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Flashcards in Early Pregnancy Problems Deck (34):
1

Define a spontaneous miscarriage. (2)

Fetal death or stillbirth before 24 weeks gestation

2

Define a threatened miscarriage. (2)

Some bleeding but fetes is alive, uterus is expected size and os is closed. 25% will go on to miscarry

3

Define an inevitable miscarriage. (2)

Heavy bleeding, fetus my still be alive but os is open and miscarriage is imminent

4

Define an incomplete miscarriage. (2)

Some fetal parts passed, os is open

5

Define a complete miscarriage. (2)

All fetal tissue passed, bleeding is diminished and os is closed

6

Define a missed miscarriage. (2)

Fetus has not developed or has died in utero, but it has not been recognised until bleeding or ultrasound. Uterus is small for dates and os is closed.

7

What is the management of bleeding in early pregnancy? (2)

Send to EPAU.
USS (TVUS) - is embryo in uterus? is it viable?
Repeat USS in one week if in doubt
hCG levels will increase by 2/3 in 48 hours if viable and in utero

If heavy bleeding or ectopic, admit.

8

What are the management options for a non-viable intrauterine pregnancy? (3)

Expectant: continue as long as patient is willing and no signs of infection. usually completes in 2-6 weeks.
Medical: Prostaglandin (sometimes with prior anti-progesterone, Mifepristone)
Surgical: Evacuation of retained products of conception under anaesthetic. Patient preference, if heavy bleeding or signs of infection.

9

Define a recurrent miscarriage. (1)

3 or more miscarriages in succession.
Affects 1% of couples

10

Give 3 causes of miscarriages. (3)
Name the most common cause of a single miscarriage. (1)

- Anti-phospholipid antibodies (cause thrombosis in the uteroplacental circulation) (treat with aspirin and LMWH)
- Parental chromosomal defects
- Anatomical factors (uterine or cervical - usually late miscarriages)
- Infection (preterm labour and late miscarriage) (treatment of bacterial vaginosis reduces risk)

Most common: one-off fetal chromosomal defects.

11

Name 3 indications for termination of pregnancy in the UK. (3)

1. Risk to life of mother
2. Grave risk to mother of physical or mental well-being
3. Less than 24 weeks and continued pregnancy would risk physical or mental health of mother
4. Less than 24 weeks and continued pregnancy would risk physical or mental health of other children
5. Risk of serious handicap if fetus was to be born

12

Name the options available for termination of pregnancy. (3)

Surgical:
- Suction curettage (7-13 weeks)
- Dilatation and evacuation (13+)
Medical:
- Mifepristone (anti-progesterone) plus Misoprostol or Gemiprost 36-48 hours later (0-22 weeks)
- 22-24 weeks, risk of live birth so fetacide with KCl in umbilical vein or fetal heart.

13

Name 2 complications of TOP. (2)

Haemorrhage, infection, uterine perforation, cervical trauma, treatment failure

14

Define an ectopic pregnancy. (2)

Implantation of an embryo outside of the uterus.
95% are tubal. Also can be in abdomen, cornu, cervix, ovary.

15

Name 3 risk factors for an ectopic pregnancy. (3)

PID, assisted conception, previous pelvic surgery, smoking, advancing maternal age, previous ectopic pregnancy

NB IUD only prevents intrauterine pregnancy

16

What are the clinical features of an ectopic pregnancy? (3)

Collapse, abdominal pain or vaginal bleeding

17

Jo has a history of amenorrhea for the last 6 weeks and now has lower abdominal pain and heavy vaginal bleeding.
You suspect an ectopic pregnancy.
What is your management? (3)

NBM
FBC and cross match. (anti-D if rh negative)
Pregnancy test
TVUS
Laparotomy (unless meets medical criteria)

18

What are the options for an acute presentation of an ectopic pregnancy? (2)

Resus and laparotomy with salpingectomy

19

What are the management options for a subacute presentation of an ectopic pregnancy? (3)

Surgical: laparoscopy with salpingostomy or salpingectomy
Medical: Single dose methotrexate if... unruptured, no cardiac activity and hCG < 3000IU/ml
Conservative: if small and unruptured or location uncertain and hCG is low. Risk of rupture is unlikely.

20

How can ectopic resolution be confirmed following surgical, medical or conservative management? (1)

Once hCG is less than 20 IU/ml

21

Define hyperemesis gravidarum. (2)

Nausea and vomiting so severe in early pregnancy that causes severe dehydration, weight loss or electrolyte disturbance. Usually resolved by 14 weeks.

22

What is the management of suspected hyperemesis gravidarum? (3)

Exclude UTI, multiple or molar pregnancy.
IV rehydration
Anti-emetics
Thiamine

23

What is gestational trophoblastic disease? (1)

Proliferation of the trophoblast more aggressively than anticipated causing very high hCG levels.

(trophoblast is part of blastocyst that invades into the endometrium)

24

What is a hydatidiform mole? (1)

Localised and non-invasive proliferation of trophoblast.
can be partial or complete.

25

What is the cause of a complete and partial hydatidiform mole? (2)

Complete: 1 sperm in empty oocyte
Partial: 2 sperm in 1 oocyte

26

What is the difference between an invasive mole and a choriocarcinoma? (2)

Invasive mole is aggressive proliferation of trophoblast into uterus.
Once it has metastasised it becomes known as a choriocarcinoma.

27

What is the typical ultrasound appearance of gestational trophoblastic disease? (1)

Snowstorm appearance.
Diagnosis is confirmed on histology.

28

What is obstetric cholestasis? (2)

Pruritis in pregnancy that resolves on delivery of fetus.
It is associated with impaired liver function but without any other identifiable pathology.

29

Describe the itching in pregnancy that is associated with obstetric cholestasis. (2)

Usually occurs after 20 weeks.
No rash
Mainly worse at night
Mainly affecting the palms and soles.

30

Name 2 risk factors associated with obstetric cholestasis. (2)

FH
Previous history
Multiple pregnancy

31

Name 2 complications of obstetric cholestasis. (2)

Fetal: IUD, neonatal death, fetal distress, preterm delivery, inter-cerebral bleed
Maternal: PPH

32

How is obstetric cholestasis diagnosed? (2)

Diagnosis of exclusion so...

PET screen: FBC, U+Es, LFTs, clotting
Liver USS
Hep A, B, C, E serology
EMV and CMV serology

33

Why does obstetric cholestasis cause increased risk of haemorrhage? (1)

LFTs show increased transaminases and increased bile salts sometimes with decreased clotting.
This occurs to due to decreased absorption of vitamin K.

34

What is the management of a mother with obstetric cholestasis? (2)

Chlorphenamine
Ursodeoxycholic acid
(Vitamin K)
Deliver at 37 weeks due to risk of fetal death.