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Early Pregnancy Flashcards

(38 cards)

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1
Q

Definition of a miscarriage

A

TVS: MSD > 20mm w no FP
FP > 7mm w no FH

TAS: MSD >25mm w no FP
FP >8mm w no FH

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2
Q

Difference between complete and incomplete miscarriage

A

ETT <15 = complete, >15mm =incomplete

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3
Q

PUV vs PUL

A

PUV: MGSD </=20mm, no FP OR FP <7mm w no FH
PUL no IUGS seen OR IUGSw no YS

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4
Q

Management of miscarriage

A

Conservative - rpt USS 2/52
Medical: 80=91% effective. Mife 200mcg+ miso 800mcgx 2, rpt USS 2/52. ADRS: N&V, diarrhoea, PVB. Admit if MGSD >50mm
Surgical: ERPC, PT 2/52 later, Anti-D

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5
Q

Risk factors for recurrent miscarriage

A

Maternal age
Smoking
Caffeine
ETOH

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6
Q

Causes of recurrent miscarriage

A

ChAII TEA
Chromosomal - parental rearrangements + embryonic abnormalities
Antiphospholipidsyndrome
Immune
Infective
Thrombophilia
Endocrine
Anatomical

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7
Q

Role & effect of antiphospholipid syndrome

A

Includes lupus anticoagulant, antiB2 gylcoprotein ab, anticardiolipin abb
Adverse outcomes: early pregnancy loss, MTL, PTB
Inhibits trophoblastic function and differentiation. Activates complement pathways at mat/fet interface –> inflammatory response; thrombosis of uteroplacental vasculature in later pregnancy
Effects reversed with LMWH

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8
Q

Diagnosis of ectopic pregnancy

A

Serial HCG measurement
TAS/ TVS:
No IUGS + YS
60% homogenous adnexal mass adjacent to ovary
20% hypoechoic ring/ bagel sign
13% GS+FP

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9
Q

Types of ectopics

A

Tubal - bagel sign/ homogenous adnexal mass
Cervical - empty uterus, barrel-shaped cervix, GS below level of internal os, absence of sliding sign
Scar - GS low in uterine cavity. MRI 2nd line
Interstitial - empty uterine cavity, POC/GS in intramural part of tube + surrounded by <5mm myometrium
Cornual - visualisation of single interstitial portion of fallopian tube in main uterine body, GS/ POC seen mobile and separate fro uterus + completely surrounded by myometrium + vascular pedicle adjoining GS to unicornuate uterus

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10
Q

MTX candidate

A
  • haemodynamically stable
  • low HCG, ideally <1500 (NICE 1500-5000)
  • No FH
  • certainty of no viable IUP
  • willingness to attend for F/U
  • no known sensitivity to MTX
    NICE:
  • no significant pain
  • unruptured, w mass <35mm and no visible FH
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11
Q

R/F for ectopic pregnancy

A
  • infertility (x2)
  • tubal pathology (x3)
  • documented salpingitis (x4)
  • prev TL ( 1/3)
  • pregnancy w IUCD (1/2)
  • prev ectopic( 1 prev - >10%, 2 prev >25%)
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12
Q

MTX MOA & mx plan

A

MOA : Folic acid antagonist –> inhibits RNA & DNA synthesis by deactivating dihydrofolate reductase
Dose : 1mg/kg
HCG D0, D4 & D7
Monitor LFTs (hepatotoxic)
If decrease <15%, rpt MTX dose

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13
Q

USS appearance molar pregnancy

A

Complete: snowstorm appearance, no embryo, bilateral thecal cystrs
Partial: embryo, cystic spaces in placenta

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14
Q

Pre-op management molar pregnancy

A

Ix: FBC, LFTs, U&E, CXR

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15
Q

F/U post molar pregnancy

A

Evacuation (12mm catheter) + anti-D if required

Monitor serum hcg weekly until normalised x 3/52

Normalisation <8/52 —> monitor for 6/12post ERPC

Normalisation > 8/52 –> monitor for 6/12 post normalisation

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16
Q

Complete vs partial molar pregnancy

Study These Flashcards
A

Complete: diploid empty ovum ( 2x sperm); uniparental disomy
Partial: triploid (1x ovum, 2x sperm)

17
Q

Treatment - choriocarcinoma - indications

Study These Flashcards
A
  • plateau or increasing bhcg
  • heavy PVB
  • mets
  • chorio on histo
  • bhcg >/= 20000
  • increase bhcg at 6/12 post ERPC
18
Q

Investigations of patients with GTN

Study These Flashcards
A

Pelvic USS
CXR and CT A-P
–> normal –> no further radiological ix
—> metastases –> CT chest, MRI brain

19
Q

Symptoms of invasive choriocarcinoma & Mx

Study These Flashcards
A

Sx: dyspnoea, haemoptysis, seizures
Ix: TFTs, hcg, U&E, LFT, FBC, CXR, CT TAP w MRI brain if lesions >2mm, USS abdo pelvis
If suspicious, run bhcg
ERPC –> histo diagnosis
Refer to GTD centre
Chemo required: complete - 15%, partial 0.5-1%
No anti-D required if complete (no fetal cells)

20
Q

Features of hyperemesis

Study These Flashcards
A

Weight loss
Ketonuria
Electrolyte imbalance/ dehydration
Vitamin and mineral deficiency
thyroid/ renal/ hepatic impairment

21
Q

Main vitamin deficiency in HG and rx

Study These Flashcards
A

Thiamine deficiency (vitamin B1) –> Wernicke’s encephalopathy –> irreversible neuro impairment
Rx w IV pabrinex (contains thiamine hydrochloride, riboflavin, pyridoxine
hydrochloride and nicotinamide (B vitamins); ascorbic acid (vitamin C); and glucose)

22
Q

HG presents as a complication of which conditions

Study These Flashcards
A
  • UTI
  • multiple pregnancy
  • GI conditions
  • Neuro conditions
  • Molar preg
  • endocrine - addisons, hypercalcaemia, uraemia, TFT
  • Psych conditions
23
Q

Assessment tool for HG

Study These Flashcards
A

PUQE score:
- /15
- 3 Q’s: how often nauseated, how many times vomited, how many times dry wretched
Aims to guide clinical decision making

24
Q

Definition and management of severe HG

Study These Flashcards
A

PUQE >/= 13
Ketonuria
Clinically dehydrated

Mx:
Admit
Cariban
Promethazine / prochlorperazine (po/ IM/ buccal) / cyclizine
IV fluids
Pabrinex
COnsider potassium replacement
No improvement: consider mteoclopramide
No improvement: consider ondansetron or hydrocortisone

25
Section 12 TOP act
<12/40 for maternal choice (from LMP) Primary: <9+6, 48 hour cool off period - mife + miso, low sensitivity PT 2/52 later - last day to be given D69 If unsure of dates --> USS >9/40 - hospital mTOP, 2 consultant sign off Hospital - if failed MTOP, unsure of dates, R/O ectopic 12/40 = 63mm
26
Section 11 TOP act
Fatal fetal anomalies 2-3% pregnancies have congenital anomalies --- 15% fatal/ life-limiting Fetal med referral Feticide can be performed no ensure no signs of life at delivery Indications include: B/L renal agenesis, severe skeletal dysplasia, anencephaly, T13, T18, hydrancephaly
27
Section 9 & 10 TOP act
Pertain to risk of life/ health of pregnant woman - 2 consultants to assess pt - women w mental health diagnoses/ medical diagnoses should have priority access
28
RCOG TOP guidelines
Cannot be reversed: <3% ongoing pregnancies, r/o congenital malformation 4.2% No need for USS if approp tissue passed If little/ no bleeding - r/o ectopic Haemodynamic instability - ERPC Offer LARC
29
TOP treatment algorithm - first trimester mTOP
Mife in clinic and admitted >24 hours to ward to commence med mx - 800mcg buccal miso stat, then 400mcg 3 hourly x 4 doses Pregnancy tissue passed --> visually inspect --> complete + no concern re GTD --> discharge No pregnancy tissue passed --> obstetrics review : ensure stable vitals, confirm correct administration of meds, US if uncertainty re all pregnancy tissue passed --> repeat medical regimen (400mcg buccal miso 3 hourly x 5doses) - OR sTOP if no pregnancy tissue passed after second round medical management --> sTOP
30
Complications TOP
Medication side effects: N&V, heavy bleeding, abdo pain Treatment failure - repeat mTOP/ sTOP Infection - rx w broad spectrum Abx sTOP complications: bleeding, perforation, cervical laceration
31
Management algorithm: acute haemorrhage following TOP
HISTORY - LMP - when were mife/ miso taken - duration of bleeding/ how much blood loss - ? passage of pregnancy tissue - ? discharge/ abdo pain - ? previous uterine surgery - PMHx EXAM - vitals/ abdo/ bimanual/ sse UNSTABLE PT - call for help - senior obstetrician/ anaesthetics - ABCs - 2x 14G IVC, FBC, LFT, U&E, CRP, coag, GXM, VBG - IV fluids, high flow O2, UC, blood products - T/F to theatre
32
Management ongoing/ incomplete termination (rx algorithm) in acute haemorrhage
- FBC, U&E, LFT, CRP, GXM - Consider theatre - ERPC (T1), MROP (T2) - consider abx - bimanual compression - consider uterotonics: IM/ IV oxytocin/ IM syntometrine/ IM carboprost - consider IV TXA/ fibrinogen/ clotting factors
33
Management infection in acute haemorrhage post TOP
FBC, U&E, LFT, CRP, GXM HVS, MSU, +- blood cultures IV broad spectrum antibiotics Consider ultrasound to r/o RPOC
34
Management uterine rupture in acute haemorrhage post TOP
FBC, U&E, LFT, CRP, GXM Emergency laparotomy Abx/ blood products
35
Algorithm for investigations recurrent miscarriage
Detailed hx from woman + partner After 2 consecutive losses: - TFTs, thyroid antibodies (thyroid peroxidase, thyroglobulin), FBC, ANA, thrombophilia (APL- lupus anticoagulant, anticardiolipin ab, B2 glycoprotein 1), consider HBA1c, TVUS If <35yo and 2 consecutive losses - perform cytogenetics. If no tissue for cytogenetics, perform parental karyotypes If >35yo and 3 consecutive losses, cytogenetics. Karyotype if no tissue available for cytogenetics
36
Modifiable risk factors for recurrent miscarriage
Smoking BMI Drugs Alcohol Diet (caffeine <200mg/d) FA Vit D
37
Treatment for unexplained recurrent miscarriage
Progesterone PV 400mcg bd Aspirin 75mg if at risk for placental insufficiency Address modifiable risk factors
38
Treatment for recurrent miscarriage by cause
Anatomy - reconstruction not recommended Thombophilia (hereditary) - aspirin 75mg preconception and LMWH once PT +ve Endocrine - rx hypothyroidism w eltroxin; progesterone 400mcg PV; hyperprolactinaemia - bromocriptine Genetics - gamete donor, PIGT

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