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Obs & Gynae > Early pregnancy compliactions > Flashcards

Early pregnancy compliactions Flashcards

1
Q

Definition of a threatened miscarriage

A

Bleeding +/- pain before 24 weeks with a viable pregnancy I.e a fetal HR and a closed cervical os

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2
Q

Definition of inevitable miscarriage

A

Internal os of cervix is open before 24 weeks

Products of conception have not yet been passed, but it is inevitable that they will

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3
Q

Definition of incomplete miscarriage

A

Some products of conception have been passed before 24 weeks but some tissue remains in uterus
Cervix open until all POC are passed

Usually 6-14 weeks gestation

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4
Q

Definition of septic miscarriage

A

Incomplete/inevitable/threatened miscarriage with fever (infected products of conception)
Patient will be septic

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5
Q

Definition of complete miscarriage

A

All products of conception have been passed before 24 weeks
Cervix was open, now closed
Bleeding and pain settle

Usually <6 or >14 weeks gestation

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6
Q

How to differentiate types of miscarriage

A

Clinical picture/os open of closed
Or
Ultrasound

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7
Q

Ultrasound classification of miscarriage

A

Missed miscarriage - no fetal HR
Anembryonic pregnancy - empty gestation sac
Incomplete miscarriage (>20mm mass in uterine cavity)
Complete miscarriage (clinical features more useful than USS)

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8
Q

Differential if US shows empty uterus but positive pregnancy test

A

Complete miscarriage
Ectopic pregnancy
POC too small to detect with USS

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9
Q

Risk factors for miscarriage

A 
High maternal age
Previous miscarriage
Antiphospholipid syndrome 
Smoking
Alcohol
Folate deficiency e.g methotrexate 
Consanguinity (higher rate of genetic defects)
Ashermans syndrome
PID
Multiple pregnancy 
Incompetent cervix 
Aneuploidy 
Abdominal trauma
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10
Q

3 options of miscarriage management

A

Conservative
Medical
Surgical

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11
Q

Describe conservative management of miscarriage

A

Wait for POC to pass naturally over 2 weeks
Pregnancy test in 3 weeks time
AntiD prophylaxis for Rh-

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12
Q

Advantages of conservative management of miscarriage

A

Patient can be at home

Avoids risks of surgery/medical

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13
Q

Disadvantages of conservative management of miscarriage

A

Need 24 hour access to gynae services as bleeding can be unpredictable and excessive
May be unsuccessful
Takes longer therefore longer to get back to work etc

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14
Q

Advantages of medical management of miscarriage

A

Avoids surgery

Done as outpatient

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15
Q

Disadvantages of medical management of miscarriage

A

Pain and bleeding
Side effects of drugs
Some need emergency surgery

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16
Q

What is medical management of miscarriage

A

Give misoprostol (prostaglandin) to stimulate uterine contraction and empty the uterus
Pregnancy test in 3 weeks
AntiD prophylaxis for Rh-

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17
Q

What is surgical management of miscarriage

A

Using a suction curette to empty the uterus under GA
Bleeding lasts for 1-2 weeks after
AntiD prophylaxis for Rh-

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18
Q

Advantages of surgical management of miscarriage

A

Successful

Day case

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19
Q

Disadvantages of surgical management of miscarriage

A

Risks of surgery and anaesthetic

20
Q

Definition of recurrent miscarriage

A

Loss of at least 3 consecutive pregnancies with same partner

21
Q

Risk factors for ectopic pregnancy

A 
Previous ectopic
Tubal surgery
Tubal pathology
PID
Endometriosis
Pregnancy with copper IUD
22
Q

Management options of ectopic pregnancy

A

Expectant
Medical
Surgery

AntiD prophylaxis for Rh-
Need weekly HCG until negative

23
Q

Criteria for medical management for ectopic pregnancy

A 
<3.5cm
HCG<5000
No symptoms
No free fluid 
No rupture 
Patient willing to return for follow up
24
Q

Criteria for surgical management for ectopic pregnancy

A

Clinically unwell
Don’t meet criteria for medical
Patient choice

25
Q

Criteria for expectant management of ectopic pregnancy

A

Asymptomatic
No rupture
<3cm
HCG<1500 and decreasing

26
Q

What is medical and surgical management of ectopic pregnancy

A

Medical: IM methotrexate (must avoid pregnancy for at least 3 months). One dose usually enough

Surgical: laparoscopic salpingostomy (if only 1 tube) or salpingectomy (both tubes present)

27
Q

How many medically managed ectopic pregnancies rupture

A

10%

28
Q

What are the pre malignant trophoblastic diseases

A

Hydatidiform mole:
Complete mole - no DNA in egg, fertilised by 1 sperm, sperm duplicates = 46 chromosomes
Partial mole - 1 egg, 2 sperm = 69 chromosomes

29
Q

What are the malignant trophoblastic diseases

A

Invasive mole

Choriocarcinoma (complete mole can transform into this)

30
Q

Symptoms of trophoblastic disease

A 
Asymptomatic - US picks up 50% of time
Bleeding
Severe N+V
Uterus large for date 
Severe symptoms of pre-eclampsia (very rare)
31
Q

Diagnosis of trophoblastic disease

A

US gives high level of suspicion - snowstorm appearance

Histology to confirm diagnosis

32
Q

Management of trophoblastic disease

A

Surgical procedure to evacuate retained products of conception
Postal follow up of serum and urine HCG (only 3 national centres) for 6 months - can’t get pregnant during this time

33
Q

What is hyperemesis gravidarum

A 
1% pregnancies characterised by:
Severe hyperemesis 
Severe dehydration
Marked ketosis
Weight loss >5%
Nutritional deficiency
34
Q

Pathophysiology of hyperemesis gravidarum

A

Higher HCG levels e.g twins or molar pregnancy

35
Q

Diagnosis of hyperemesis gravidarum

A

Diagnosis of exclusion:
No abdo pain
No infection e.g UTI
No metabolic disorder e.g thyrotoxicosis, Graves’ disease, Addison’s, DKA
Drug side effect
No tumours such as molar pregnancy, choriocarcinoma, teratoma, germ cell tumour, islet cell tumour

36
Q

Investigation for hyperemesis gravidarum

A 
Urine dipstick for UTI and ketones
Haematocrit and U+Es to look for dehydration 
Amylase to rule out pancreatitis
Thyroid function tests 
USS
37
Q

Management of hyperemesis gravidarum

A

Rehydrate - NOT WITH GLUCOSE (precipitates Wernicke’s)
Thiamine replacement IV
Folic acid
Antiemetics - 1st line cyclizine
Ranitidine if evidence of Mallory Weiss tear
Thromboprophylaxis if severe dehydration
PUQE index to classify severity and decide appropriate setting for management

38
Q

Risks of threatened miscarriage

A

Prematurity
Low birthweight
Half eventually miscarry

39
Q

Symptoms of septic miscarriage

A

Fever
Abdo tenderness
Foul smelling discharge
Raised inflammatory markers

40
Q

Definition of ectopic pregnancy

A

Implantation occurring in any location other than the endometrial lining of the uterus

41
Q

Symptoms of ectopic pregnancy

A

Lower abdo pain +/- iliac fossa pain
Vaginal spotting
Secondary amenorrhoea
Adnexal mass

If ruptured:
Shoulder pain
Tachycardia
Hypotension

42
Q

Investigations for ectopic pregnancy

A

Serial beta-hCG levels don’t rise by double every 48 hours
Progesterone <20
TA or TV ultrasound
Culdocentesis shows blood in pouch of Douglas
Laparoscopy if location not found on TVUS

43
Q

Normal beta-HCG levels with medical management of ectopic pregnancy

A

Decrease by at least 15% from day 4-7

Levels may rise from day 1-4

44
Q

Management of pregnancy of unknown location

A

Beta HCG 48 hours apart:
If at least doubled - rescan 1 week
If < doubled - monitor for ectopic/laparoscopy

45
Q

Describe red degeneration of fibroids

A

Necrosis of fibroids caused by enlarging fetus in first half of pregnancy
Abdo pain

46
Q

Test for recurrent miscarriage

A

Karyotyping for mother, father and POC
TVUS - cervical length
Antiphospholipid antibodies -

Obs & Gynae (37 decks)

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