Embedded Files
Guidance and Resources – Early pregnancy and complications
Case Introduction – Early pregnancy and complications
Further Case Information – Early pregnancy and complications
Background Science – Early pregnancy and complications
Case Conclusion – Early pregnancy and complications
Formative Assessment – Early pregnancy and complications
CASE Women’s Health – Early pregnancy and complications
In module Women’s Health
Pregnancy is a life changing event for women and their families. While the majority of pregnancies are planned and result in a good outcome for both the mum and her child (or children!), complications do occur.About 80 percent of miscarriages happen in the first trimester. Black women are at higher risk for miscarriage.The crude miscarriage rates were; White 9.5%,Asian 11%, Black 12.5%, Chinese 3.7%, Mixed 10.3%, other 6.3% and not stated 8.3%.
The estimated incidence of miscarriage among clinically recognized pregnancies is about 10-15%.
It is our privilege as obstetricians and gynaecologist to be able to look after women and their families during this time. This e-learning package focuses on early pregnancy and its complications.
MAIN CASE
CASE COMPONENT
Guidance and Resources – Early pregnancy and complications MED 35
In case Women’s Health – Early pregnancy and complications
eBooks
1) Johns Hopkins Handbook of Obstetrics & Gynecology.
2) Hacker and Moore’s essentials of obstetrics and gynecology,6th edition.
Resources
It is often difficult to find the right words to say when you are with a patient or someone who has miscarried. They often have many questions like ‘Why has it happened? Why has it happened to me? Is it something I did or didn’t do? Will it happen again? Will I be able to have children? What’s going to happen next?’ It takes time and experience to learn to break bad news in a sensitive and empathetic manner, however the patient leaflets provided by the miscarriage association is one of the best places to start. They have phrased things in a straight-forward and easily to understand fashion and I would highly recommend reading them.
Ectopic pregnancy and miscarriage: diagnosis and initial management – NICE Guidelines
The most updated guideline on the management of miscarriage was published by NICE in 2012. It talks about the common symptoms and signs of presentation with miscarriage and ectopic pregnancies, the diagnostic criteria of miscarriages and also its management options.
RCOG guidelines on management of ectopic pregnancies
This guideline was released the Royal College of Obstetricians and Gynaecologists in 2016 for management of ectopic pregnancies and includes some of the latest evidence available for its management.
MRRACE-UK report 2016 ‘Saving lives, improving mother’s care’
This is the triannual confidential enquiry report of maternal deaths and morbidity. It is a very good read and help us clinicians understand why women die in pregnancy and childbirth and the lessons learnt to try and prevent them in the future.
CASE COMPONENT
Case Introduction – Early pregnancy and complications
In case Women’s Health – Early pregnancy and complications
Common complications in early pregnancy include miscarriages and ectopic pregnancies. In addition 1 in 6 pregnancies are unplanned with one in 60 women experiencing an unplanned pregnancy each year.
Although it is rare in the UK, women still die from early pregnancy complications. Between the year 2009 to 2014, 191 women lost their lives before 24 weeks gestation. 12 of these women died directly from early pregnancy related causes. Knowledge and awareness of early pregnancy complications are therefore important in primary care and regardless of which specialty you may decide to pursue in the future.
Case Presentation
Jenny is a 24 year old, nulliparous lady who presents to the emergency gynaecology unit with symptoms of vaginal bleeding. She tells us that her last menstrual period was 7 weeks and 4 days ago. She did a home pregnancy test 1 week ago and found out that she was pregnant. Yesterday she had a small amount of fresh red vaginal bleeding and decided to self-refer to the emergency gynaecology unit.
This material will explore 3 different scenarios that could follow from Jenny’s initial presentation.
CASE COMPONENT
Further Case Information – Early pregnancy and complications
In case Women’s Health – Early pregnancy and complications
Jenny – SCENARIO 1
Jenny is a 24 year old, nulliparous lady who presents to the emergency gynaecology unit with symptoms of vaginal bleeding. She tells us that her last menstrual period was 7 weeks and 4 days ago. She did a home pregnancy test 1 week ago and found out that she was pregnant. Yesterday she had a small amount of fresh red vaginal bleeding and decided to self-refer to the emergency gynaecology unit.
What would you look for in your examination and why?
As with anyone presenting with bleeding you would assess their A, B and C. In her case her observations are normal on admission. As her clinician you would look for signs of pallor / temperature of peripheries / capillary refill time to assess the quantity of blood loss.
Abdominal examination would exclude signs of peritonism (think ectopic!). Speculum examination would enable visualisation of the cervix to exclude an open cervix (diagnosis of inevitable miscarriage) and to assess the quantity of vaginal bleeding.
Digital examination would also allow assessment of the cervix, whether cervical excitation is present and whether there is any adnexal tenderness.’
This showed no abdominal tenderness on palpation. On speculum examination minimal bleeding was seen in the vagina, the cervix was visualised and normal and digital examination was also normal.
As with anyone presenting with bleeding you would assess their A, B and C. In her case her observations are normal on admission. As her clinician you would look for signs of pallor / temperature of peripheries / capillary refill time to assess the quantity of blood loss.
Abdominal examination would exclude signs of peritonism (think ectopic!). Speculum examination would enable visualisation of the cervix to exclude an open cervix (diagnosis of inevitable miscarriage) and to assess the quantity of vaginal bleeding.
Digital examination would also allow assessment of the cervix, whether cervical excitation is present and whether there is any adnexal tenderness.’
This showed no abdominal tenderness on palpation. On speculum examination minimal bleeding was seen in the vagina, the cervix was visualised and normal and digital examination was also normal.
A scan was subsequently organised for Jenny and she returned for the scan appointment the next day.
A transvaginal scan was performed. Inside the uterine cavity there was a single gestational sac (pregnancy sac) with a yolk sac and a fetal pole. The fetal pole measured 10mm which corresponded to 7 weeks and 2 days gestation. Fetal heart action was seen.
The scan confirmed an intrauterine pregnancy that was developing normally. She was reassured that all appears well at this point and advised that if she were to develop heavy bleeding or pain she can return to the emergency gynaecology unit.
Jenny – SCENARIO 2
On arrival Jenny was triaged by the nursing team and was found to have a mild tachycardia of 105, a BP of 110/70, a temperature of 37.3. She was assessed by a nurse specialising in early pregnancy and emergency gynaecology. A full obstetric and gynaecology history was taken and an examination was performed. This included an abdominal palpation, speculum examination and digital internal examination.
Her history included a one day history of central lower abdominal pain with vaginal bleeding. The pain was intermittent and ‘cramping’ in nature. Jenny felt this pain was similar to her period pains but in greater severity. Abdominal palpation showed no abdominal tenderness. On speculum examination moderate amount of vaginal bleeding was noted. The cervix was visualised and the bleeding appear to come from the cervix. The cervix was closed on digital internal examination and there were no tenderness in both adnexae.
A full blood count and ‘Group and Save’ was taken in view of the vaginal bleeding and tachycardia. This showed her haemoglobin to be 103g/L. The bleeding decreased and her observations returned to normal during her assessment. A scan was organised for Jenny and she returned for the scan appointment the next day.
A transvaginal scan was carried out. Inside the uterine cavity there was a single gestational sac (pregnancy sac) with a yolk sac and a fetal pole. The fetal pole measured 7mm which corresponded to 6 weeks and 4 days gestation. Unfortunately no fetal heart action was seen. The findings were confirmed by a second sonographer and a diagnosis of a miscarriage was made.
What practically should happen next?
Ideally the diagnosis should be sensitively communicated to the patient. The patient should have privacy (a quiet room exists in most units), be offered a drink, opportunity to inform their family and a discussion about what happens next.
What are Jenny’s options in managing her miscarriage? Are there any advantages or disadvantages to each?
Read this presentation about 'Early pregnancy and miscarriage' by Dr Ken Ma:
Early Pregnancy and miscarriage - Dr Ken Ma
The diagnosis was discussed with her sensitively and support was offered by the nursing team. The management options of her miscarriage were explained to her by the team. This included conservative management, medical management and surgical management of her miscarriage. After the discussion and having read the leaflets about the different options she opted to have a surgical management of her miscarriage under a local anaesthetic.
Jenny – SCENARIO 3
On arrival Jenny was triaged by the nursing team and was found to have a tachycardia of 110 and a BP of 110/70. She assessed by a nurse specialising in early pregnancy and emergency gynaecology. A full obstetric and gynaecology history was taken and an examination was performed. This included an abdominal palpation, speculum examination and digital internal examination.
She presented with a 5 day history of right iliac fossa pain associated with right shoulder tip pain. The pain was intermittently worse but was constantly there with a pain score of 4/10. Her symptoms of bleeding were described as spotting and was noted when she was wiping after passing urine.
Abdominal palpation revealed tenderness over the right iliac fossa. No sign of guarding or rebound tenderness was noted. Speculum examination was normal but digital examination showed tenderness in the right adnexae and cervical excitation was noted.
What is your differential diagnosis?
What are you worried about?
Jenny gives a clear history of iliac fossa pain associated with shoulder tip pain. This is highly suggestive of peritoneal irritation due to intra-peritoneal bleeding. Shoulder tip pain occurs because of diaphragmatic irritation from blood.
In a woman or reproductive age you should always consider an ectopic pregnancy. This history is highly suggestive of an ectopic pregnancy, although you need to exclude other causes such as a haemorrhagic luteal cyst or non-gynaecological causes such as appendicitis.
Ectopic pregnancy is a potentially life threatening condition as it can cause catastrophic bleeding. You must always be vigilant about the possibility of an ectopic pregnancy, monitoring and treating the patient appropriately. Patients may present in a state of collapse and in these cases prompt resuscitation is essential.
She was assessed by a member of the gynaecological team and a diagnosis of an ectopic pregnancy was suspected. A large bore cannula was inserted and blood tests was sent including a full blood count, group and save and serum HCG. An ultrasound scan was performed.
This showed an anteverted uterus with no sign of an intrauterine pregnancy. The endometrium was thin and measured 7mm. Both ovaries were seen on ultrasound with a corpus luteal cyst on the right side. Of note was a moderate amount of free fluid in the pouch of Douglas. No adnexal masses were seen.
CASE COMPONENT
Background Science – Early pregnancy and complications MED 35
In case Women’s Health – Early pregnancy and complications
Watch this presentation on ‘Early pregnancy and miscarriage’ by Dr Ken Ma:
Video Player http://www.taibahumbbs.com/wp-content/uploads/2017/09/kenneth-ma-early-pregnancy-and-miscarriage_hd-1.mp4?_=1
Early Pregnancy and miscarriage – Dr Ken Ma
Watch this presentation on ‘Ectopic pregnancy’ by Dr Ken Ma:
Video Player http://www.taibahumbbs.com/wp-content/uploads/2017/09/ken-ma-ectopic-teaching-2017_hd.mp4?_=2
CASE COMPONENT
Case Conclusion – Early pregnancy and complications MED 35
In case Women’s Health – Early pregnancy and complications
Jenny – SCENARIO 1
Jenny attended her GP surgery the next day to arrange a ‘booking’ appointment with the community midwife. Her symptoms of bleeding subsided and the rest of the pregnancy was uneventful.
Jenny – SCENARIO 2
A surgical management of miscarriage was carried out a few days later by a gynaecologist. The procedure was uneventful and Jenny went home the same day. She experienced some light vaginal bleeding for a few days and her symptoms settled afterwards.
Physically her recovery was uneventful. However the experience of losing her pregnancy was very difficult for her and her partner. She also found it helpful to share and read about other people’s experiences with a support group through the miscarriage association.
Jenny – SCENARIO 3
During the night her pain became suddenly worse, scoring 10/10 and became tachycardic and hypotensive. She was diagnosed with a presumed ruptured ectopic pregnancy and underwent an emergency laparoscopy. At laparoscopy a haemoperitoneum of 1000ml was found with a right fallopian tubal ectopic pregnancy. A right salpingectomy was performed and she made an uneventful recovery.
Jenny had a few questions when you review her the day after her operation:
· Will I be able to have another pregnancy?
· Will I have another ectopic pregnancy?
· What should I do next time I am pregnant?
We would advise Jenny that once she has recovered from her operation and she and her partner feels ready they are able to try for a pregnancy again. There is no need to wait for a certain period of time. Don’t forget that an ectopic pregnancy is a bereavement event and they will need the same support as someone who may have had a miscarriage.
It is important to reassure women that although they have lost one fallopian tube as long as the other fallopian tube appears normal they would have a good chance of spontaneous conception. They will be at higher risk of a further ectopic pregnancy (approximately 10% risk). For this reason we would offer them an ultrasound scan at 7 weeks to determine whether the pregnancy is intrauterine.
Formative Assessment – Early pregnancy and complications
Ectopic pregnancies are most commonly found in the:
· Uterine horn
· Ovary
· Fallopian tubes
· Caesarean scar
· Uterus
· Fallopian tubes
.Correct answer.
The most common site for ectopic pregnancy implantation is the fallopian tubes, most commonly in the ampullary portion. Ovarian ectopics, uterine horn ‘Cornu’ ectopics and caesarean scar ectopics are rare. Pregnancies within the uterine cavity are normal.
Which of the following are symptoms associated with ectopic pregnancy?
· Abdominal pain
· Shoulder tip pain
· Rectal pain
· Diarrhoea
· All of the above
· All of the above
.Correct answer.
All the above symptoms are associated with ectopic pregnancies. Don’t forget however symptoms will depend on the patient and the stage of disease. Women may present with no symptoms in the early stages.
In the first trimester of an on-going intrauterine pregnancy Serum Human chorionic gonadotrophin (HCG):
· Increases by at least 53% every 48 hours
· Decreases by at least 53% every 48 hours
· Increases by at least 83% every 48 hours
· Remains the same in the first trimester
. Is not detectable
· Increases by at least 53% every 48 hours
.Correct answer.
Serum HCG in normal viable pregnancies increased by at least 53% every 48 hours, although in most cases doubles every 48 hours. Falling HCG levels suggests a failing pregnancy
Which of the following is NOT a risk factor for miscarriages?
· Increasing maternal age
· Increasing paternal age
· Sexual intercourse in the first trimester
· High BMI
· High alcohol intake
· Sexual intercourse in the first trimester
.Correct answer.
There is no evidence to suggest sexual intercourse is associated with a higher risk of miscarriages.
Which of the following is NOT a complication of surgical management of miscarriage?
· Retained pregnancy tissue
· Uterine perforation
· Infection
· Haemorrhage
· Pre-eclampsia
· Pre-eclampsia
Page updated
Google Sites
Report abuse