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Development of Protocols for Early Pregnancy

Abstract

This study analyzes the development of early pregnancy protocols that can be potentially useful to clinicians when dealing with the care of pregnant mothers experiencing non-viable pregnancies like complete miscarriage, incomplete miscarriage, and delay miscarriage; pregnancy of unknown location; intrauterine pregnancies of unknown viability; ectopic pregnancies and hydatidiform pregnancies. It’s established that ultrasonography can be used to determine the gestation age in care management and at the same time remedy care dilemmas like the type of pregnancy as witnessed in pregnancies of unknown location. Ultrasonography is, therefore, a key factor in early pregnancy care.

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Introduction

Most emergencies of gynecological nature are usually attributed to problems that are associated with early pregnancy. Previously, the administration of ultrasound treatment was a delayed process but the trend has changed to warrant ultrasound observation an important factor in early pregnancy monitoring. Recent ultrasound diagnosis of various conditions during pregnancy like ectopic pregnancies and miscarriages has necessitated the use of a defined protocol in taking care of such patients (RCR/RCOG, 1995).

Such provisions are essential for caretakers of expectant mothers because it prepares them to deal with each situation in a standard manner. However, these guidelines are periodically revised with new medical developments and customized to suit the unique needs of each patient (Russel, 2005). This is important because there are a varied number of conditions posed by expectant mothers thereby necessitating the development of proper protocols for early pregnancy assessment (Bigrigg, 1991).

This study will analyze the development of care protocols for various pregnancy conditions including the care of pregnant mothers experiencing non-viable pregnancies like complete miscarriage, incomplete miscarriage, and delay miscarriage. In addition, protocols to do with the pregnancy of unknown location, intrauterine pregnancies of unknown viability, ectopic pregnancy, and hydatidiform pregnancies will be a basis of analysis as common conditions in pregnancy. The analysis will therefore be conclusive for all conditions that commonly present themselves in the care of pregnant mothers. In essence, the study will seek to develop the best protocol guidelines developed from practices that have been evidenced in medical studies to provide standard guidelines for early pregnancy care.

Non-viable Pregnancies

The rhesus anti D is not essential for women below twelve weeks of the gestation period (for women who are rhesus negative). The analysis of rhesus anti D is important for the analysis of early pregnancy care because it is an important component in the care of women who have experienced miscarriages. Medical research has confirmed that there is very little evidence that administering globulin that is immune to the Rhesus factor for the first trimester in vaginal bleeding prevents the sensitization of the expectant mothers or the development of diseases to the newly born such as hemolytic disease (Royal College of Obstetricians and Gynecologists, 1995).

Incomplete Miscarriage

Anti D should be the standard care given to mothers with incomplete miscarriages or threatened miscarriages especially when there is the probability of building.. However, its treatment varies with the gestation period, and therefore caretakers should conduct a thorough ultrasound analysis using ultrasound to establish the precise gestation period. 1 gram of anti D should be administered to all expectant women with a threatened or incomplete miscarriage, twelve weeks after conception (Royal College of Obstetricians and Gynecologists, 1995).

This should however be exclusive to non-sensitized women with the rhesus negative factor. However, when bleeding continues for long, especially after the twelve weeks gestation period, the anti D should be administered in intervals of six weeks. Nonetheless, antibodies should first be checked before administering this procedure. An RCOD recommendation of grade C should be okay to the treatment (Royal College of Obstetricians and Gynecologists, 1995). Anti D is therefore important when there are incidences of heavy bleeding or instances of abdominal pains especially when the pregnancy approaches the two weeks gestation period (Hinshaw, 2006).

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Ultrasound is however not only useful in determining the gestation period of the pregnancy for the administration of anti D treatment but also the care of bleeding patients. In an incomplete miscarriage, the ultrasound scan should be undertaken on an intrauterine tissue diameter of 15-50 millimeters. Medical research has affirmed that the conservative method is a better option when dealing with mild bleeding (Royal College of Obstetricians and Gynecologists, 1995). The ultrasound should also be done two weeks after the conservative method is recommended. Advice should however be given to the patient on the correct procedures to be observed but if the bleeding persists after the two weeks, further scanning should be done (Russel, 2005).

Alternative methods of care remain viable options but with the preference of the patient. For example, surgical evacuation may be undertaken if the expectant mother strongly prefers it as opposed to other methods of care. Medical management may also be observed if the expectant mother is not patient enough to wait for the care to be through. Mothers should however be discouraged from choosing any of the above forms of care because the contemporary, conservative method of care using ultrasound observation has been noted to have high success rates and at the same time reduce the frequency of infections as compared to the surgical method (Royal College of Obstetricians and Gynecologists, 1995).

Complete Miscarriage

Ultrasound scans done in complete miscarriages should be observed with an endometrial thickness of fewer than fifteen millimeters. Nonetheless, medical practitioners point out that it’s the morphology that stands out in ultrasound care as opposed to the amount of tissue. The pregnancy tissue having the ability to emit bright echoes may be limited in this sense. In addition, a large volume of blood may also fail to show pathogenicity. Patients should however report back to the clinic if the bleeding persists after 2/52 (Dogra, 2006).

Missed Miscarriage

Missed miscarriage was previously known in medical circles as an embryonic pregnancy. Since the introduction of the new term, it is felt that this is a reflection of different aspects or stages in the care of early pregnancy. However, upon identification of an absent fetal pole through ultrasound scan, the diagnosis is usually referred to as a presence of an empty sac. An identified fetal heart action that had previously occurred, followed by a lack of detection of heart activity should be referred to as fetal loss. These two situations, therefore, amount to a missed miscarriage. The likelihood of such an occurrence happening is said to be 5% (Royal College of Obstetricians and Gynecologists, 1995). Ultrasound studies can show the fetal heart action 7 weeks after conception, though this is more evident as the fetus matures.

Just like the incomplete miscarriage, patients experiencing missed miscarriage should be provided with the same options of surgical, conservative, and medical management. The patient’s choice among these three methods of patient care should then determine whether the ultrasound treatment will be used or not. Anyway, the choice of the care management method should be left exclusively to the patient.

In conservative management, the ultrasound scan should be done between intervals of 2-3 weeks though it is recommended that such scans be followed with scanning in intervals of two weeks (Royal College of Obstetricians and Gynecologists, 1995). Proper care will however be better facilitated by frequent patient contact, so it’s recommended that the medical practitioner and the patient should exchange contacts (Royal College of Obstetricians and Gynecologists, 1995). Medical management is administered at the request of the patient and surgical care is administered upon evaluation of certain conditions.

Pregnancy of Unknown Location

Depending on the quality or administration of ultrasound treatment, medical research has observed that about 10%-30% of all pregnancies of unknown locations usually end up as ectopic pregnancies (Goldstein, 2007). However, the first dilemma clinicians are faced with when cases are reported of vaginal bleeding is the location of the pregnancy. Despite many pregnancies of this kind resulting in ectopic pregnancies, it is a known fact that such conditions may also result in intrauterine pregnancies. Ultrasonography should therefore be first used as a tool to determine the location of the pregnancy within the first trimester. The establishment of the location of the pregnancy will be followed by the correct care about the possibility of ectopic or intrauterine pregnancy thereafter, care should be given accordingly.

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Ectopic Pregnancy

The frequency of the occurrence of ectopic pregnancies is 1 in every 80 pregnancies. Moreover, the prevalence of ectopic pregnancies in early pregnancy assessment units is 3% (Basama, 2001). Usually, ectopic pregnancies pose several challenges to the mother, such as dealing with the loss of a baby or dealing with the possible condition of being infertile or on rare occasions, the possible loss of life. When undertaking clinical procedures such as ultrasound scans on the patient, a balance should be made between the patient’s psychological and emotional needs together with clinical needs.

Most of all ectopic pregnancies usually occur in the fallopian tube and ultrasound features that relate to the condition are usually observed as a combination of uterine and adnexal scans. In the absence of any diagnostic features as a result of the ultrasound scan, usually, hCG assays are performed instead of management through ultrasound (Bottomley, 2009). Medical practitioners should be able to quantify the pain experienced by the patient; if it is significant, she should be hospitalized but in the realization of the contrary, she should be discharged. Transvaginal ultrasound is not only essential in the diagnosis of ectopic pregnancies but also in the definition of the modes of management the caretaker may use in caring for such patients (Jurkovic, 2007).

Intrauterine Pregnancies of Unknown Viability

The causes of intrauterine pregnancies are usually equated to those relating to the emergence of miscarriages. This condition is rare, though it may lead to the death of the fetus. In such situations, when undertaking patient care, clinicians should bear in mind the psychological implications of the condition. Ultrasounds done after the second semester would rarely show this condition though (Jurkovic, 2007).

In ultrasound management, any vaginal bleeding should be followed by an ultrasound scan in the first trimester. Significant bleeding should be recommended by hospitalization; however, the ultrasound may show no movement of the fetus meaning the fetus may have died. This should be done within the following two weeks. In such a case, the placenta should be separated from the fetus and care should be done surgically.

Hydatidiform Pregnancies

Hydatidiform pregnancies have a prevalence of 1 in every 700 pregnancies (Fowler, 2006). Its most common symptoms are high uterine expansion, vaginal bleeding, and preeclampsia among other symptoms. Often, this condition presents itself in the second trimester. However, ultrasound scanning can detect it before it manifests itself.

Histopathological examination is usually the standard procedure used after surgical management. The likely explanation behind it is that ultrasound usually shows no sign of hydatidiform pregnancies. Instead, they usually suggest the presence of an empty sac or the presence of a delayed miscarriage (Fowler, 2006).

The diagnosis of a scan that results in more than 6 millimeters is regarded as delayed miscarriage. If the diameter is less than 6 millimeters, an ultrasound treatment should be repeated within one or two weeks after which a diagnosis should be made. However, an emphasis should be made on the gestational age. Nevertheless, vaginal bleeding is the common manifestation of this condition and medical practitioners should analyze the magnitude of the situation before undertaking care (Kirk, 2007).

Conclusion

Ultrasonography aids in determining and increasing the effectiveness of the care treatment given to early pregnancy management cases. These conditions presented in this study are potentially life-threatening or influencers of the woman’s fertility. Though the methods of management differ slightly from one condition to the other, ultrasonography is majorly useful in determining the precise care for early pregnancy management; especially in the first trimester. The technique is especially useful because it can detect a condition before it even manifests itself, as can be evidenced through hydatidiform pregnancies. It is therefore imperative that clinicians incorporate the use of ultrasonography when they are faced with early pregnancy care challenges to determine the best treatments for the condition.

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Evaluation

The learning experience was enlightening because ultrasonography turned out to be a key element in the administration of early patient care. For example, the determination of gestation period which is a very important element in the administration of care is effectively established through ultrasonography. However, more ground in this study needs to be covered in the analysis of alternative imagery techniques that can serve the same purpose as ultrasonography.

References

Basama, J. (2001) FMS audit: women’s perception of transvaginal sonography In an early pregnancy assessment unit. J Obstet Gynecol, 21(1), 603-604.

Bigrigg, A. (1991) Management of women referred to early pregnancy assessment unit: care and cost-effectiveness. BMJ, 302, 577-579.

Bottomley, C. (2009) Diagnosing miscarriage. Best Practice & Research Clinical and Gynaecology, 23, 463–477.

Dogra, V. (2006) First-trimester bleeding evaluation. Ultrasound Quarterly, 21, 69-85.

Fowler, D. (2006) Routine pre-evacuation ultrasound diagnosis of hydatidiform mole: experience of more than 1000 cases from a regional referral center. Ultrasound in Obstetrics and Gynecology, 27, 56-60.

Goldstein, S. (2007) Ultrasound in Gynecology. New York, Elsevier Health Sciences.

Hinshaw, K. (2006) The Management Of Early Pregnancy Loss. London, RCOG Press.

Jurkovic, D. (2007) Catch me if you can: ultrasound diagnosis of ectopic pregnancy. Ultrasound Obstet Gynecol, 30(3), 1–7.

Kirk, E. (2007) The accuracy of first trimester ultrasound in the diagnosis of hydatidiform Mole. Ultrasound Obstet Gynecol, 29(1), 70–75.

RCR/RCOG. (1995) Guidance on Ultrasound Procedures in Early Pregnancy. London, RCOG Press.

Royal College of Obstetricians and Gynecologists. (1995) Guidance on Ultrasound Procedures in Early Pregnancy. London, Standing joint committee on obstetricultrasound of RCR/RCOG.

Russel, M. (2005) Does patient ethnicity or sonographer gender have any bearing on patient acceptability of transvaginal ultrasound? Ultrasound, 13, 170 172.

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