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Obstetrics & Gynaecology > Early Pregnancy > Flashcards

Early Pregnancy Flashcards

1
Q

Risk factors for ectopic pregnancy

A

Previous ectopic pregnancy

Previous pelvic inflammatory disease

Previous surgery to the fallopian tubes

Intrauterine devices (coils)

Older age

Smoking

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2
Q

When do ectopic pregnancies typically present?

A

6-8 weeks

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3
Q

Classic features of ectopic pregnancy

A

Missed period

Constant lower abdominal pain in the right or left iliac fossa

Vaginal bleeding

Lower abdominal or pelvic tenderness

Cervical motion tenderness (pain when moving the cervix during a bimanual examination)

Dizziness/syncope (blood loss)

Shoulder tip pain (peritonitis)

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4
Q

US findings in ectopic

A

TV USS

Yolk sac may be seen in tube

Empty uterus

Fluid in uterus

Empty sac -> blob/bagel/tubal ring sign

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5
Q

What is a pregnancy of unknown location (PUL)?

A

Positive pregnancy test but no evidence of pregnancy on USS

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6
Q

Follow up test for PUL

A

Serum hCG

Repeat after 48hrs to measure change from baseline

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7
Q

Serum hCG levels after 48hrs in:

Intrauterine pregnancy

Ectopic pregnancy

Miscarriage

A

Intrauterine pregnancy: rise of more than 63%

Ectopic pregnancy: rise of less than 63%

Miscarriage: fall of more than 50%

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8
Q

Management of ectopic pregnancy

A

Expectant management (awaiting natural termination)

Medical management (methotrexate)

Surgical management (salpingectomy or salpingotomy)

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9
Q

Criteria for expectant management of ectopic pregnancy

A

Follow up needs to be possible to ensure successful termination

Ectopic needs to be unruptured

Adnexal mass <35mm

No visible heartbeat

No significant pain

HCG level <1,500 IU/l

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10
Q

Criteria for methotrexate (medical management) of ectopic pregnancy

A

Follow up needs to be possible to ensure successful termination

Confirmed absence of intrauterine pregnancy on USS

Ectopic needs to be unruptured

Adnexal mass <35mm

No visible heartbeat

No significant pain

HCG level must be <5,000 IU/l

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11
Q

Outline methotrexate management of ectopic pregnancy

A

IM injection into buttock

Advise patient not to get pregnant for 3 months following treatment

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12
Q

Methotrexate side effects

A

Vaginal bleeding

Nausea and vomiting

Abdominal pain

Stomatitis (inflammation of the mouth)

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13
Q

Surgical management of ectopic pregnancy is indicated in patients with what symptoms?

A

Pain

Adnexal mass >35mm

Visible heartbeat

HCG levels >5,000 IU/l

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14
Q

What are the two options for surgical management of ectopic pregnancy?

A

Laparoscopic salpingectomy (first-line)

Laparoscopic salpingostomy (women at increased risk of infertility due to damage of other tube)

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15
Q

What is an early miscarriage?

A

Miscarriage before 12 weeks

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16
Q

What is a late miscarriage?

A

Miscarriage between 12 and 24 weeks

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17
Q

Define missed miscarriage

A

Foetus is no longer alive, but no symptoms have occurred

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18
Q

Define threatened miscarriage

A

Vaginal bleeding with a closed cervix and a foetus that is alive

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19
Q

Define inevitable miscarriage

A

Vaginal bleeding with an open cervix

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20
Q

Define incomplete miscarriage

A

Retained products of conception remain in the uterus after the miscarriage

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21
Q

Define complete miscarriage

A

A full miscarriage has occurred, and there are no products of conception left in the uterus

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22
Q

Define anembryonic miscarriage

A

A gestational sac is present but contains no embryo

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23
Q

What key features does a sonographer look for in early pregnancy?

A

Mean gestational sac diameter

Foetal pole and crown-rump length

Foetal heartbeat

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24
Q

What does the crown-rump length need to be in order to detect foetal heartbeat?

A

> 7mm

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25
Q

When is a foetal pole expected to be visible on USS?

A

Once mean gestational sac diameter is 25mm or more

26
Q

Management of miscarriage at less than 6 weeks gestation

A

Can be managed expectantly if no pain/complications/risk factors

Repeat urine test after 7-10 days

27
Q

Management of miscarriage at more than 6 weeks gestation

A

Expectant management (do nothing and await a spontaneous miscarriage)

Medical management (misoprostol)

Surgical management

28
Q

Management of women with positive pregnancy test (>6/40) bleeding

A

Refer to early pregnancy assessment service

USS to confirm location/viability

29
Q

Outline expectant management of miscarriage

A

Women without risk factors for heavy bleeding or infection

1-2 weeks to allow miscarriage to occur spontaneously

Repeat urine pregnancy test at 3 weeks

30
Q

Persistent or worsening bleeding during expectant management of miscarriage

A

Further assessment required

Repeat USS

May indicate incomplete miscarriage and require additional management

31
Q

Outline medical management of miscarriage

A

Misprostol (prostaglandin analogue)

Binds to prostaglandin receptors and activates them

Softens cervix and stimulates uterine contractions

Vaginal suppository or oral dose

32
Q

Key side effects of misoprostol

A

Heavier bleeding

Pain

Vomiting

Diarrhoea

33
Q

Surgical management of miscarriage options

A

Manual vacuum aspiration under local anaesthetic as an outpatient

Electric vacuum aspiration under general anaesthetic

34
Q

What is classed as “recurrent miscarriage”

A

Three or more consecutive miscarriages

35
Q

When are investigations for recurrent miscarriage initiated?

A

Three or more first-trimester miscarriages

One or more second-trimester miscarriages

36
Q

Causes of recurrent miscarriage

A

Idiopathic (particularly in older women)

Antiphospholipid syndrome

Hereditary thrombophilias

Uterine abnormalities

Genetic factors in parents (e.g. balanced translocations in parental chromosomes)

Chronic histiocytic intervillositis

Other chronic diseases such as diabetes, untreated thyroid disease and SLE

37
Q

Patient presents with recurrent miscarriages and a history of DVT.

Which investigations would you do?

What is the management for the likely diagnosis?

A

Antiphospholipid syndrome

Tets for antiphospholipid antibodies

Treat with aspirin and LMWH

38
Q

Managing risk of miscarriage in patients with antiphospholipid syndrome

A

Low dose aspirin

LMWH

39
Q

Which hereditary thrombophilias increase risk of recurrent miscarriage?

A

Factor V Leiden (most common)

Factor II (prothrombin) gene mutation

Protein S deficiency

40
Q

Uterine abnormalities causing recurrent miscarriage

A

Uterine septum (a partition through the uterus)

Unicornuate uterus (single-horned uterus)

Bicornuate uterus (heart-shaped uterus)

Didelphic uterus (double uterus)

Cervical insufficiency

Fibroids

41
Q

Investigations in recurrent miscarriage

A

Antiphospholipid antibodies

Testing for hereditary thrombophilias

Pelvic ultrasound

Genetic testing of the products of conception from the third or future miscarriages

Genetic testing on parents

42
Q

Medical abortion options

A

Mifepristone (anti-progestogen)

Misoprostol (prostaglandin analogue) 1-2 days later

43
Q

Which type of anaesthetic is used in surgical abortions?

A

Can be under local, local + sedation, or general

44
Q

Medications used for cervical priming prior to surgical abortion

A

Misoprostol

Mifepristone

Osmotic dilators (devices inserted into the cervix that gradually expand as they absorb fluid, opening the cervical canal)

45
Q

What are the options for surgical abortion?

A

Cervical dilatation and suction of the contents of the uterus (usually up to 14 weeks)

Cervical dilatation and evacuation using forceps (between 14 and 24 weeks)

46
Q

Post-abortion care

A

Women may experience vaginal bleeding and cramps intermittently for up to 2 weeks post-procedure

Pregnancy test 3 weeks after abortion to confirm complete

Discuss contraception

Support and counselling offered

47
Q

Abortion complications

A

Bleeding

Pain

Infection

Failure of the abortion (pregnancy continues)

Damage to the cervix, uterus or other structures

48
Q

Latest gestational age for abortion

A

24 weeks

49
Q

An abortion can be performed at any time during pregnancy if…

A

Continuing the pregnancy is likely to risk the life of the woman

Terminating the pregnancy will prevent “grave permanent injury” to the physical or mental health of the woman

There is “substantial risk” that the child would suffer physical or mental abnormalities making it seriously handicapped

50
Q

What is hyperemesis gravidarum?

A

Severe form of nausea and vomiting during pregnancy

51
Q

Hyperemesis gravidarum diagnostic criteria

A

Protracted NVP plus:

More than 5% weight loss compared with before pregnancy

Dehydration

Electrolyte imbalance

52
Q

Assessing severity of vomiting

A

Pregnancy-Unique Qualification of Emesis score (out of 15)

<7: Mild
7-12: Moderate
>12: Severe

53
Q

Antiemetics for hyperemesis gravidarum

A

Prochlorperazine (stemetil)

Cyclizine

Ondansetron

Metoclopramide

54
Q

When to consider admission in mild cases of hyperemesis gravidarum

A

Unable to tolerate oral antiemetics or keep down any fluids

More than 5% weight loss compared with pre-pregnancy

Ketones are present in the urine on a urine dipstick (2+ ketones on the urine dipstick is significant)

Other medical conditions need treating that required admission

55
Q

When to consider admission/ambulatory care in moderate to severe cases of hyperemesis gravidarum

A

IV or IM antiemetics

IV fluids (normal saline with added potassium chloride)

Daily monitoring of U&Es while having IV therapy

Thiamine supplementation to prevent deficiency (prevents Wernicke-Korsakoff syndrome)

Thromboprophylaxis (TED stockings and low molecular weight heparin) during admission

56
Q

What is a molar pregnancy?

A

A hydatidiform mole (type of tumour) growing inside the uterus

57
Q

What are the types of molar pregnancy?

A

Complete mole

Partial mole

58
Q

What is a complete mole and how does it occur?

A

Two sperm cells fertilise an ovum that contains no genetic material (an “empty ovum”)

Sperm then combine genetic material, and cells start to divide and grow into a tumour called a complete mole.

No foetal material will form

59
Q

What is a partial mole and how does it occur?

A

Two sperm cells fertilise a normal ovum (containing genetic material) at the same time

New cell now has three sets of chromosomes (it is a haploid cell)

Cell divides and multiplies into a partial mole

Some fetal material may form

60
Q

What indicates a molar pregnancy rather than a normal pregnancy?

A

More severe morning sickness

Vaginal bleeding

Increased enlargement of the uterus

Abnormally high hCG

Thyrotoxicosis (hCG can mimic TSH and stimulate the thyroid to produce excess T3 and T4)

61
Q

What is the USS finding in molar pregnancy?

A

Snowstorm sign

62
Q

Management of molar pregnancy

A

Evacuation of uterus to remove mole

Products of conception need to be sent for histological examination to confirm a molar pregnancy

Referred to gestational trophoblastic disease centre for management and follow up

hCG levels monitored until they return to normal

Occasionally mole can metastasise, and patient may require systemic chemotherapy

Obstetrics & Gynaecology (13 decks)

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