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Early pregnancy Complications Flashcards

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1
Q

What percentage of women have bleeding in early pregnancy?

A

20%

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2
Q

What are the abnormal pregnancy outcomes?

A
  • Miscarriage (normal embryo)
  • Ectopic pregnancy (abnormal site of implantation)
  • Molar pregnancy (abnormal embryo)
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3
Q

What are the causes of bleeding in pregnancy?

A
  • Implantation bleeding
  • Chorionic haematoma
  • cervical causes
    • infection
    • malignancy
    • polyp
  • vaginal causes
    • infection
    • malignancy (rare)
  • unrelated : haematuria, PR bleeding
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4
Q

What are the other common symptoms in early pregnancy?

A

Pain (cramps)

Hyperemesis

Dizziness/fainting

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5
Q

What are the symptoms of miscarriage?

A
  • bleeding
  • cramping
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6
Q

What is used to diagnose miscarriage?

A

ultrasound Scan

Speculum exam

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7
Q

What is determined in US scan of miscarriage?

A

Confirm pregnancy in situ (+/- foetal heart), in process of expulsion, empty uterus

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8
Q

What is seen on speculum exam in miscarriage?

A

Closed os (threatened)

Products sited at open os (inevitable)

Products in vagina and os closing (complete)

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9
Q

How does cervical shock present?

A

Cramps, nausea/vomiting, sweating, fainting

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10
Q

When does cervical shock resolve?

A

When products are removed from cervix

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11
Q

How should patients with cervical shock be resuscitated?

A

IVI, uterotonics

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12
Q

What are the causes and pathophysiology for miscarriage?

A

Embryonic abnormality

Immunologic

Infections

Severe emotional upset, stress

Iatrogenic after CVS (infection or uterine irritability)

Uncontrolled diabetes

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13
Q

What Embryonic abnormality causes miscarriage?

A

Chromosomal

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14
Q

What immunologic issues cause miscarriage?

A

APS (LAC)

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15
Q

What infections cause miscarriage?

A

CMV, rubella, toxoplasmosis, listeriosis

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16
Q

What lifestyle choices are associated with miscarriage?

A

Heavy smoking, cocaine, alcohol misuse

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17
Q

What is a proposed pathophysiology of miscarriage?

A

Bleeding from placental bed or chorion causing hypoxia and villous/placental dysfunciton

Causes embyronic demise

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18
Q

Define threatened miscarriage

A

There is a risk to pregnancy

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19
Q

Define inevitable miscarriage

A

Pregnancy can’t be saved

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20
Q

Define incomplete miscarriage

A

Part of pregnancy lost already

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21
Q

Define complete miscarriage

A

All of pregnancy lost, uterus is empty

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22
Q

What is early foetal demise?

A

Pregnancy in-situ, no heartbeat: MSD > 25mm, FP >7mm

MSD: mean gestational sac diameter

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23
Q

What is an anembryonic pregnancy?

A

No foetus, empty sac

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24
Q

How is management of miscarriage dictated?

A

Dictated by findings

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25
What are the treatment options for miscarriage?
Conservative, medical, MVA/surgical
26
What is recurrent miscarriage?
3 or more pregnancy loses
27
What are the causes of recurrent miscarriage?
* antiphospholipid syndrome APS (LAC, ACA, B2 Glycoprotein1) * thrombophilia (factor V leiden) and prothrombin gene mutations (protein c, free protein S and antithrombin) * balanced translocation * uterine abnormality * uterine natural killer cells
28
When would uterine abnormality be suspected as cause for miscarriage?
Recurrent miscarriages in late first trimester
29
What can be done for women with recurrent miscarriages?
Use of low dose aspirin (LDA) and daily fragmin injections after confirmation of viable IUP in evidence of APS or thrombophilia
30
What are the common sites for ectopic pregnancy?
Fallopian tube; interstitial, isthmic, ampullary or fimbrial
31
What are sites of ectopic pregnancy other than fallopian tube?
Ovary, peritoneum, other organs e.g. liver, cervix, c-section scar
32
Describe presentation of ectopic pregnancy
Pain \> bleeding, dizziness/collapse/shoulder tip pain, short on breath
33
Describe findings in ectopic pregnancy
Pallor Haemodynamic instability Signs of peritonism Guarding and tenderness
34
What is the commonest site of ectopic pregnancy?
Ampullary
35
What is recommended for a woman with a suspected ectopic pregnancy and deteriorating symptoms?
Urgently reviewed by a senior gynaecologist
36
What are the red flag signs for ectopic pregnancy?
* Repeated presentation with abdominal and/or pelvic pain * pain requiring opiates
37
What are the investigations for ectopic pregnancy?
FBC, G&S, bHCG, USS
38
What may be seen on USS of ectopic pregnancy?
Empty uterus/pseudo sac Mass in adnexa Free fluid in pouch of douglas
39
Describe assessment of hCG in ectopic pregnancy
Comparative assesment 48hours apart if haemodynamically stable, to assess doubling
40
What is the management of ectopic pregnancy?
Manage as per presentation; * surgical management (if patient is acutely unwell) * medical management (if woman is stable, low levels of BhCG and ectopic is small and unruptured) * conservative management (for the 'well patient' who is compliant with follow up)
41
What is the standard treatment for medically managed ectopic pregnancy?
Methotrexate
42
What is molar pregnancy?
Gestational trophoblastic disease A non-viable egg is fertilised and there is **overgrowth of placental tissue** with **chorionic villi swollen** with fluid giving a picture of 'grape like structures'
43
What are the types of molar pregnancy?
Complete and partial
44
\_\_\_\_\_\_\_\_ mole has a 2.5% risk of \_\_\_\_\_\_\_\_\_\_\_
Complete mole has a 2.5% risk of choriocarcinoma
45
What is a complete mole?
* egg without DNA * 1 or 2 sperm fertilise, result in diploid (paternal contribution only) * no foetus * overgrowth of placental tissue
46
What is a partial mole?
* haploid egg * 1 sperm (reduplicating DNA material) or 2 sperms fertilising egg, result in triploidy * may have foetus * overgrowth of placental tissue
47
What creates the snowstorm appearance of complete moles?
Multiple placental vesicles
48
What are the important issues at presentation suggesting molar pregnancy?
* hyperemesis * varied bleeding and passage of 'grapelike tissue' * fundus \> dates * occasional SOB
49
What is the management of molar pregnancy?
Surgical and tissue for histology Follow up with molar pregnancy services
50
What is implantation bleeding?
Bleeding when egg implants into uterine wall About 10 days post-ovulation Bleeding is light/brownish and limited Ocassionally mistaken as period
51
What is chorionic haematoma?
Pooling of blood between endometrium and the embryo due to separation: sub-chorionic
52
How does chorionic haematoma present?
Bleeding, cramping and threatened miscarriage
53
What is the prognosis of chorionic haematoma
If small pregnancy usually continues If large may be source of infection, irritability causing cramping and miscarriage
54
What are the cervical causes of bleeding in early pregnancy?
Ectopy/ectropion Infections: chlamydia, gonococcal or bacterial Polyp Malignancy- growth or generalised angry erosion
55
What are the vaginal causes of bleeding in early pregnancy?
* infections * trichomoniasis (strawberry vagina) * bacterial vaginosis * chlamydia * malignancy * ulcers * rare cause of bleeding in reproductive age * forgotten tampon
56
How is BV treated in pregnancy?
Metronidazole 400mg b.d. 7 days Can have vaginal gel
57
How is chlamydia treated during pregnancy?
Erythromycin, amoxicillin test of clearance 3 week later
58
What are the causes of pain in pregnancy?
* miscarriage * *usually more bleeding than pain* * Ectopic pregnancy * *predominant symptom* * *dull ache to sharp stabbing* * *peritonism cases cause rigidity and rebound tenderness* * *​*Unrelated * UTI, Appendicitis * vaginal infections, PID
59
What is the dose of Anti-D for rhesus negative women who have a surgical miscarriage?
500 IU
60
What is hyperemesis gravidarum?
Excessive, protracted vomiting altering the quality of life beyond the 1st trimester
61
What can hyperemesis gravidarum result in?
* dehydration, ketosis, electrolyte and nutritional disbalance * weight loss, altered liver funciton (50%) * malnutrition * emotional instability, anxiety, depression
62
What must be excluded before HG is diagnosed?
UTI, gastritis, peptic ulcer, viral hepatitis, pancreatitis
63
What is the managment of HG?
* rehydration IVI, electrolyte replacement * parenteral antiemetic * nutritional supplement * vitamin supplement : thiamine/pabrinex * NG feeding, TPN * steroid use in recurrent, severe cases * thromboprophylaxis
64
What are the 1st line antiemetics for HG?
* cyclizine (50mg p.o. IM or IV 8hourly) * prochloperazine (12.5mg IM/IV 8 hourly or 5-10mg p.o. 8 hourly)
65
What are the second line antiemetics for HG?
* Ondansetron ( serotonin inhibitor) 4-8 mg IM 8 hourly, max 5/7. Limited safety data * Metoclopramide 5-10 mg IM 8 hourly . Oculogyric crisis : treatable with Atropine * XONVEA UK licensed for pregnancy
66
What medications aside from anti-emetics should be given in HG?
Thiamine supplement (50mg tds)/ pabrinex IV H2 receptor blocker (ranitidine) and PPI (Omeprazole)] Steroid: oral prednisolone 40mg/day in divided doses, tapered as per effect

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