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1. Senior Block- O&G > Infertility, TOP and Early Pregnancy Problems > Flashcards

Infertility, TOP and Early Pregnancy Problems Flashcards

(51 cards)

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1
Q

What is the definition of infertility?

A

A couple cannot conceive despite having regular (2/3 times a week) unprotected sex for a year. Affects 1 in 7 couples

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2
Q

What is primary infertility?

A

Someone who has not conceived in the past and is having difficulty to

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3
Q

What is secondary infertility?

A

Someone who has had 1 or more pregnancies but is now struggling to conceive

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4
Q

Give 4 risk factors for infertility

A

Age- fertility decreases after 30 years old
Weight- BMI >30 or <18
STIs
Smoking and passive smoking
Alcohol excess
Stress
Environmental factors- pesticides, solvants, metals

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5
Q

Give 5 potential causes for infertility in women

A 
PCOS
Premature ovarian failure
Thyroid problems 
Phx of pelvic surgery- adhesions 
Cervical mucus problems
Fibroids
Endometriosis
PID
Sterilisation- hard to reverse
Drugs- long term NSAIDs, chemotherapy, antipsychotics, spironolactone, illegal drugs (cocaine, marijuana)
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6
Q

Give 5 potential causes for infertility in a man

A 
Low sperm count 
Abnormal sperm shape
Testicular cancer
Undescended testis
Testicular injury 
Vasectomy
Ejaculation disorder, erectile dysfunction 
Hypogonadism
Drugs- sulfasalazine, anabolic steroids, chemotherapy, some herbal remedies, illegal drugs
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7
Q

How is infertility investigated in a woman?

A

Progesterone levels- check ovulation
Rubella status
Prolactin levels
Testosterone levels
Gonadotropin levels- FSH/LH on day 2 of cycle
Chlamydia swab
USS- look for fibroids, endometriosis + blocked fallopian tubes
Hysterosalpingogram- x-ray of uterus and fallopian tubes with dye inserted to check for blockages

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8
Q

How is infertility in a man investigated?

A

Semen analysis x2 3 months apart
If no sperm- FSH/LH/Testosterone/USS
Chlamydia test

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9
Q

How is infertility managed pharmacologically?

A 
Clomifene- encourages ovulation 
Tamoxifen- alternative to clomifene
Metformin 
Gonadotrophins
Gonadotropin-releasing hormone + dopamine agonists
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10
Q

How is infertility managed surgically?

A

Fallopian tube surgery
Laparoscopic surgery to treat fibroids, endometriosis, PCOS
Correct epididymal blockage
Surgical extraction of sperm.

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11
Q

What is intrauterine insemination (IUI)?

A

Sperm inserted into the womb via a fine blastic tube passed through the cervix

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12
Q

What is in vitro fertilisation (IVF)?

A

Eggs removed from ovaries and fertilised with sperm in a lab. Embryo then returned to woman’s womb to grow

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13
Q

What is an abortion?

A

The termination of a pregnancy by removal or expulsion of a fetus from the uterus. Can be done medically or surgically. Legal up to 24 weeks of pregnancy, unless fetal abnormality found or severe consequences for the mother

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14
Q

What things are covered in the pre-assessment for an abortion?

A 
Reasons for abortion 
Offer counselling 
Pregnancy test and ultrasound to confirm pregnancy
Test for STIs
Blood type 
Anaemia screen 
Antibiotics given to reduce risk of infection 
Sign consent form
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15
Q

Describe what happens in a medical abortion

A

Used at any time but better <7 weeks

Take the anti-progesterone Mifepristone in the hospital clinic. 24-48 hours later, Misoprostol is taken which is a prostaglandin. In 4-6 hours the womb lining breaks down and the pregnancy is lost.

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16
Q

Describe a vacuum/suction aspiration surgical abortion

A

Used up to 15 weeks

Tube inserted into the uterus and pregnancy removed via suction. Medication to relax the cervix is given beforehand.

Oral analgesia and local anaesthetic used

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17
Q

Describe a Dilation and evacuation (D+E) surgical abortion

A

Used after 15 weeks

Forceps inserted into the uterus to remove the pregnancy. The cervix is dilated for several hours before and it is done under general anaesthetic.

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18
Q

What advice is given to the patient after an abortion?

A

Symptoms:
May experience nausea and diarrhoea
GA side effects
Vaginal cramps and stomach cramps

Advice: 
Avoid tampons for 4 weeks 
Can take extra OTC analgesia
Counselling available 
Monitor symptoms
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19
Q

Give 5 potential complications of abortions

A 
Infection of uterus 
Failure of TOP (continuing pregnancy) 
Retained products of pregnancy
Excessive bleeding 
Damage to cervix
Damage to the uterus- perforation 
Psychological trauma
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20
Q

What is a spontaneous miscarriage?

A

Fetus dies or delivers dead before 24 weeks of pregnancy. Mainly occur before 12 weeks.

Happens to 15% of clinically recognised pregnancies

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21
Q

What is a threatened miscarriage?

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A

Bleeding but fetus still alive. Uterus normal size and cervix closed

22
Q

What is an inevitable miscarriage?

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A

Heavy bleeding, clots and pain. Fetus may be alive or dead. Cervical os open so not viable

23
Q

What is an incomplete miscarriage?

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A

Some fetal tissue is passed, cervical os open

24
Q

What is a complete miscarriage?

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A

All fetal tissue passed. Hx of bleeding, clots and pain. No products of conception seen in uterus on USS

25
What is a septic miscarriage?
the products of conception are infected causing endometritis. Fevers, rigors, uterine tenderness, bleeding/discharge, pain. Need IV Abx and fluids
26
What is a missed miscarriage?
Fetus has not developed or died in utero but no symptoms to indicate miscarriage. Uterus smaller than in should be and cervical os closed.
27
Give 4 risk factors for miscarriage
``` Maternal age >35 PMHx of miscarriage PHx of uterine surgery Antiphospholipid syndrome Obesity Smoking Coagulopathies Chromosomal abnormalities Uterine anomalies ```
28
Give 3 clinical features of a miscarriage
Vaginal bleeding while pregnant Cramping abdominal pain Increased blood loss- dizzy, pale, SOB Can be found incidentally on USS
29
How is a suspected miscarriage investigated?
Sent to Early Pregnancy Assessment Unit Transvaginal USS- will show viable fetus, retained products, non-viable pregnancy, ectopic pregnancy Serum beta-HCG Bloods- FBC, blood group, Rh status, triple swabs, CRP
30
If a miscarriage is confirmed, how might it be managed conservatively? What are the positives and negatives of using this method?
Allow products of conception to pass naturally ``` + = can stay at home, no side effects, no surgical risk - = unpredictable timing, heavy bleeding and pain, can be unsuccessful ```
31
If a miscarriage is confirmed, how might it be managed medically? What are the positives and negatives of using this method?
Use of vaginal Misoprostol to stimulate cervical ripening and myometrial contractions. Mifepristone taken 24 hours before ``` + = can do at home, avoid surgical risk - = side effects of medication (N+V), pain, heavy bleeding on passing POC, risk of needing surgery ```
32
If a miscarriage is confirmed, how might it be managed surgically? What are the positives and negatives of using this method?
Manual vacuum aspiration (<12 weeks)- under LA Evacuation of retained POC (ERPC)- under GA, suction tube placed into uterus to remove POC + = planned procedure, no symptoms of passing POC - = anaesthetic risk, uterine infection, uterine perforation, haemorrhage, Asherman's syndrome, bowel or bladder damage
33
What is the definition of recurrent miscarriages?
The occurrence of 3 or more consecutive pregnancies that end in miscarriage before 24 weeks gestation.
34
Give 4 risk factors for recurrent miscarriage
``` Advancing maternal age Paternal age >40 Previous miscarriages- risk of further miscarriage increases after each one Maternal smoking Heavy alcohol intake ```
35
Give 5 potential causes of recurrent miscarriage
Antiphospholipid syndrome Parental chromosomal rearrangements- Robertsonian translocation Embryonic chromosomal abnormalities- Trisomy 21 Uncontrolled DM and thyroid disease PCOS Uterine malformations Cervical weakness Acquired uterine abnormalities- fibroids, adhesions Bacterial vaginosis Inherited thrombophilias
36
How is recurrent miscarriage investigated?
``` Antiphospholipid antibodies Inherited thrombophilia screen Cytogenetic analysis Parental peripheral blood karyotyping Pelvic USS ```
37
Give 4 predisposing factors for Ectopic pregnancy
``` Previous ectopic PID Endometriosis IUD Progesterone contraception Pelvic surgery IVF Advanced age Lower socioeconomic class ```
38
What is the pathophysiology of an ectopic pregnancy?
Embryo implants outside the uterine cavity most commonly in the fallopian tube. The tube is unable to sustain trophoblastic invasion and so ruptures. Can lose lots of blood intraperitoneally
39
Give 4 clinical features of ectopic pregnancy
``` Lower abdominal/pelvic pain Dark, scanty vaginal bleeding Amenorrhoea Syncope Shoulder tip pain ```
40
How is ectopic pregnancy diagnosed?
Pregnancy test- urine Beta-HCG Pelvic USS- visualise where pregnancy is implanted Serum beta-HCG If b-HCG >1500 with no pregnancy visualised= pregnancy of unknown location If b-HCG <1500 with no pregnancy visualised= take test again in 48 hours. Viable pregnancy will double, miscarriage will half every 48 hours
41
How is an ectopic pregnancy managed medically, who is it offered to and what are the positives and negatives to this?
IM Methotrexate given to cause miscarriage Offered to women who are stable, well controlled pain, b-HCG<1500, unruptures, no fetal heartbeat ``` + = avoids surgery, no hospital stay - = side effects of methotrexate (abdo pain, hepatitis), treatment can fail ```
42
How is an ectopic pregnancy managed surgically, who is it offered to and what are the positives and negatives to this?
Laparoscopic salpingectomy- remove fallopian tube and ectopic. Salpingotomy- just removes pregnancy, maintain fertility Offered to women with severe pain, serum b-HCG >5000, adnexal mass >34mm, fetal heartbeat present ``` + = high success rate, definitive treatment - = surgical and anaesthetic complications, can damage nearby structures ```
43
How is an ectopic pregnancy managed conservatively, who is it offered to and what are the positives and negatives to this?
Watch and wait for the ectopic to resolve naturally. Take serum b-HCG every 48 hours Offered to stable women, very low serum b-HCG, well controlled pain, small ectopic visualised on USS ``` + = avoid medical and surgical risks and side effects - = method failure, ectopic rupture ```
44
Give 4 risk factors for gestational trophoblastic disease
``` Maternal age <20 or >35 Previous gestational trophoblastic disease Previous miscarriage Use of oral contraceptive pill Asian women ```
45
What is a partial molar pregnancy?
1 ovum with 23 chromosomes is fertilised by 2 sperm each with 23 chromosomes. Cell has a total of 69 chromosomes.
46
What is a complete molar pregnancy? | Hydatidiform Mole
1 ovum with no chromosomes is fertilised by 1 sperm which duplicates. Leads to 46 chromosomes of paternal origin only. The trophoblastic tissue proliferates aggressively and secretes excessive b-HCG. Benign tumours which can become malignant.
47
What is a choriocarcinoma?
Malignancy of the intermediate trophoblasts which normally attach the placenta to the uterus. Presents 3 years after pregnancy
48
Give 2 clinical features of gestational trophoblastic disease in early and late pregnancy
Early: Vaginal bleeding Abdominal pain Late: Hyperemesis Hyperthyroidism Anaemia
49
When examining a woman with gestational trophoblastic disease, what do you expect the uterus to be like?
Larger than expected | Softer
50
How is gestational trophoblastic disease investigated?
Urine + serum b-HCG USS Histology of POC after removal MRI/CT if metastatic spread suspected
51
How is a molar pregnancy managed?
Removal via suction curettage (ERPC) Post evacuation anti-D prophylaxis if Rhesus neg. Specialist management and long term follow up

1. Senior Block- O&G (11 decks)

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