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Obstetrics > Early pregnancy > Flashcards

Early pregnancy Flashcards

1
Q

Most common site of ectopic pregnancy

A

ampulla and isthmus of fallopian tube

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2
Q

risk factors for ectopic pregnancy

A

Previous ectopic pregnancy

Previous pelvic inflammatory disease/ endometriosis

Previous surgery to the fallopian tubes or pathology

Intrauterine devices (coils)

POP

Older age

Smoking

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3
Q

presentation of ectopic pregnancy

A

6-8 weeks gestation
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)

Unilateral pain RIF/ LIF

Irregular PV spotting/ bleeding, dark sticky prune juice

GI symptoms: N/V, diarrhoea

dizziness/syncope
shoulder tip pain

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4
Q

Tubal types of ectopic

A

Isthmic, majority

Fimbrial

Cornual

Interstitial

Bilateral (very rare)

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5
Q

types of ectopic

A

Tubal >99%

Ovarian

Abdominal

Cervical

Uterine (rare)

Diverticulum, intramural, rudimentary horn (cornual), scar (becoming more common)

Heterotopic with IVF

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6
Q

USS ectopic

A

blob/bagel/tubal ring: empty gestational sac

gestation sac containing yolk sac or fetal pole

empty uterus, pesudogestational sac

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7
Q

Pregnancy of unknown location management

A

monitor hCG
rise in >63% 48 hrs indicates intrauterine pregnancy, hCG>1500, repeat USS 1-2 weeks

rise 63% -> ectopic

> 50% fall: miscarriage, pregnancy test after 2 weeks

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8
Q

criteria for expectant management of ectopic pregnancy

A

Follow up needs to be possible to ensure successful termination

The ectopic needs to be unruptured

Adnexal mass < 35mm

No visible heartbeat

No significant pain

HCG level < 1500 IU / l and falling

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9
Q

criteria for medical management of ectopic pregnancy

A

HCG level must be < 5000 IU / l

Confirmed absence of intrauterine pregnancy on ultrasound

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10
Q

how long after methotrexate can u get pregnant?

A

3 months

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11
Q

side effects of methotrexate

A

vaginal bleeding
N/V
abdominal pain
stomatitis

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12
Q

surgical management of ectopic pregnancy

A

laparoscopic salpingectomy
lap salpingotomy if otther tube is damaged or low infertility
anti-D prophylaxis if rhesus negative

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13
Q

early and late miscarriage

A

Early miscarriage is before 12 weeks gestation.

Late miscarriage is between 12 and 24 weeks gestation.

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14
Q

aetiology of miscarriage

A

Sporadic in most cases, never established in most cases

Chromosomal abnormalities

Congenital abnormalities

Maternal disease:

Poorly controlled diabetes

Acute illness/ infection

Uterine abnormalities

Thrombophilia/ antiphospholipid syndrome

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15
Q

risk factors for miscarriage

A

Advanced maternal age

Previous miscarriage

Smoking

Alcohol and drug use:
NSAIDs and aspirin
Street drugs

Folate deficiency

Consanguinity

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16
Q

missed miscarriage

A

the fetus is no longer alive, but no symptoms have occurred

Failed pregnancy with no cardiac pulsations on USS

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17
Q

threatened miscarriage

A

vaginal bleeding with a closed cervix and a fetus that is alive

Bleeding and/or pain up to 24/40 with a viable ongoing pregnancy

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18
Q

inevitable miscarriage

A

vaginal bleeding with an open cervix

Cervix open, internal os

Products of conception not yet passed but they will

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19
Q

incomplete miscarriage

A

retained products of conception remain in the uterus after the miscarriage

Some products of conception have been passed

Cervix stays open until all tissues passed

Still bleeding and pain

Echogenic mass of blood clot and tissue within the uterine cavity >20mm in AP diameter

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20
Q

complete miscarriage

A

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

All products of conception have been passed

Complete sac may be identifiable

Bleeding and pain reducing

Cervix now closed

Cannot diagnose with USS

Empty uterine cavity

Rough guide AP <20mm

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21
Q

anembryonic pregnancy

A

a gestational sac is present but contains no embryo
Failed pregnancy with empty gestation sac

No fetus present

22
Q

USS features miscarriage

A

Mean gestational sac diameter

Fetal pole and crown-rump length

Fetal heartbeat

23
Q

fetal heartbeat

A

When a fetal heartbeat is visible, the pregnancy is considered viable. A fetal heartbeat is expected once the crown-rump length is 7mm or more.

When the crown-rump length is less than 7mm, without a fetal heartbeat, the scan is repeated after at least one week to ensure a heartbeat develops. When there is a crown-rump length of 7mm or more, without a fetal heartbeat, the scan is repeated after one week before confirming a non-viable pregnancy.

24
Q

fetal pole

A

A fetal pole is expected once the mean gestational sac diameter is 25mm or more. When there is a mean gestational sac diameter of 25mm or more, without a fetal pole, the scan is repeated after one week before confirming an anembryonic pregnancy.

25
Q

<6 weeks miscarriage management

A

expectant management

repeat urine pregnancy test after 7-10 days

26
Q

> 6 weeks miscarriage management

A

EPAU
USS
expectant, medical, surgical

27
Q

expectant management miscarriage

A

Expectant management is offered first-line for women without risk factors for heavy bleeding or infection.

1 – 2 weeks are given to allow the miscarriage to occur spontaneously. A repeat urine pregnancy test should be performed three weeks after bleeding and pain settle to confirm the miscarriage is complete.

Persistent or worsening bleeding requires further assessment and repeat ultrasound, as this may indicate an incomplete miscarriage and require additional management.

Must have 24 hour access to gynae services

28
Q

expectant management of miscarriage advantages and disadvantages

A

Advantages:
Avoid risks of surgery/meds
Can be at home

Disadvantages: 
Pain and bleeding can be unpredictable 
Worries regarding being at home 
Takes longer 
May be unsuccessful
29
Q

misoprostol advantages and disadvantages

A

Advantages:
Avoids surgery
High patient satisfaction if successful
Can be done as outpatient

The key side effects of misoprostol are: 
Heavier bleeding 
Pain 
Vomiting 
Diarrhoea
30
Q

surgical management of miscarriage

A

Manual vacuum aspiration under local anaesthetic as an outpatient

Electric vacuum aspiration under general anaesthetic

Give misoprostol before to soften the cervix

anti-D prophylaxis

31
Q

surgical management of miscarriage advantages and disadvantages

A

Advantages:
Planned procedure, closure

Disadvantages: 
Surgical (perforation, bowel/bladder damage) 
Damage to cervix 
Asherman's 
Cervical weakness 
Anaesthetic risk
32
Q

complication of evacuation of retained products of conception

A

endometritis

33
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 systemic lupus erythematosus (SLE)

34
Q

The risk of miscarriage in patients with antiphospholipid syndrome is reduced by using

A

Low dose aspirin

Low molecular weight heparin (LMWH)

35
Q

hereditary thrombophilias

A

Factor V Leiden (most common)

Factor II (prothrombin) gene mutation

Protein S deficiency

36
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

37
Q

investigations for 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

38
Q

N/V peak in pregnancy

A

Nausea and vomiting in pregnancy starts in the first trimester, peaking around 8 – 12 weeks gestation.

39
Q

pathophysiology of hyperemesis

A

Elevated HCG:
More common in twin/ molar pregnancies
Same alpha subunit TSH-> thyrotoxicosis

Elevated oestrogen/ progesterone:
Decreased gut motility
Increased liver enzymes
Decreased cardiac sphincter pressure

H, Pylori:
Sub-clinical infection activated by altered immunity in pregnancy

Psychological:
Difference in incidence in different populations and cultures

40
Q

hyperemesis gravidarum diagnosis

A

More than 5 % weight loss compared with before pregnancy

Dehydration

Electrolyte imbalance

41
Q

PUQE

Pregnancy unique quantification of emesis

A

< 7: Mild

7 – 12: Moderate

> 12: Severe

42
Q

investigations of hyperemesis

A

Urine: PT/ ketonuria/ UTI

FBC: haematocrit

UE (esp K)

LFT and amylase

TFT

USS: exclude GTD/ multiple pregnancy

43
Q

hyperemesis management

A

Prochlorperazine (stemetil)

Cyclizine

Ondansetron

Metoclopramide

if reflux is a problem: ranitidine/ omeprazole
ginger or acupressure

44
Q

admission criteria hyperemesis

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

45
Q

admission management hyperemesis

A

IV or IM antiemetics

IV fluids (normal saline with added potassium chloride)

Not with glucose as it precipitates Wernicke’s

Daily monitoring of U&Es while having IV therapy

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

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

Folic acid

Ranitidine

46
Q

Gestational trophoblastic disease types

A

Pre-malignant conditions (more common):
Hydatidiform mole/ molar pregnancy
Complete mole (empty egg, 1 sperm)
Partial mole (egg and 2 sperm)- more common

Malignant conditions (rarer):  
Invasive mole 
Choriocarcinoma 
Placental trophoblastic site tumour  
Epithelioid trophoblastic tumour.
47
Q

risk factors for GTD

A

Maternal age <20 or >35

Previous gestational trophoblastic disease (this risk is not decreased by a change of partner)

Previous miscarriage

Use of the oral contraceptive pill

48
Q

clinical features of molar pregnancy

A

vaginal bleeding and abdominal pain

Hyperemesis – because there is an increased titre of B-hCG which is thought to be linked to nausea in pregnancy.

Hyperthyroidism – gestational thyrotoxicosis due to stimulation of the thyroid by high HCG levels.

Anaemia

Bleeding/ haemorrhage

Severe, very early PET

Uterus large for dates

49
Q

investigations for molar pregnancy

A

urine bCHG HIGH
USS: granular/ snowstorm appearance
histology: post-treatment

mets: CT CAP, pelvic USS

50
Q

management of molar pregnancy

A

suction curettage or

medical evacuation with urinary bHCG measured 3 weeks post-treatment

Obstetrics (10 decks)

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