Early Pregnancy Stuff Flashcards by Laura Wharton

Definition of recurrent miscarriage

Loss of 3 or more consecutive pregnancies

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How common is recurrent miscarriage?

1% of couples

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What percentage of second trimester pregnancies miscarry?

1-2%

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What is the risk of miscarriage by maternal age?

<35 - 15%
35-40 - 25%
40-45 - 50%
>45 - 93%

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What is the risk of miscarriage after 3 consecutive losses?

40%

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How to diagnose antiphospholipid syndrome?

Antibodies: Lupus anticoagulant, anticardiolipin, antiB2glycoprotein 1 (Two +ve tests at least 12 weeks apart)

+ Adverse pregnancy outcome OR Vascular thrombosis

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What constitutes adverse pregnancy outcome in definition of APLS?

Loss of 3 or more consecutive pregnancies <10 weeks
Loss of 1 or more morphologically normal fetus > 10 weeks
1 or more PTB <34 weeks due to placental disease

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What percentage of women with recurrent miscarriage have antiphospholipid syndrome & what percentage of women with low risk obstetric history?

15% of women with recurrent miscarriage.

2% of women with low risk obstetric history.

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What is the live birth rate for APLS if untreated?

10%

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What percentage of couples with recurrent miscarriage have one partner with a balanced structural chromosomal anomaly?

2-5%

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What percentage of embryos miscarried have chromosomal abnormalities?

30-60%

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What investigations should be performed for a couple with recurrent miscarriage?

Antiphospholipid antibodies.
Cytogenetics on 3rd and subsequent consecutive miscarriages (and parental karyotyping if POC reveal unbalanced structural chromosomal abnormality)
Pelvic USS
(If second trimester miscarriage - inherited thrombophilias. BUT NOT RECURRENT FIRST TRIMESTER MC).

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What is the treatment for APLS and what is the effect of this?

Aspirin and LMWH from +ve UPT.

Reduces miscarriage rate 54%

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How to proceed if abnormal parental genetic karyotype noted?

Refer to geneticist.
Proceed to natural pregnancy or IVF/PGD or gamete donation or adoption.

Higher chance (50-70%) of healthy live birth in future untreated pregnancies following natural conception than is currently achieved with IVF + PGD (30%).

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What is the chance of successful pregnancy rate in patients with unexplained recurrent miscarriage?

75%

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What percentage of pregnancies are affected by nausea & vomiting?

80%

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What percentage of pregnancies are affected by hyperemesis?

0.3-3.6%

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What is the definition of hyperemesis?

Protracted nausea and vomiting associated with the triad of:

> 5% pre pregnancy weight loss
Electrolyte disturbances
Dehydration

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What is the timeline for usual NVP?

Starts 4th-7th week, peaks 9th week and 90% have resolved by 20 weeks.

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PUQE score

In the last 24 hours how long have you felt nauseous:
Not at all (1)
1 hour (2)
2-3 hours (3)
4-6 hours (4)
>6 hours (5)

In the last 24 hours how many times have you vomited and how many times have you retched?
Not at all (1)
1-2 (2)
3-4 (3)
5-6 (4)
>7 (5)

Score 6 or less = Mild
7-12 = Moderate
13-15 = Severe

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Management of NVP/hyperemesis

Mild = community + oral antiemetics
Mild/Moderate + failed community = ambulatory day care
Inpatient if:
- unable to keep down oral anti-emetics
- ongoing N&V with ketonuria & weight loss despite anti-emetics
- confirmed/suspected comorbidity e.g. UTI

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What blood test abnormalities might you see in hyperemesis?

Low Na
Low K
Low Urea
Increased haematocrit
Hypochloraemic alkalosis (if severe --> acidosis)

2/3 have biochemical thyrotoxicosis
40% have abnormal LFTs

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First line anti-emetics

Cyclizine
Prochlorperazine
Promethazine
Chlorpromazine

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Second line anti-emetics

Metoclopramide
Domperidone
Ondansetron

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Third line anti-emetics

Steroids - hydrocortisone 100mg BD IV and once improvement occurs convert to 40-50mg prednisone daily and taper down

When should growth scans be arranged?

If continued symptoms into late 2nd or 3rd trimester. HG and <7kg weight gain during pregnancy are at increased risk of PTB and low birth weight.

Recurrence rate of hyperemesis

15%

What percentage of pregnancies affected by HG end in termination?

10%

Incidence of gestational trophoblastic disease

1 in 714 (more common in Asian population - 1 in 387)

Cure rate of GTD

98-100%

Need for chemotherapy for GTN

5-8% - Complete mole 15% - Partial mole 0.5%

Genetic make up of complete moles

75%: Duplication of single sperm following fertilisation of "empty" ovum 25%: Dispermic fertilisation of "empty" ovum

Genetic make up of partial moles

90%: Dispermic fertilisation of an ovum | 10%: Tetraploid/mosaic

How should molar pregnancy be managed?

Suction curettage (unless partial mole with fetal parts too big in which case medical management) and POC to histology to confirm diagnosis.

What are the outcomes for normal pregnancy with complete molar pregnancy coexisting?

25% live birth rate - 40% early fetal loss - 40% PTB

What to do if unclear whether partial mole or complete mole + normal pregnancy?

Invasive karyotyping

How long is follow up after GTD?

If hCG normal within 56 days of pregnancy then follow up for 6 months. If hCG not normal then follow up 6 months from normalisation.

When to conceive after GTD?

Don't conceive until follow up complete and if you have chemotherapy not for 1 year after treatment.

What to hCG centres do after future pregnancies?

Measure hCG at 6-8 weeks

Risk of further molar pregnancy

1 in 80

Effect of chemotherapy on menopause

1 year earlier if single agent. | 3 years earlier if multi-agent.

Effect of etoposide

Increased risk of secondary cancers

How to determine what chemo regimen required?

FIGO 2000 scoring: - Score 6 or less is low risk (cure risk 100%) and they receive single agent IM methotrexate alternating daily with folinic acid for 1 week followed by 6 rest days. - Score 7 or higher is high risk (cure rate 95%) and they receive IV multi agent chemo including methotrexate, dactinomycin, etoposide, cyclophosphamide, vincristine.

What is the FIGO 2000 scoring system?

(1) Age: <40 = 0 >40 = 1 (2) Antecedent pregnancy: Molar = 0 Abortion = 1 Term = 2 ``` (3) Months from end of pregnancy to treatment: <4 = 0 4-7 = 1 7-13 = 2 >13 = 4 ``` ``` (4) Pretreatment hCG: <10^3 = 0 10^3-10^4 = 1 10^4-10^5 = 2 >10^5 = 4 ``` (5) Largest tumour size (cm): <3 = 0 3-5 = 1 >5 = 2 ``` (6) Site of metastases Lung = 0 Spleen/Kidney = 1 GI Tract = 2 Liver/Brain = 4 ``` ``` (7) Number of metastases 0 = 0 1-4 = 1 5-8 = 2 >8 = 4 ``` (8) Previous failed chemo Single drug = 2 Multi-agent = 4

Contraception after GTD

Coils should wait until bhCG normalised but anything else can be started straight away. EC can be used (but again try to avoid coils) if UPSI >5d after pregnancy treated.

Incidence of ectopic pregnancy

11/1000 pregnancies | 2-3% in EPAU

Maternal mortality associated with ectopic pregnancy

0.2 per 1000 estimated ectopic pregnancies

What percentage of women with ectopic pregnancy have no RF?

1/3

What percentage of ectopics are tubal and what is the most common site within tube?

97% are tubal and 80% of those are ampullary.

What are common USS findings with tubal ectopic pregnancy?

``` 60% inhomogeneous mass 30% empty GS 15% YS/FP/FH Pseudosac 20% Echogenic fluid 30-60% ```

What is the false negative laparoscopy rate for ectopics?

Management options for ectopic pregnancy and when to do them

EXPECTANT - If clinically stable with bhcg < 1500 MEDICAL - Methotrexate 50mg/m2 IM - First line option if no significant pain, unruptured <35mm with no FH, no IUP and bhCG <1500 - It is an option for bhCG up to 5000 SURGICAL - If don't meet criteria above or patient preference

When should bhCG be monitored during expectant management of an ectopic and what would you expect to see?

D2, D4, D7. | >15% fall.

When should bhCG be monitored during medical management of an ectopic and what should you see?

D4 + D7 15% decline is optimal - repeat weekly until <15 If <15% decline then re-scan and consider second dose.

Success rate of expectant management of ectopic

60-100%

Success rate of medical management of ectopic

65-95%

What percentage of people require second dose methotrexate?

3-27%

What percentage of people require surgery after methotrexate?

When to give methotrexate?

Never give on 1st visit. Repeat bhCG 48h and if increasing then rescan to confirm diagnosis.

Rate of persistent trophoblastic tissue after salpingotomy?

7% (compared to 1% salpingectomy)

What are the effects of treatment options for ectopic on future pregnancies?

If no tubal factor infertility then no difference in rates of fertility, rates of ectopic or tubal patency between methods. If tubal problem - expectant/medical improves outcomes compared to surgery and salpingotomy increases rates of IUP to 75% from 40% with salpingectomy. MTX doesn't affect ovarian reserve.

Monitoring after salpingotomy

bhCG D7 and then weekly

What percentage of people need further treatment after salpingotomy?

1 in 5

Recurrence rate of ectopic pregnancy

18%

How long to wait after MTX before conceiving?

3 months

Percentage of ectopics which are cervical

<1%

Management of cervical ectopic

Consider methotrexate | Reserve surgical methods for women with life threatening bleeding.

How common is CS scar ectopic?

1 in 2000

What percentage of CS scar ectopics are misdiagnosed?

13%

Incidence of cornual ectopics

1 in 76000

Definition of cornual ectopic

In rudimentary horn of bicornuate uterus

Management of cornual ectopic

Excision of rudimentary horn

Incidence of interstitial ectopic

1-6%

What percentage of pregnancies miscarry after FH seen?

Patient presents with pain (at any gestation) and/or bleeding (>6w) - what to do?

Refer to EPAU

Patient presents with bleeding only at <6 weeks (and no RF for ectopic) - what to do?

Expectant management Return if bleeding continues or pain develops Repeat UPT 7-10d and return if +ve

Diagnosis of miscarriage on USS

CRL >7mm on TVUS and no FH. OR GS >25mm on TVUS and no FP. Need either 2nd opinion or rescan 7 days to confirm.

When to repeat scans if miscarriage diagnosis criteria not met?

If TVUS and CRL<7mm or GS<25mm then repeat in 7 days. | If TAUS done then record size and rescan 14 days.

Management of confirmed miscarriage

Expectant management 7-14d first line option Medical management (single dose misoprostol) Surgical management

Success rate of expectant management of miscarriage

50%

Risk of infection with expectant management of miscarriage

3% (lowest of all the options)

What follow up during expectant management of miscarriage?

If resolution of pain and bleeding - UPT 3/52 | If pain and bleeding don't start or don't stop - repeat scan.

Contraindications to expectant management of miscarriage

``` Increased risk haemorrhage Previous trauma Increased risk of effects of bleeding Evidence of infection Pt request ```

Risk of infection with medical management of miscarriage

Success rate of medical management of miscarriage

85%

Bleeding necessitating return to hospital after MMM

Complications with MMM

1/70

Doses of misoprostol for MMM

800 microgram missed | 600 microgram for incomplete (but can use 800)

Follow up for MMM

Return if bleeding not started after 24h | UPT 3/52

Infection associated with SMM

Success rate of SMM

95%

Management of PUL

Take 2 x bhCG 48 hours apart and if increasing >63% then likely IUP (do TVUS 7-14d) If falling >50% likely non-viable and do UPT 14d after second serum hCG. Changes in between refer EPAU.

Overall significant complication rate of SMM

Risk of heavy bleeding necessitating blood transfusion after SMM

0-3/1000

Risk of localised pelvic infection after SMM

40/1000

Risk of retained tissue after SMM

40/1000

Repeat surgery required after SMM

3-18/1000

Intrauterine adhesions after SMM

190/1000 (after any management type) - 60% mild 30% mod, 10% severe - No sig difference in future fertility

Perforation with SMM

1/1000

Cervical trauma with SMM

<1/1000

Overall risk of serious complications with laparoscopic management of ectopic

2 in 1000

Percentage of bowel injuries which may not be diagnosed at time of laparoscopy

15%

Risk of death associated with laparoscopic management of ectopic

3-8 per 100,000

Risk of GTN after a livebirth

1 in 50,000

Early Pregnancy Stuff Flashcards

(104 cards)