early pregnancy problems
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Early Pregnancy Problems
Jacqueline WoodmanM.B.,Ch.B.; Dipl Obst; MRCOG; D.Phil (Oxon)
Introduction
Bleeding in early pregnancy and miscarriage
Ectopic Pregnancy
Gestational Trophoblastic Disease
Hyperemesis Gravidarum
Bleeding in Early Pregnancy
& Miscarriage
Definitions
Remember – MISCARRIAGE not ABORTION
Threatened miscarriage Vaginal bleeding at < 24 weeks gestation (cervix closed)
Inevitable miscarriage Bleeding, pregnancy still in uterus (cervix open)
Incomplete miscarriage Retained products of conception in uterus (cervix open)
Complete miscarriage Uterus empty (cervix closed)
Delayed miscarriage Gestational sac with/without fetus present (but no FH),
cervix closed
Miscarriage
Approximately 30% of pregnant women will experience bleeding in early pregnancy
At least 50% of women with threatened miscarriage will have continuing pregnancy
Miscarriage occurs in 15-20% of clinically diagnosed pregnancies
Causes of miscarriage
Genetic abnormalities Progesterone deficiency? Maternal illness e.g. diabetes Uterine abnormalities ‘Cervical incompetence’
History LMP Bleeding: amount (spotting/gush), clots Pain: type – crampy/sharp/dull
location: lower abdomen, shoulder tip, back pain
Passed products?
Examination
ABC (vital signs) stable or cervical shock Abdominal tender/ rebound tenderness Vaginal (speculum)
Cervix: open/closed Amount of bleeding Products visible? .............TAKE IT OUT!
Speculums
Cusco speculum Sims speculum
Investigations
Ideally in dedicated ‘Early Pregnancy Assessment Unit’
Ultrasound Measurement of serum βhCG Determination of blood & Rhesus group FBC, G&S and admit if significant bleeding Psychological support
Ultrasound Expect to see viable fetus from around 6.5 weeks transabdominally,
5.5 weeks transvaginally
Other possible appearances ‘POC’ Incomplete miscarriage
Empty uterus Not pregnantToo early gestationExtrauterine pregnancyComplete miscarriage
Empty sac Non-viable pregnancyToo early gestation
Fetal pole with no FH If tiny, may be very early gestation
Delayed miscarriage
Gestational sac
Very early..
Normal 8-9 wk pregnancy
Empty sac
Measurement of βhCG
Not necessary if diagnosis unequivocal on scan
Useful as part of investigations to diagnose/exclude extrauterine pregnancy/miscarriage
Doubling time approx 2 days in viable pregnancy Halving time 1-2 days in complete miscarriage Should see fetal pole with βhCG of 1500-2000
Management of Incomplete Miscarriage Conservative
Risk of bleeding, infection, retained POC needing ERPC,
unpredictable
Medical (Prostaglandin e.g. Misoprostol)
Risk of bleeding, retained POC, need for ERPC
Surgical [Evacuation of retained products of conception (ERPC)]
Suction curettage usually under GA, risk of bleeding, infection,
perforation of uterus, longer term complications (e.g. Ashermans
syndrome)
Ectopic Pregnancy
Definition
Pregnancy occurring outside uterine cavity
Approx 0.5-1% of pregnancies – rate increasing
Maternal mortality in 1/2500 ectopic pregnancies
(13 deaths 1997-1999 in UK)
Site
Fallopian tubeOvaryAbdominal cavityCervix
Risk factors
Previous PID Previous ectopic pregnancy Previous tubal surgery (e.g. sterilisation, reversal) Pregnancy in the presence of IUCD
Symptoms
AcuteLow abdominal pain – peritoneal irritation by
blood Vaginal bleeding – shedding of deciduaShoulder tip pain – referred from diaphragmFainting - hypovolaemia
Chronic (Atypical)Asymptomatic, gastrointestinal symptoms, back
pain
Signs
Shock – tachycardia, hypotension, pallor
Abdominal tenderness
Adnexal tenderness
Adnexal mass
None
Diagnosis
UltrasoundEmpty uterus, adnexal mass, free fluid in POD,
rarely live pregnancy outside of uterus
Serum βhCGSuboptimal rise, plateau
Laparoscopy
Ultrasound
Left Ectopic on laparoscopy
Management
MedicalMethotrexate
SurgicalLaparoscopic salpingectomy / salpingotomyLaparotomy
‘Conservative’ Self resolving with close watch
Gestational Trophoblastic Disease
Hydatidiform Mole
1 in 1000 pregnancies
PartialAssociated with fetus, triploid
CompleteNo fetal pole, diploid chromosomes paternally
derived
Presentation
Asymptomatic – incidental finding at dating or anomaly USS
Vaginal bleeding Hyperemesis gravidarum Uterus large for dates
Diagnosis
Ultrasound (Snow storm appearance)
Histology after surgical evacuation
Snowstorm appearance
Hydatidiform Mole after hysterectomy
Follow-up
Monitor via regional centres – London, Sheffield, Dundee
3% risk choriocarcinoma following complete mole, less following partial mole
Choriocarcinoma may follow any subsequent pregnancy – miscarriage, TOP, term delivery
Choriocarcinoma is curable
Monitor βhCG levels to check resolution – for 6 months to 2 years
Avoid pregnancy for minimum 6 months or until all clear
Hyperemesis Gravidarum
Hyperemesis GravidarumNausea/vomiting in pregnancy is normal –
‘morning sickness’
Rarely excessive – hyperemesis gravidarum
Related to level of βhCG
Associated Factors
UTI
Multiple pregnancy
Molar pregnancy
Socio-economic factors
Investigations
Renal function
Liver function
FBC
Urinalysis and MSU
Ultrasound
Consequences &
Management
IV fluids
Electrolyte replacement
Antiemetics
Thromboprophylaxis
Dietary advice
Vitamin supplementation
Steroids
Antibiotics if UTI
Termination of pregnancy
Dehydration
Electrolyte imbalance Metabolic alkalosis, hypokalaemia, hypernatremia
Oesophageal tears (Mallory Weiss)
Thrombosis DVT/PE/Cerebral sinus Weight loss
Vitamin deficiency (vit B1- thiamine) Wernicke's encephalopathy
Psychological impact
in CONCLUSION
GYNAECOLOGICAL EMERGENCIES
1. MISCARRIAGE 2. ECTOPIC3. PELVIC SEPSIS4. OVARIAN TORSION
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