problems in early pregnancy

1. Problems in Early Pregnancy By Lydia Jones

3. Hyperemesis in early pregnancy Vomiting is a normal feature of early pregnancy, especially between 7 and 12 weeks. Severe vomiting may cause weight loss and electrolyte imbalance. In very rare instances jaundice may result - thought to be due to severe protein and vitamin malnutrition. The cause of the vomiting is primarily physiological but psychological factors may affect the apparent severity

4. Hyperemesis in early pregnancy Thyroid function should be assessed in all women with hyperemesis gravidarum. This is because hyperthyroidism may result from higher serum concentrations of BHCG, which has TSH-like activity. High levels of BHCG occur in: hydatidiform mole multiple pregnancy

5. Hyperemesis in early pregnancy Usually nausea and vomiting improve after 14-16 weeks Symptoms can usually be controlled by dietary measures e.g. avoidance of greasy foods and having frequent small meals. Note vomiting could be due to a UTI Nausea during the first trimester of pregnancy does not necessarily require pharmacological intervention NICE suggest that: if a woman requests, the following interventions appear to be effective in reducing symptoms: non-pharmacological ginger P6 acupressure pharmacological antihistamines.

6. P6 acupuncture point

7. Management of nausea If vomiting is severe then treat with an antihistamine 1st choice is promethazine teoclate at an initial dose of 25 mg at bedtime (BNF states no evidence of teratogenicity/embryotoxicity in animal studies at high dose ? How useful is this) 2nd line treatments such as metoclopramide and prochlorperazine are then often used.

8. Hyperemesis Gravidarum Defined as persistent severe vomiting in pregnancy which causes weight loss & ketosis Affects 1% of pregnant women Admit to Gynae ward where they will have twice daily urine analysis for ketones, M,C&S, UE, LFT,fluid balance, US to rule out twins/molar pregnancy, alternate day weighing. Anti-emetics given: SC/ PO cyclizine IM/PO Prochlorperazine, SC/ IM Metoclopramide (women under 20 yrs watch closely for extra-pyramidal symptoms/ occulogyric crisis.)

9. Bleeding and abdominal pain in Early pregnancy Causes of bleeding in the first trimester include: threatened abortion inevitable abortion ectopic pregnancy hydatidiform mole

10. Threatened abortion is the earliest stage of most spontaneous abortions. There is bleeding from the genital tract, but the cervix is closed and there is no discharge of products of conception. History involves asking: any period of amenorrhoea?- last menstrual period; regularity of cycle; any other episodes of vaginal bleeding ? amount of bleeding – is it less or more than a normal period? - heavy bleeding suggests incomplete miscarriage; a minimal brown loss may be the result of a missed miscarriage degree of pain - a threatened miscarriage usually presents with minimal pain onset of pain and bleeding - if the pain started before the bleeding then this is suggestive of an ectopic pregnancy were any products passed? - this question is difficult to answer because organized clot may be mistaken by the patient for passed products shoulder tip pain? suggestive of diaphragmatic irritation and possible ectopic

11. Threatened abortion The clinical features of a threatened abortion are: uterus is normal size for dates vaginal bleeding - the bleeding may be slight as faint brown discharge or a profuse red discharge with clotting no products have been passed - do not confuse clots with products cervix is closed there is generally no pain although there may be a dull ache or discomfort due to congestion of the pelvic organs pregnancy test is positive fetal heart sounds and movements are observed

12. Threatened abortion On Examination: cardiovascular status - evidence of shock? abdominal examination - tenderness should not usually be unilateral; rebound tenderness may occur with an ectopic pregnancy examination with speculum and by vaginal examination cervical examination - open or closed; any cervical excitation; any products visible uterine size HVS taken if appropriate

13. Threatened abortion Management: bed rest, sedation there is no evidence that progestogens or gonadotrophins are of any help in the treatment of threatened abortion Rhesus prophylaxis if appropriate

14. Inevitable spontaneous abortion occurs in about 25% of women with a threatened abortion. It is characterised by: considerable bleeding lower abdominal pain a dilated cervix products may have been passed - do not confuse with clots

15. An Incomplete abortion where the products of conception have not been completely lost from the uterus. most likely to occur between 8 to 14 weeks gestation when the placenta is not expelled completely and an ERPC is necessary. In the acute presentation the cervix is dilated, there is continuing haemorrhage and uterine contractions. Blood loss may be severe and require immediate transfusion In the non-acute presentation a few days after an abortion, continued blood loss and a bulky, tender uterus may suggest that an abortion was incomplete and may necessitate an ERPC

16. Ectopic pregnancy Sites: most common site is the fallopian tube - 17.4% in the fimbria, 55% in the ampulla, 25% in the isthmus 2% in the interstitial portion. Less commonly in the ovary - 0.5% abdominal cavity - 0.1%.

17. Ectopic pregnancy

18. Ectopic pregnancy Occurs with an incidence of 1 in every 300 -1000 UK deliveries. It is usually associated with a period of amenorrhoea followed by bleeding and pain. Note- advice from the CEMD report states "it is essential that GPs and other clinicians, consider the diagnosis of ectopic pregnancy in any woman of reproductive age who complains of abdominal pain. It is important to recognise that the clinical presentation is not often "classical". BhCG (pregnancy) testing should be considered in any woman of reproductive age with unexplained abdominal pain whether or not she has missed a period or had abnormal vaginal bleeding."

19. Ectopic pregnancy Predisposing factors: previous tubal surgery previous ectopic pregnancy previous induced abortion PID IUDs progestogen only, or mini, pill diethylstilboestrol exposure non-caucasian race history of sub-fertility - probably because it identifies a group of women with tubal problems hormonal factors: induction of ovulation IVF delayed ovulation

20. Ectopic pregnancy Acute ectopic- severe pain in the pelvis and lower abdomen, and often in in the shoulder tips due to diaphragmatic irritation from blood in the peritoneum tenesmus may be a feature collapse and eventually hypovolaemic shock minimal vaginal loss, usually slight dark red vaginal examination is extremely painful especially on moving the cervix. It may provoke further bleeding and should be kept to a minimum

21. Ectopic pregnancy Chronic ectopic- Unruptured ectopic pregnancies are extremely variable in their presentation: most patients are afebrile abdominal pain is moderate, intermittent and usually unilateral 90% have abdominal tenderness pain on defaecation (due to blood in the pouch of Douglas) positive rebound tenderness is uncommon pelvic examination reveals a palpable adnexal mass in 50% of cases, in half of which, it occurs contralaterally to the ectopic pregnancy, representing the corpus luteum the uterus is usually soft and of normal size or only moderately enlarged

22. Indications for a US scan Scans usually done in EPAU after 8 weeks however scans can be ordered before this time: May be indicated in the following cases: Vaginal bleeding in patients with the following known risk factors for ectopic pregnancy: History of PID Coil or IUCD History of STD Previous ectopic pregnancy Previous pelvic or tubal surgery Clinical picture suggestive of ectopic pregnancy Scanning before 8 weeks’ gestation (7 completed weeks) is likely to be inconclusive

23. Contra-indications for a US scan Scanning before 8 weeks’ gestation is not indicated in the following patients: Patients with light painless bleeding (with a closed os) and with none of the above risk factors Patients of any gestation, who have had a vaginal examination, in whom the internal cervical os is open, since the miscarriage is probably inevitable.

24. Discretionary scans Scanning before 8 weeks’ gestation is discretionary in the following patients Patients with a history of recurrent pregnancy loss may be scanned before 7 completed weeks at the discretion of the referring doctor, but should be encouraged to delay scanning until after 7 completed weeks when the scan is more likely to be conclusive. Patients whose dates do not coincide with the size at palpation (i.e. large or small for dates) should be scanned according to their clinical gestational age (as determined by examination findings).

25. Overall causes of abdominal pain in pregnancy Abortion/ectopic Red degeneration of a fibroid Placental abruption Uterine abruption Ovarian cyst increased risk of(torsion/rupture) Appendicits Renal colic Porphyria

26. Remember: Pain in early pregnancy =usually threatened abortion Pain that precedes bleeding suggests ectopic

27. The End