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Gynaecology > Disorders of early pregnancy > Flashcards

Disorders of early pregnancy Flashcards

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1
Q

1st

A

1st

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2
Q

What produces hCG?

A

The trophoblast produces the hCG - this maintains the corpus luteum which produces the oestrogen and progesterone to maintain the endometrium

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3
Q

What is the definition of spontaneous miscarriage?

A

Fetus dies or is delivered dead before 24 weeks completed gestation

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4
Q

When do you the majority of spontaneous miscarriages occur?

A

Before 12 weeks

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5
Q

What % of clinically recognised pregnancies miscarry

A

15%

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6
Q

What is threatened miscarriage?

A

There is bleeding but the fetus is still alive, the uterus is the expected size for dates and the os is shut

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7
Q

What % of threatened miscarriages actually miscarry?

A

25%

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8
Q

What is inevitable miscarriage?

A

Bleeding usually heavier than threatened, although fetus is still alive the os is open and miscarriage is about to occur

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9
Q

What is incomplete miscarriage?

A

Some fetal parts have been passed but os is usually still open

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10
Q

What is complete miscarriage?

A

All fetal tissue has been passed, bleeding has diminished, uterus is no longer enlarged and os is closed

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11
Q

What is septic miscarriage

A

Contents of the uterus are infected causing endometritis - vaginal loss is usually offensive and uterus is tender. Fever can be absent

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12
Q

Signs of septic miscarriage with pelvic infection

A

There is abdominal pain and peritonism

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13
Q

What is missed miscarriage?

A

Fetus has not developed or died in utero - but its not recognised until bleeding occurs or ultrasound is performed - uterus is smaller than expected from dates and os is closed

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14
Q

What is the cause of >60% of one-off or sporadic miscarriages?

A

Isolated non-recurring chromosomal abnormalities

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15
Q

When are miscarriages considered to be “recurrent miscarriages”

A

3 or more

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16
Q

Signs of miscarriage

A

Bleeding!!

Pain from uterine contractions can cause confusion with ectopic pregnancy

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17
Q

Management of miscarriage

A

Admission if septic of heavy bleeding
Anti-D if rhesus negative if surgical/medical treatment or if bleeding after 12 weeks
Ergometrine IM reduces bleeding by contracting uterus but only if fetus not viable

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18
Q

Management of threatened miscarriage

A

Bed rest or hormone treatment with progesterone or hCG do not prevent miscarriage

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19
Q

When is expectant management okay for non-viable intrauterine pregnancy and how long does it usually take

A

If no infection and if woman is willing

Usually takes 2-6 weeks

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20
Q

What is medical management of non-viable intrauterine pregnancy

A

Prostaglandin (oral, sublingual or vaginal) sometimes preceeded by oral antiprogesterone mifepristone

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21
Q

What is the surgical management of non-viable intrauterine pregnancy?

A

Evacuation of retained products of conception under anaesthetic using vacuum - suitable if woman prefers it, if heavy bleeding or signs of infection

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22
Q

Chance of miscarriage a 4th time after 3 miscarriages

A

40%

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23
Q

What systemic disease can cause recurrent miscarriages and management?

A

Anti-phospholipid syndrome - managed with aspirin and low-dose LMWH

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24
Q

When do uterine abnormalities cause miscarriage?

A

Usually late miscarriage

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25
Legal time limit for abortion in the UK
24 weeks gestation
26
When are abortions allowed after the legal time limit?
If grave risk to womans life/physical or mental health or severe fetal abnormality
27
What should be given within 72h of TOP
Anti-D to rhesus neg women
28
When can contraception be administered following TOP?
Either with misoprostol (oral pills, condoms. injections or implants) or following next menstrual cycle (IUD or sterilisation)
29
What surgical method is used for TOP between 7-13 weeks
Suction curettage
30
What surgical method is used for TOP after 13 weeks
Dilatation and evacuation
31
What is medical TOP?
Mifepristone followed by misoprostol 36-48hr later
32
What is needed with TOP after 22 weeks?
Feticide - KCl injected into umbilical vein or fetal heart - normally only performed when fetal abnormality is present
33
Complications of TOP
``` Haemorrhage Infection Uterine perforation Cervical trauma Failure ```
34
Incidence of ectopic pregnancy
1 in 60-100 pregnancies
35
Where is the most common site for ectopic pregnancy?
Fallopian tube (95%)
36
What is the risk with ectopic pregnancy?
Thin-walled fallopian tube may bleed into lumen or rupture with trophoblastic invasion - intraperitoneal blood loss can be catastrophic
37
Risk factors for ectopic pregnancy
``` Damage to fallopian tubes PID usually from SIT Assisted conception Pelvic surgery Previous ectopic Smoking ```
38
When does ectopic pregnancy need to be excluded urgently?
In a woman who conceives with copper-IUD because prevents intrauterine pregnancy but not those destined to implant in tube
39
Presentation of ectopic pregnancy?
Lower abdominal pain followed by scanty, dark vaginal bleeding
40
Type of pain in ectopic pregnancy
Initially colicky as tube tries to extrude the sac and then constant
41
Signs of intraperitoneal bleeding in ectopic pregnancy x2
Syncopal episodes | Shoulder tip pain
42
Examination in ectopic pregnancy
Abdominal tenderness and rebound tenderness Moving cervix may cause pain (cervical excitation) and either adenexum may be tender Uterus is smaller than expected and os is closed
43
Investigations in suspected ectopic pregnancy
Urine hCG (in all women of reproductive age who present with pain, bleeding or collapse) Ultrasound Quantitative serum hCG - if uterus is empty on US
44
Serum hCG and early pregnancy
If >1000 then intrauterine pregnancy should be visible on TV USS Declining or slow rising (plateauing) levels suggest ectopic or non-viable intra-uterine pregnancy
45
When can pregnancy be seen on TV US?
5 weeks
46
Surgical management of ectopic pregnancy
Either salpingostomy (higher change of recurrence) or salpingectomy (not done if other tube is gone)
47
When can you do medical management of ectopic pregnancy
If unruptured, no cardiac activity, hCG below 3000, no symptoms
48
What is medical management of ectopic pregnancy
Single-dose methotrexate - followed by monitoring of hCG levels
49
When can you do conservative management of ectopic pregnancy
If small, unruptured and hCG levels are low
50
Rate of second ectopic pregnancy
up to 10%
51
What is hyperemesis gravidarum?
Nausea and vomiting in early pregnancy that is so severe that it causes severe dehydration, weight loss or electrolyte disturbance
52
Incidence of hyperemesis gravidarum
1 in 750 women
53
When does hyperemesis gravidarum occur
Seldom persists beyond 14 weeks
54
In whom in hyperemesis gravidarum common
Multiparous women
55
Management of hyperemesis gravidarum
Antiemetics such as metoclopramide, cyclzine and ondansetron | Thiamine - to prevent Wernickes
56
Conditions which predispose to hyperemesis gravidarum x3
Urinary infection and multiple or molar pregnancy
57
What is gestational trophoblastic disease?
Proliferation of the trophoblastic tissue - causing a molar pregnancy (not formation of a fetus)
58
What is hCG like in trophoblastic disease
Very high
59
What is a hydatidiform mole
When proliferation of trophoblastic tissue is localised and non-invasive
60
What are the invasive types of trophoblastic disease
Have characteristics of malignant tissue - if only locally within uterus then invasive mole - but if metastasis then choriocarcinoma
61
What is gestational trophoblastic neoplasia?
Persistence of gestational trophoblastic disease and elevated hCG
62
When is gestational trophoblastic disease more common
Extremes of reproductive age and twice as common in asians
63
Examination findings in GTD
Uterus is often large | Early preeclampsia and hyperthyroidism may occur
64
Signs of GTD
Vaginal bleeding and may be heavy | Severe vomiting
65
Investigations in GTD
USS shows snowstorm appearance of swollen villi
66
Management of GTD
Trophoblastic tissue is removed by suction curettage - bleeding is often heavy
67
How is definitive diagnosis of GTD made
Histologically
68
Monitoring post removal of GTD
hCG - to check for malignancy persistence | Wait for hCG levels to be normal before conception because may need chemotherapy
69
Recurrence of molar pregnancy
1 in 60
70
Treatment of tumour following GTD
Chemotherapy and is very sensitive to it - 5 year survival rates approach 100%

Gynaecology (8 decks)

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