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OBGYN > Early Pregnancy > Flashcards

Early Pregnancy Flashcards

1
Q

What is an ectopic pregnancy?

A

Pregnancy which is implanted outside the uterus

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2
Q

Where is an ectopic pregnancy most likely to implant?

A

Fallopian tubes

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3
Q

What are the risk factors of ectopic pregnancy?

A 
Previous ectopic pregnancy 
Previous pelvic inflammatory disease 
Previous surgery to the Fallopian tubes 
Intrauterine devices 
Older age
Smoking
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4
Q

What are the features of an ectopic pregnancy?

A

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)

It is also worth asking about…

Any dizziness (indicates blood loss)
Shoulder tip pain (peritonitis)
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5
Q

What investigations would you carry out for an ectopic pregnancy?

A

Pregnancy test (urine B-HCG)

If positive- pelvic USS should be performed, this determines the presence of absence of an intrauterine ‘normal’ pregnancy. If an intrauterine pregnancy is not seen on trans abdominal USS then transvaginal should be offered

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6
Q

What could of happened if pregnancy is identified on ultrasound scan but the pregnancy test comes back as positive?

A

Very early intrauterine pregnancy
Miscarriage
Ectopic pregnancy

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7
Q

How do you distinguish between early intrauterine pregnancy, miscarriage and ectopic pregnancy?

A

In this situation a serum BHCG level should be taken

If the initial B-HCG level is >1500 and there is no intrauterine pregnancy on trans vaginal ultrasound, then this should be considered an ectopic pregnancy until proven otherwise, a diagnostic laparoscopy should be offered.

If the initial B-HCG level is <1500 and the patient is stable, a further blood test can be taken 48 hours later…
. In a viable pregnancy, HCG level would be expected to double every 48 hours

. In a miscarriage, HCG level would be expected to halve every 48 hours

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8
Q

What is the immediate treatment of an ectopic pregnancy?

A

Admission to hospital
A to E approach if they are unstable
This may include the use of blood products if there are signs of haemodynamic instability.

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9
Q

What is the medical management of an ectopic pregnancy?

A

IM methotrexate

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10
Q

How does methotrexate work in terms of abortion?

A

An anti folate cytotoxic agent which disrupts the folate dependent cell division of the developing foetus, the pregnancy will then gradually resolve.

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11
Q

What are the advantages and disadvantages of IM methotrexate?

A

Advantages: avoids the complications of surgical management and the patient can be at home after the injection.

Disadvantages: potential side effects of methotrexate- abdominal pain, myelosuppression, renal dysfunction, hepatitis, teratogenesis (patient must use contraception for 3-6 months after methotrexate use)

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12
Q

What is the surgical management of ectopic pregnancy?

A

Laparoscopic salpingectomy is usually performed- removing the tube that it is implanted in.

Salpingotomy May be needed if collateral tube is also affected.

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13
Q

What are the advantages and disadvantages of surgical management of an ectopic pregnancy?

A

Advantages- reassurance about when the definitive treatment can be provided, high success rate

Disadvantages: general anaesthetic risk, risk of damage to neighbouring structures like the bladder, bowel ureters, DVT/PE, haemorrhage, infection.

All rhesus negative women who Recieve surgical management of an ectopic pregnancy, should be offered Anti D prophylaxis.

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14
Q

What is the conservative management of an ectopic pregnancy?

A

Watchful waiting of the stable patient while allowing the ectopic pregnancy to resolve naturally. This is suitable for a small number of patients only.

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15
Q

What are the complications of an ectopic pregnancy?

A

An untreated ectopic pregnancy can lead to Fallopian tube rupture, the resulting blood loss can result in hypovolaemia shock and result in organ failure and death.

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16
Q

What is a miscarriage?

A

Spontaneous termination of a pregnancy

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17
Q

What is the difference between 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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18
Q

What is a missed miscarriage?

A

The foetus is no longer alive but no symptoms have occurred

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19
Q

What is a threatened miscarriage?

A

Vaginal bleeding with a closed cervix and a foetus which is alive

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20
Q

What is an inevitable miscarriage?

A

Vaginal bleeding with an open cervix

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21
Q

What is an incomplete miscarriage?

A

This is where retained products of conception remain in the uterus after the miscarriage

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22
Q

What is a complete miscarriage?

A

A full miscarriage has occurred, there are no products of conception left in the uterus.

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23
Q

What is an anembryonic pregnancy?

A

Gestational sac is present but contains no embryo

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24
Q

How do you diagnose a miscarriage?

A

Transvaginal ultrasound scan is the investigation of choice for diagnosing a miscarriage

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25
Q

What are the risk factors for miscarriage?

A 
Maternal age >30-35 
Previous miscarriage 
Obesity 
Chromosomal abnormalities 
Smoking 
Uterine anomalies 
Previous uterine surgery 
Anti phospholipid syndrome 
Coagulopathies
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26
Q

What are the clinical features of miscarriage?

A

Vaginal bleeding, including passing clots or products of conception however many are found incidentally on ultrasound

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27
Q

How would someone present if there is excessive bleeding iniscarriage?

A

Dizziness, pallor and shortness of breath. The bleeding is also often accompanied by a suprapubic cramping pain

28
Q

What signs would you have on examination of a patient who has suffered from miscarriage?

A

Haemodynamic instability- pallor, tachycardia, tachypnoea, hypotension

Abdominal examination- abdomen may be distended, with localised areas of tenderness

Speculum examination- assess the diameter of the cervical os, and observe for any products of conception in cervical canal, or local areas of bleeding

Bimanual examination- looking for any uterine tenderness and any adnexal masses or collections (consider ectopic pregnancy)

29
Q

What is differential diagnosis of miscarriage?

A

Ectopic pregnancy
Hydatidiform mole
Cervical/uterine malignancy

30
Q

How do you diagnose miscarriage in imaging?

A

Transvaginal ultrasound scan
Most important finding to exclude a miscarriage is fetal cardiac activity, observed transvaginally at 5 1/2-6 weeks gestation

If the crown rump length is <7mm and no foetal heart rate is identified, then a scan is needed again in at least 7 days.

31
Q

What other tests other than a transvaginal ultrasound (ruling out ectopic pregnancy/miscarriage) would you want to do for a woman bleeding during pregnancy?

A

Blood tests
Serum b-HCG measurements are useful in assessing the possibility of an ectopic pregnancy.

Other investigations indicated in women bleeding are…
. FBC
. Blood group and rhesus status
. Triple swabs and CRP (if pyrexial)

32
Q

What are the advantages and disadvantages of conservative management of miscarriage?

A

Conservative management allows the products of conception to pass naturally.
Patients should have 24/7 access to gynaecology services during this time

Advantages- can remain at home, there are no side effects of medications, no anaesthetic or surgical risk

Disadvantages- unpredictable timing, HMB, pain during passage of POC, chance of being unsuccessful requiring further intervention and need for transfusion.

33
Q

How can you follow up someone who has had a conservative management of miscarriage?

A

Scan in 2 weeks or pregnancy test in 3 weeks.

34
Q

What are the contraindications of conservative management of miscarriage?

A

Infection

High risk of haemorrhage- coagulopathy, haemodynamic instability

35
Q

What is the medical management of miscarriage?x

A

Vaginal misoprostol (prostaglandin analogue) this stimulates cervical ripening and myometrial contractions. It is usually preceded by mifepristone 24-48 hours prior to administration

36
Q

What are the advantages, disadvantages of medical management of miscarriage and what is the follow up?

A

Ad.vantages- can be at home if patient desires, with 24/7 access to gynaecology services, avoid anaesthetic and surgical risk

Disadvantages- side effects of medication, vomiting, diarrhoea, heavy bleeding and pain during passage of POC, chance of requiring emergency surgical intervention

Follow up- pregnancy test 3 weeks after

37
Q

What is the surgical management of miscarriage?

A

Manual vacuum aspiration with local anaesthetic if <12 weeks or evacuation of retained products of conception (ERCP)

38
Q

What are the indications for surgical management of miscarriage?

A

Haemodynamically unstable, infected tissue, gestational trophoblastic disease.

39
Q

What are the advantages and disadvantages of surgical management of miscarriage?

A

Advantages- planned procedure, and unaware of procedure (patient is under GA)

Disadvantages- anaesthetic risk, infection (endometritis), uterine perforation, haemorrhage, Ashermann syndrome, bowel or bladder damage, retained products of conception.

40
Q

What is recurrent miscarriage?

A

The occurrence of three or more consecutive pregnancies that end in miscarriage of the foetus before 24 weeks of gestation.

41
Q

What are the several factors that have been associated with recurrent miscarriage?

A

Antiphospholipid syndrome refers to the associationbetween antiphodpholipid antibodies and vascular thrombosis or pregnancy failure/complications

Genetic factors

Parental Chromosomal rearrangements

Embryonic chromosomal abnormalities

Endocrine factors- PCOS/ diabetes mellitus and thyroid

Uterine malformations

Cervical weakness

Acquired uterine abnormalities

Infective agents

Inherited thrombophilias

42
Q

What are the risk factors of miscarriage?

A

Advancing maternal age- if there is a decline in both the number and quality of the remaining OOCYTES.

Number of previous miscarriages

Lifestyle- cigarette smoking, moderate to heavy alcohol intake and caffeine consumption have been associated with an increased risk of spontaneous miscarriage in a dose dependent manner

43
Q

What investigations are done for recurrent miscarriage?

A

Blood tests
Antiphospholipid antibodies
Inherited thrombophilia

Genetic tests (karyotyping) 
Cytogenic analysis (chromosome abnormalities) performed on products on conception of third and subsequent consecutive msiscarrige

Parental peripheral blood karyotyping indicated when testing of products of conception reports an unbalanced structural chromosomal abnormality, performed on both partners

Imaging to assess uterine anatomy

44
Q

What is gestational trophoblastic disease?

A

A term used to describe group of pregnancy related tumours, they can be divided into 2 main groups…

Pre malignant conditions- partial molar pregnancy and complete molar pregnancy

Malignant conditions

45
Q

What is antepartum haemorrhage?

A

Vaginal bleeding from week 24 gestation until delivery

46
Q

What is placental abruption?

A

Where part or all of the placenta separates from the wall of the uterus prematurely,

47
Q

How does abruption of the placenta occur?

A

Abruption is thought to occurfollowing a rupture of the maternal vessels within the basal layer of the endometrium, blood accumulates and splits the placental attachment from the basal layer, the detached portion of the placenta is then unable to function which leads to a rapid fetal compromise.

48
Q

What are the two main types of placental abruption?

A

Revealed- this is where bleeding tracks down from the site of placental separation and drains through the cervix, it results in vaginal bleeding

Concealed- the bleeding remains within the uterus, and forms a clot retroplacentally

The bleeding is not visible but can cause systemic shock

49
Q

What are the risk factors for placental abruption?

A 
Previous 
Pre eclampsia 
Trauma (domestic violence) 
Multiple pregnancy 
Fetal growth restriction 
Multigravida 
Increased maternal age 
Smoking 
Cocaine/amphetamine use
50
Q

What are the clinical features of a placental abruption?

A

Painful vaginal bleeding
If the woman is in labour she may have pain between contractions
On examination the uterus will be tense all the time and painful on palpation

51
Q

What are the differential diagnoses of placental abruption?

A

Placenta praevia
Marginal placental bleed
Vasa praevia
Uterine rupture

Local genital causes…
benign or malignant lesions (polyps, carcinoma, cervical ectropion (common)

Infections- candidiasis, bacterial vaginosis, chlamydia.

52
Q

What investigations can you do for placental abruption?

A

If major bleeding is suspected then resuscitate and perform investigations simultaneously

FBC, clotting profile, KLEIHAUER test, group and save, cross match

U and Es, LFTS

CTG (cardiotocograph) in women above 26 weeks gestation

Ultrasound scan

53
Q

How do you manage placental abruption?

A

Any woman with significant antepartum haemorrhage should be resuscitated with an ABcDE approach, do not delay maternal resuscitation in order to determine fetal viability.

Ongoing management depends on the health of the foetus

Emergency delivery- Caesarean section unless spontaneous delivery is imminent or operative vaginal birth is achievable.

Induction of labour- for haemorrhage at term without maternal or feral compromise

Conservative management- partial or marginal abruption, not associated with maternal or fetal compromise

In all cases give anti D within 72 hours of the onset of bleeding if the woman is rhesus D negative

54
Q

What is placenta praevia?

A

Where the placenta is fully or partially attached to the lower uterine segment. It is an important cause of antepartum haemorrhage- vaginal bleeding from week 24 of gestation until delivery.

55
Q

What is the difference between a minor and major placenta praevia?

A

Minor- placenta is low but does not cover the internal cervical os
Major placenta praevia- placenta lies over the internal cervical os

56
Q

What is the risk factor for placenta praevia?

A

Previous Caesarean section is the main one
Others;
High parity
Maternal age>40
Multiple pregnancy
Previous placenta praevia
History of uterine infection (endometritis)
Curettage to the endometrium after a miscarriage or termination

57
Q

What are the clinical features of placenta praevia?

A

Clinically presents as painless vaginal bleeding, can vary between spotting to massive haemorrhage. Can be pain if the woman is in labour.

58
Q

What are the bloods for placenta praevia?

A 
FBC 
Clotting profile 
KLEIHAUER test 
Group and save 
Cross match

U and Es
LFTS
Used to exclude hypertensive disorders including pre eclampsia and HELLP syndrome

59
Q

What imaging is done for placenta praevia?

A

Imaging via ultrasound

60
Q

What is the management of placenta praevia?

A

A to E approach

If placenta praevia has been identified at their 20 weeks then for a minor it should be repeated at 36 weeks, whereas for a major it should be repeated at 32 weeks and plan for delivery should be made.

Caesarean section is the safest mode of delivery, usually warrants an elective Caesarean section at 38 weeks.

61
Q

What is thought to be responsible for nausea and vomiting during pregnancy?

A

Human chorionic gonadotropin (produced by the placenta)

62
Q

What is hyperemesis gravidarum?

A

The severe form of nausea and vomiting in pregnancy, the criteria for diagnosing this is protracted nausea and vomiting, plus…

. More than 5% weight loss compared with before pregnancy
. Dehydration
. Electrolyte imbalance

63
Q

What antiemetics can be used for hyperemesis gravidarum?

A
  1. Prochlorperazine
  2. Cyclizine
  3. Ondansetron
  4. Metaclopramide

Other complimentary therapies may be used by the woman…
. Ginger
. Acupressure on the wrist at the PC6 point (inner wrist) can improve the symptoms

64
Q

What is a molar pregnancy?

A

This is where there is a hydatiform mole (type of tumour that grows like a pregnancy inside the uterus), can either be partial or complete.

65
Q

Molar pregnancy behaves like a normal pregnancy, periods stop and hormonal changes of pregnancy occur, what things may indicate a molar pregnancy versus a normal pregnancy?

A 
More severe morning sickness 
Vaginal bleeding 
Increased enlargement of the uterus 
Abnormally Hugh hCG 
Thyrotoxicosis (hCG can mimic TSH and stimulate the thyroid to produce  excess T3 and T4)
66
Q

How can you diagnose a molar pregnancy?

A

Ultrasound scan will show ‘ snowstorm appearance’ of the pregnancy
Provisional diagnosis can be made by ultrasound and confirmed with histology of mole after evacuation.

67
Q

How do you manage a molar pregnancy?

A

Evacuation of the uterus to remove the mole.
The products of conception then need to be sent for histological examination to confirm a molar pregnancy. Patients should be referred to the gestational trophoblastic disease centre for management and follow up. HCG levels aren’t monitored until they return to normal

Mole can metastasise and patient may require systemic chemo

OBGYN (10 decks)

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