Early Pregnancy Complications Flashcards Preview

6. OBSTETRICS > Early Pregnancy Complications > Flashcards

Flashcards in Early Pregnancy Complications Deck (53)
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What is morning sickness?

Nausea + vomiting: usually settles 12-16 weeks, some experience none at all. Appears to mirror rise & fall of hCG in maternal serum.

Often retching rather than true vomiting, rarely affects mother’s health.


What are risk factors for hyperemesis gravidarum?

Multiple pregnancies + molar pregnancies associated with high hCG & therefore may be more severe symptoms.


What are the complications of hyperemesis gravidarum?

Weight loss, dehydration + electrolyte disturbances (e.g. hypochloraemic hypokalaemic alkalosis?).

Very rarely: vitamin B deficiency / polyneuropathy.

Extremely rare: liver failure, renal failure, fetal/maternal death.


How should hyperemesis gravidarum be managed?

Admission: urine for ketones + serum renal function (U+Es), LFTs. USS appropriate if not already had pregnancy scan.

IV fluids often sufficient to reduce nausea, antiemetics if not settling (none licensed for pregnancy, but risk of teratogenesis very low with metoclopramide, cyclizine, prochlorperazine).

Very rarely: vitamin B supplementation and/or parenteral feeding


What is gestational trophoblastic disease?

Spectrum of disorders originating from placental trophoblast:

Molar pregnancy: complete hydatiform mole or partial hydatiform mole

Malignant conditions of invasive mole: choriocarcinoma or (very rarely) placental site trophoblastic tumour (PSTT)


What is gestational trophoblastic neoplasia?

Evidence of persisting GTD - most commonly defined as persistent ↑bhCG.

May develop after a molar pregnancy, a non-molar pregnancy or a livebirth.

Treated with chemotherapy (if partial: lower risk of needing chemo: just 0.5%).

Any woman who develops persistent vaginal bleeding after a pregnancy event (miscarriage, postpartum or following termination) is at risk of GTN and should have urine pregnancy test.


What is a molar pregancy? What are the risk factors?

Proliferation of villous trophoblast.

Previous molar pregnancy, age ≤15 or >35, Asian ethnicity.


How is molar pregnancy diagnosed?

Urine pregnancy test.

USS helpful in making pre-evacuation diagnosis (more accurate when >14 weeks), however, histological examination of products of conception is definitive.

Majority of confirmed complete moles are associated with USS diagnosis of anembryonic pregnancy or delayed miscarriage. Partial mole diagnosis is more complex: requires multiple soft markers on USS. hCG estimation may also be useful: >2x median.


What are clinical features of a molar pregnancy?

o Irregular vaginal bleeding (1st or early 2nd trimester)
o Hyperemesis
o Early failed pregnancy
o Uterine enlargement
o Very high serum hCG

Rarer: hyperthyroidism e.g. tremor, (hCG can mimic PTH), early-onest pre-eclampsia, abdominal distension due to theca lutein cysts

Very rarely: acute respiratory failure, neurological symptoms e.g. seizures – likely due to metastatic disease


What are the typical features of a COMPLETE mole? (pathophysiology and clinical features)

Empty’ ovum by single sperm + duplicates DNA (75-80%) or dispermic fertilisation of ‘empty’ ovum (20-25%)

46 XX or 46 XY (diploid, paternal only)

Fetal tissue/amnion/RBCs absent (2% → choriocarcinoma) and 'snowstorm’ USS

Diffuse villous oedema (‘grape cluster’ appearance) and diffuse trophoblastic proliferation (slight to severe)

50% large uterus for dates
25-30% theca lutein cysts


What are the typical features of a PARTIAL mole? (pathophysiology and clinical features)

Egg by 2 sperm
(10% = tetraploid or mosaic conceptions)

90% triploid: 69 XXX, 69XXY, 69XYY

Fetal tissue often present (fetal parts may be seen), amnion and RBCs usually present

Variable, focal villous oedema and focal trophoblastic proliferation (slight to moderate)

Uterus small for dates
Theca lutein cysts are rare


How is molar pregnancy managed?

Evacuation: Suction curettage is method of choice for complete moles (medical evacuation avoided due to theoretical risk of embolising trophoblastic tissue through venous system).

Partial moles: suction curettage EXCEPT when size of fetal parts deters use - medical preferred (also true in twin pregnancies with normal pregnancy + molar pregnancy).

Urine pregnancy test 3 weeks after medical management if PoC are not sent for histological examination. Anti-D required following evacuation of a PARTIAL mole.


How should women be followed up after molar pregnancy?

All women with GTD: referred to a GTD-screening centre (including women with atypical placental-site nodules as these may transform into PSTT).

Has high cure (98-100%) and low (5-8%) chemotherapy rates: 6 month follow up if hCG normal 56 days after pregnancy, otherwise follow-up for 6 months from the normalisation

Notify screening centre at the end of any future pregnancy, whatever the outcome: hCG levels are measured 6-8 weeks after the end of the pregnancy to exclude disease (GTN can occur after any GTD event, even when separated by a normal pregnancy, however, probability of developing GTN is very low after hCG levels have normalised).


When are PoC sent for histological assessment?

From medical or surgical management of all failed pregnancies (to exclude GTN).

As persistent trophoblastic neoplasia may develop after any pregnancy, all PoC should undergo histological evaluation (including repeat evacuations). However, not necessary after termination of pregnancy provided fetal parts have been identified on prior USS.


What is choriocarcinoma?

Malignant trophoblastic tissue made of cytotrophoblasts and syncytiotrophoblasts without villi.


How is GTN managed?

15% need chemotherapy after complete mole and 0.5% after partial mole.

FIGO scoring system: scores ≤6 (~100% cure rate) are low risk and are treated with IM methotrexate with folinic acid

Women with scores ≥7 (~95% cure rate) are high risk: IV multi-agent chemotherapy, including combinations of methotrexate, dactinomycin, etoposide, cyclophosphamide + vincristine. Treatment continued until hCG normal, then a further 6 consecutive weeks.


What is an ectopic pregnancy?

Implantation of pregnancy outside the endometrial cavity e.g. fallopian tube (98%), cervix, ovary

UK incidence ~1%.

Risk of massive intraperitoneal bleeding, Lining of salpinx very thin, as placenta develops - bleeding into abdominal cavity


What are risk factors for ectopic pregnancy?

Anything causing damage to cilia or tube occlusion

1. Previous sterilisation / tubal surgery / abdominal surgery
2. Previous tubal infections (STIs) or pelvic adhesions (PID)
3. IUD in situ
4. Subfertility / IVF treatment
5. Smoking
6. Previous ectopic pregnancy (10% risk of recurrence)

1/3 of all women with ectopic will have no risk factors!


What are symptoms of an ectopic pregnancy?

Abdominal / pelvic pain & bleeding (varies in presentation)

Signs of possible rupture:
1. dizziness / shoulder tip pain (referred from diaphragm – blood is an irritant)
2. pain on urination/defecation, 3. diarrhoea/vomiting
4. tenderness +/- rebound,
5. cervical excitation
6. signs of shock: pallor, ↑HR (first sign to change in shock), ↓BP.


How would you assess a woman with suspected ectopic and positive pregnancy test (UPT or bHCG)?

1. ABC assessment (always correct haemodynamic instability first)

2. History: chlamydia/LMP/sexual history/obstetric history/PID, how much bleeding, how much pain

3. Examine: (gentle to avoid tubal rupture):
• shock/rebound
• speculum: os? POC?
• bimanual: uterus enlarged / cx excitation. do NOT examine for adnexal mass (rupture risk)

If not shocked, transvaginal USS may help distinguish between ectopic, miscarriage & continuing IUP.

Decide: location (uterus, tube or unknown), can we wait or need to go straight to theatre?


Management of unstable woman with suspected ectopic?

Grey cannula (16G): antecubital fossa (quickest and easiest)

Bloods: FBC, cross-match 2 units (4 if really worried), HCG

Arrange theatre: SMM/laparoscopy

Examination plus spec / bimanual


Management of stable woman with suspected ectopic? (what are the different options)

1. Expectant management: 50% end spontaneously

2. Medical (methotrexate): anti-metabolite, prevents growth of rapidly dividing cells by interfering with DNA synthesis: stringent criteria, robust follow up

3. Surgical (laparoscopic or laparotomy, salpingectomy or salpingostomy)


When would you manage suspected ectopic expectantly?

If positive pregnancy test, but no pelvic tenderness / cervical motion tenderness / abdominal tenderness.

Clinically stable asymptomatic women with USS diagnosis of ectopic pregnancy + decreasing serum hCG (initially <1500IU/L).

If any of these signs: immediate referral to EPAU & offer USS to aid management.

Also offered for pregnancy of unknown location (PUL).


How does bHCG aid diagnosis of ectopic pregnancy?

Take immediately & again in 48 hours managed via EPAU.

Likely IUP pregnancy if increases >63% every 48h

Ectopic pregnancy ‘suboptimal rise’

Failing pregnancy: suboptimal rise - plateau then falls


When is pregnancy of unknown location diagnosed?

Serum hCG <1000IU/L and no pregnancy visible on transvaginal USS (intra or extrauterine).

Using initial upper level of 1000-1500 IU/L to diagnose PUL, women with minimal / no symptoms but risk of ectopic should be managed expectantly with 48h follow up (consider active intervention if rises above 1500IU/L or starts to plateau). Serial measurements until <5 or 15IU/L required.


When is diagnostic laparoscopy indicated for ectopic pregnancy?

If positive test & clinical signs ectopic (e.g. pelvic tenderness, cervical excitation, shoulder tip pain) with empty uterus on USS


When is medical management of ectopic pregnancy indicated?

If well with positive urine test and empty uterus on USS- measure serum hCG & repeat 48 hours.

If ectopic likely, but hCG ≤ 3000IU/L & remains asymptomatic: consider medical management (methotrexate single or multiple dose regimen) – must give verbal + written info about possible need for further treatment, need to avoid pregnancy for 3 months after last dose & adverse effects following treatment. Must be able to return easily for assessment at any time during follow-up.


What is the preferred treatment for a tubal ectopic

If haemodynamically stable tubal ectopic: laparoscopic approach to surgical management preferable. No evidence that salpingotomy is preferable to salpingectomy if healthy contralateral tube, but postoperative tracking of serum hCG needed following salpingectomy to identify small number of cases complicated by persistent trophoblast.

Salpingectomy is offered to women who have had a tubal ectopic unless they have other risk factors for infertility e.g. contralateral tube damage (otherwise, salpingotomy is offered as an alternative)

Inform women having salpingotomy that up to 1 in 5 may need further treatment including methotrexate and/or salpingectomy.

Non-sensitised rhesus negative women with confirmed or suspected ectopic pregnancy should receive anti-D immunoglobulin.


What is the preferred approach for a tubal ectopic?

If haemodynamically stable tubal ectopic: laparoscopic approach preferable.

Salpingectomy is offered to women who have had a tubal ectopic unless they have other risk factors for infertility e.g. contralateral tube damage (otherwise, salpingotomy is offered as an alternative)

No evidence that salpingotomy preferable to salpingectomy if healthy contralateral tube, but postoperative tracking of serum hCG needed following salpingectomy to identify small number of cases complicated by persistent trophoblast.

Inform women having salpingotomy that up to 1 in 5 may need further treatment (methotrexate and/or salpingectomy).


When is surgery considered for ectopic pregnancy?

- adnexal mass >4cm
- ectopic with positive fetal heart
- significant free fluid in the Pouch of Douglas
- serum hCG >3000IU/L (depending on local guideline)
- symptoms consistent with pain or bleeding from an ectopic pregnanc