Early Pregnancy Care

Question 1

Risk factors for ectopic

Answer 1

Mat age 35-44
Prev ectopic
Preb pelvic or abdominal surgery
PID
Conceiving after having a tubal ligation or while an IUCD is in situation
Smoking
Endometriosis

1/3rd of women with an ectopic will have no RFs

Question 2

What is the rate of recurrence after a caesarean scar pregnancy CSP

Answer 2

3.2-5% in a women with one prev CS treated by dilation and currettage with or without uterine artery embolisation

-

Question 3

What are risk factors associated with increased risk of recurrence of a CSP

Answer 3

factors associated with increased risk of recurrence include a uterine segment thickness measuring les than 5mm,
gestational sac bulging into the utero-vesicle fold,
caesarean delivery in a rural community hospital and
history of irregular vagnial bleeding and
abdominal pain during previous CSP

Question 4

What is a positive sliding sign

Answer 4

When gentle pressure at the level fo the internal cervical os may displace the gestational sac thus demonstrating what is know as the sliding sign

The sliding sign is absent in CSP and cervical ectopic pregnancy

Positive = moving independently of the other tissue
Negative= all stuck together moving together

Question 5

USS features of a CSP

Answer 5

Sometimes need both TAS and TVS

-Empty uterine cavity and closed and empty cervical canal
-placenta and or GS embedded int he scar of a prev CS
- a triangular /round or oval-shaped GS that fills the niche of the scar
- a thin or absent myometira layer between the GS and the bladder
-yolk sac , embryo and cardiac activity may or may not be present
- evidence of functional Trophoblastic/placental circulation on color flow Doppler examination,
Characterized by high velocity and low impedance blood flow
- negative sliding sign

Question 6

What is the incidence of anueploidy in recurrent miscarriage

Answer 6

40% so non genetic factors may play a more important role

Question 7

When to do a TAS in early pregnancy

Answer 7

When an enlarged uterus or other pelvic pathology such as fibroid or an ovarian cyst is present

Question 8

Risk of miscarriage by age

Answer 8

12-19 yr old= 13%
20-24 yr old = 11%
25-29 yr old = 12%
30-34 yr old = 15%
35-39 yr old = 25%
40-44 yr old = 51%
45 or > = 93%

Question 9

What risk factor makes it more likely for a CSP to occur

Answer 9

Prev caesarean section for breech presentation

Question 10

Probability of a successful pregnancy after miscarriages

No prev to 6 prev

Answer 10

No prev = 11.3
1 prev= 17%
2 or 3 prev = 28%
4 = 39.6%
5 = 47.2%
6 = 63.9%

Question 11

When does she not need an USS in early preg

Answer 11

If less than 6 weeks preggo and bleeding and no pain, can just do a preg test in 7-10 days

Question 12

Which parental chromosomal rearrangements carries the highest rate of miscarriage

Answer 12

Reciprocal translocation - 54%
Inversions- 49%
Robertsonian - 34%
Others - 27%

Question 13

Risk of CSP if had one prev CS and has an ectopic

Answer 13

6.1%

Incidence range from 1/1800 to 1/2500 of all pregnancies

Question 14

Definitions of common and uncommon,,,

Answer 14

Question 15

How to treat an exogenous CSP if live and over 5000 HCG and over 8 w

Answer 15

Surgical resection - laparoscopic excision and resuturing
Can also be done via laparotomy and as an interval after termination of pregnancy with methotrexate

Question 16

How to treat live CSP if HCG <5000 and <8 weeks

Answer 16

Methotrexate

Question 17

What is antiphospholipid syndrome?

Answer 17

The association between antiphospholipid antibodies (lupus anticoagulant ,anticardiolipid antibodies and anti-beta 2 glycoprotein 1 antibodies) and adverse pregnancy outcome or vascular thrombosis

Adverse preg. Outcomes=
3 or more consecutive miscarriages before 10w
One or morephrphologically normal fetal mosses after 10w
One or more preterm births before 34w because of placental disease

Question 18

What has the strongest association with recurrent miscarriage

Answer 18

Lupus anticoagulant

Question 19

Which thrombophilias have been shown to have an association with miscarriage

Answer 19

Factor V Leiden - associated with 1st and especially 2nd trim. Miscarrriage

Methylentatrahydrofolate reductase mutation- hetero and homo- has been found to have a significant association with recurrent miscarriage in one meta-analysis from china.

Prothrombin gene mutation- recurrent miscarriage

Prostein S deficiency - 2nd trimester miscarriage

Question 20

The incidence of parental chromosomal rearrangements appears to be associated with recurrent miscarriage translocation present in parents with 1,2,3 recurrent miscarriage is

Answer 20

One is 2.2%
Two= 4.8%
3= 5.7%

Question 21

Recurrence rate after one ectopic ?post methotrexate treatment

Answer 21

20%

Question 22

Pregnancy with coil in situ?

Answer 22

Go to EPAU
Has a risk of 1 in 20 of an ectopic
Don’t remove the IUCD until location of pregnancy is confirmed

Question 23

MVA suitability

Answer 23

Stable
Parous women
Well motivated nulliparound who can tolerate specs
USS of CRL <25mm
USS of incomplete miscarriage or RPPC <50mm
No signs of infection

Question 24

Not suitable for MVA

Answer 24

> 10w gestations
Cervical stenosis
Fibroid uterus >12w size
Uterine malformation
Haemorrhagic disorder and treatment of anticoagulants
Postnatal retained products
Uterine infection
RPOC > 50mm

Question 25

Consent

Answer 25

Fraser’s competent can give consent under 16 If over 18 can consent fully and withhold Can’t withhold consent if under 16 Patient can consent if under 16 On Scotland 16 and over can consent and withhold consent

Question 26

What to do if bleeding and viable preggo in early preg

Answer 26

Return to epau if bleeding worse or persists beyond 14 days Of prev miscarriage and now bleeding- give progesterone 400mg BD , continue progesterone until 16w

Question 27

1st line meds for nausea and vomiting in preggo

Answer 27

Cyclizine Prochloperazine 5-10mg 6-8hrly PO, 12.5mg TDS IM Promethazine 12.5mg -25mg , 4-8h PO,IM Chlorpromazine 10-25mg , 4-6h

Question 28

2nd line meds for nausea and vomiting in preggo

Answer 28

Metochlopramide 5-10mg TDS PO, IV Dimperidone 10mg TDS PO Ondansetron 4-8mg PO 6-8h

Question 29

3rd line meds for nausea and vomiting in preggo

Answer 29

Corticosteroids - hydrocortisone 100mg BD IV , once clinical improvement occurs then convert to prednisone 40-50mg daily PO with the dose gradually tapered until the lowest maintenance dose that controls the symptoms is reached

Question 30

Pre op MVA analgesia

Answer 30

400-800 mg ibuprofen or 500mg naproxen given 1 hour pre MVA If can’t have NSAIDS Give paracetamol or codeine Paracevical block - 30mg/ml prilocaine and 0.03 IU /ml feiypressin

Question 31

Sliding sign when present?

Answer 31

Present in incomplete miscarriage, Not present in a cervical ectopic

Question 32

When to give methotrexate

Answer 32

If no significant pain (If PUL) Un ruptured ectopic preg with a mass small than 35mm with no visible heartbeat A serum HCG between 1500 and 5000 No intrauterine preg. As confirmed on USS

Question 33

What to do if BHCG decreases more than 50% after 48h

Answer 33

Inform pt that preg unlikely to continue but can’t confirm at the time Give info about support and epac Ask to do preg. Test 2 weeks after second BHCG

Question 34

Remember conservative management for an ectopic Is possible!

Answer 34

If BHCG is less than 1500 and decrease it and if she is stable

Question 35

Treatment of CSP as endogenic but also as exogenic

Answer 35

Suction evacuation of uterus is the most described method Can be done as hysteroscopy as well , Evac can be combined with cervical cerclage , foley catherter insertion or UAE as additional haemostatis measures

Question 36

Risk factor for heterotopic preg and symptoms

Answer 36

IVF is a RF If IU preg and complaining of peristnat pelvic pain and if constantly raised BHCG level post TOP or miscarriage

Question 37

Treatment for cervical pregnancy

Answer 37

Methotrexate Surgical management have a high failure rate and should be reserved for women suffering life threatening bleeding

Question 38

Cervical preg what does it look like

Answer 38

1% of all ectopics Empty uterine cavity A barrel shaped cervix A gestational sac present below the level of the internal cervical os No sliding sign

Question 39

Interstitial ectopic pregnancy signs

Answer 39

When ectopic implants in the interstitial part of the fallopian tube 1-6.3% incidence The interstitial part of the fall pain tube is about 1-2cm in length and traverses the muscular myometrium of the uterine wall opening via the tubal ostium into the uterine cavity Empty cavity and closed cervix in a lateral spect of the uterus with an thin echogenic line extending from the central uterine cavity echo to the periphery of the sac - the interstitial line sign surrounded by less than 5 mm of myometrium in all imaging planes, and presence of the‘interstitial line sign’. • further confirmed using three-dimensionalultrasound, where available, to avoid misdiagnosis with early intrauterine or angular(implantation in the lateral angles of the uterine cavity) pregnancy. • Supplementation with MRI can also be helpful in the diagnosis of interstitial pregnancy. •

Question 40

Interstitial ectopic preg management

Answer 40

Nonsurgical management is an acceptable option for stable interstitial pregnancies. Expectant management is only suitable for women with low or significantly fallingb-hCG levelsin whom the addition of methotrexate may not improve the outcome. A pharmacological approach using methotrexate has been shown to be effective, although,there is insufficient evidence to recommend local or systemic approach. Surgical management by laparoscopic cornual resection or salpingotomy is an effective option. Alternative surgical techniques could include hysteroscopic resection under laparoscopic or USS guidance. There is insufficient evidence on safety and complications in future pregnancies to recommendother nonsurgical methods.

Question 41

Management of an abdominal pregnancy

Answer 41

If stable - DO MRI! Can help tp confirm the diagnosis and to identify placental implantation over vital structures such as major blood vessels or bowel USS and or MRI can be used to precisely map the location of the placenta prior to laparotomy so as to avoid incising th placenta and the associated risk of uncontrollable haemorrga e If need op better to do laparotomy

Question 42

Ovarian pregnancy USS findings

Answer 42

Adnexa shows a complex left adnexal mass with mixed echogenicity arising from the left ovary which if tender during scanning Wide echogenic ring with an internal anechoic area on the ovary Negative sliding organ sign - not possible to separate the cystic structure or gestational sac from the ovary on gentle palpation There are no specific agreed criteria for the ultrasound diagnosis of ovarian ectopic pregnancy. • A single serum b-hCG should be carried, a repeat serum b-hCG in 48 hours may be useful in deciding further management

Question 43

Ovarian pregnancy management

Answer 43

Definitive surgical treatment is preferred if laparoscopy is required to make the diagnosis of ovarian ectopic pregnancy Methotrexate can be used to treat ovarian ectopic pregnancy when the risk of surgery is high or post operativley in the presence of perisistant residual trophoblast or persistently raised HBCG levels, Or if static /lowering HCG levels