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Chapter: Medicine Study Notes : Reproductive and Obstetrics

Complications of Early Pregnancy

20% of women bleed in early pregnancy – it is never normal -> investigate

Complications of Early Pregnancy


Differential of early pain/bleeding


·        20% of women bleed in early pregnancy – it is never normal Þ investigate

·        Obstetric causes: miscarriage, ectopic, trophoblastic disease


·        Gynaecological causes: period, STI, cervical (eg polyps), vaginitis, endometriosis, ovarian cyst (may be functional ® irregular cycles), PID

·        Non-gynaecological: UTI, GI (eg haemorrhoids)

·        Exam:

o   CV, Resp, temp

o   Abdominal: tenderness/guarding/rebound

o   Pelvic exam:

§  Speculum: discharge, bleeding, swabs, os 

§  Bimanual: mass, endometriosis (® fixed, retroverted uterus and utero-sacral nodularity on PR), cervical motion tenderness (Þ ?PID)


·        Investigations:

o   MSU, FBC

o   Blood type + Rhesus


Spontaneous abortion/Miscarriage


·        = Loss of products of conception before the 20th week.

·        10 – 15% of recognised pregnancies.  >75% in first trimester and due to fetal causes


·        Threatened abortion: os is closed and fetus is viable (still has heart beat). Uterus right size for dates. 75% will settle. Associated with preterm delivery


·        Incomplete abortion: cervix is dilating, more pain, heavier bleeding. Conservative treatment if < 13 weeks. If ­pain, ­bleeding or retained tissue on US then suction curettage. Ergometrine (uterine smooth muscle contractor) for serve bleeding


·        Complete abortion: Products of conception expelled, bleeding stopped, cervix closed (don‟t confuse with threatened), uterus small for dates


·        Septic Abortion: as for incomplete abortion + uterine and adnexal tenderness, purulent loss, pyrexia. Can lead to severe sepsis


·        Missed abortion: Fetus dead but not expelled, uterus small for dates, confirmed by 2 US scans 7 days apart. Usually active management to remove fetus

·        Causes:

o   None found – most common

o   Chromosomal abnormalities

o   Hormonal imbalance: eg failure of corpus luteum to produce enough progesterone

o   Maternal illness, abnormalities of the uterus (eg cervical incompetence), immunological factors

·        Recurrent miscarriage = loss of 3 or more consecutive pregnancies, occurs in < 1%


Ectopic pregnancy


·        = Any implantation outside the uterine cavity.  > 95% in the fallopian tube

·        0.5 – 1 % of pregnancies.  Fatal if untreated.  Most common cause of death in 1st trimester

·        Risk factors – anything slowing ovum‟s path to the uterus: salpingitis (eg PID), surgery, previous ectopic (recurrence in 10 – 20%), endometriosis, IUCD

·        Presentation:

o   Abdominal pain or bleeding in any sexually active woman

o   Usually around 8 weeks amenorrhoea, but may not have missed a period

o   Can present with acute rupture – sudden severe abdominal pain and shock

o   Shoulder tip pain due to blood in the peritoneum irritating the diaphragm

o   Cervical excitation

·        Diagnosis: 

o   bHCG – low for gestational age and rises slower than normal (normal doubling time is 2 days) 

o   ?Quantitative bHCG: at 1500-2000 should see sac on trans-vaginal US, at 6000 should see sac on abdominal US 

o   US can visualise in 2% of cases – key finding is empty uterus

o   Laproscopy is gold standard

·        Treatment: surgical or methotrexate (folate antagonist)


 Trophoblastic disease

·        Complete or partial hydatiform mole: abnormal placenta without/with a fetus. Placenta replaced by a mass of grape-like vesicles

·        Choriocarcinoma:  malignant invasion by trophoblastic cells – can arise years after a pregnancy

·        1 in 2000 pregnancies

·        Risk factors: early or late maternal age, previous mole, previous multiple pregnancies

·        Presentation:

o  Uterus large for dates in 50%

o  Vaginal bleeding +/- passage of grape-like villus

o  Early pre-eclampsia

o  Very high levels of HCG

o  Ground glass appearance on US and no fetus or absence of fetal movements/heart sounds


Hyperemesis gravidarum*


·        Rare (1 in 1000).  ­ Risk if young and primip


·        Presents with inability to keep food or drink down, hypovolaemia, polyneuritis (¯Vit B), liver and renal failure


·        Admit to hospital.  Rehydrate, exclude UTI, twins, and hydatiform mole


Cardiovascular Problems in Pregnancy


·        Common clinical findings in pregnancy: ­pulse volume, ­JVP pressure waves, ­heart size (apex beat displaced by approx 1 cm), loud first heart sound, 3rd heart sound, ejection systolic murmur up to grade 3/6 in 90% women, peripheral oedema


·        Maternal mortality = 1 per 10,000 – most in puerperium (especially mitral problems ® ¯pulmonary flow ® pulmonary oedema, especially during 3rd stage of labour due to sudden ­ in blood volume as uterus contracts).


·         Risk of heart failure, especially due to Rheumatic fever, congenital disease, Marfan‟s, prosthetic valves, given reduced functional reserve in pregnancy (ie further stresses an already stressed heart)


·        Fetal mortality: usually little impact, except mums with cyanotic congenital heart disease

·        History: breathlessness (although very common in pregnancy), syncope, arrhythmia


·        ECG: T wave inversion in III, S-T changes and Q waves occur frequently. ECG best for arrhythmias, not structural problems (use echocardiogram)


·        Management: avoid exacerbating factors: infection, hypertension, obesity, anaemia, arrhythmias, smoking etc. Multiple pregnancy ® further 30% increase in CO which compromises function further

·        Drug Treatment: digoxin, diuretic therapy, b blockers


·        Labour: care not to fluid overload, monitor BP carefully (don‟t want it either up or down – care with aorto-caval compression and epidural).


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