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E A R LY P R E G N A N C Y A N D C O M P L I C AT I O N S Megan Jarman A RO U G H T I M E L I N E st • 1 trimester – up to 12 weeks • 2ndtrimester – 13 to 26 weeks • 3 trimester – 27 to birth • Booking clinic – before 10 weeks (general advice, booking bloods, baseline measures – height, weight ect, bp ect…) • Booking bloods – blood group, antibodies and rhesus D status, FBC, screening for thalassemia (all) and sickle cell (higher risk) • Dating scan – between 10-13+6 weeks (gestational age from crown to rump length and multiple pregnancies identified) • Antenatal appointment – 16 weeks • Whopping cough vaccine from 16 weeks • Anomaly scan – 18 to 20+6 weeks • Foetal movements should be felt from 20 weeks to birth • Frequent appointments in antenatal clinic from 25 weeks onwardsL I F E S T Y L E A DV I C E Continue moderate Take folic acid 400mcg Take vit d – 10mcg Avoid vit a – supplements, exercise but avoid eating liver for pate comntact sports Flying increasesVTE risk, ok up to 37 weeks in Place car seat belt above No alcohol and no singleton pregnancy and 32 and below bump not across smoking weeks in a twin pregnancy it as long as it is uncomplicatedM O L A R P R E G N A N C Y Hydatidiform mole – tumour that grows like a pregnancy inside the uterus Complete mole – 2 sperm cells fertilise an empty ovum Partial mole – 2 sperm cells fertilise a normal ovum Red flags – severe morning sickness,vaginal bleeding,abnormally high b-hcg,thyrotoxicosis,enlarged uterus size USS shows snowstorm appearance Management – evacuation of contents of uterus sent to lab, H Y P E R E M E S I S G R AV I DA RU M • Nausea and vomiting are normal during early pregnancy. Symptoms usually start from 4 – 7 weeks, are worst around 10 – 12 weeks and resolve by 16 – 20 weeks. Symptoms can persist throughout pregnancy. • The placenta produces human chorionic gonadotropin (hCG) during pregnancy. This hormone is thought to be responsible for nausea and vomiting. Theoretically, higher levels of hCG result in worse symptoms. • Nausea and vomiting are more severe in molar pregnancies and multiple pregnancies due to the higher hCG levels. It also tends to be worse in the first pregnancy and overweight or obese women. • More than 5% weight loss, dehydration, electrolyte imbalance and ketones • PUQE used to assess severity • Manage with antiemetics (prochlorperazine) and rehydration using IVF • Risk factors – previous ectopic, PID, previous surgery to tubes, coils, older age, smoking • Typically presents at 6-8 weeks with lower abdo pain, bleeding, cervical excitation • Possible shoulder tip pain • Tubal ring sign/bagel sign seen on uss • Pregnancy of unknown location – ectopic, miscarriage or too early to be seen • A rise of more than 66% in Bhcg after 48hrs is indicative of an intrauterine pregnancy • Management – conservative, medical or surgical • Medical – methotrexate – must come to follow up (HCG levels <5000). No children for 3 months • Expectant – need follow up and repeat HCGs • Surgical – needed if Bhcg>5000 or ectopic over 35mm • After medical bhcg – can go up on day 4 but must go down by day 7 • Salpingostomy – open tube and take out ectopic • Salpingectomy – whole tube removed E C TO P I C • Next pregnancy early scan at 7/8 weeks if asymptomatic P R E G N A N C Y • Anti D prophylaxis must be consideredM I S C A R R I AG E D I AG N O S I S Normally due to chromosomal abnormalities that would make them incompatible with life • Early = before 12 weeks • Late = 12 to 24 weeks • Anembryonic = sac but contains no embryo • Threatened miscarriage – bleeding but cervix is closed and foetus is alive • Inevitable miscarriage – bleeding,cervix is open • Crown – rump length of more than 7mm with no heartbeat, repeat 1 week later if still no heartbeat = non – viable pregnancy • Mean gestational sac diameter over 25mm without foetal pole – repeat scan in one week if no change = anembryonic pregnancy M I S C A R R I AG E M A N AG E M E N T • Less than 6 weeks = expectant management – with pregnancy test 7 to 10 days later • More than six weeks = go to EPAU, USS needed, rule out ectopic Expectant, medical or surgical management: • Expectant – pregnancy test after 3 weeks of no bleeding to confirm complete • Medical = misoprostol vaginal or oral • With surgical consider need for anti d • Surgical = manual vacuum aspiration – under local as out pt • Surgical = electric vacuum aspiration under GA • Misoprostol used before to soften cervix (prostaglandins) • Incomplete – retained products of conception = infection risk, need surgical evacuation under GA Recurrent = three or more consecutive miscarriages or one or more in second trimester Causes – idiopathic,antiphosolipid syndrome,uterine abnormalities,genetic factors,SLE,diabetes ect… R E C U R R E N T M I S C A R R A I G E and LMWHpholipid – give low dose aspirin Investigations – antiphospholipid antibodies, USS,genetic testing of products of conception,genetic testing on parents • Legal until 24 weeks • Pre abortion care – offered counselling to ensure informed decision • Medical – mifepristone (anti progesterone) and then 1-2 days later misoprostol • If gestation over 10 weeks = anti d may be needed • Surgical – medication used to soften cervix (misoprostol), anti D considered, local or general anaesthetic depending T E R M I N AT I O N • Up to 14 weeks – cervical dilation and suction • Over 14 – cervical dilation and evacuation using forceps • Post abortion – expect bleeding, pregnancy test needed in 3 weeks to confirm completed, contraception discussed, support and counselling • Complications – bleeding, pain, infection, fails