Early Pregnancy Problems

Question 1

Define a spontaneous miscarriage. (2)

Answer 1

Fetal death or stillbirth before 24 weeks gestation

Question 2

Define a threatened miscarriage. (2)

Answer 2

Some bleeding but fetes is alive, uterus is expected size and os is closed. 25% will go on to miscarry

Question 3

Define an inevitable miscarriage. (2)

Answer 3

Heavy bleeding, fetus my still be alive but os is open and miscarriage is imminent

Question 4

Define an incomplete miscarriage. (2)

Answer 4

Some fetal parts passed, os is open

Question 5

Define a complete miscarriage. (2)

Answer 5

All fetal tissue passed, bleeding is diminished and os is closed

Question 6

Define a missed miscarriage. (2)

Answer 6

Fetus has not developed or has died in utero, but it has not been recognised until bleeding or ultrasound. Uterus is small for dates and os is closed.

Question 7

What is the management of bleeding in early pregnancy? (2)

Answer 7

Send to EPAU.
USS (TVUS) - is embryo in uterus? is it viable?
Repeat USS in one week if in doubt
hCG levels will increase by 2/3 in 48 hours if viable and in utero

If heavy bleeding or ectopic, admit.

Question 8

What are the management options for a non-viable intrauterine pregnancy? (3)

Answer 8

Expectant: continue as long as patient is willing and no signs of infection. usually completes in 2-6 weeks.
Medical: Prostaglandin (sometimes with prior anti-progesterone, Mifepristone)
Surgical: Evacuation of retained products of conception under anaesthetic. Patient preference, if heavy bleeding or signs of infection.

Question 9

Define a recurrent miscarriage. (1)

Answer 9

3 or more miscarriages in succession.

Affects 1% of couples

Question 10

Give 3 causes of miscarriages. (3)

Name the most common cause of a single miscarriage. (1)

Answer 10

• Anti-phospholipid antibodies (cause thrombosis in the uteroplacental circulation) (treat with aspirin and LMWH)
• Parental chromosomal defects
• Anatomical factors (uterine or cervical - usually late miscarriages)
• Infection (preterm labour and late miscarriage) (treatment of bacterial vaginosis reduces risk)

Most common: one-off fetal chromosomal defects.

Question 11

Name 3 indications for termination of pregnancy in the UK. (3)

Answer 11

1. Risk to life of mother
2. Grave risk to mother of physical or mental well-being
3. Less than 24 weeks and continued pregnancy would risk physical or mental health of mother
4. Less than 24 weeks and continued pregnancy would risk physical or mental health of other children
5. Risk of serious handicap if fetus was to be born

Question 12

Name the options available for termination of pregnancy. (3)

Answer 12

Surgical:
- Suction curettage (7-13 weeks)
- Dilatation and evacuation (13+)
Medical:
- Mifepristone (anti-progesterone) plus Misoprostol or Gemiprost 36-48 hours later (0-22 weeks)
- 22-24 weeks, risk of live birth so fetacide with KCl in umbilical vein or fetal heart.

Question 13

Name 2 complications of TOP. (2)

Answer 13

Haemorrhage, infection, uterine perforation, cervical trauma, treatment failure

Question 14

Define an ectopic pregnancy. (2)

Answer 14

Implantation of an embryo outside of the uterus.

95% are tubal. Also can be in abdomen, cornu, cervix, ovary.

Question 15

Name 3 risk factors for an ectopic pregnancy. (3)

Answer 15

PID, assisted conception, previous pelvic surgery, smoking, advancing maternal age, previous ectopic pregnancy

NB IUD only prevents intrauterine pregnancy

Question 16

What are the clinical features of an ectopic pregnancy? (3)

Answer 16

Collapse, abdominal pain or vaginal bleeding

Question 17

Jo has a history of amenorrhea for the last 6 weeks and now has lower abdominal pain and heavy vaginal bleeding.
You suspect an ectopic pregnancy.
What is your management? (3)

Answer 17

NBM
FBC and cross match. (anti-D if rh negative)
Pregnancy test
TVUS
Laparotomy (unless meets medical criteria)

Question 18

What are the options for an acute presentation of an ectopic pregnancy? (2)

Answer 18

Resus and laparotomy with salpingectomy

Question 19

What are the management options for a subacute presentation of an ectopic pregnancy? (3)

Answer 19

Surgical: laparoscopy with salpingostomy or salpingectomy
Medical: Single dose methotrexate if… unruptured, no cardiac activity and hCG < 3000IU/ml
Conservative: if small and unruptured or location uncertain and hCG is low. Risk of rupture is unlikely.

Question 20

How can ectopic resolution be confirmed following surgical, medical or conservative management? (1)

Answer 20

Once hCG is less than 20 IU/ml

Question 21

Define hyperemesis gravidarum. (2)

Answer 21

Nausea and vomiting so severe in early pregnancy that causes severe dehydration, weight loss or electrolyte disturbance. Usually resolved by 14 weeks.

Question 22

What is the management of suspected hyperemesis gravidarum? (3)

Answer 22

Exclude UTI, multiple or molar pregnancy.
IV rehydration
Anti-emetics
Thiamine

Question 23

What is gestational trophoblastic disease? (1)

Answer 23

Proliferation of the trophoblast more aggressively than anticipated causing very high hCG levels.

(trophoblast is part of blastocyst that invades into the endometrium)

Question 24

What is a hydatidiform mole? (1)

Answer 24

Localised and non-invasive proliferation of trophoblast.

can be partial or complete.

Question 25

What is the cause of a complete and partial hydatidiform mole? (2)

Answer 25

Complete: 1 sperm in empty oocyte
Partial: 2 sperm in 1 oocyte

Question 26

What is the difference between an invasive mole and a choriocarcinoma? (2)

Answer 26

Invasive mole is aggressive proliferation of trophoblast into uterus.
Once it has metastasised it becomes known as a choriocarcinoma.

Question 27

What is the typical ultrasound appearance of gestational trophoblastic disease? (1)

Answer 27

Snowstorm appearance.

Diagnosis is confirmed on histology.

Question 28

What is obstetric cholestasis? (2)

Answer 28

Pruritis in pregnancy that resolves on delivery of fetus.

It is associated with impaired liver function but without any other identifiable pathology.

Question 29

Describe the itching in pregnancy that is associated with obstetric cholestasis. (2)

Answer 29

Usually occurs after 20 weeks.
No rash
Mainly worse at night
Mainly affecting the palms and soles.

Question 30

Name 2 risk factors associated with obstetric cholestasis. (2)

Answer 30

FH
Previous history
Multiple pregnancy

Question 31

Name 2 complications of obstetric cholestasis. (2)

Answer 31

Fetal: IUD, neonatal death, fetal distress, preterm delivery, inter-cerebral bleed
Maternal: PPH

Question 32

How is obstetric cholestasis diagnosed? (2)

Answer 32

Diagnosis of exclusion so…

PET screen: FBC, U+Es, LFTs, clotting
Liver USS
Hep A, B, C, E serology
EMV and CMV serology

Question 33

Why does obstetric cholestasis cause increased risk of haemorrhage? (1)

Answer 33

LFTs show increased transaminases and increased bile salts sometimes with decreased clotting.
This occurs to due to decreased absorption of vitamin K.

Question 34

What is the management of a mother with obstetric cholestasis? (2)

Answer 34

Chlorphenamine
Ursodeoxycholic acid
(Vitamin K)
Deliver at 37 weeks due to risk of fetal death.