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Laura MRCOG Part 2 > Early Pregnancy Stuff > Flashcards

Early Pregnancy Stuff Flashcards

1
Q

Definition of recurrent miscarriage

A

Loss of 3 or more consecutive pregnancies

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2
Q

How common is recurrent miscarriage?

A

1% of couples

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3
Q

What percentage of second trimester pregnancies miscarry?

A

1-2%

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4
Q

What is the risk of miscarriage by maternal age?

A

<35 - 15%
35-40 - 25%
40-45 - 50%
>45 - 93%

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5
Q

What is the risk of miscarriage after 3 consecutive losses?

A

40%

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6
Q

How to diagnose antiphospholipid syndrome?

A

Antibodies: Lupus anticoagulant, anticardiolipin, antiB2glycoprotein 1 (Two +ve tests at least 12 weeks apart)

+ Adverse pregnancy outcome OR Vascular thrombosis

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7
Q

What constitutes adverse pregnancy outcome in definition of APLS?

A

Loss of 3 or more consecutive pregnancies <10 weeks
Loss of 1 or more morphologically normal fetus > 10 weeks
1 or more PTB <34 weeks due to placental disease

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8
Q

What percentage of women with recurrent miscarriage have antiphospholipid syndrome & what percentage of women with low risk obstetric history?

A

15% of women with recurrent miscarriage.

2% of women with low risk obstetric history.

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9
Q

What is the live birth rate for APLS if untreated?

A

10%

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10
Q

What percentage of couples with recurrent miscarriage have one partner with a balanced structural chromosomal anomaly?

A

2-5%

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11
Q

What percentage of embryos miscarried have chromosomal abnormalities?

A

30-60%

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12
Q

What investigations should be performed for a couple with recurrent miscarriage?

A
  • Antiphospholipid antibodies.
  • Cytogenetics on 3rd and subsequent consecutive miscarriages (and parental karyotyping if POC reveal unbalanced structural chromosomal abnormality)
  • Pelvic USS
  • (If second trimester miscarriage - inherited thrombophilias. BUT NOT RECURRENT FIRST TRIMESTER MC).
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13
Q

What is the treatment for APLS and what is the effect of this?

A

Aspirin and LMWH from +ve UPT.

Reduces miscarriage rate 54%

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14
Q

How to proceed if abnormal parental genetic karyotype noted?

A

Refer to geneticist.
Proceed to natural pregnancy or IVF/PGD or gamete donation or adoption.

Higher chance (50-70%) of healthy live birth in future untreated pregnancies following natural conception than is currently achieved with IVF + PGD (30%).

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15
Q

What is the chance of successful pregnancy rate in patients with unexplained recurrent miscarriage?

A

75%

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16
Q

What percentage of pregnancies are affected by nausea & vomiting?

A

80%

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17
Q

What percentage of pregnancies are affected by hyperemesis?

A

0.3-3.6%

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18
Q

What is the definition of hyperemesis?

A

Protracted nausea and vomiting associated with the triad of:

  • > 5% pre pregnancy weight loss
  • Electrolyte disturbances
  • Dehydration
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19
Q

What is the timeline for usual NVP?

A

Starts 4th-7th week, peaks 9th week and 90% have resolved by 20 weeks.

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20
Q

PUQE score

A 
In the last 24 hours how long have you felt nauseous:
Not at all (1)
1 hour (2)
2-3 hours (3)
4-6 hours (4)
>6 hours (5)
In the last 24 hours how many times have you vomited and how many times have you retched?
Not at all (1)
1-2 (2)
3-4 (3)
5-6 (4)
>7 (5)

Score 6 or less = Mild
7-12 = Moderate
13-15 = Severe

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21
Q

Management of NVP/hyperemesis

A

Mild = community + oral antiemetics
Mild/Moderate + failed community = ambulatory day care
Inpatient if:
- unable to keep down oral anti-emetics
- ongoing N&V with ketonuria & weight loss despite anti-emetics
- confirmed/suspected comorbidity e.g. UTI

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22
Q

What blood test abnormalities might you see in hyperemesis?

A 
Low Na
Low K
Low Urea
Increased haematocrit
Hypochloraemic alkalosis (if severe --> acidosis)

2/3 have biochemical thyrotoxicosis
40% have abnormal LFTs

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23
Q

First line anti-emetics

A

Cyclizine
Prochlorperazine
Promethazine
Chlorpromazine

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24
Q

Second line anti-emetics

A

Metoclopramide
Domperidone
Ondansetron

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25
Q

Third line anti-emetics

A

Steroids - hydrocortisone 100mg BD IV and once improvement occurs convert to 40-50mg prednisone daily and taper down

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26
Q

When should growth scans be arranged?

A

If continued symptoms into late 2nd or 3rd trimester. HG and <7kg weight gain during pregnancy are at increased risk of PTB and low birth weight.

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27
Q

Recurrence rate of hyperemesis

A

15%

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28
Q

What percentage of pregnancies affected by HG end in termination?

A

10%

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29
Q

Incidence of gestational trophoblastic disease

A

1 in 714 (more common in Asian population - 1 in 387)

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30
Q

Cure rate of GTD

A

98-100%

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31
Q

Need for chemotherapy for GTN

A

5-8%

  • Complete mole 15%
  • Partial mole 0.5%
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32
Q

Genetic make up of complete moles

A

75%: Duplication of single sperm following fertilisation of “empty” ovum
25%: Dispermic fertilisation of “empty” ovum

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33
Q

Genetic make up of partial moles

A

90%: Dispermic fertilisation of an ovum

10%: Tetraploid/mosaic

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34
Q

How should molar pregnancy be managed?

A

Suction curettage (unless partial mole with fetal parts too big in which case medical management) and POC to histology to confirm diagnosis.

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35
Q

What are the outcomes for normal pregnancy with complete molar pregnancy coexisting?

A

25% live birth rate

  • 40% early fetal loss
  • 40% PTB
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36
Q

What to do if unclear whether partial mole or complete mole + normal pregnancy?

A

Invasive karyotyping

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37
Q

How long is follow up after GTD?

A

If hCG normal within 56 days of pregnancy then follow up for 6 months.
If hCG not normal then follow up 6 months from normalisation.

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38
Q

When to conceive after GTD?

A

Don’t conceive until follow up complete and if you have chemotherapy not for 1 year after treatment.

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39
Q

What to hCG centres do after future pregnancies?

A

Measure hCG at 6-8 weeks

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40
Q

Risk of further molar pregnancy

A

1 in 80

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41
Q

Effect of chemotherapy on menopause

A

1 year earlier if single agent.

3 years earlier if multi-agent.

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42
Q

Effect of etoposide

A

Increased risk of secondary cancers

43
Q

How to determine what chemo regimen required?

A

FIGO 2000 scoring:
- Score 6 or less is low risk (cure risk 100%) and they receive single agent IM methotrexate alternating daily with folinic acid for 1 week followed by 6 rest days.

  • Score 7 or higher is high risk (cure rate 95%) and they receive IV multi agent chemo including methotrexate, dactinomycin, etoposide, cyclophosphamide, vincristine.
44
Q

What is the FIGO 2000 scoring system?

A

(1) Age:
<40 = 0
>40 = 1

(2) Antecedent pregnancy:
Molar = 0
Abortion = 1
Term = 2

(3) Months from end of pregnancy to treatment:
<4 = 0
4-7 = 1
7-13 = 2
>13 = 4
(4) Pretreatment hCG:
<10^3 = 0
10^3-10^4 = 1
10^4-10^5 = 2
>10^5 = 4

(5) Largest tumour size (cm):
<3 = 0
3-5 = 1
>5 = 2

(6) Site of metastases
Lung = 0
Spleen/Kidney = 1
GI Tract = 2
Liver/Brain = 4
(7) Number of metastases
0 = 0
1-4 = 1
5-8 = 2
>8 = 4

(8) Previous failed chemo
Single drug = 2
Multi-agent = 4

45
Q

Contraception after GTD

A

Coils should wait until bhCG normalised but anything else can be started straight away. EC can be used (but again try to avoid coils) if UPSI >5d after pregnancy treated.

46
Q

Incidence of ectopic pregnancy

A

11/1000 pregnancies

2-3% in EPAU

47
Q

Maternal mortality associated with ectopic pregnancy

A

0.2 per 1000 estimated ectopic pregnancies

48
Q

What percentage of women with ectopic pregnancy have no RF?

A

1/3

49
Q

What percentage of ectopics are tubal and what is the most common site within tube?

A

97% are tubal and 80% of those are ampullary.

50
Q

What are common USS findings with tubal ectopic pregnancy?

A 
60% inhomogeneous mass
30% empty GS
15% YS/FP/FH
Pseudosac 20%
Echogenic fluid 30-60%
51
Q

What is the false negative laparoscopy rate for ectopics?

A

4%

52
Q

Management options for ectopic pregnancy and when to do them

A

EXPECTANT
- If clinically stable with bhcg < 1500

MEDICAL

  • Methotrexate 50mg/m2 IM
  • First line option if no significant pain, unruptured <35mm with no FH, no IUP and bhCG <1500
  • It is an option for bhCG up to 5000

SURGICAL
- If don’t meet criteria above or patient preference

53
Q

When should bhCG be monitored during expectant management of an ectopic and what would you expect to see?

A

D2, D4, D7.

>15% fall.

54
Q

When should bhCG be monitored during medical management of an ectopic and what should you see?

A

D4 + D7
15% decline is optimal - repeat weekly until <15
If <15% decline then re-scan and consider second dose.

55
Q

Success rate of expectant management of ectopic

A

60-100%

56
Q

Success rate of medical management of ectopic

A

65-95%

57
Q

What percentage of people require second dose methotrexate?

A

3-27%

58
Q

What percentage of people require surgery after methotrexate?

A

7%

59
Q

When to give methotrexate?

A

Never give on 1st visit. Repeat bhCG 48h and if increasing then rescan to confirm diagnosis.

60
Q

Rate of persistent trophoblastic tissue after salpingotomy?

A

7% (compared to 1% salpingectomy)

61
Q

What are the effects of treatment options for ectopic on future pregnancies?

A

If no tubal factor infertility then no difference in rates of fertility, rates of ectopic or tubal patency between methods.

If tubal problem - expectant/medical improves outcomes compared to surgery and salpingotomy increases rates of IUP to 75% from 40% with salpingectomy.

MTX doesn’t affect ovarian reserve.

62
Q

Monitoring after salpingotomy

A

bhCG D7 and then weekly

63
Q

What percentage of people need further treatment after salpingotomy?

A

1 in 5

64
Q

Recurrence rate of ectopic pregnancy

A

18%

65
Q

How long to wait after MTX before conceiving?

A

3 months

66
Q

Percentage of ectopics which are cervical

A

<1%

67
Q

Management of cervical ectopic

A

Consider methotrexate

Reserve surgical methods for women with life threatening bleeding.

68
Q

How common is CS scar ectopic?

A

1 in 2000

69
Q

What percentage of CS scar ectopics are misdiagnosed?

A

13%

70
Q

Incidence of cornual ectopics

A

1 in 76000

71
Q

Definition of cornual ectopic

A

In rudimentary horn of bicornuate uterus

72
Q

Management of cornual ectopic

A

Excision of rudimentary horn

73
Q

Incidence of interstitial ectopic

A

1-6%

74
Q

What percentage of pregnancies miscarry after FH seen?

A

5%

75
Q

Patient presents with pain (at any gestation) and/or bleeding (>6w) - what to do?

A

Refer to EPAU

76
Q

Patient presents with bleeding only at <6 weeks (and no RF for ectopic) - what to do?

A

Expectant management
Return if bleeding continues or pain develops
Repeat UPT 7-10d and return if +ve

77
Q

Diagnosis of miscarriage on USS

A

CRL >7mm on TVUS and no FH.
OR GS >25mm on TVUS and no FP.

Need either 2nd opinion or rescan 7 days to confirm.

78
Q

When to repeat scans if miscarriage diagnosis criteria not met?

A

If TVUS and CRL<7mm or GS<25mm then repeat in 7 days.

If TAUS done then record size and rescan 14 days.

79
Q

Management of confirmed miscarriage

A

Expectant management 7-14d first line option
Medical management (single dose misoprostol)
Surgical management

80
Q

Success rate of expectant management of miscarriage

A

50%

81
Q

Risk of infection with expectant management of miscarriage

A

3% (lowest of all the options)

82
Q

What follow up during expectant management of miscarriage?

A

If resolution of pain and bleeding - UPT 3/52

If pain and bleeding don’t start or don’t stop - repeat scan.

83
Q

Contraindications to expectant management of miscarriage

A 
Increased risk haemorrhage
Previous trauma
Increased risk of effects of bleeding
Evidence of infection
Pt request
84
Q

Risk of infection with medical management of miscarriage

A

3%

85
Q

Success rate of medical management of miscarriage

A

85%

86
Q

Bleeding necessitating return to hospital after MMM

A

3%

87
Q

Complications with MMM

A

1/70

88
Q

Doses of misoprostol for MMM

A

800 microgram missed

600 microgram for incomplete (but can use 800)

89
Q

Follow up for MMM

A

Return if bleeding not started after 24h

UPT 3/52

90
Q

Infection associated with SMM

A

5%

91
Q

Success rate of SMM

A

95%

92
Q

Management of PUL

A

Take 2 x bhCG 48 hours apart and if increasing >63% then likely IUP (do TVUS 7-14d)

If falling >50% likely non-viable and do UPT 14d after second serum hCG.

Changes in between refer EPAU.

93
Q

Overall significant complication rate of SMM

A

6%

94
Q

Risk of heavy bleeding necessitating blood transfusion after SMM

A

0-3/1000

95
Q

Risk of localised pelvic infection after SMM

A

40/1000

96
Q

Risk of retained tissue after SMM

A

40/1000

97
Q

Repeat surgery required after SMM

A

3-18/1000

98
Q

Intrauterine adhesions after SMM

A

190/1000 (after any management type)

  • 60% mild 30% mod, 10% severe
  • No sig difference in future fertility
99
Q

Perforation with SMM

A

1/1000

100
Q

Cervical trauma with SMM

A

<1/1000

101
Q

Overall risk of serious complications with laparoscopic management of ectopic

A

2 in 1000

102
Q

Percentage of bowel injuries which may not be diagnosed at time of laparoscopy

A

15%

103
Q

Risk of death associated with laparoscopic management of ectopic

A

3-8 per 100,000

104
Q

Risk of GTN after a livebirth

A

1 in 50,000

Laura MRCOG Part 2 (56 decks)

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