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Early Pregnancy Problems

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Early Pregnancy Problems Jacqueline ... hyperemesis gravidarum Related to level of hCG Associated Factors UTI Multiple pregnancy Molar pregnancy Socio-economic ... – PowerPoint PPT presentation

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Title: Early Pregnancy Problems


1
Early Pregnancy Problems
Jacqueline Woodman M.B.,Ch.B. Dipl Obst MRCOG
D.Phil (Oxon)
2
Introduction
  • Bleeding in early pregnancy and miscarriage
  • Ectopic Pregnancy
  • Gestational Trophoblastic Disease
  • Hyperemesis Gravidarum

3
Bleeding in Early Pregnancy Miscarriage
4
Definitions
  • Remember MISCARRIAGE not ABORTION
  • Threatened miscarriage Vaginal bleeding at lt 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

5
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

6
Causes of miscarriage
  • Genetic abnormalities
  • Progesterone deficiency?
  • Maternal illness e.g. diabetes
  • Uterine abnormalities
  • Cervical incompetence

7
History
  • LMP
  • Bleeding amount (spotting/gush), clots
  • Pain type crampy/sharp/dull
  • location lower abdomen, shoulder
    tip, back pain
  • Passed products?

8
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!

9
Speculums
  • Cusco speculum Sims speculum

10
Investigations
  • Ideally in dedicated Early Pregnancy
    Assessment Unit
  • Ultrasound
  • Measurement of serum ßhCG
  • Determination of blood Rhesus group
  • FBC, GS and admit if significant bleeding
  • Psychological support

11
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 pregnant
  • Too early gestation
  • Extrauterine pregnancy
  • Complete miscarriage
  • Empty sac Non-viable pregnancy
  • Too early gestation
  • Fetal pole with no FH If tiny, may be very early
    gestation
  • Delayed miscarriage

12
Gestational sac
13
Very early..
14
Normal 8-9 wk pregnancy
15
Empty sac
16
Measurement of ßhCG
  • Not necessary if diagnosis unequivocal on scan
  • Useful as part of investigations to
    diagnose/exclude extrauterine pregnancy/miscarriag
    e
  • Doubling time approx 2 days in viable pregnancy
  • Halving time 1-2 days in complete miscarriage
  • Should see fetal pole with ßhCG of 1500-2000

17
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)

18
Ectopic Pregnancy
19
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)

20
Site
  • Fallopian tube
  • Ovary
  • Abdominal cavity
  • Cervix

21
Risk factors
  • Previous PID
  • Previous ectopic pregnancy
  • Previous tubal surgery (e.g. sterilisation,
    reversal)
  • Pregnancy in the presence of IUCD

22
Symptoms
  • Acute
  • Low abdominal pain peritoneal irritation by
    blood
  • Vaginal bleeding shedding of decidua
  • Shoulder tip pain referred from diaphragm
  • Fainting - hypovolaemia
  • Chronic (Atypical)
  • Asymptomatic, gastrointestinal symptoms, back
    pain

23
Signs
  • Shock tachycardia, hypotension, pallor
  • Abdominal tenderness
  • Adnexal tenderness
  • Adnexal mass
  • None

24
Diagnosis
  • Ultrasound
  • Empty uterus, adnexal mass, free fluid in POD,
    rarely live pregnancy outside of uterus
  • Serum ßhCG
  • Suboptimal rise, plateau
  • Laparoscopy

25
Ultrasound
26
Left Ectopic on laparoscopy
27
Management
  • Medical
  • Methotrexate
  • Surgical
  • Laparoscopic salpingectomy / salpingotomy
  • Laparotomy
  • Conservative
  • Self resolving with close watch

28
Gestational Trophoblastic Disease
29
Hydatidiform Mole
  • 1 in 1000 pregnancies
  • Partial
  • Associated with fetus, triploid
  • Complete
  • No fetal pole, diploid chromosomes paternally
    derived

30
(No Transcript)
31
Presentation
  • Asymptomatic incidental finding at dating or
    anomaly USS
  • Vaginal bleeding
  • Hyperemesis gravidarum
  • Uterus large for dates

32
Diagnosis
  • Ultrasound (Snow storm appearance)
  • Histology after surgical evacuation

33
Snowstorm appearance
34
Hydatidiform Mole after hysterectomy
35
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 ßhCG levels to check resolution for 6
    months to 2 years
  • Avoid pregnancy for minimum 6 months or until all
    clear

36
Hyperemesis Gravidarum
37
Hyperemesis Gravidarum
  • Nausea/vomiting in pregnancy is normal morning
    sickness
  • Rarely excessive hyperemesis gravidarum
  • Related to level of ßhCG

38
Associated Factors
  • UTI
  • Multiple pregnancy
  • Molar pregnancy
  • Socio-economic factors

39
Investigations
  • Renal function
  • Liver function
  • FBC
  • Urinalysis and MSU
  • Ultrasound

40
Consequences Management
  • 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
  • IV fluids
  • Electrolyte replacement
  • Antiemetics
  • Thromboprophylaxis
  • Dietary advice
  • Vitamin supplementation
  • Steroids
  • Antibiotics if UTI
  • Termination of pregnancy

41
in CONCLUSION
GYNAECOLOGICAL EMERGENCIES 1. MISCARRIAGE 2.
ECTOPIC 3. PELVIC SEPSIS 4. OVARIAN TORSION
42
(No Transcript)
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