Early Pregnancy Complications

Question 1

Define miscarriage

Answer 1

Pregnancy loss before 24 weeks

Question 2

What are the symptoms of a miscarriage?

Answer 2

Positive pregnancy test, bleeding with period cramps

Question 3

What can help to identify a miscarriage?

Answer 3

Ultrasound

Speculum examination to assess stage

Question 4

What are the symptoms of cervical shock?

Answer 4

Cramps, nausea/vomiting, sweating, fainting

Question 5

How is cervical shock managed?

Answer 5

Remove products from cervix, occasionally IV resuscitation is required

Question 6

Name the causes of miscarriage

Answer 6

Embryonical abnormality 
Immune cause - anti phospholipid syndrome 
Infection - CMV, rubella, listeria 
Severe emotional upset/stress
Iatrogenic 
Uncontrolled diabetes 
Alcohol/drugs

Question 7

What are the four types of miscarriage?

Answer 7

Threatened
Inevitable
Incomplete
Complete

Question 8

Describe a threatened miscarriage

Answer 8

Closed os and no product can be seen, risk to pregnancy

Question 9

Describe an inevitable miscarriage

Answer 9

Pregnancy cannot be saved, open os but nothing in the vagina

Question 10

Describe an incomplete miscarriage

Answer 10

Part of pregnancy is lost already, os is open and pregnancy can be seen

Question 11

Describe a complete miscarriage

Answer 11

All of pregnancy is lost and the uterus is empty

Question 12

On a scan what counts as a non-viable pregnancy

Answer 12

Sac diameter >25mm and foetal pole >7mm with no heartbeat

Question 13

What is the name given to the presence of a sac but no foetus?

Answer 13

Anmbryonic pregnancy

Question 14

Describe the different management options in a miscarriage

Answer 14

Conservative
Medical (miepristone and misoprostol)
Manual Vacuum Aspiration
Surgical Evacuation

Question 15

What investigations should be done on a patient with a suspected miscarriage?

Answer 15

FBC, group and save, serum hCG, ultrasound and histology

Question 16

What should be given in patients who require surgical intervention for miscarriage?

Answer 16

Anti-D

Question 17

What counts as recurrent miscarriage?

Answer 17

3 or more pregnancy losses

Question 18

State the causes of recurrent miscarriage

Answer 18

Antiphospholipid syndrome 
Thrombophilia 
Balanced translocations 
Uterine abnormality 
Age
Previous miscarriage

Question 19

How is anti phospholipid syndrome managed?

Answer 19

Low dose aspirin

Daily frogmen

Question 20

What treatment can be given in recurrent miscarriages?

Answer 20

Progesterone pessary if >35 and more than two miscarriages

Question 21

Define ectopic pregnancy

Answer 21

Normal embryo implanted out with the uterine cavity

Question 22

What are sites for ectopic pregnancy?

Answer 22

Fallopian tube - interstitial, isthmus, ampulla or fibrial part
Ovary
Peritoneum
Other organs - liver, cervix, C-section scar

Question 23

How will an ectopic pregnancy present?

Answer 23

Pain, bleeding, dizziness, collapse, shoulder tip pain, SOB, pallor, peritonism, haemodynamically unstable, guarding and tenderness

Question 24

What are the red flags in early pregnancy?

Answer 24

Repeated presentation with abdominal +/- pelvic pain or pain requiring opiates

Question 25

Describe the investigations for ectopic pregnancy

Answer 25

FBC, blood group and save, beta HCG, transvaginal ultrasound

Question 26

What may be seen on transvaginal ultrasound in an ectopic pregnancy?

Answer 26

Empty uterus, pseudo sac, mass outside of cavity, free fluid in the pouch of douglas

Question 27

What is the use of serum hCG?

Answer 27

It can be used to show a comparison and if decreasing conservative treatment can be used

Question 28

What are the risk factors for an ectopic pregnancy?

Answer 28

Previous ectopic pregnancy, pelvic inflammatory disease (chlamydia), tubal surgery, C-section

Question 29

How are ectopic pregnancies managed?

Answer 29

Conservative Medical if woman is stable and low levels of beta HCG Surgery

Question 30

Describe the medical management of an ectopic pregnancy

Answer 30

Small un-ruptured ectopic pregnancy, beta HCG<5000 methotrexate given in one or two doses

Question 31

What guides the progress of an ectopic pregnancy?

Answer 31

Progesterone levels

Question 32

What is the surgical management of an ectopic pregnancy?

Answer 32

Laparoscopic salpingectomy

Question 33

Define molar pregnancy

Answer 33

Non-viable fertiliser egg part of gestational trophoblastic disease

Question 34

Describe a molar pregnancy histologically

Answer 34

Overgrowth of placental tissue with chorionic villi swollen with fluid in grape like clusters

Question 35

What are the two types of molar pregnancy?

Answer 35

Complete | Partial

Question 36

What is the DNA difference between complete and partial?

Answer 36

Complete - only paternal 46 chromosomes | Partial - Triploidy 69 chromosomes

Question 37

Describe the classic ultrasound appearance of a molar pregnancy

Answer 37

Snowstorm created by multiple placental vesicles in complete mole May be theca lutein cysts

Question 38

What are important warning signs of a molar pregnancy?

Answer 38

``` Hyperemesis Hyperthyroidism Early onset pre-eclampsia Varied bleeding and passage of grape like tissue Uterus size > gestational age SOB or seizures are rare ```

Question 39

How is a molar pregnancy managed?

Answer 39

Uterine evacuation and biopsy

Question 40

What is the risk of a complete molar pregnancy?

Answer 40

Choriocarcinoma

Question 41

Describe implantation bleeding and how it is managed

Answer 41

Occurs when the fertilised egg implants in the endometrial lining - 10 days post ovulation Light brown often mistaken as a period as it can be similar - watchful waiting

Question 42

What is a chorionic haematoma?

Answer 42

Pooling of blood between endometrium and embryo due to separation (sub-chorionic)

Question 43

What does a chorionic haematoma cause?

Answer 43

Bleeding, cramping, threatened miscarriage

Question 44

How are chorionic haematomas managed?

Answer 44

Usually self limiting and resolve | Larger - source of infection, irritability or miscarriage so follow up is important

Question 45

What are the cervical causes of bleeding?

Answer 45

Polyps, ectopy, infection, malignancy

Question 46

What are the vaginal causes of bleeding?

Answer 46

Infection (trichomaniosis, bacterial vaginosis, chlamydia) Malignancy Forgotten tampon

Question 47

How is vaginosis treated in pregnancy?

Answer 47

Metronidazole 400mg BD 7 days

Question 48

How is chlamydia treated in pregnancy?

Answer 48

Erythromycin/amoxicillin with cure test 3 weeks later

Question 49

What is the aim of an anti-D injection?

Answer 49

Neutralise anti-D antigen and prevent sensitisation of immune system from forming anti-D antibody in rhesus negative women

Question 50

Define Hyperemesis Gravidarum

Answer 50

Vomiting excessively altering quality of life

Question 51

How does Hyperemesis Gravidarum present?

Answer 51

Dehydration, ketosis, electrolyte/nutritional disturbance, weight loss, altered liver function, emotional instability

Question 52

How is Hyperemesis Gravidarum managed?

Answer 52

Diagnosis of exclusion IVI rehydrate and electrolyte replacement Antiemetic (cyclizine, prochloperazine, metaclopromide) Vitamin supplement Nutritional support Thromboprophylaxis

Question 53

What is given in Hyperemesis Gravidarum if severe and recurrent?

Answer 53

Steroids

Question 54

In very extreme circumstances where a woman's life is at risk in Hyperemesis Gravidarum what may be required?

Answer 54

Termination of Pregnancy