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Early Pregnancy Complications Flashcards

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1
Q

What is measured in a urine pregnancy test?

A

hCG = human chorionic gonadotrophin

High sensitivity = can detect pregnancy as early as 20 IU

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2
Q

Where does fertilisation occur?

A

In the fallopian tubes

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3
Q

Where does the morula/blastocyst migrate to after fertilisation?

A

The uterine cavity = implantation occurs

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4
Q

What are the normal outcomes of fertilisation?

A

Embryo, normal in location and development, live birth

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5
Q

How common in minimal bleeding in early pregnancy?

A

Common issue = 20%

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6
Q

What are some abnormal pregnancy outcomes?

A

Miscarriage, ectopic pregnancy, molar pregnancy

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7
Q

What are some symptoms that commonly accompany bleeding in early pregnancy?

A

Pain (cramps), hyperemesis, dizziness/fainting

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8
Q

How may a miscarriage present?

A

Positive pregnancy test with varied gestation
Bleeding is most common symptom
May bring in passed products

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9
Q

What will a speculum exam help confirm in a miscarriage?

A

Is os closed (threatened), products sited at open os (inevitable) or in vagina and os closing (complete)?

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10
Q

What will a scan help confirm in a miscarriage?

A

Helps confirm pregnancy in-situ, expulsion or empty uterus

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11
Q

What are the symptoms of cervical shock?

A

Cramps, nausea/vomiting, sweating, fainting

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12
Q

When does cervical shock resolve?

A

If products are removed from cervix

May need IV infusion and uterotonics

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13
Q

What are some causes of miscarriage?

A 
Embryonic abnormality or antiphospholipid syndrome
CMV, rubella, toxoplasmosis or listeria
Severe emotional upset or stress
Following chorionic villus sampling
Heavy smoking, alcohol abuse or cocaine
Uncontrolled diabetes
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14
Q

What is the pathophysiology of a miscarriage?

A

Bleeding from placental bed or chorion leads to hypoxia and villous/placental dysfunction = causes embryonic demise

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15
Q

What are the types of miscarriage?

A 
Threatened = risk to pregnancy
Inevitable = pregnancy can't be saved
Incomplete = part of pregnancy lost already
Complete = all of pregnancy lost, uterus is empty
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16
Q

What is early foetal demise?

A

Type of miscarriage = pregnancy in-situ, no heartbeat, mean sac diameter >25mm, foetal pole >7mm

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17
Q

What is an anembryonic pregnancy?

A

Type of miscarriage = no foetus and empty sac

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18
Q

What investigations may be done for a miscarriage?

A

FBC, group and save, hCG, USS, histology

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19
Q

How are miscarriages managed?

A

Assess and ensure haemodynamic stability

May discharge or admit as inpatient

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20
Q

How are miscarriages treated?

A

Conservative, medical, manual vacuum aspiration, surgery = begin anti-D if surgery needed
Emotional support, info leaflets and support groups

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21
Q

What is recurrent miscarriage?

A

3 or more pregnancy losses

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22
Q

What are some causes of recurrent miscarriage?

A

Antiphospholipid syndrome or balanced translocation
Thrombophilia = factor V leiden or prothrombin mutations, protein C, free protein S, antithrombin
Uterine abnormality = 1st trimester losses

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23
Q

What are the independent risk factors for recurrent miscarriage?

A

Age, previous miscarriage

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24
Q

What was the PRISM trial?

A

Showed that progesterone may prevent miscarriage in women with bleeding in early pregnancy

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25
What is an ectopic pregnancy?
Implantation outwith the uterine cavity
26
What are some common sites for ectopic pregnancy to occur?
Fallopian tubes, interstitium, isthmus, ampulla, fimbriae
27
What are some other sites an ectopic pregnancy may occur?
Ovary, peritoneum, other organs (e.g liver, cervix)
28
How do ectopic pregnancies present?
Pain. bleeding, dizziness/collapse, shoulder tip pain, SOB, pallor, haemodynamic instability, signs of peritonism, guarding and tenderness
29
How should a woman with suspected ectopic pregnancy and deteriorating symptoms be managed?
Urgent reviewal directly by senior gynaecologist
30
What are the red flags for ectopic pregnancy?
Repeated presentation with abdominal pain and/or pelvic pain, or any pain requiring opiates in a woman known to be pregnant
31
What investigations can be done for ectopic pregnancy?
FBC, group and save, USS, serum hCG
32
What may an USS of an ectopic pregnancy show?
Empty uterus or pseudo-sac +/- mass in adnexa | Free fluid in pouch of Douglas
33
How is serum hCG measured in a suspected ectopic pregnancy?
Comparative assessment 48hrs apart if haemodynamically stable = to assess doubling
34
How is ectopic pregnancy managed?
``` Surgical = if patient acutely unwell Medical = if stable, low levels of hCG and ectopic is small and unruptured Conservative = well patient who is compliant with follow up visits ```
35
What is molar pregnancy?
Gestational trophoblastic disease = non-viable fertilised egg
36
What occurs in molar pregnancy?
Overgrowth of placental tissue with chorionic villi swollen with fluid = grape-like clusters
37
What are the types of molar pregnancy?
Complete or partial
38
What malignancy do complete molar pregnancies carry a risk of?
Have 2.5% risk of choriocarcinoma
39
What are the features of a complete molar pregnancy?
Egg without DNA 1 or 2 sperm fertilise = results in diploid with only parental DNA present No foetus
40
What are the features of a partial molar pregnancy?
Haploid egg 1 sperm reduplicates DNA or 2 sperm fertilise egg = results in triploidy Foetus may be present
41
How can molar pregnancy present?
Hyperemesis Varied bleeding and passage of grape-like tissue Fundus is bigger than dates Occasional SOB
42
What does a USS of a molar pregnancy show?
Snow storm appearance +/- foetus
43
What is the management of molar pregnancy?
Surgical and tissue sampling for histology | Follow up with molar pregnancy service
44
When does implantation bleeding occur?
Timing is about 10 days post ovulation = occurs when fertilised egg implants into uterine wall
45
What is the blood that passes during implantation bleeding usually like?
Light/brown and limited
46
Why might implantation bleeding be mistaken for a period?
Can occur 2 weeks post ovulation | May be heavier bleed of bright red blood
47
How is implantation bleeding managed?
Watchful waiting = usually settles and pregnancy continues
48
What is a chorionic haematoma?
Pooling of blood between endometrium and embryo due to separation
49
What are the symptoms of a chorionic haematoma?
Bleeding, cramping, threatened miscarriage
50
How are chorionic haematomas managed?
Usually self limiting and resolves on its own = surveillance is needed
51
What may large chorionic haematomas cause?
Infection, irritability and miscarriage
52
What are some cervical causes of bleeding in early pregnancy?
Ectopy/ectopion and polyps Infection = chlamydia, gonococcal, bacteria Malignancy = growth or generalised erosion
53
What may be present in the history of a patient with a cervical cause to their bleeding?
Missed attendance at colposcopy | Never had a cervical smear
54
What are some vaginal causes of bleeding in early pregnancy?
Infection = trichomoniasis, bacterial vaginosis, chlamydia Malignancy = ulcers, tends to be rare Forgotten tampon
55
How is bacterial vaginosis treated in pregnancy?
Metronidazole 400mg twice daily for 7 days Avoid alcohol when taking medication Option of vaginal gel
56
How is chlamydia treated in pregnancy?
Erythromycin or amoxicillin Test for resolution 3 weeks later Include partner tracing
57
What are some causes of bleeding unrelated to the reproductive tract?
``` Urinary = bladder infection with haematuria Bowel = haemorrhoids, malignancy (rare) ```
58
What is the character of the pain felt during a miscarriage?
Varied intensity and frequency | Bleeding tends to be more common than pain
59
What is the character of the pain felt with an ectopic pregnancy?
Pain is predominant symptom May range from dull ache to sharp stabbing Peritonism may cause rigidity or rebound tenderness
60
What are rhesus negative women at risk of?
May miscarry of develop ectopic/molar pregnancy
61
When is anti-D given?
To women being managed with surgery = dose is 500 IU
62
How common is vomiting in the first trimester?
Common = 50-80%, tends to be limited and mild, starts as early as around time of missed period
63
What is hyperemesis gravidarium?
Excessive and protracted vomiting during pregnancy = damaging to quality of life, occurs in 0.3-3%
64
What effects can hyperemesis gravidarium have?
Dehydration, ketotsis, electrolyte/nutritional disbalance, weight loss, altered liver function (up to 50%), signs of malnutrition
65
What mood disturbances can occur in hyperemesis gravidarium?
Emotional instability and anxiety | Severe cases can cause mental health issues
66
What must be ruled out before you diagnose hyperemesis gravidarium?
Diagnosis of exclusion = rule out UTI, gastritis, peptic ulcer, viral hepatitis, pancreatitis
67
What is the management for hyperemesis gravidarium?
Replacement with IV fluids and electrolytes Parenteral anti-emetics and nutritional support Thiamine and vitamin supplement Steroids if recurrent or severe Thromboprophylaxis
68
What are the first line anti-emetics used to treat hyperemesis gravidarium?
Cyclizine 50mg | Prochlorperazine 12.5 mg IM/IV or 5-10mg orally
69
What are the second line anti-emetics used to treat hyperemesis gravidarium?
Ondansetron 4-8mg | Metoclopramide 5-10mg
70
What are some other medications given for hyperemesis gravidarium?
H2 receptor blocker (ranitidine) and PPI Omeprazole Oral prednisolone 40mg/day
71
Why is early symptom resolution in hyperemesis gravidarium important?
Avoids need for medications for epilepsy, hypertension, diabetes and thyroid
72
What is the outcome of hyperemesis gravidarium?
Can rarely extend to 2nd trimester or throughout pregnancy | Termination of pregnancy may be required in severe cases

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