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EOY4 > Gynae - Early Pregnancy Problems > Flashcards

Gynae - Early Pregnancy Problems Flashcards

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1
Q

Define an ectopic pregnancy

A

Fertilised egg implants outside of the uterine cavity (essentially where it shouldn’t)

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2
Q

What is the pathophysiology of an ectopic pregnancy?

A

Decidual cells are present in the uterus which tell the zygote to stop implanting

These cells are not present elsewhere e.g. in the fallopian tubes so nothing to stop the implantation leading to rupture and haemorrhage

Most EPs are tubal so in ampulla or isthmus. Isthmus more at risk of rupture

Can also happen elsewhere e.g. abdominal or previous caesarean scar

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3
Q

What are the risk factors for ectopic pregnancy? (4)

A

Non-modifiable - Previous Ectopic

Modifiable - Contraception e.g. IUD/IUS or IVF, Tubal factors e.g. PID

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4
Q

How can tubal factors increase risk of EP?

A

Tubal damage e.g. adhesions due to PID etc

Smoking - damages cilia so don’t waft the egg as much

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5
Q

Which contraception increases risk of EP?

A

IUCD

POP

Tubal ligation

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6
Q

How does IVF increase risk of EP?

A

Heterotropic - multiple ovulation = one fertilised ovum implants normally in the uterus but the other implants abnormally

If they’re needing an assisted pregnancy anyway do they have damaged tubes?

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7
Q

What are the symptoms of an EP? (4)

A

ALWAYS TREAT ABDO/LIF/RIF PAIN AS IF ITS AN ECTOPIC UNTIL PROVEN OTHERWISE SO DO A URINE PREGNANCY TEST AND B-HCG

Pain - unilateral, lower abdominal. can refer to shoulder tip due to diaphragm irritation from haemoperitoneum

PV bleeding > fainting if rupture

Amenorrheoa!

GI symptoms e.g. DNV or dyschezia

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8
Q

What are the gynae signs of an EP? (3)

A

Normal size uterus

Pelvic tenderness

Cervical excitation +/- adnexal tenderness

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9
Q

What are the abdominal and other signs of an EP?

A

pain/tender +/- guarding +/- peritoneum

Signs of haemorrhage - tachycardia/hypotension/shock/collapse

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10
Q

What are the bedside investigations for an EP?

A

Baseline obs - blood loss

Urine pregnancy test!!!!!!!

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11
Q

What are the blood tests to investigate an EP?

A

Group n Save - crossmatch 6 units if unstable

B-hCG - if TVS can’t find the pregnancy

Rhesus status

FBC - baseline

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12
Q

What is the deal with B-hCG in EP?

A

Doubles within 48 hours

Normal pregnancy increases by 63% in 48 hours but EP doesn’t

If 1000 on the day then repeat in 24 hours

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13
Q

What imaging should be done to investigate an EP?

A

TVS - location/foetal pole/heartbeat

TAS - pelvic pathology or enlarged uterus

Do a diagnostic laparoscopy to determine location if PuL

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14
Q

What is the conservative management for EP?

A

Signpost to contact HCP for post-op/emergency help

Ectopic pregnancy trust for info and support

Contraceptive advice if wanted

Expectant management - only offered If low or rapidly falling hCG and clinically symptomatic. Give 24hr access to GAU

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15
Q

When can medical management be offered for EP?

A

Asymptomatic/mild symptoms

hCG <1500 or < 5000

No IUP on USS

Unruptured adnexal mass <35mm and no visible heartbeat

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16
Q

What are the benefits and risks of medical management of EP?

A

Benefits - preserves Fallopian tubes so preserves fertility in the long run

Risks - Can’t get pregnant for 3 months. May fail

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17
Q

What is the medical management of an EP?

A

Methotrexate IM

Do a hCG on day 4 and 7 and use reliable contraception for 3 months after

May need another dose if hCG has fallen by less than 15%

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18
Q

What is the MOA of methotrexate?

A

Antifolate

Competitive inhibitor of DHFR which makes folate

Folate needed for DNA synthesis

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19
Q

What are the ADRs of methotrexate?

A

Myelosuppression - don’t use if renal impairment, older or using another antifolate e.g. trimethoprim

GI toxicity

Hepatotoxicity - discontinue if deranged LFTs

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20
Q

What is the surgical management of EP?

A

Laparoscopic - shorter/better recovery, less blood loss, less analgesia

Salpingectomy - remove tube and ectopic if contralateral tube is healthy

Salpingotomy - open tube and scoop out ectopic if contralateral tube is damaged (failure/persistence)

Have to follow up with serum b-hCG

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21
Q

When should surgical management be offered?

A

Patient wants it

Medical criteria not met

Clinically unwell

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22
Q

What is the definition of a miscarriage?

A

Loss of pregnancy before 24 weeks (no signs of life)

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23
Q

What are the viable types of miscarriage?

A

Threatened

Little bleeding and pain
Signs of life
Os is closed

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24
Q

What are the non-viable types of miscarriage? (4)

A

Complete

Incomplete

Missed

Inevitable

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25
What is a complete miscarriage?
All pregnancy tissue has been passed Pain and bleeding gone Os is open
26
What is an incomplete miscarriage?
Not all tissue has passed Os is open Risk of sepsis due to retained products/intrauterine infection
27
What is a missed miscarriage?
No foetal heartbeat but signs of pregnancy as body has not recognised the pregnancy to be lost No pv bleeding Os is closed
28
what is an inevitable miscarriage?
Products will eventually pass Os is open
29
What are the risk factors for early miscarriage (<12 weeks)?
Chromosomal abnormalities Implantation problems e.g. uterine abnormalities
30
What are the risk factors for late miscarriage (>12 weeks)?
Placental problems e.g. antiphospholipid syndrome or thrombophilias
31
What are general risk factors for miscarriage? (5)
Unknown! Increased age e.g. >30 Substance abuse - cocaine, smoking Multiple pregnancy More pregnancy/multips
32
What are the bedside investigations for miscarriage?
urine pregnancy test Baseline observations - signs of haemodynamic instability
33
Which blood tests should be done to manage a miscarriage?
Group n Save - don't have physiological increase in blood volume yet so may lost lots! B-hCG if ectopic suspected
34
What imaging should be done to investigate miscarriage?
TVS or TAS
35
What is the conservative management of a miscarriage? (7)
Expectant - let the miscarriage happen naturally. manage pain and bleeding when it does Analgesia - paracetamol/ibuprofen/hot water bottle No strenuous exercise Only go to work if you feel you can Take urine pregnancy test in 2 weeks Reduce infection risk by using condoms and not tampons Signpost for when to seek medical help
36
What is the medical management of miscarriage?
Misoprostol PV/PO Prostaglandin analogue to cause cervical ripening and myometrial contractions Use if HAEMODYNAMICALLY STABLE
37
What is the surgical management of a miscarriage?
Manual vacuum aspiration if <12 weeks Evacuation under local/GA if >12 weeks Do if HAEMODYNAMICALLY UNSTABLE
38
When should anti-D be given when treating a miscarriage?
All rhesus-negative women who have a surgical procedure to manage an ectopic pregnancy or a miscarriage.
39
Define hyperemesis gravidarum
Persistent vomiting in pregnancy leading to weight loses that is more than 5% of pre-pregnancy weight and ketosis
40
What is the pathophysiology of hyperemesis?
Mainly unknown but could be: 1) ↑ B-hCG from placenta causes GIT distension (also explains pregnancy induced hyperthyroidism as crosses over with TSH) 2) ↑ oestrogen and progesterone from CL and placenta causes reduced gut motility and LOS pressure and increased LFTs
41
What are the risk factors for hyperemesis?
FHx/Hx Molar pregnancy Multiple pregnancy First pregnancy Hx of eating disorder
42
Why is USS offered at 8-9 weeks if presenting with hyperemesis?
Molar pregnancy / multiple pregnancy has increased risk of HG so offered to exclude
43
What are the symptoms of HG?
Vomiting - can't keep food or fluids down Spitting/unable to swallow saliva Weight loss
44
What are the signs of HG?
Nutritional deficiencies e.g. reduced B vitamins leading to growth restriction Signs of dehydration: low BP, tachycardia, hypokalaemia and hyponatraemia Ketosis!
45
What are the bedside investigations for HG?
Urinalysis - +++ ketones and UTI exclusion Baseline obs for dehydration
46
What are the blood tests to investigate HG?
U&E - electrolyte disturbance BM - Exclude DKA if diabetic TFTs if showing symptoms of hyperthyroidism
47
What imaging should be done to investigate HG?
USS @ 8-9 weeks to exclude molar pregnancy or to diagnose multiple pregnancy
48
What is the conservative management of HG?
Primary care - eat ginger [biscuits] and psychological support Admit if: Can't keep anything down + ketonuria + co-morbidities
49
What is the conservative management of HG in secondary care?
Rehydrate and correct electrolyte imbalances Don't give glucose as can precipitate Wernicke's TED stockings due to VTE risk
50
What is the medical management of HG? (4)
1) Cyclizine PO/ Promethazine PO/ Prochlorperazine PO 2) Metoclopramide PO or Ondansetron PO (not for >5 days) 3) Supplements - Folic Acid 5mg, Thiamine, TPN if v bad 4) Thromboprophylaxis - Enoxaparin
51
What is the surgical management of HG?
In very, VERY extreme cases and as a very, VERY last resort, can offer TOP
52
What are the complications of HG?
GI - GORD and Mallory-Weiss Tear Endocrine - Hyperemesis induced hyperthyroidism Nutritional Deficiencies - Polyneuritis (B12) VTE - Hypercoaguable in pregnancy + dehydration
53
Describe decidualisation
Implantation leads to thickening and structural changes of the endometrium Leads to formation of the decidua
54
What is the funcitonof the decidua?
Nutrition - fat and glycogen storage Immune privileged via tight junctions Prepares placental circulation by transforming into a network of anastamosing spiral arteries under the influence of progesterone
55
What are the 3 parts of the decidua?
Basalis - maternal portion Capsularis - grows over blastocyst after implantation Parietals - lines pregnant uterus everywhere but implantation site
56
What is implantation?
Development of the placenta Embryonic = trophoblast Maternal = decidua basalis
57
What occurs during early placental development?
Pre-lacunar = until day 9 Lacunar = day 9-12. lacunae form in synctiotrophoblast which then fill with maternal blood early villous = day 12-28
58
Where do primary, secondary and tertiary villi develop from?
Primary: inner = cytotrophoblast, outer = syncytiotrophoblast Secondary = same as primary but with a mesenchymal core Tertiary = foetal capillaries in mesenchymal core and vascularised
59
When does the placenta fully establish?
month 4?
60
What is the function of the placenta?
Hormone production Gas and nutrient exchange
61
What is gestational trophoblastic disease?
Abnormal or overgrowth of all or part of the placenta causing a molar pregnancy/hydatidiform mole
62
What is the pathophysiology behind GTD?
Overgrowth of trophoblast cells that produce hCG Pre-malignant - partial and complete molar Malignant - invasive moles, choriocarcinoma and placental site trophoblastic tumours
63
What is a hydatidiform mole?
Commonest trophoblastic disease Benign overgrowth
64
What is a partial mole?
Part of the normal placenta proliferates but part develops normally Foetus is genetically abnormal and non-viable 2 sperm enter egg but is just wrong rather than twins
65
What is a complete mole?
Whole placenta is abnormal and rapidly proliferating No foetus developing One sperm in egg but half set of chromosomes Bigger risk of malignancy
66
What is an invasive mole?
Malignant Molar tissue invades myometrium - uterine mass and raised hCG May rupture utures
67
What is a choriocarcinoma?
V rare and v malignant cancer Can arise from a molar pregnancy or an otherwise normal pregnancy
68
How does choriocarcinoma present?
PV bleeding Really raised hCG Mets? V sensitive to chemo
69
What are the risk factors for molar pregnancy?
Complete = age. more common in teenage women and post menopausal History Ovulatory disorders Low in vit a diet
70
Define recurrent miscarriage
The loss of 3 or more consecutive pregnancies.
71
What are the causes of recurrent miscarriage?
Maternal - uterine structural anomalies (e.g. septate uterus, fibroids), cervical incompetence, PCOS, antiphospholipid/thrombophilia, increased maternal age Foetal - chromosomal abnormalities

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