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MFSRH part 2 > Early Pregnancy > Flashcards

Early Pregnancy Flashcards

1
Q

Possible sites of ectopic pregnancy

A 
Fallopian tube = 95 %
Interstitial = 2%
Cervical = 0.1%
Ovarian = 0.01%
C/S scar -rare
Abdominal - rare
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2
Q

Risk factors for ectopic pregnancy

A 
Previous PID
Previous tubal surgery
Previous ectopic pregnancy
Infertility
Assisted reproduction 
IUD 
Smoking
Increased maternal age
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3
Q

When should women with confirmed ectopics be scanned in subsequent pregnancies?

A

6 weeks to confirm IUP

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4
Q

Symptoms of ectopic pregnancy

A

Amenorrhoea
PV Bleeding
Abdominal pain
GI symptoms

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5
Q

Signs of ectopic pregnancy

A

Lower abdominal tenderness
Adnexal tenderness
Cervical excitation
Shock / collapse

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6
Q

Diagnosis of ectopic pregnancy

A

USS - empty uterus, variable endometrial thickening, thin endometrium, intrauterine pseudogestational sac.

  • adnexal - hyperechoic tubal ring, mixed adnexal mass, ectopic sac / embryo
  • Adnexal tenderness to vaginal probe
  • Fluid in POD
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7
Q

Investigations in ectopic pregnancy

A

FBC
G+S (2U crossmatch)
BhCG

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8
Q

Who can have methotrexate to mange ectopic pregnancy

A 
No significant pain
Unruptured adnexal mass <35 mm with no
visible heartbeat
Serum hCG <1500 IU/litre
Able to return for FU
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9
Q

Who can have expectant management of ectopic pregnancy

A

Able to attend for follow-up
ultrasound diagnosis of ectopic pregnancy
Absent /mild clinical symptoms
No signs of rupture or intraperitoneal bleeding
b-hCG initially less than 1500 iu/l.
and decreasing

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10
Q

% risk of miscarriage for a maternal age at conception of >45yrs

A

93%

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11
Q

% risk of miscarriage for a maternal age at conception of 20-24yrs

A

9%

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12
Q

% risk of miscarriage for a maternal age at conception of 30-34 yrs

A

15%

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13
Q

% risk of miscarriage for a maternal age at conception of 35-39 yrs

A

25%

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14
Q

Incidence of ectopic pregnancy?

A

Ectopic pregnancy occurs in 11 in 1000 pregnancies.

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15
Q

Maternal mortality rate for ectopic pregnancy in UK?

A

Maternal Mortality rates for ectopic pregnancy in the UK

2 per 1000 = (0.2%)

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16
Q

What are the possible locations of ectopic pregnancy and which are most common?

A

The majority of ectopics are tubal
Non-tubal ectopics account for 3-5%

Tubal 93-95%
Interstitial 2-5%
Cervical <1%
Ovarian <1%
Abdominal <1%
Heterotopic <0.1%
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17
Q

Tubal ectopics account for 93-95% of all ectopics, what can they be sub-categorised into?

A

Tubal pregnancies can be further subdivided into:

Ampullary section 70-80%
Isthmus 12%
Fimbrial 5-11%
Cornual and interstitial part of the tube 2%

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18
Q

Definition of recurrent miscarriage

A

Recurrent miscarriage is

loss of three or more consecutive pregnancies before the 24th week of gestation

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19
Q

What treatment is recommended in the Greentop guideline for recurrent miscarriage

A

Pregnant women with antiphospholipid syndrome - consider low-dose aspirin plus heparin

an abnormal parental karyotype should prompt referral to a clinical geneticist

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20
Q

What is the most important treatable cause of recurrent miscarriage

A

Antiphospholipid syndrome

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21
Q

How is Antiphospholipid syndrome diagnosed

A

two positive tests
taken at least 12 weeks apart
for either lupus anticoagulant or anticardiolipin antibodies of immunoglobulin G and/or immunoglobulin M class
present in a medium- high levels over 40g/l or >99th percentile

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22
Q

Management of Pregnant women with antiphospholipid syndrome

A

Pregnant women with antiphospholipid syndrome

considered low-dose aspirin plus heparin

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23
Q

When should Parental peripheral blood karyotyping be performed?

A

In recurrent miscarriage patients

where an unbalanced structural chromosomal abnormality is detected on products of conception.

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24
Q

Management if a Parental peripheral blood karyotyping is abnormal

A

An abnormal parental karyotype should prompt referral to a clinical geneticist

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25
Q

What is the % of trophoblastic activity which persists after surgery for ectopic pregnancy?

A

8% after laparoscopic salpingotomy.

4% after open surgery.

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26
Q

At what gestation do symptoms of ectopic pregnancy usually start?

A

6weeks

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27
Q

Definition of incomplete miscarriage

A

Bleeding with an open cervical os and passage of some tissue but some pregnancy tissue remains in the uterus

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28
Q

What % of incomplete miscarriages will resolve without intervention?

A

90%

29
Q

In what % of pregnancies does a molar pregnancy occur

A

0.1% of pregnancies

30
Q

In what ethnicity is molar pregnancy more common?

A

3x more common in Asian women

31
Q

Presentation of a molar pregnancy

A 
Painless vaginal bleeding in the 4-5th month.
Passage of grape like vesicles. 
Persistent nausea and vomiting.
Ovarian cysts.
Large for dates. 
Visible on USS.
32
Q

What is the difference between complete and partial hydatiform moles?

A

Complete moles are diploid + have no evidence of fetal tissue.
Partial moles have some fetal tissue or an abnormal fetus.

33
Q

Definition of a complete miscarriage

A

Passage of all the pregnancy tissue.

Closed os on examination. No tissue in the uterus.

34
Q

Definition of a threatened miscarriage

A

Vaginal bleeding in early pregnancy but no other symptoms.
Cervical os closed.
May progress to normal pregnancy or to miscarriage

35
Q

Definition of a inevitable miscarriage

A

Cervical os is open , abdominal cramping and bleeding started/increasing

36
Q

Definition of a septic miscarriage

A

Miscarriage developing into an infection of the uterus.

Fever, chills, discharge, abdo pain, myalgia.

37
Q

What % of miscarriages occur by 12 weeks?

A

80% of all miscarriages occur by week 12.

38
Q

What % of women who know they are pregnant miscarry before 20 weeks?

A

Up to 20%

1/5

39
Q

Causes of miscarriage

A

Embryo fails to develop inside gestational sac.
Abnormal embryo.
Chromosomal abnormalities.
Structural abnormality of the reproductive tract.

40
Q

Miscarriage risk factors

A 
increasing maternal age.
young maternal age
Previous miscarriage
Smoking >10 day 
Alcohol 
Fever >37.8
Uterine trauma
Very high caffeine levels (>10 cups of coffee/1000mg)
41
Q

Management of miscarriage

A

Conservative - watch and wait.
Medical.
Surgical.

42
Q

Until what gestation is the term ‘embryo’ correct?

A

Embryo until 10 weeks gestation.

43
Q

What is the most common complication in early pregnancy?

A

Miscarriage

44
Q

Next structure to be visible on USS after the gestational sac

A

Yolk sac

5th week

45
Q

Size of a normal yolk sac on USS

A

Up to 6mm

46
Q

What is the most common sonographic abnormality in the presence of a live embryo

A

Subchorionic hemorrhage (subchorionic hematoma)

47
Q

Where does a subchorionic hemorrhage (hematoma) collect?

A

subchorionic hemorrhage (hematoma) collects between the uterine wall and the chorionic membrane and may leak through the cervical canal

48
Q

How is a Pregnancy dated?

A

Historically dated from the last menstrual period not the date of conception

49
Q

What is the Dubowitz score an assessment of?

A

Gestational age

50
Q

Does smoking increase the rate of miscarriage?

A

Yes. Smokers have a 20-30% of 1st trimester miscarriage

51
Q

Definition of recurrent miscarriage.

A

3 or more consecutive pregnancy losses before 24 weeks

52
Q

What % of women are affected by recurrent miscarriage?

A

1%

53
Q

What treatments for recurrent miscarriage are highlighted in the RCOG guidance as lacking evidence?

A

treatments for recurrent miscarriage that have insufficient evidence

  • Paternal cell immunisation, third-party donor leucocytes, trophoblast membranes and intravenous immunoglobulin
  • Corticosteroids
  • Metformin
  • LH suppression in PCOS
  • HCG supplementation
  • Progesterone supplementation
  • Preimplantation genetic screening with IVF for women with unexplained recurrent miscarriage
  • Uterine septum resection in women with recurrent miscarriage and uterine septum
54
Q

What antibodies are tested for in antiphospholipid syndrome

A

Anticardiolipin
Beta-2 glycoprotein I (2GPI)
Lupus anticoagulant

55
Q

Management of women who experience a second trimester miscarriage

A

A single 2nd T miscarriage should be investigated

  • Screen for inherited thrombophilias
    incl factor V Leiden, factor II (prothrombin) and protein S
  • Antiphospholipid antibodies
  • Pelvic ultrasound
56
Q

What is the live birth rate in women with recurrent miscarriage associated with antiphospholipid antibodies without treatment?

A

10%

combined aspirin and heparin treatment reduces miscarriage rate by 54%.

57
Q

What percentage of women with recurrent miscarriage have antiphospholipid antibodies?

A

In women with recurrent miscarriage the rate is around

15%

58
Q

What percentage of women with no known risk factors have antiphospholipid antibodies?

A

2%

59
Q

What percentage of women are affected by recurrent miscarriage?

A

1-3%

60
Q

How many women with an ectopic pregnancy have no risk factors?

A

1 in 3

61
Q

Who should be referred to an EPAU and how urgent?

A

Immediate / ED OOH if UPT +ve with pain on examination or cervical motion tenderness

Non urgent referal if UPT postive and reporting pain but non identified on examination
or pregnancy >6wk with bleeding
or pregnancy unknown gestation with bleeding

62
Q

Management of F with +ve UPT <6/40 with bleeding but NOT pain

A

expectant management
repeat UPT in 7-10 days and return if remains positive
Negative UPT at that time confirms miscarraige

Return if bleeding worsens or pain develops

63
Q

Management in EPAU if CRL on TV USS <7mm and no FH

A

Perform second scan a minimum of 7 days later before diagnosing miscarraige

64
Q

EPAU management of TV USS with CRL ≥ 7mm and No FH

A

Second opinion to confirm no FH present
and to confirm diagnosis of miscarriage

OR repeat USS in 7/7

65
Q

Steps for confirming viability on EPAU TV scan

A

Look for FH
If no FH measure CRL if fetal pole present
If no fetal pole measure gestational sac diameter

66
Q

EPAU management of no FH and CRL measured by TA scan only

A

Record CRL measured TA

Repeat scan in 14 days before making a diagnosis of miscarriage

67
Q

EPAU management of TV USS showing mean sac diameter <25mm and no fetal pole

A

Repeat scan in 7 days

68
Q

when does an EPAU accept patient self referal

A

F with recurrent miscarriage (3 consecutive)
Previous ectopic
Previous molar pregnancy

69
Q

3 Common symptoms of ectopic pregnancy

7 other symtoms

A
  1. UPT +Ve / amenorrhoea / missed period
  2. Pain - abdominal or pelvic
  3. bleeding PV +/- clots

others - breast tenderness

  • GI symptoms
  • dizziness / fainting
  • shoulder tip pain
  • urinary symptoms
  • passage of tissue
  • rectal pressure / pain / pain on defecation

MFSRH part 2 (24 decks)

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