Early Pregnancy

Question 1

How does an ectopic pregnancy ususlly present ?

Answer 1

Usually around 6-8 weeks 
Missed period 
Constant pain in right or left iliac fossa 
Vaginal bleeding 
Lower Abdo tenderness 
Cervical motion tenderness

Question 2

What could syncope or dizziness indicate

Answer 2

Blood loss

Question 3

Shoulder tip pain ?

Answer 3

Periontonititis so it has ruptured

Question 4

How do you investigate an ectopic pregnancy

Answer 4

Transvaginal ultrasounds scan

Question 5

What is a pregnancy of unknown location

Answer 5

Positive pregnancy test and no evidence of pregnancy on USS

Question 6

What marker can you look at to help monitor a pregnancy of unknown location ? And what rise is suggestive of a normal intrauterine pregnancy ?

Answer 6

Serum HCG do and then do 48 hours later
If risen more than 63 percent intrauterine
Less than 63 percent may indicate an ectopic pregnancy
A fall of more than 50 percent is likely a miscarriage

Question 7

How do you treat an ectopic pregnancy ?

Answer 7

All non viable and all need to be terminated
Three options
Expectant management
Medical
Surgical
Criteria for expectant - HCG less than 1500 , no rupture , no pain , no heart beat , Adnexal mass less than 35 mm
Need to followed up to check for successful termination

Medical
HCG less than 5000
Confirmed absence of intrauterine pregnancy on USS

This is dine by giving methotrexate which is highly teratogenic
IM injection
Women told to not get pregnant for 3 months as harmful effects for pregnancy can last this long

Surgical - most women 
Pain 
Adnexal mass greater than 35 mm 
Heartbeat 
HCG greater than 5000

Question 8

What is the surgical management of ectopic

Answer 8

Laparoscopic salpinectomy - 1st line - GA - remove whole Fallopian tube
Laparoscopic salpingomtomy - if other tube already damged - try just remove ectopic pregnancy - may need further treatment with methotrexate or sapingoectimy - 1/5 needs this

Anti D prohylaxis for all women who rhesus negative

Question 9

What is a missed miscarriage

Answer 9

Fetus not alive but syntoms not occurred

Question 10

Threatened miscarriage

Answer 10

Fetus alive , cervix closed and vaginal bleeding

Question 11

Inevitable miscarriage

Answer 11

Vaginalis bleeding and open cervix

Question 12

Incomplete miscarriage

Answer 12

Retained products of conception still in uterus after the miscarriage

Question 13

Complete miscarriage

Answer 13

Full miscarriage had occured and no products of conception left in the uterus

Question 14

Anembryonic pregnancy

Answer 14

Gestational sac present but no embryo

Question 15

How do you investigate a miscarriage

Answer 15

Transvaginal USS
3 key features

As each appears , previous feature less relevant in assessing viability

Mean gestational sac diameter - expect fetal pole when sac diameter is 25 mm , if gestational sac greater than 25 and no pole - repeat USS in a week and still no fetal pole , it is an anembryonic pregnancy

Fetal pole and crown rump length - if crown rump length greater than 7 mm and no heart beat do USS in a week and if still no heart beat - it is a non viable pregnancy

Fetal heartbeat - if heartbeat present it is considered a viable pregnancy

Question 16

How do manage a miscarriage less than 6 weeks gestation

Answer 16

Manage expectantly and do repeat urine pregnancy test after 7-10 days and if negative , miscarriage can be confirmed
Assuming no pain or other complications or risk factors
No need for investigations or treatment
USS not helpful as orgencncy too small to be seen

Question 17

How do you treat a miscarriage greater than 6 weeks gestation

Answer 17

Refer to early pregnancy assessment service EPAU
( greater than 6 weeks gestation and bleeding = referral )

Will arrange an USS to check location and viability - must exclude ectopic 
The either 
Expectant
Medical 
Surgical

Question 18

Expectant management of miscarriage

Answer 18

No risk factors for heavy bleeding or infection
1-2 weeks given for miscarriage to happen spontaneously
Do repeat urine pregnancy test 3 weeks after symptoms settled to confirm
Worsening or persistent bleeding requires further assessment as may indicate incomplete miscarriage

Question 19

What is a medical management of miscarriage

Answer 19

Misoprostol is the medication given

Question 20

How does misoprostol work

Answer 20

It is a prostaglandin analogue so binds to prostaglandin receptors and activates them and prostaglandin causes softening of the cervix and stimulates uterine contractions
Misoprostol can be given orally or as a vaginal suppository

Question 21

What is surgical management of a miscarriage

Answer 21

Give prostaglandins to soften cervix - misoprostol
Anti rhesus D prophylaxis given to rhesus negative women
The can either do
Manual vaccum evacuation - can be done with a local anaesthetic but must be below 10 weeks gestation
Electric vacuum evacuation - GA

Question 22

How do you treat an incomplete miscarriage

Answer 22

Medical - misoprostol

Surgical - GA - vacuum aspiration and curettage - key complication of procedure is endometritis infection

Question 23

What’s the definition of recurrent miscarriage

Answer 23

3 or more consecutive miscarriages

Question 24

What can cause recurrent miscarriages?

Answer 24

Idiopathic 
Antiphosphilipid syndrome 
Hereditary thrombophilias 
Uterine abnormalities 
Genetic factors 
Chronic histiocytic intervillositis 
Chronic diseases such as diabetes , untreated hypothyroidism and SLE

Question 25

What is anti phospholipid syndrome

Answer 25

Antiphosplipid antibodies Blood becomes prone to clotting Hypercoaguabke state - thrombosis , can have histiry if DVTs Causes recurrent miscarriage Treat with aspirin and LMWH

Question 26

Management of recurrent miscarriages

Answer 26

Dependent on cause Some evidence to suggest vaginalis progesterone pessaries during early pregnancy for women with recurrent miscarriages can help

Question 27

How and when do you do a medical abortion

Answer 27

Medical abortions involves two treatments Mifepristone Misoprostol Mifepristone is an anti progesterone medication , blocking the action of progesterone , halting the pregnancy and softening the cervix You take misoprostol 1-2 days after mifepristone , this works by activating prostaglandin receptors softening the cervix and stimulating uterine contractions Give anti rhesus D prophylaxis if greater than 10 weeks gestation to rhesus negs

Question 28

How do surgical abortions work

Answer 28

Prime the cervix prior to surgery using misoprostol and mifepristone or osmotic dilators Osmotic dilators work by inserting a device into the cervix , and it expands as it absorbs fluid Two surgical options Up to 14 weeks - cervical dilation and suction of contents Between 14 and 24 weeks - cevical dilatation and evacuation of contents with forceps

Question 29

What is hyperemesis gravidarum

Answer 29

``` Protracted nausea and vomiting Plus Losing 5 percent of body weight since pre pregnancy Dehydrated Electrolyte imbalance ```

Question 30

Management of hyperememis gravidarum

Answer 30

``` Anti emetics In this order approx of known safety Prochlorperazine Cyclizine Ondansetron Metacloperamide Can give orally or IV or IM ``` If moderate or severe can also give Iv fluids And monitor U and Es daily Thromboprophylaxis if in hospital Can give rnaistidine and omeprazike if reflux is issue

Question 31

What is a molar pregnancy

Answer 31

Complete is ovum with no genetic material and two sperm fertilise , divides and grows ,no fetal matierial Partial is ovum with genetic material that had two sperm fertilise, divides and grows , some fetal matierial may form

Question 32

How do you manage a molar pregnancy

Answer 32

Evacuation of uterus Refer gestational trophoblastic centre Some may need systemic chemo as can mestatsise