Early pregnancy

Question 1

Ectopic pregnancy most common site

Answer 1

Fallopian tube

Question 2

Risk factors for ectopic pregnancy

Answer 2

Previous ectopic pregnancy
Previous PID
Previous surgery to Fallopian tubes
IUD
Older age
Smoking
PID- previous clamydia infection

Question 3

When do ectopic pregnancies usually present?

Answer 3

6-8 weeks gestation

Question 4

Features of ectopic pregnancies

Answer 4

Missed period
Constant lower abdominal pain
Vaginal bleeding
Lower abdominal or pelvic tenderness

Question 5

Investigations for ectopic pregnancy

Answer 5

Transvaginal ultrasound - ‘blob sign’, ‘bagel sign’, ‘tubal ring sign’

Other features: empty uterus

Question 6

What is PUL? What should you do if this is confirmed?

Answer 6

PUL - pregnancy of unknown location.

Track serum hCG over time to monitor PUL. Serum hCG should be repeated in 48 hours.

If rise more than 63% -> likely intrauterine pregnancy. hCG doubles every 48 hours.

If less than 63% after 48 hours -> could indicate ectopic pregnancy

If less than 50% - likely miscarriage.

Question 7

Management options for ectopic pregnancies

Answer 7

All ectopic pregnancies should be terminated.

Three options:
- Expectant management (await natural termination)
- Medical
- Surgical

Question 8

Management of ectopic pregnancies with methotrexate

Answer 8

Given as IM injection in the buttock and halts progress of pregnancy and results in spontaneous termination.

Question 9

Criteria for surgical management of ectopic pregnancy

Answer 9

Pain
Adnexal mass >35mm
Visible heartbeat
HCG >5000

Question 10

Criteria for use of methotrexate management of ectopic pregnancy

Answer 10

hCG <5000
Confirmed absence of intrauterine pregnancy on ultrasound.

Question 11

Surgical management option for ectopic pregnancy

Answer 11

Laparoscopic salpingectomy (first-line)
Laparoscopic salpingotomy

Question 12

Define missed miscarriage

Answer 12

Fetus is no longer alive and no symptoms occured

Question 13

Define threatened miscarriage

Answer 13

Vaginal bleeding with closed cervix and foetus that is alive

Question 14

Define inevitable miscarriage

Answer 14

vaginal bleeding with open cervix

Question 15

Define incomplete miscarriage

Answer 15

retained products of conception remained in the uterus after the miscarriage

Question 16

Define complete miscarriage

Answer 16

Full miscarriage has occurred with no retained products

Question 17

Define Anembryonic pregnancy

Answer 17

a gestational sac is present but contains no embryo

Question 18

Investigations of choice for miscarriage and key features

Answer 18

Transvaginal ultrasound is investigation of choice.
Key features:

• Mean gestational sac diameter
• Foetal pole and crown-rump length
• Fetal heartbeat

Question 19

Management of miscarriage under 6 weeks gestation

Answer 19

manage expectantly provided they have no pain

repeat urine pregnancy test after 7-10 days and if negative miscarriage confirmed, if not, further investigations is indicated.

Question 20

Management of miscarriage over 6 weeks gestation

Answer 20

three options:

• expectant
• medical (misopristol)
• surgical

Question 21

What is medical management of miscarriage?

Answer 21

Misopristol - prostaglandin analogue which causes cervix to soften and stimulate uterine contractions.

Question 22

Surgical management of miscarriage? And describe the process.

Answer 22

Manual vacuum aspiration and electric vacuum aspiration.

Manual - involved local anaesthetic and involves manual aspiration of contents of uterus

Electric - requires general anaesthetic, cervix widened using dilators and electric powered vacuum removes products of contraception.

Question 23

What is classed as recurrent miscarriage?

Answer 23

Three or more consecutive miscarriages

Question 24

When are investigations initiated for recurrent miscarriages?

Answer 24

3 or more first trimester miscarriages or one or more second trimester miscarriages

Question 25

Causes of recurrent miscarriages

Answer 25

Idiopathic (especially in older women) Antiphospholipid syndrome Hereditary thrombophilias Uterine abnormalities

Question 26

Antiphospholipid syndrome

Answer 26

A condition that causes a hyper coagulable state associated with thrombosis and recurrent miscarriages. It can occur on its own or secondary to SLE. Risk of miscarriage is reduced by low dose aspirin and low molecular weight heparin

Question 27

Most common inherited thrombophilia

Answer 27

Factor V leiden

Question 28

Types of uterine abnormalities that can cause recurrent miscarriages

Answer 28

Uterine septum Unicornate uterus Bicornate uterus Fibroids

Question 29

Investigations for recurrent miscarriages

Answer 29

Antiphospholipid antibodies Testing for hereditary thrombophilias Pelvic USS Genetic testing of the products of conception Genetic testing on parents

Question 30

Medical abortion treatments

Answer 30

Mifepristone (anti-progestogen) Misoprostol (prostaglandin analogue)

Question 31

MOA of mifepristone

Answer 31

Anti-progestogen medication that blocks the action of progesterone, halting the pregnancy and relaxing the cervix

Question 32

MOA of misoprostol

Answer 32

prostaglandin analogue, meaning it binds to prostaglandin receptors and activates them. Prostaglandins softens the cervix and stimulate uterine contractions.

Question 33

Complications of medical abortions

Answer 33

Bleeding Pain Infection Failure of the abortion Damage to the cervix, uterus or other structures

Question 34

Diagnosis hyperemesis gravidarum

Answer 34

Continuous nausea and vomiting plus: DEW Dehydration Electrolyte imbalance More than 5% weight loss compared with before pregnancy unable to keep down anti-emetics

Question 35

Management of hyperemesis gravidarum

Answer 35

1. cyclizine or promethazine 2. ondansetron or metoclopramide

Question 36

Risk factors of hyperemesis gravidarum

Answer 36

Multiple pregnancies Hyperthyroidism Nulliparity Obesity Trophoblastic disease