Early Pregnancy Care

Question 1

What are the normal symptoms and signs of early pregnancy?

Answer 1

missed period 
N&V
tiredness 
tender breasts 
frequent urination 
constipation 
increased vaginal discharge without soreness or irritation
sensory changes

Question 2

What is the definition of a spontaneous miscarriage?

Answer 2

fetus dies or delivers dead before 24 completed weeks of pregnancy

Question 3

What is a threatened miscarriage?

Answer 3

bleeding but fetus still alive, os closed

Question 4

What is an inevitable miscarriage?

Answer 4

bleeding heavier, fetus may be alive but os is open

miscarriage about to occur

Question 5

What is an incomplete miscarriage?

Answer 5

some fatal parts have been passed but os usually open

Question 6

What is a completed miscarriage?

Answer 6

all fetal tissue has been passed
bleeding has diminished
uterus no longer enlarges and os closed

Question 7

What is a septic miscarriage?

Answer 7

contents of uterus infected causing endometritis, vaginal loss offensive,
uterus tender but poss no fever, poss abdo pain + peritonism (indicates pelvic infection)

Question 8

What is a missed miscarriage?

Answer 8

fetus has not developed or died in utero, not recognised until bleeding
occurs or US performed, uterus small and os closed

Question 9

What is the cause of miscarriage?

Answer 9

isolated non-recurring chromosomal abnormalities account for >60% sporadic miscarriages

Question 10

What investigations are needed in potential miscarriage?

Answer 10

US – show if fetus in uterus + if viable, may detect retained fetal tissue (products)

Blood tests – HCG levels in blood increase by >66% in 48hr with viable intrauterine
pregnancy (helps differentiate between ectopic + viable intrauterine pregnancies)

FBC + rhesus group should also be checked

Question 11

What is the conservative management option for miscarriage?

Answer 11

as long as woman willing and no infection signs

successful within 2-6 weeks in >80% women with incomplete miscarriage

cons - bleeding is heavy and painful, may need surgical evacuation, infection

Question 12

What is the medical management option for miscarriage?

Answer 12

prostaglandin sometimes preceded by oral anti-progesterone mifepristone

successful in >80% women with incomplete miscarriage

cons - bleeding is heavy and painful, may need surgical evacuation, infection

Question 13

What is the surgical management option for miscarriage?

Answer 13

evacuation of retained products of conception under anaesthetic using aspiration

suitable for women with heavy bleeding, infection

cons - infection, perforation of uterus

Question 14

When should anti D be given to women?

Answer 14

give to rhesus negative women if treat miscarriage surgically/medically or bleeding after 12 weeks

Question 15

What is recurrent miscarriage?

Answer 15

3+ miscarriage occur in succession

Question 16

What are the causes of miscarriage?

Answer 16

antiphospholipid antibodies - treat with aspirin and LMWH

chromosomal defects parental karyotyping

anatomical factors - uterine abnormalities diagnosed with US

Question 17

What other support can be offered after miscarriage?

Answer 17

miscarriage support groups
reassurance is important
refer to support group

Question 18

What is an ectopic pregnancy?

Answer 18

embryo implants outside uterine cavity

Question 19

What is the cause ectopic pregnancy?

Answer 19

any factor which damages the tube
assisted conception
pelvic surgery
previous ectopic smoking copper IUD in place

Question 20

What are the characteristic of ectopic pregnancy?

Answer 20

abnormal vaginal bleeding
abdominal pain - often colicky and then constant
collapse - syncopal episodes and shoulder tip pain = intraperitoneal blood loss
typical - lower abdomen pain followed by scanty, dark vaginal bleeding
amenorrhoea of 4-10 weeks but patient may be unaware she was pregnant

Question 21

What would be seen on examination in an ectopic pregnancy?

Answer 21

Tachycardia suggests blood loss, hypotension + collapse only if severe

Abdominal/rebound tenderness

Movement of uterus may cause pain (cervical excitation) + adnexum may be tender

Uterus smaller than expected from gestation + cervical os closed

Question 22

What investigations are needed for an ectopic pregnancy?

Answer 22

urine hCG
US - preferably transvaginal
serum hCG if uterus empty
laparoscopy but invasive

Question 23

How is an ectopic managed?

Answer 23

nil by mouth 
FBC and cross match blood 
pregnancy test 
US 
Laparoscopy or med management 
IV access 
Salpingectomy may be needed

serial hCG measurements until confirmed ectopic resolution

Question 24

What is cervical shock?

Answer 24

vasovagal syncope produced by stimulation of cervical canal

Question 25

How is cervical shock managed?

Answer 25

Abandon procedure, lower head and/or raise legs Monitor vital signs Ensure clear airway Oxygen + suction if required Consider atropine for persistent bradycardia, adrenaline for anaphylaxis AED should be available Arrange ambulance if no recovery

Question 26

What is a molar pregnancy?

Answer 26

Trophoblastic tissue proliferates in a more aggressive way than normal hCG secreted in excess

Question 27

What are the two types of hydatidiform mole?

Answer 27

proloferation localised and non invasive - complete - partial

Question 28

What is a complete hydatidform mole?

Answer 28

entirely paternal in origin, usually when one sperm fertilises empty oocyte + undergoes mitosis, no fetal tissue

Question 29

What is a partial hydatidform mole?

Answer 29

usually triploid, derived from 2 sperms entering one oocyte, variable evidence of fetus

Question 30

What is an invasive mole?

Answer 30

invasion only locally within the uterus

Question 31

What is a choriocarcinoma?

Answer 31

invasion with metastasis

Question 32

What is gestational trophoblastic neoplasia?

Answer 32

persistence of gestational trophoblastic neoplastic disease (GTD) with persistent elevation of hCG

Question 33

What are the characteristics of molar pregnancy?

Answer 33

Uterus large Early pre-eclampsia and hyperthyroidism may occur Vaginal bleeding usual and may be heavy Hyperemesis possible US shows ‘snowstorm’ appearance of swollen villi with complete moles but diagnosis only confirmed histologically Serum hCG levels may be very high

Question 34

What is management of molar pregnancy?

Answer 34

Trophoblastic tissue is removed by suction curettage (ERPC) and diagnosis confirmed histologically Bleeding often heavy Serial blood/urine hCG levels taken, persistent/rising levels suggestive of malignancy Pregnancy + combined oral contraceptive avoided until hCG levels normal because may increased need for chemo

Question 35

What are the complications of molar pregnancy?

Answer 35

Recurrence occurs in about 1 in 60 After every future pregnancy further hCG samples required to exclude disease recurrence Molar pregnancy precedes only 50% of malignancies Tumour highly malignant but normally sensitive to chemotherapy Low risk patients get methotrexate with folic acid High risk patients get combination chemotherapy

Question 36

What is the national register of trophoblastic disease?

Answer 36

women with a molar pregnancy are registered with the supra regional centre to guide management and follow up

Question 37

What are the options for sensitive disposal of fatal remains?

Answer 37

Hospital burial or cremation – communal or individual Private burial or cremation Burial outside cemetery as long as – no danger to others, no interference with other people’s land, no danger to water supplies or watercourses, no chance of leaking into or onto adjoining land, depth of >45cm, permission from landowner