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Early pregnancy problems Flashcards

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1
Q

Name 4 conditions that can cause bleeding in early pregnancy

A
  1. Miscarriage
  2. Ectopic pregnancy
  3. Gestational trophoblastic disease
  4. Gynae infection
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2
Q

What is miscarriage?

A

Loss of an intrauterine pregnancy <24 weeks.

Early: <12 weeks.

Expulsion of foetus <500g <22 weeks

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3
Q

When does the majority of miscarriage occur? and what is the most common cause?

A

Early miscarriage

Genetic/chromosomal abnormalities

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4
Q

What advice would you give to women with threatened miscarriage?

A

If bleeding doesn’t stop for 14 days - seek help

If bleeding stops, continue antenatal care.

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5
Q

When is US/TVS used for diagnosis?

A
  1. If the gestational sac >/= 25mm without a cold sac present.
  2. Foetal pole with crown rump length >/=7 without evidence of heart activity
    - seek second opinion on viability of pregnancy
    - perform scan in 7 days
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6
Q

What would you do if gestational sac <25 on US?

A

Wait 7 days then re-measure before making a diagnosis

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7
Q

when is expectant management used to treat miscarriage?

A

First line for 7-14 days in women with a confirmed diagnosis

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8
Q

When do you not consider expectant management?

A
  1. high risk of bleeding (late miscarriage)
  2. infection
  3. previous traumatic pregnancy experience
  4. increased risk from the effects of haemorrhage
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9
Q

How long is conservative management continued for?

A
  1. as long as the women is willing
  2. As long as there are no signs of infection

usually takes 6-8 weeks

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10
Q

What is the medical management of miscarriage?

A
  1. Pain relief and anti-emetic
  2. inform about treatment + SE associated (diahroeaa, pain, N+V)
  3. return to doctor if experiencing worsening symptoms
  4. Take a pregnancy test 3 weeks after treatment commenced - if positive, return to Dr for review - potential ectopic/molar
  5. Mifepristone
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11
Q

When is mifepristone contraindicated? what do you offer instead.

A

Missed or incomplete miscarriage.

Offer oral/reftam misoprostol

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12
Q

How do you treat a missed/ incomplete miscarriage?

A

800 mg misoprostol + tell them to contact EPAU if bleeding doesn’t start in 24 hours

Offer antiemetic/Pain relief

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13
Q

What is the surgical management of miscarriage?

A
  1. Manual vacuum aspiration - local/GA
  2. SMOM - day case, FBC, G+S, anti-D, chlamydia screening
    give prophylactic doxycycline 100 mg for 10 days + PR metronidazole1g
    send products to histology to exclude molar pregnancy +
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14
Q

What are the complications of SMOM?

A 
Infection
haemorrhage
uterine perforation
intrauterine adhesions
cervical tears
intra-abdominal trauma
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15
Q

What minimises cervical + uterine trauma?

A

Administering prostaglandins

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16
Q

When would you give Anti-D in confirmed miscarriage?

A
  1. Any Rhesus -ve women that is not sensitised + miscarries after 12 weeks
  2. Any women who miscarries <12 weeks when the uterus is medically/surgically evacuated
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17
Q

What dose of anti-D do you give?

A

<12 weeks = 250iU

after 12 weeks = 500 iU

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18
Q

When would you give Anti-D in threatened miscarriage?

A

All non-sensitised women >12 weeks

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19
Q

When would you give Anti-D in confirmed ectopic?

A

ALL pregnant women with ectopic

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20
Q

Are hCG + TVS useful diagnostic tools in early pregnancy problems?

A

NO

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21
Q

What is threatened miscarriage?

A

Features: vaginal bleed, abdominal pain, foetus alive + heartbeat present. uterus size is normal.

only 1/4 miscarry

Cervical OS: Closed

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22
Q

What is inevitable miscarriage?

A

Features: vaginal bleeding and abdominal pain. No foetal heart beat.

all miscarry

Cervical OS: open

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23
Q

What is incomplete miscarriage?

A

Features: some foetal parts have passed, retains some products of conception, vaginal bleed and abdominal pain.

Cervical OS: open.

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24
Q

What is complete miscarriage?

A

Features: all foetal tissue passed, bleeding and pain resolved. uterus no longer enlarged. Serum hCG to exclude ectopic.

Cervical OS: closed

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25
What is septic miscarriage?
Features: infected content --> endomemetritis. vaginal loss is offensive, uterus tender, +/- fever, pelvic infection. Cervical OS: open/closed
26
What is missed miscarriage?
Features: Foetus not developed/died in utero. Asymptomatic, not recognised until bleeding occurs. Cervical OS: closed
27
What is Recurrent miscarriage?
When miscarriage happens >3 x
28
What are the 10 causes of recurrent miscarriage?
1. Age: Maternal age mainly >40, paternal age also. 2. Anti-phospholipid syndrome: causes adverse pregnancy outcomes. 3. Thrombophilia 4. Genetic factors 5. Cervical incompetence 6. Infection 7. Diabetes + thyroid 8. Immune factors 9. Uterine anomalies 10. No cause found
29
What are the adverse pregnancy outcomes associated with APS?
1. 3+ miscarriages before 10 weeks of gestation 2. 1+ morphologically normal foetal losses after 10 weeks of gestation 3. 1+ preterm birth before 34 weeks due to placental abnormality
30
Name 3 APS antibodies
1. lupus anticoagulant 2. anticardioplin antibodies 3. B2 glycoprotein 1 antibodies
31
Name Types of thrombophilia:
1. protein C+S deficiency 2. Factor 5 leiden 3. PT gene mutation
32
How are Genetic factors diagnosed?
Cytogenetics + blood karyotyping
33
How is cervical incompetence diagnosed?
1. History of second trimester miscarriage proceeded by ruptured membranes/painless cervical dilation cervical sonographic surveillance for 24 hours
34
What infection increases the risk of miscarriage and how is it treated?
Bacterial vaginosis in first trimester. Treat with clindamycin.
35
What secretes bHCG? and what is its function? Which hormone is it identical to?
Trophoblasts - to maintain corpus luteum identical to LH
36
When is bhCG mainly used? and what does a very increased number indicate?
4-8 weeks Molar pregnancy
37
How much does bhCG rise by every 48 hours?
66%
38
What is an ectopic pregnancy?
Implantation of a pregnancy outside the endometrial cavity
39
Where is the commonest place of an ectopic?
1. Tubal - ampulla 2. ovarian 3. interstitial 4. CS scar 5. abdominal
40
What features are associated with tubal miscarriage?
1. Haematosalpinx 2. tubal miscarriage 3. Rupture 4. Pain
41
How do you diagnose ectopic?
1. history + examination 2. TVS: to establish the location of pregnancy + presence of adnexal masses 3. Serum progesterone to distinguish if the pregnancy is failing <20 nmol 4. serial bhCG measurements 5. Laparoscopy: used if diagnosis is unclear.
42
What can give a false TVS diagnosis of ectopic?
1. pseudosac | 2. heterotrophic
43
At what level of hCG can TVS identify an intrauterine pregnancy?
1000 iU
44
What constitutes a confirmed gestation sac?
1. yolk sac 2. foetal pole 3. foetal HR
45
When are ectopic pregnancies at a higher risk of rupture?
Associated high hCG
46
How do you approach a haemodynamically stable patient?
1. History + examination - abdominal tenderness, rebound tenderness, cervical excitation 2. Look for signs of miscarriage - open cervical OS 3. Look for the passage of products of conception
47
What are the signs of a harm-dynamically unstable patient
-raised HR, low BP, LOC
48
How do you approach a haemodynamically unstable patient?
1. Urgent resuscitation 2. 2 large bore canulas + IV fluids 3. Crossmatch 6U blood 4. call senior help
49
What are the symptoms of an ectopic pregnancy? (8)
1. Assymptomatic 2. Amenorrhea 6-8w 3. Lower abdominal pain - unilateral + vague 4. vaginal bleed - bwon 5. diarrhoea + vomiting 6. Dizziness 7. Shoulder tip pain - haematoperitoneum 8. collapse
50
What are the signs of ectopic pregnancy?
1. Non-specific 2. Normal uterus size 3. cervical excitation + adnexal tenderness 4. adnexal mass 5. Peritonism
51
What are the risk factors of an ectopic pregnancy? (7)
1. History of infertility/ assisted conception 2. PID/ endometriosis 3. pelvic/tubal surgery 4. previous ectopic 5. IUCD 6. IVF 7. smoking
52
What information do you need to give women with ectopic pregnancy?
1. How to contact emergency department 2. Post-operative advice 3. When to seek help
53
When would you go for expectant management for ectopic pregnancies? (5)
1. Clinically stable women 2. Assymptomatic women 3. US diagnosis 4. decreasing b/hcg <1500 iU 5. Women is willing to attend follow up appointments
54
When would you go for medical management for ectopic pregnancies? (6)
1. Able to return for follow up 2. No pain 3. Unruptured ectopic with adnexal mass <35 mm 4. no visible heart beat 5. Serum h/cg <1500 iU 6. no intrauterine pregnancy confirmed on US
55
What drug do you use in the medical management of ectopic pregnancy?
Systemic Methotrexate
56
When would you go for surgical management for ectopic pregnancies? (5)
1. Methotrexate is contraindicated/not accepted 2. Visible foetal heart beat 3. Significant pain 4. Adnexal mass >35mm 5. serum hCG > 5000 iU
57
Is the chance of needing further intervention with methotrexate high or low?
High
58
What two surgical approaches are used to treat an ectopic pregnancy?
1. Laparotomy | 2. Laparoscopy: GS. Stable patient and competent doctor.
59
When is salpingectomy offered to women with an ectopic pregnancy?
When she has no other risk factors for infertility
60
What Information do you give patients post operatively (ectopic)?
1. You will take a serum hCG weekly until it is negative | 2. Advice patient to take a urine pregnancy test and to return if it is still positive
61
When would you conifer salpingotomy instead of salpingectomy?
When the patient has other risk factors for infertility
62
What is the MOA of methotrexate and how can it be administered?
1. It is a folcic acid antagonist (acts by blocking the di-hyra-folate enzyme) blocking DNA synthesis. 2. Can be administered systemically (PO/IV/IM) or locally via hysteroscopy/laparoscopy
63
What are the pros of using methotrexate over surgery?
1. Preserves uterine tube | 2. No surgical risks
64
Name 4 side effects of methotrexate?
1. leucopenia 2. Conjunctivits 3. GI disturbances 4. Mucocytis
65
How do you know if methotrexate is failing to treat miscarriage?
1. Significant pain 2. haematoperitoneum 3. increased bhCG day 7 4. hCG decrease <15% after day 7 5. Rise in bHCG levels
66
Name 3 risk factors for developing a Molar pregnancy?
1. Extremes of age 2. Asian 3. Previous molar
67
What is molar pregnancy?
Gestational trophoblastic disease caused by the overgrowth of placents
68
Name 3 types of molar pregnancies
1. Choriocarcinoma - local invasion 2. Invasive mole 3. Hydatiform Mole
69
What is the MOA for developing a complete hydatiform molar pregnancy
Sperm fertilises empty ovum+ undergoes mitosis duplicating its own chromosomes
70
What are the two types of hydatiform molar pregnancies?
1. Complete | 2. Partial
71
What are the characteristics of complete hydatiform moles?
1. 46 XX 2. hydronic villi 2. trophoblastic hyperplasia
72
What is the MOA for developing a Partial hydatiform molar pregnancy?
2 sperms fertilize one oocyte --> triploid. A foetus is present
73
What are the clinical features of a molar pregnancy? (4)
1. Vaginal bleed 2. uterus large for dates 3. Pain - ovarian hyperstimulation 4. N+V
74
What Investigations do you do for a patient with a Molar pregnancy?
1. Bloods: FBC, group and save, Rhesus antibody 2. bHCG 3. US 4. Histopathological analysis to look for products of conception
75
What is the classical US appearance of a molar pregnancy called?
Snowstorm vesicular pattern
76
How do you treat patients with a Molar pregnancy who want to preserve their fertility?
Surgical evacuation - suction curretage
77
Why should medical management be avoided in Molar pregnancy?
Risk of increased trophoblastic embolisation by inducing uterine contractions
78
What medical options are available to treat a Molar pregnancy and when do you use them?
1. Oxytocin: After complete evacuation. | 2. Anti-D: All Rhesus -ve women

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