Early Pregnancy Problems Lydia Burland. Learning Outcomes To recognise common problems presenting in early pregnancy To know about important risk

Early Pregnancy Problems

Lydia Burland

Learning Outcomes To recognise common problems presenting in

early pregnancy

To know about important risk factors

To know about basic investigations an initial management

To be able to counsel parents appropriately

To be able to answer questions on common obstetric and gynaecology topics

Case 1 A primigravida woman presents at 6/40 with

crampy abdominal pain and PV bleeding

Blood loss is mild, with no clots or products

She has changed her pad twice in 6 hours

The pain is suprapubic and constant

No previous obs/gynae history

Case 1

Obs: HR 96, BP 123/65, T 36.4

OE: Comfortable at restAbdo soft, no guarding or massesTender lower 1/3

What are the differential diagnoses?What would your initial management be?

Case 1

Speculum: Red-brown dischargeNo active bleedingOs closed

Bloods: Hb 113, WCC 7.8, Plt 235

What are your differentials now?What is your plan for further management?

Miscarriage

Loss of pregnancy prior to viability (24 weeks)

Affects 15-20% of confirmed pregnancies

85% occur in the 1st trimester

Risk factors;age gravidity Uncontrolled DM Alcohol Drug use Uterine surgerySmoking

Miscarriage

The cause is unknown in most cases

Other causes include foetal or genetic abnormality, placental insufficiency, uterine abnormality and cervical insufficiency

Presents with PV bleeding and abdo pain

Increased chance of miscarriage if heavy bleeding, passage of clots or associated vomiting

Miscarriage Threatened: light bleeding +/- mild pain

os closed, viable pregnancy

Inevitable: heavy bleeding, clots + painos open

Incomplete: partially expelled productsmay be stuck in os

Missed: persistent dark brown dischargenon-viable foetus retained

Recurrent: 3 or more consecutive

Miscarriage Investigations;

Transvaginal USS is 1st lineSerial βHCG can be used if no IUP is seen

Management;Expectant Medical (misoprostol)Surgical (evacuation)

All women should repeat a pregnancy test in 3 weeks, and contact EPAU if positive

Case 2 A 17 year old G1P0 presents to her GP at 9/40

with nausea and vomiting

She has been sick 4-5x a day for 4/7

She is managing some oral fluids, but very little food

Urine output is reduced, but adequate

What key investigation will help guide her management?

Case 2 Obs: HR 97, BP 112/76

OE: Pulse regularMildly dry mucous membranesAbdo SNT

Urine: protein trace, blood trace, ketones trace

What would be your initial management plan?

Case 2 She returns 1 week later with persistent vomiting,

and is struggling to get to work

Now vomiting small amounts hourly

Struggling to tolerate oral diet, concentrated urine

Urine dip shows 1+ ketones

How should she be managed now?

Vomiting in Pregnancy 70-85% of women experience nausea and

vomiting in early pregnancy

Risk factors include primips, multiple pregnancies and previous hyperemesis

Increasing maternal age is protective

Presents between 4-7 weeks, and resolves by 4 months

If persistent may lead to hyperemesis gravidarum

Vomiting in Pregnancy Urinary ketones essential in guiding management

Absent/trace ketones = community based care

+/++ ketones = short-stay admission

+++/++++ = inpatient admission

Antiemetics include cyclizine, metoclopramide and prochlorperazine

Case 3 A 19 year old presents with RIF pain, dizziness

and syncope

The pain has been gradually increasing over 3 days, and is now constant

She is uncomfortable mobilising and cannot lie flat

She has associated shoulder tip pain

Case 3

Obs: HR 118, BP 105/67, T 36.7, RR 23

OE: In obvious discomfortAbdomen soft, no massesPain and guarding over RIF

What would you expect to find on VE?How should this patient be managed?

Ectopic Pregnancy

Ectopic Pregnancy Presents 6-8 weeks after LMP

More common of the right side

2/3 of women have identifiable risk factors

These include;Fertility treatment Intrauterine devicesPrevious PID EndometriosisSterilisation reversal

Usually presents with gradually increasing pain

Ectopic Pregnancy There may be unilateral pain on examination,

cervical excitation and adnexal tenderness

USS may show an adnexal mass or free fluid in the pelvis

Serial βHCGs usually show a suboptimal rise of less than 60%

Diagnostic laparoscopy is gold standard

Ectopic Pregnancy

ABCDE assessment (resuscitation as needed)

2x IV access, FBC and G+S

Immediate laparotomy if haemodynamically compromised

If stable management can be;Medical – IM methotrexateSurgical – laparoscopic salpingectomy

Questions

MCQs

1. Progesterone is secreted by the corpus luteum until...

a. 7 days b. 21 daysc. 35 days d. 42 days

2. Crown-rump length is most useful in...a. 1st trimester b. 2nd trimesterc. 3rd trimester d. Nuchal

screening

MCQs

3. Which of the following is most commonly performed in the 3rd trimester?

a. Anomaly scan b. Cardiac echoc. Glucose tolerance d. Rubella screening

4. A woman presents with persistent nausea and vomiting. She has 2+ of ketones. What is the best maintenance fluid?

a. 5% dextrose b. Dextrose-salinec. Hypertonic saline d. 0.9% saline + KCl

MCQs

5. Which of the following is not a cause of raised AFP in maternal serum?

a. Trisomy 21 b. Fetal deathc. Gastroschisis d. Spina bifida

6. Risk of congenital abnormality secondary to rubella is highest...

a. In 1st trimester b. At 13-14 weeksc. In 2nd trimester d. Re-infected

MCQs

7. Which of the following is not a common complication of termination of pregnancy?

a. Infection b. Retained productsc. Hysterectomy d. Cervical trauma

8. Ectopic pregnancy most commonly occurs in the...

a. Ampulla b. Isthmusc. Cornua d. Ovary

MCQs

9. A woman is referred for USS due to RIF pain. It shows an intrauterine gestation sac and right adnexal mass suspicious for an ectopic. This is known as...

a. Monochorionic twins b. Ectopicc. Heterotropic pregnancy d. Twins

10. A woman with proven ectopic has a βHCG of 700. What treatment most is appropriate?

a. Methotrexate b. Misoprostolc. Surgical evacuation d. Salpingectomy

EMQs

a. Threatened miss b. Inevitable missc. Incomplete miss d. Complete misse. Missed miss f. Recurrent miss

1. A woman presents with heavy bleeding and clots. The os is open with visible products.

2. A woman attends for her dating scan. No intrauterine pregnancy is seen and a repeat pregnancy test is negative.

EMQs


3. A woman attends for her dating scan which shows an 8mm intrauterine gestation sac with yolk sac and fetal pole. No fetal heart seen.

4. A woman comes to A+E with PV bleeding at 7/40. The os is open and an IUP is seen on USS. She has had 2 previous miscarriages, followed by 2 NVDs.

EMQs

a. Very early pregnancy b. Ectopic pregnancyc. Miscarriage d. Menstruatinge. Twin pregnancy f. Failing pregnancyg. Ongoing pregnancy h. Heterotropic

pregnancy

5. A woman is referred to EPAU with PV bleeding. Her pregnancy test is positive, and serial βHCG rises from 1730 to 4013 after 48 hours.

6. A woman is referred to EPAU with LIF pain. Her pregnancy test is positive, and serial βHCGs are 2450, 2786 and 3103.

EMQs

a. Early pregnancy b. Ectopic pregnancyc. Miscarriage d. Menstruatinge. Twin pregnancy f. Failing pregnancyg. Ongoing pregnancy h. Heterotropic pregnancy

7. A woman is referred to EPAU with PV bleeding. No IUP or masses are seen on USS, and serial βHCGs are 236 and 567.

8. A woman is referred to EPAU with PV bleeding. Her pregnancy test is negative and βHCG is <1.

EMQs

a. Early pregnancy b. Ectopic pregnancyc. Miscarriage d. Menstruatinge. Twin pregnancy f. Failing pregnancyg. Ongoing pregnancy h. Heterotropic

pregnancy

9. A woman is referred to EPAU with PV bleeding. Her pregnancy test is positive, and serial βHCGs are 765, 340 and 125.

10. A woman is referred to EPAU with PV bleeding. An irregular intrauterine sac and yolk sac are seen on USS, and serial βHCGs are 936 and 667.

Clinical Images

1a. What is this device?

1b. To whom does it cause more trauma?

Clinical Images

2. How would you define this CTG;a. Reassuring b. Suspiciousc. Pathological d. Typical pre-term labour

Clinical Images

3. A woman presents with post-coital bleeding at 25/40.

a.What is the diagnosis?

b.Is follow up normally required?

Clinical Images

4a. What is this device?

4b. When is it most commonly used?

Answers

MCQs




screening

MCQs




screening

MCQs


a. Anomaly scan b. Cardiac echoc. Glucose tolerance d. Rubella screening



MCQs


a. Anomaly scan b. Cardiac echoc. Glucose tolerance d. Rubella

screening



MCQs





MCQs





MCQs





MCQs





MCQs





MCQs





EMQs




EMQs




EMQs


3. A woman attends for her dating scan which shows an 8mm intrauterine gestation sac with yolk sac and fetal pole. No fetal heart seen.

4. A woman comes to A+E with PV bleeding at 7/40. The os is open and an IUP is seen on USS. She has has 2 previous miscarriages, followed by 2 NVDs.

EMQs


3. A woman attends for her dating scan which shows an 8mm intrauterine gestation sac with yolk sac and fetal pole.

4. A woman comes to A+E with PV bleeding at 7/40. The os is open and an IUP is seen on USS. She has had 2 previous miscarriages, followed by 2 NVDs.

EMQs


pregnancy



EMQs


pregnancy



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EMQs




EMQs


pregnancy



EMQs


pregnancy



Clinical Images

1a. What is this device?Ventouse

1b. To whom does it cause more trauma?

More trauma to baby, less to mum

Clinical Images

2. How would you define this CTG;a. Reassuring b. Suspiciousc. Pathological d. Typical pre-term labour

CTG Classification

Clinical Images

3. A woman presents with post-coital bleeding at 25/40.

a.What is the diagnosis?Cervical ectropion

a.Is follow up required?No – normal in pregnancy

Clinical Images

4a. What is this device?Sims speculum

4b. When is it most commonly used? When examining for rectocele/cystocele (should be done in left lateral position)

Any questions?

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Documents

Early Pregnancy Problems Lydia Burland. Learning Outcomes To recognise common problems presenting in early pregnancy To know about important risk