup to 15% of RH -ve women carrying Rh Positve fetuses. To prevent this antiD immun globulin is routinely administered to motehrs at approximatly 28 weeks of pregnancy

Other events that should have anti D include: spont miscarriage, threatened miscarriage, surgery for extopic pregnancy and amniocentesis.

50 mic anti D <12weeks and 300mic after

Question 29

Discuss appendicits in pregnacny

Answer 29

occurs with the same incidence as non pregnant patients. During the first half of gestation presentation is the same. But clinical picture can become more atypical in the second half of gestation

Traditionally the appendix was thought to be displace counterclockwise out of the right lower quadrant with its ultimate lolcation deepo in the right upper quadrant

Displacement of the abdominal wall away from the abdominal vicera can result in difficulty in palpation of organs and loss of signs of peritoneal irritation.

During its migration the appendix is very close to the right kidney resulting in a high incidence of pyuria and flank pain

Question 30

Discuss liver disorders during pregnancy

Answer 30

Hepatitis is the most common cause of lidver disease accounting for 40% of cases of jaundice. management and treatment are supportive and unchanged from those for non pregnant patients. Hep E however may have a more aggresive course in pregnancy a

Acute fatty liver of pregnancy is a disorder of the third trimester and can result in liver failure, complciated labour and feotal mortality. The disease is rare occuring most commonly in primiparous women with twin gestation. Clinical features include nausea and vomiting associated with malaise or jaundice during the third trimester should trigger consideration of acute fatty liver. May progress to coaguloapthy jaundice siezures DIC and hepatic encephaoloapthy. May require stabilisation from seizures or coma. Hypoglycaemia can occur which should be rapidly corrected.

Intrahepatic cholestasis of pregnancy also temred idiopathic jaundice of pregnacny and icterus gravidarum is a rare syndrom taht occurs during the third trimester of prenancy- characterised by cholestasis and dilated canaliculi with a normal liver. Clinical features include generalised pruritis and mild jaundice - usually presenting complaint is pruritis only begins in the palms and soles and ascends to the trunk. - resolution occurs with delivery of the baby

Question 31

Discuss nasuea and vomiting in pregnancy

Answer 31

Nausea and vomitng are extremly common in pregnancy particularly from 6-20 weeks of gestation. Symptoms are usually self limited and often resolve with lifestyle changes such as diet modification and avoidance of environmental trigger.

Ginger has been found to be quite effective as an anti-emetic

Hyperemesis Gravidarum occurs in approxiamtly 1% of pregnancy and is defined by nausea and vomting that cause starvation metbaolism, weight loss greater than 5% and prolonged ketonemia and keonuirai. -Without treatment there is an increased risk fo micronutrient defiecny and there respective sequalea

Management involves appropraite rehydration + thiamine. Antiemetics as per pregnancy with pyridoxine being useful.

Question 32

Discuss VTE in pregnancy

Answer 32

Accounts for 20% of all maternal mortality

Pregnancy is a hypercoagubale state with increased coagulation factors and stasis Risk of VTE in pregnancy increase 5-6 times

Pre test probability score WELLS cannot be used as pregnant patients were excluded from the study

D-Dimer rises from the second trimester and remains evlevated for 4-6 weeks post partum

Question 33

Discuss alcohol abuse during pregnancy

Answer 33

Associated with increased risk of miscarraige and intrauterine foetal demise.

Foetal alcohol sydnrome is characterized by at least one of a series of morphological abnormalities in assoaicetion with heavy ETOH use including midfacial hypoplasia, flat philtrum low nasal birdge epicanthal folds shortened palpebral fissue low set ears and microcephaly.

Treatment of an alcohol dependent mother is dicciult as with non pregnant patients withdrawal symptoms are likley to manifest 6-24 hours after last consumption.

Question 34

Discuss the use of methamphatamines and cocaine in pregnancy

Answer 34

Maternal cocaine and methamphetamine use is independtly linked to IUGR from imparied placental circulation and preterm birth less than 36 weeks, preeclampsia, IUFD and GDM.

Cocaine increase the risk of placental abruption and infarction.