Problems in the first half of pregnancy

Common abnormalities in the first trimester

- Miscarriage
- Ectopic pregnancy
- Hyperemesis gravidarum
- Gestational trophoblastic disease (rare but important)

PC: Vaginal bleeding in the first half of pregnancy

Differentials:

- Miscarriage (< 24 weeks gestation, pelvic pain, may pass clots of products of conception)
- Ectopic pregnancy
- Cervical pathology:
 Infection
 Polyp
 Cancer
 Trauma (ectropion – post coital especially)
- Implantation bleed (light short-lived bleeding/spotting, dark with pink/brown tinge, 6-12
after conception)
- Vaginal/vulval pathology
- Urinary/bowel pathology.

PC: Abdominal pain

Differentials:

Obstetric

- Ectopic pregnancy: unilateral pain + bleeding + amenorrhoea (usually 5-9 weeks gestation)
- Miscarriage: <24 weeks gestation (PV bleeding, may pass clots or products of conception)
- Braxton Hicks contractions: late pregnancy, infrequent, irregular contractions
- Labour: >24 weeks gestation (premature if <37 weeks), painful, regular rhythmic
contractions

Gynaecological

- Fibroids (uterine fibroids – benign tumours that infiltrate the smooth muscle): severe
abdominal pain, fever, vomiting)
- Pelvic inflammatory disease: PV discharge, bilateral pelvic pain, dyspareunia, fever, post-
coital bleeding, unprotected intercourse with new/multiple partners
- Ovarian torsion/haemorrhage/rupture: severe unilateral pain, fever/vomiting

Other:

- Placental abruption
- Pre-eclampsia
- Uterine rupture
- Chorioamnionitis
- Acute fatty liver of pregnancy
- Round ligament pain