Early pregnancy complications

Question 1

When is a pregnancy considered full term and what is the average length of pregnancy ?

Answer 1

Full term = 37-42 weeks, average length is 40 weeks

Question 2

Define the duration of each of the 3 trimesters of pregnancy

Answer 2

• 1st trimester = 0-12 weeks
• 2nd trimester = 13-27 weeks
• 3rd trimester = 28-birth

Question 3

What marker do pregnancy tests test for ?

Answer 3

Levels of βHCG

Question 4

What is the normal outcome of ferilisation ?

Answer 4

A developing embryo in the normal location with development on-going

Question 5

List the main abnormal outcomes of pregnancy

Answer 5

1. Misscardige (embryo is normal)
2. Ectopic pregnancy (abnormal site of implantation)
3. Molar pregnancy (abnormal embryo)

Note all of these can cause vaginal bleeding

Question 6

How common is PV bleeding in early pregnancy ?

Answer 6

Very - occurs in about 20% of pregnancies

Question 7

Other than the 3 main abnormal outcomes of pregnancy list some of the other causes of PV bleeding in early pregnancy

Answer 7

• Implantation bleeding
• Chorionic haematoma
• Cervical causes - infection, malignancy, polyps, ectopy/ectropion
• Vaginal causes - infection, malignancy (rare)
• Unrelated bleeding in pregnancy - haematuria, PR bleeding

Question 8

If a women in early pregnancy presents with any symptoms of bleeding, pain (cramps), hyperemesis (nausea, vomiting, WL), dizziness/fainting, where should they be assessed?

Answer 8

The early pregnancy assessment clinic/unit (EPAC/EPAU)

Question 9

Define what miscarridge is and what a stillbirth is

Answer 9

Miscarriage = loss of pregnancy up to 23+6 weeks, after this known as stillbirth

Question 10

What percentage of pregnancies miscarry ?

Answer 10

20-40%, mainly in the 1st trimester

Question 11

Pregnancy tests remain +ve for several days after a fetal death - T or F?

Answer 11

True

Question 12

What are the general symptoms of miscarriage ?

Answer 12

• Vaginal bleeding
• Abdo cramps - period like
• Passage of tissue through the vagina
• +ve urine pregnancy test

Question 13

How is miscarriage diagnosed ?

Answer 13

Initially assess if haemodynamically stable, if not then admit to hospital immediately, if they are stable then investigate as follows:

1. Confirm pregnancy with UPT
2. Carry out abdo exam & transvaginal U/S to assess location and viability of pregnancy - U/S will show if there is a FH, if they are in the process of expulsion or if they have an empty uterus
3. Speculum examination then used to assess if cervical os closed (threatened miscarriage), if products (tissue) are sited at the os (miscarriage inevitable) or if products/tissue in vagina (complete)

Question 14

Describe the features of a threatened miscarriage

Answer 14

• Mild symptoms (bleeding often less than menstruation & painless) and the cervical os is closed
• It typically occurs between 6-9 weeks
• The fetus is still seen on scan

Question 15

Describe the features of a inevtiable miscarriage

Answer 15

• Severe symptoms (heavy bleeding, clots & pain)
• The cervical os is open

Question 16

Describe the features of a incomplete miscarriage

Answer 16

• Most but not all products of conception have been expelled but there are some remaining
• Pain and vaginal bleeding
• Cervical os is open

Question 17

Describe the features of a complete miscarriage

Answer 17

Empty uterus - Products may be in the vagina

Question 18

Describe what a Missed (delayed) miscarriage (also called early fetal demise) is

Answer 18

• A gestational sac which contains a dead fetus before 20 weeks without the symptoms of expulsion
• Mother may have light vaginal bleeding / discharge and the symptoms of pregnancy which disappear. Pain is not usually a feature
• Cervical os is closed

Question 19

Define what a anembryonic pregnancy is

Answer 19

When the gestational sac is > 25 mm and no embryonic/fetal part can be seen it is sometimes described as a ‘blighted ovum’ or ‘anembryonic pregnancy’

Question 20

What is the management of miscarriage ?

Answer 20

• Ensure haemodyanmically stable
• Emotional support, ensure routine antenatal care cancelled & ensure if required that anti-D is given
• If no tissue left in the womb the no treatment given

If incomplete or missed miscarriage then:

1. 1st line = expectant management (for 7-14 days)
2. 2nd line = medical management - vaginal or oral misoprostol
3. 3rd line = surgical intervention with manual vacuum aspiration or surgical management

Question 21

When is medical or surgical treatment of incomplete or missed miscarriages preferred rather than expectant ?

Answer 21

• If increase risk of haemorrhage
• Had previous adverse/traumatic experience

Question 22

List some of the potential causes of miscarriage

Answer 22

• Embryonic abnormality
• Anti-phospholipid syndrome
• Infection
• Severe emotional upsets
• Environmental
• Iatrogenic after CVS or amniocentesis
• Smoking, cocaine, alcohol use

Question 23

All women who have had surgical management/intervention for miscarriage should have what?

Answer 23

Anti-D immunoglobulin

Question 24

Define what recurrent miscarriage is

Answer 24

This is 3 or more consecutive spontaneous abortions.

Question 25

What should be done for someone with recurrent miscarriages ?

Answer 25

They should be referred for investigations: * Assessment for anti-phospholipid syndrome & possibly other immunological abnormalities * Investigate for genetic abnormalities in both partners * Investigate for fetal genetic abnromalities if fetal tissue available * Pelvic U/S for uterine abnormalities

Question 26

What is the prognosis for someone with recurrent miscarriages even if no underlying cause is found ?

Answer 26

75% chance of a future successful pregnancy

Question 27

If the mother is found to be anti-phospholipid syndrome +ve what should she be treated with during pregnancy and the postpartum period ?

Answer 27

Aspirin + heparin

Question 28

Define what an ectopic pregnancy is

Answer 28

This is implantation and development of the fetus outwidth the uterus

Question 29

State the most common site of ectopic pregnancy and also the additional other areas it can occur

Answer 29

Most common site is the fallopian tubes (in particular the ampulla of the fallopian tubes) Other sites include: * Ovary * Peritoneum * Organs e.g. liver, cervix * C-section scar

Question 30

What are the signs/symptoms of ectopic pregnancy ?

Answer 30

* Missed period & other signs of pregnancy * Strong cramps or lower abdo/pelvis pain * Vaginal bleeding * Shoulder tip pain * Dizziness/ collapse * SOB A typical history is a female with a history of 6-8 weeks amenorrhoea (longer past 10wks suggests other cause) who presents with lower abdominal pain and later develops vaginal bleeding

Question 31

How is ectopic pregnancy diagnosed ?

Answer 31

Firstly assess is haemodynamically stable or not. If not stable then transfer to hospital immediately If haemodynamically stable then: * **1st line =** confirm pregnacy using betaHCG pregnancy test + followed by Transvaginal U/S to determine locaiton of pregnancy * **2nd line =** serial serum HCG test (2 tests 48hrs apart) if transvaginal U/S doesn't confirm pregnancy

Question 32

State the management of ectopic pregnancy

Answer 32

There are 3 ways to manage ectopic pregnancies: 1. **Expectant management -** For low risk, hemodynamically stable, asymptomatic patients (or with minimal pain) with a plateau or decrease in human chorionic gonadotrophin (hCG) levels. RCOG recommends it as an option when there is a decreasing hCG level which was initially \<1500 IU/L. Or in patients with an initial hCG \<200 IU/L 2. **Medical management (methotrexate) -** reserved for haemodynamically stable patients who have a confirmed or high clinical suspicion of ectopic pregnancy, an unruptured mass, and no absolute contraindications to methotrexate. RCOG recommends that hCG levels patients need a hCG ideally \<1500 and no fetal cardiac activity on an U/S with certainty that there is no intrauterine pregnancy 3. **Surgical management** (laproscopy + salpingectomy or salpingotomy) - If a patient shows signs of haemodynamic instability, symptoms of a ruptured ectopic mass, or signs of intraperitoneal bleeding then surgical intervention is required.

Question 33

After management of an ectopic pregnancy what do almost all women need followed up with and who is the exception

Answer 33

All women (except those who have had a salpingectomy) need to be followed up with serum betahCG tests to ensure it is decreasing at an acceptable rate until non-pregnant levels reached which may take up to 6 weeks

Question 34

What do all Rhesus -ve women undergoing surgical management of an ectopic pregnancy require ?

Answer 34

Anti-D

Question 35

Define what gestational trophoblastic disease is

Answer 35

This is a group of disorders spanning the conditions of complete & partial molar pregnancies through to the malignant conditions of invasive mole, choriocarcinoma & the very rare placental site trophoblastic tumour (PSTT)

Question 36

Define what a molar pregnancy is

Answer 36

* This is an abnormal form of pregnancy in which a non-viable ferilised egg implants in the uterus & will fail to come to term, it grows into a mass in the uterus & has swollen chorionic villi which resemble grapes * The growth is called a 'hydatidform mole' which can either be a complete or partial mole

Question 37

Describe how a complete mole forms

Answer 37

An empty ovum 'egg without DNA' is ferilised by 1 or 2 sperm resulting in diploidy. No fetus develops (makes sense as only DNA from father), there is then an overgrowth of placental tissue

Question 38

Describe how a partial mole forms

Answer 38

A haploid egg (ovum) is fertilised by 1 or 2 sperm (usually 2) resulting in triploidy. There may be evidence of an abnormal fetus (cant survive or develop into a baby) and an overgrowth of abnormal placental tissue (makes sense as there is maternal and paternal DNA to contribute to actually makking the fetus albeit abnormal)

Question 39

What does a complete mole carry a risk of ?

Answer 39

A 2.5% risk of developing into a choriocarcinoma

Question 40

Describe the presentation of a molar pregnancy

Answer 40

* The hydatidiform mole makes a lot of betaHCG causing exaggerated pregnancy symptoms & strongly +ve pregnancy tests * Hypermesis gravidarum - servere nausea, vomiting, weight loss, feeling faint * PV bleeding * Passage of 'grapelike tissue' * Fundus height \> than gestational dates * SOB * Snow storm appearance on U/S +/- an abnormal fetus

Question 41

How is molar pregnancy diagnosed ?

Answer 41

U/S is useful in making pre-evacuation diagnosis but definitive diagnosis is made by histological examination of the products of conception

Question 42

What is the management of molar pregnancies

Answer 42

* 1st line = Surgical curratage for complete & partial molar pregnancies * 2nd line = medical evacuation for partial molar pregnancies when the size of the fetal parts doesn't allow for surgical curretage Following this send tissue to histology, carry out regular pregnancy tests until acceptable levels reached & follow-up with molar pregnancy services

Question 43

Describe what implantation bleeding is

Answer 43

* This is PV bleeding which occurs after the fertilised egg implants into the uterine wall * It occurs roughly 10 days post ovulation * The PV bleeding is light/brownish & limited/spotting * Signs of pregnancy soon then emerge * Occasionally mistake as a period

Question 44

What is the management of implantation bleeding ?

Answer 44

Watchful waiting

Question 45

Define what a chorionic haematoma is

Answer 45

This is pooling of blood between the endometrium (uterine wall) & the outer fetal membrane (covering embryo)

Question 46

Describe the presentation of a chorionic haematoma

Answer 46

* PV bleeding ranging from spotting to heavier bleeding +/- clots * Cramping * If bleeding is excessive enough then may get a prognosis of threatened miscarriage * Usually is self-limiting & resolve * U/S is used to monitor them

Question 47

How is a chorionic haematoma diagnosed ?

Answer 47

U/S

Question 48

What is the treatment of a chorionic haematoma ?

Answer 48

Reassurance & surveillance with U/S