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Women's Health > Early pregnancy problems > Flashcards

Early pregnancy problems Flashcards

1
Q

In a normally progressing pregnancy at 4-8 wks, what pattern should beta HCG levels be displaying?

A

Beta HCG should double every 48 hrs

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2
Q

What can a plateauing or decreasing beta HCG signify?

A

Poor outcome / miscarriage / ectopic pregnancy

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3
Q

What can an abnormally increasing beta HCG signify?

A

Molar pregnancy

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4
Q

Can a pregnancy be seen on trans-abdominal ultrasound at 5 or less weeks?

A

No

Trans-vaginal ultrasound is required - may see a gestational sac

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5
Q

On a trans-abdominal u/s, what can be seen at 5-6 wks, and 7 wks?

A

5-6 wks: Gestational sac (but be aware, it could be a pseudo-gestational sac)

7 wks: 5-10 mm embryo, fetal pole

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6
Q

When is the typical period that women experience morning sickness?

A

Typically 5-6 wks gestation
Peaks at 9 wks
Typically abates by 16-18 wks

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7
Q

At what point is morning sickness no longer “morning sickness”, but hyperemesis gravidarum?

A

Persistent vomiting + weight loss of greater than 5% of body weight
+ dehydration
+ ketonuria (unrelated to other causes)

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8
Q

When a woman is experiencing N&V during pregnancy, what is another Ddx to consider other than hyperemesis gravidarum?

A

Hyperthyroidism - beta HCG stimulates the thyroid

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9
Q

What Ix should be done in a woman experiencing N&V that may be excessive?

A 
Weight
Serum free T4 concentration
TSH
LFTs 
U/S (exclude GTD/multiple pregnancy)

Dehydration consequences

  • Serum electrolytes
  • Orthostatic BP
  • Urine ketones
  • FBE
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10
Q

What are some pharmacological means to manage hyperemesis gravidarum?

A

Antiemetics
> ondansetron (beware of constipation + dehydration = impaction)
> metoclopramide (dopamine antagonist)

Corticosteroids
> for severe and refractory hyperemesis
> must do a 2 wk tapering regime

Antihistamines / anticholinergics

IV fluids
  > NS or Hartmans
  > replete Mg, K and P
  > thiamine - prevent Wernicke's encephalopathy
  > consider dextrose

Enteral / parenteral nutrition
> last resort TPN
> consider PICC or gastric/duodenal intubation

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11
Q

At what stage in pregnancy does loss of a fetus occur for it to be a “miscarriage”?

A

< 20 wks gestation

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12
Q

What are the different types of miscarriage?

A

Threatened
> pain +/ vaginal bleeding
> closed cervix
> live IUP on u/s

Incomplete
> pain +/ vaginal bleeding ongoing
> open or closed cervix
> some PoC present on u/s

Complete
> pain +/ vaginal bleeding settling
> closed cervix
> uterus empty on u/s

Inevitable
> pain +/ vaginal bleeding on going
> open cervix
> PoC present on u/s

Missed
> no sx/signs
> closed cervix
> non-viable IUP on u/s

Septic
  > pain +/ vaginal bleeding ongoing
  > sx +/ signs of infection
  > cervix open or closed
  > on u/s, PoC present/absent
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13
Q

What is the most common cause of miscarriage under 12 wks gestation?

A

Chromosomal abnormalities

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14
Q

What are some of the causes of miscarriage between 12-20 wks?

A 
Uterine abnormalities
'Cervical incompetence'
Progesterone deficiency
Trauma (iatrogenic / other)
Unexplained
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15
Q

What are some of the causes of miscarriage under 12 wks gestation?

A

Chromosomal abnormalities

Maternal illness
> DM
> thyroid dse
> anti-phospholipid syndrome / lupus

Advanced maternal age

Lifestyle factors
  > smoking
  > drugs/meds
  > alcohol
  > caffeine
  > extremes of weight
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16
Q

At what gestational ages can you diagnose miscarriage on U/S?

A

Transabdominal U/S: 6.5 wks

Transvaginal U/S: 5.5 wks

17
Q

What are the criteria for diagnosing miscarriage?

A

CRL (ie. fetal pole) equal to or greater than 7mm, with no fetal cardiac activity

OR

Empty gestational sac with a mean diameter equal to or greater than 25 mm (no yolk sac / fetal pole)

** Pregnancies of uncertain viability may not meet the criteria, so need to do a repeat scan in 1-2 wks

18
Q

What are some of the predictors of a failing pregnancy?

A

Abnormal gestational sac
Abnormal yolk sac
Slow fetal HR
Subchorionic haematoma

19
Q

What are the various options for managing miscarriage, and when are they appropriate?

A

Expectant management
> often the approach for inevitable / incomplete / missed miscarriage
> wait & see approach

Medical management
> misoprostol (prostaglandin) + mifepristone (progesterone antagonist)
> use if any PoC present in the uterus

Surgical management
> dilatation and curettage
> indicated if: heavy/persistent bleeding +/ pain, greater amount of PoC remaining, or preferred by the patient

20
Q

Is a miscarriage or threatened miscarriage a sensitising event, and what is the significance of this?

A

Must test blood group - is the mum Rhesus negative?

If rhesus negative: give Anti-D

21
Q

What investigations should be done if a woman has recurrent miscarriages (3 or > consecutive losses)?

A

Should investigate and refer

Investigations:

  • Pelvic U/S
  • Thrombophilia screen
  • Test for anti-phospholipid syndrome
  • Parental karyotype
22
Q

What is a complete and partial/incomplete molar pregnancy?

A

Complete: 2 sperm fertilise an empty egg
> 46XX
> no fetal tissue

Incomplete/partial: 2 sperm fertilise a haploid egg
> 69XXX / 69XXY
> fetus can be present

23
Q

What are the risk factors for a molar pregnancy (gestational trophoblastic disease)?

A
  • Extremes of age
  • Asian ethnicity
  • Previous gestational trophoblastic disease
24
Q

How can a molar pregnancy present?

A

Vaginal bleeding 80%
> sx of miscarriage

Uterus larger than dates 50%

Hyperemesis 30%

Pre-eclampsia 20%

Torsion/rupture/bleeding 3%

Trophoblastic embolisation <2%

Thyrotoxicosis
> beta HCG stimulates the thyroid

Beta HCG >200 000
> out of proportion with wks

25
Q

What U/S findings might be present in a molar pregnancy?

A

Vesicular pattern
Multiple honeycomb cystic space
Bilateral theca luteal cysts

26
Q

What is the management of molar pregnancy (GTD)?

A

Surgical D&C
> incl. oxytocic administration, cross-match, TFTs, FBE, anti-D (if Rh -ve)

+/- chemotherapy (methotrexate)

+/- Fluid resus.

+/- Antiemetics

27
Q

What follow-up is required after a woman has had a molar pregnancy?

A

Register with the mole registry

Follow the beta HCG level
> weekly until 2 normal levels (partial)
> monthly for 6 monthly (complete)
> 6 weekly (following a subsequent pregnancy)

28
Q

What are the risk factors for ectopic pregnancy?

A
  • Previous PID or ruptured appendix
  • Previous ectopic pregnancy
  • Previous tubal surgery
  • Pregnancy in the presence of IUCD
  • Progesterone-only pill
  • Artificial reproductive technology (ART)
29
Q

What is the most common site for ectopic pregnancies?

A

Tubal (> 95%)

> ampullary most common (93%) - consequences of rupture are not as significant as cornual

30
Q

What signs of ectopic pregnancy can be seen on U/S?

A
  • Empty uterus
  • Adnexal mass
  • Tubal ring sign (echogenic ring surrounding an unruptured ectopic pregnancy)
  • Free fluid
  • Adnexal gestational sac
31
Q

What is the particularly dangerous site for an ectopic pregnancy and why?

A

Isthmic ectopic pregnancy
> rupture more easily because of where they are
> significant blood loss (vessels close by - Ovarian artery)

32
Q

What are some of the symptoms of ectopic pregnancy?

A

Low abdominal pain (due to peritoneal irritation)

Vaginal bleeding

Adnexal tenderness

Acute abdomen

Shoulder tip pain

Fainting (hypovolaemia / shock)

    • But the presentation can be atypical
  • asymptomatic
  • GI symptoms
  • incidental finding on U/S
33
Q

If a woman presents with pain in early pregnancy, what are some of the differential diagnoses to consider?

A 
Ectopic pregnancy
Appendicitis
UTI
Ovarian cyst
Ureteric stone
GI issues
Musculoskeletal issue
34
Q

Other than signs on U/S, what other signs/sx may be suggestive of an ectopic pregnancy?

A

Collapsed woman early in pregnancy
> clinical dx of ectopic pregnancy UPO

Serial beta HCG +/- progesterone
> 3x beta HCGs not increasing normally +/ symptoms present
> if beta HCG is 1500&raquo_space; refer for U/S
> if beta HCG > 2000 IU, a viable IUP should be seen on transvaginal U/S

FBE

Blood group + antibodies

UEC (if considering methotrexate)

LFTs (if considering methotrexate)

35
Q

What is the natural hx of ectopic pregnancy?

A
  1. Rupture
    > urgent surgical intervention required
  2. Tubal miscarriage
  3. Spontaneous resolution
36
Q

What are the management options for ectopic pregnancy?

A

Conservative mngt
> ONLY appropriate if:
- beta HCG is < 1000 and decreasing
- no signs/sx
- patient is stable
- patient is able to have f/u quickly if required

Medical
  > methotrexate (1-2 doses)
  > ONLY appropriate if:
      - beta HCG < 4000
      - less than 3 cm
      - no fetal heart
      - asymptomatic
      - patient is able to have f/u quickly if required
      - no C/I to methotrexate

Surgical
> laparoscopy / laparotomy

** MUST have follow-up until beta HCG level have reached zero **

Women's Health (4 decks)

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