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Early Pregnancy Pathology Flashcards

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1
Q

How common is hyperemesis gravidarum?

A

0.1-1% of pregnancies, however general N&V is common and affects >50%

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2
Q

Describe the pathophysiology of hyperemesis gravidarum

A

Level of hCG is directly related to severity, higher in multiple and molar pregnancy

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3
Q

What is the prognosis of hyperemesis gravidarum?

A

Usually improves by 12 weeks gestation as hCG levels fall

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4
Q

How does hyperemesis gravidarum present?

A

N&V

Dehydration

Electrolyte imbalance

Ketonuria

Occasional muscle wasting

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5
Q

How is hyperemesis gravidarum managed?

A

Fluids

Antiemetics

Potassium replacement

Thromboprophylaxis

Vitamin B1 replacement

Severe cases may require prolonged hospital stay and total parental nutrition

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6
Q

What is first line anti-emetic in pregnancy?

A

Promethazine

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7
Q

Give complications of hyperemesis gravidarum

A

Thyrotoxic crisis, as hCG and TSH have similar subunits

Wernicke’s encephalopathy, due to B1 deficiency

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8
Q

Define spontaneous abortion/miscarriage

A

Loss of pregnancy <24 weeks gestation

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9
Q

Define recurrent miscarriage

A

Loss of 3 or more consecutive pregnancies

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10
Q

When do miscarriages usually occur?

A

First trimester

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11
Q

What are the causes of miscarriage?

A

Uterine abnormality

  • Congenital
  • Fibroids
  • Ashermans Syndrome

Fetal/chromosomal abnormality

Cervical Incompetence, in which cervix opens prematurely

Maternal factors

Idiopathic

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12
Q

What maternal factors can cause miscarriage?

A

>Age

Hypothyroidism

SLE

Diabetic

Obesity

Acute infections

Anti-phospholipid syndrome

PCOS

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13
Q

What is the most common cause of miscarriage?

A

Chromosomal abnormality

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14
Q

What are the types of miscarriage?

A

Threatened

Inevitable

Complete

Incomplete

Septic

Missed

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15
Q

What is a threatened miscarriage?

A

Viable pregnancy with vaginal bleeding and pain with a closed cervical os, uterus is expected size of dates given

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16
Q

What is an inevitable miscarriage?

A

Viable pregnancy with pain and bleeding with an open cervical os

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17
Q

What is an incomplete miscarriage?

A

Evidence of retained products of conception on USS with open cervical os

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18
Q

What is a complete miscarriage?

A

Expulsion of the products of conception, cervical os closed, bleeding stopped

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19
Q

What is a septic miscarriage?

A

Following an incomplete abortion, there is risk of ascending infection into the uterus which can spread throughout the pelvis

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20
Q

What is a missed miscarriage?

A

Pregnancy in which the fetus has died but the uterus has made no attempt to expel the products of conception, so mother has no symptoms

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21
Q

What investigations are used to diagnose miscarriage and the cause?

A

FSH and LH

Prolactin

  • Suppresses FSH

TFT

  • Hypothyroidism

Clotting Factors

  • Protein S and C

Testosterone

  • PCOS

US

  • Fibroids
  • PCOS
  • Crown rump length >7mm with no cardiac activity is diagnostic

Karyotype

  • Chromosomal abnormalities
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22
Q

How are threatened miscarriages managed?

A

Conservative, try get fetus passed 24 weeks so can deliver

Avoid exercise

Weekly US

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23
Q

How are inevitable miscarriages managed?

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A

No point trying to save fetus

Evacuation of uterus if bleeding is heavy

24
Q

How are missed miscarriages managed?

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A

Conservative in hope uterus will self evacuate

Prostaglandins/misoprostol which will contract the uterus

Surgical (SMM)

25
What additional management is given in Rh- mothers suffering from miscarriage?
Anti-D for Rh- mothers with spontaneous miscarriage \>12 weeks
26
How are patients with anti phospholipid syndrome managed to prevent further miscarriage?
Aspirin and LMWH after a missed period
27
What is an ectopic pregnancy?
Pregnancy implanted outside the uterine cavity with invasion into the muscularis layer and subsequent rupture and bleeding into the abdominal cavity
28
When do ectopic pregnancies usually present?
6-8 weeks
29
Give the sites of ectopic pregnancies
Tubal Cervix Ovary Fimbria Abdomen
30
What is the most common ectopic pregnancy site?
Tubal (cornial region)
31
What location do ectopic pregnancies have an increased rupture risk?
Isthmus
32
What is the prognosis of ectopic pregnancies?
60-70% of women will have an intrauterine pregnancy in the future
33
Give risk factors for ectopic pregnancy
PID Previous tubal surgery Previous ectopic pregnancy Intrauterine contraceptive device (does not increase risk but if an individual with an IUD becomes pregnant, it is likely to be ectopic) Assisted reproduction Endometriosis Smoking \>Age
34
How do ectopic pregnancies present?
Period of amenorrhoea, with positive pregnancy test Light vaginal bleeding Lower abdominal or pelvic pain Shoulder tip pain in peritonitis/rupture Signs of haemorrhagic shock * Hypotension * Tachycardia * Syncope
35
What investigations are used for ectopic pregnancy diagnosis?
US Serum BHCG levels * Serially track levels over 48 hour intervals as * If levels fall, suggests miscarriage * Slight increase or plataeu, suggests ectopic pregnancy * Large increase, suggests normal intrauterine pregnancy * In normal pregnancies beta hCG will double around every two days until it reaches a peak at week 10/40. Serum progesterone levels * In viable IU pregnancy high levels \> 25ng/ml Group and save and cross-match if abdominal bleeding suspected Laparoscopy
36
What ectopic pregnancy signs are seen on US?
No intrauterine gestational sac/empty uterus May see adnexal mass Fluid in pouch of Douglas
37
What is the management of ectopic pregnancy?
Expectant management Medical management with IM Methotrexate Surgical management in those who do not need expectant or medical criteria
38
What are the surgical options for ectopic pregnancy management?
Laparoscopic salpingectomy of affected tube is first line Laproscopic salpingotomy in which there is incision and extraction of ectopic, if collateral tube is absent or damaged
39
When are anti-D immunoglobulins given in ectopic pregnancy management?
Given for rhesus - mothers in surgical management, but not required in medical management
40
How long are women treated with methotrexate advised not to get pregnant for?
3 months following treatment
41
What is the criteria for expectnant management of ectopic pregnancy?
Unruptured ectopic No heartbeat No pain/asymptomatic Adnexal mass \<35mm hCG \<1000 and declining
42
What is the criteria for medical management of ectopic pregnancy?
Unruptured ectopic No pain/asymptomatic Confirmed absence on US Adnexal mass \<35mm hcG\<1500
43
What is the criteria for surgical management of ectopic?
Ruptured Symptomatic Visible fetal heartbeat Confirmed absence on US Adnexal mass \>35mm hcG\>1500
44
When can a pregnancy termination be carried out up to?
24 weeks (20 in scotland)
45
What drugs are given for medical termination of pregnancy?
Mifepristone * Switches off pregnancy hormones which are keeping uterus from contracting and allowing pregnancy to grow Misoprostol * 48 hours later, initiates uterine contraception, which opens cervix and expels pregnancy
46
What is a molar pregnancy?
Abnormal placental development, causing overgrowth of abnormal pregnancy tissue/precancer trophoblast
47
Describe the pathophysiology of molar pregnancy
In a normal ovary, female switches off certain genes in ova by methylating them (adding methyl groups onto DNA), these changes promote baby growth In normal testis, male switches off different genes in the sperm by methylating them, these changes promote placenta growth by trophoblast proliferation In molar, two lots of male genes fertilise egg with no chromosomes, resulting in an imbalance in methylated genes and trophoblast overgrowth
48
What are the two types of molar pregnancy?
Benign: Complete or partial hydatiform mole Malignant: Choriocarcinoma
49
How does molar pregnancy present?
Vaginal bleeding in early pregnancy Hyperemesis Pelvic mass Non tender, large for dates uterus
50
What molar pregnacy sign is seen on US?
Snow storm appearance
51
What investigations are used in molar pregnancy diagnosis and monitoring?
US * Snowstorm within endometrial cavity Surgical evacuation * To obtain histology \>hCG * Persistent hCG indicates active disease and warrants chemotherapy
52
Give differential diagnoses of pelvic pain
Appendicitis Ovarian cyst Ovarian torsion PID Constipation UTI
53
Give complications of termination of pregnancy
Infection, most common Retained tissue Haemorrhage Cervical trauma Failure
54
How long can pregnancy tests remain positive after termination?
4 weeks, a positive beyond this point indicates incomplete abortion or persistent trophoblast
55
What drugs are used in the termination of pregnancy
Methotrexate Misoprostol, a prostaglandin analogue which is used to promote softening and dilatation of the cervix and uterine contractions
56
57
Give features of cervical ectropion
Post coital bleeding Reddened and irritated cervix Common in pregnancy and oral contraceptive pill use

Reproduction (18 decks)

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