Problems in Early Pregnancy

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Problems in Early Pregnancy

• By Lydia Jones

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Hyperemesis in early pregnancy
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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

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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

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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.

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P6 acupuncture point
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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/embry
  otoxicity in animal studies at high dose ? How
  useful is this)
• 2nd line treatments such as metoclopramide and
  prochlorperazine are then often used.

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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,CS, 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.)

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Bleeding and abdominal pain in Early pregnancy

• Causes of bleeding in the first trimester
  include
• threatened abortion
• inevitable abortion
• ectopic pregnancy
• hydatidiform mole

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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

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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

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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

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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

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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

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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

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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.

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Ectopic pregnancy
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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."

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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

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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

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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

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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

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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.

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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).

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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

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Remember

• Pain in early pregnancy usually
  threatened abortion
• Pain that precedes bleeding suggests ectopic

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The End