Early Pregnancy Complications Flashcards by Joanne McEwan

most common problem in early pregnancy?

bleeding

20% have minimal bleeding

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causes of bleeding?

implantation bleeding
chorionic haematoma
cervical
- infection
- mlignancy
- poly
vaginal
- infection
- malignancy (rare)
unrelated
- haematuria
- PR bleeding

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EPAC/EPAU?

early pregnancy assessment clinic/unit

open 24/7

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symptoms of miscarriage?

positive pregnancy test
varied gestation
bleeding (mainly)
cramping
may have passed products

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examination in miscarriage?

scan +/- FH 
speculum exam
- os closed (threatened)
- products at open os (inevitable)
- products in vagina (complete miscarriage)

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what is cervical shock?

cramps/nausea
sweating
nausea
vomiting
fainting
resolves if products removed from cervix

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ho is cervical shock managed?

should resolve when products removed

recuscitation with IVI uterotonics may be needed

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causes of miscarriage?

chromosomal abnormality
immune (APS/LAC)
infection (CMV, rubella, toxoplasmosis, listeriosis)
severe stress
iatrogenic after CVS (can cause infection or uterine irritability)
associations (heavy smoking, cocaine, alcohol misuse)
uncontrolled diabetes

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pathophysiology of miscarriage?

unclear
bleeding from placental bed or chorion causing hypoxia and villous placental dysfunction is proposed to cause embryonic demise

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stages of miscarriage?

threatened (risk to pregnancy)
inevitable miscarriage (cant be saved)
incomplete (cervix dilated and bleeding has began but pregnancy tissue still in uterus)
complete (pregnancy tissue has exited the uterus)
early fetal demise (pregnncy in situ, no heartbeat, MSD>25mm, FP >7mm)
anembryonic pregnancy (no foetus, empty sac

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what does a missed miscarriage look like?

irregular gestation sac with some bleeding behind it

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investigation in miscarriage?

assess haemodynamic disability
bloods 
- FBC
- G&amp;S
- bHCG
US
histology

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management in miscarriage?

depends on outcomes of investigation (admit or discharge)
conservative/medical/surgical (vacuum)
anti D administration if surgical intervention needed
emotional support etc

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what is recurrent miscarriage?

3 or more losses

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what can cause recurrent miscarriage?

antiphospholipid syndrome
- (test for LAC, ACA and B2glycoprotein1)
thrombophilia
- test for (factor V leiden and prothrombin gene mutations, protein C, free protein S and antithrombin)
balanced translocation
uterine abnormality
uterine NK cells are hypothesised
independant risk factors

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what is given in evidence of APS or thrombophilia when pregnant?

use of LDA and daily fragmin injections after confirmation of viable pregnancy

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what may help recurrent miscarriage in future?

progesterone

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common site of ectopic pregnancy?

fallopian tube
interstitial
isthmic ampullary
fimbrial
can also be in ovary, peritoneum or other organs

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presentation of ectopic?

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pain
bleeding
dizziness/collapse
shoulder tip pain (blood irritates sub diaphragmatic area when lying flat)
short on breath
guarding

red flag signs of ectopic pregnancy?

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repeated presentation with abdominal and/or pelvic pain or pain requiring opiates in a women known to be pregnant

investigations in ectopic?

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FBC
G&S
HCG (2 assessments 48 hrs apart and compare - should double if normal)
US - empty uterus/pseudo sac +/- mass in adnexae, free fluid in POD

management of ectopic?

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surgical (if acutely unwell)
medical management = gefitinib + methotrexate (if stable, low HCG and small unruptured ectopic pregnancy)
conservative for well patient

New trial = GEM III trial to enhance medical management of stable and well patient, avoids surgery and can save the tube
- gefitinib + methotrexate

describe molar pregnancy?

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gestational trophoblastic disease where non viable egg is fertilized
overgrowth of placental tissue with chorionic villi swollen with fluid giving picture of grape like clusters
can be complete or incomplete

complete mole?

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egg without DNA
1 or 2 sperm fertilise causing diploid paternal DNA
no fetus
overgrowth of placental tissue
snowstorm appearance

incomplete?

``` haploid egg 1 sperm with duplicating DNA or 2 sperm results in triploid foetus overgrowth of placental tissue foetus present but non-viable ```

issues at presentation of molar pregnancy?

hyperemesis varied bleeding and passage of grape like tissue fundus grows faster than it should for age of foetus occassional shortness of breath - very dangerous sign as molar tissue can embolise/haemorrhage? USS can diagnose snowstorm appearence +/- foetus

management of molar pregnancy?

surgical to empty uterus and tissue for histology - if any is left behind it can turn into choriocarcinoma follow up with molar pregnancy services

describe implantation bleeding?

``` normal happens when fertilised egg implants into uterine wall usually around 10 days after ovulation light brownish and limited bleeding signs of pregnancy emerge soon after usually settles ```

what is a chorionic haematoma?

pooling of blood between endometrium and embryo due to separation - sub-chorionic

features of chorionic haematoma?

bleeding cramping threatened miscarriage symptoms and course follow size and perpetuation usually self limited and resolve and pregnancy continues normal large can be source of infection, irritability and miscarriage

cervical causes of bleeding in early pregnancy?

ectopy/ectropion infection (chlamydia, gonorrhoea, bacteria) poly malignancy (growth or generalised angry erosion presentation)

vaginal causes of bleeding?

infection (trichomoniasis, bacterial vaginosis, chlamydia) malignancy ulcers forgotten tampon

management of bacterial vaginosis?

metronidazole 400mg for 7 days avoid alcohol option of vaginal gel

chlamydia management?

erythromycin, amoxicillin TOC 3 weeks later liase with sexual health, include partner tracing

unrelated bleeding?

bladder infection with haematuria bowel - haemorrhoids - malignancy

pain in miscarriage?

varied intensity, frequency depending onstage | bleeding more than pain

pain in ectopic?

pain main symptom dull ache to sharp stabbing peritonism in cases cause rigidity and rebound tenderness

unrelated causes of reproductive pain?

UTI appendicitis vaginal infection

rhesus negative women may have what problems in pregnancy?

miscarriage ectopic pregnancy molar pregnancy

dosage for anti D?

500 IU

hyperemesis gravidarum?

vomiting in first trimester (usually resolves by 2nd/3rd) common, limited and mild start as early as around time of missed period if excessive, protracted and altering QoL, called hyeperemesis gravidarum

complications of hyperemesis gravidarum?

``` dehydration ketosis electrolyte and nutritional imbalance weight loss altered liver function (starvation) malnutrition emotional instability/anxiety/depression ```

principles of amnagement of hyperemesis gravidarum?

``` rehydration IVI, electrolyte replacement parenteral antiemetic nutritional supplement vitamin supplement (thiamine, pabrinex) NG feeding, TPN steroid use in recurrent, severe cases thromboprophylaxis (high risk of clots due to dehydration and immobility) ```

first line antiemetics?

cyclizine (50mg Po/IM/IV 8 hourly) | Prochlorperazine (12.5mg IM/IV 8 hourly or 5-10mg po 8 hourly)

2nd line antiemetics?

``` ondansetron (serotonin inhibitor) - 4-8mg IM 8 hourly for max 5 days metoclopromide - 5-10 mg IM 8 hourly - can cause ucologyric crisis which can be managed with atropine ```

other medications in antiemetics?

thiamine supplement 50mg tds / pabrinex IV H2 receptor blocker and PPI oral steroid - prednisolone 40mg/day in divided doses

Early Pregnancy Complications Flashcards

(46 cards)