Obstetrics 1 Flashcards
(38 cards)
1
Q
What is a miscarriage and what are the classifications?
A
- Miscarriage is a spontaneous termination of pregnancy
- <12 weeks: early
- 12-24 weeks: late
- > 24 weeks: stillbirth
2
Q
What are the types of miscarriage?
A
- Missed (no symptoms
- Threatened (bleeding, closed cervix, foetus alive)
- Inevitable (bleeding, open cervix)
- Incomplete (RPOC)
- Complete (no RPOC)
- Anembryonic (sac present but no embryo)
3
Q
What are the chances of miscarriage occurring at different ages?
A
- 20-30: 10%
- 30-35: 15%
- 35-40: 25%
- > 40: 50%
4
Q
How is miscarriage diagnosed?
A
- Transvaginal US
5
Q
What is looked for on transvaginal USS in miscarriage?
A
- Mean sac diameter
- Crown-rump length
- Foetal heartbeat
- Once 1 is present the use of the other diminishes
6
Q
When to expect each finding on TVUS?
A
- Mean sac of >25mm should see foetal pole (if empty sac rescan in 1 week, if still empty then an embryonic)
- Crown-rump length of >7mm should see foetal heartbeat (if not then rescan in 1 week, if still can’t be seen then pregnancy not viable)
- Won’t see anything before 6 weeks
7
Q
How is miscarriage managed before 6 weeks?
A
- If no pain and complications then expectant management
- Do pregnancy test 10 days later
- If bleeding or pain then investigate
8
Q
How is miscarriage managed >6 weeks?
A
- Refer to EPAU for USS
- Expectant
- Medical
- Surgical
9
Q
Expectant management of miscarriage after 6 weeks?
A
- First line in healthy women with no complications
- Give 2 weeks
- Retest in 3 weeks
10
Q
Medical management of miscarriage after 6 weeks?
A
- Misoprostol (prostaglandin analogue that softens cervix and causes contractions)
- Side effects include bleeding, pain, diarrhoea and vomiting
11
Q
What is the surgical management of miscarriage after 6 weeks?
A
- MVA (outpatient procedure done under local; appropriate for pre-10 week and multiparous women)
- EVA (requires general anesthetic)
12
Q
Incomplete miscarriage and treatment?
A
- Infection risk from RPOC
- Can be managed medically
- Surgery is MVA and curettage (risk of post-curettage endometritis)
13
Q
What should miscarriages be investigated?
A
- 3 consecutive first trimester miscarriages
- Any second trimester miscarriage
14
Q
What are some causes of miscarriage?
A
- Idiopathic
- Chromosomal abnormality
- Bleeding disorders (inherited thrombophilias or antiphospholipid syndrome)
- Chorionic histolytic intervillositis
- Uterine abnomalities
- DM, thyroid and SLE
15
Q
Chromosomal abnormalities and miscarriage?
A
- 50-60% or miscarriage
- Trisomy most common cause (trisomy 16)
- Turner’s is most common specific abnormality
- Aneuploidy risk increases with age
16
Q
Antiphospholipid syndrome?
A
- Primary or secondary to SLE
- APL or anticardiolipin antibodies
- Give LMWH and aspirin in pregnancy
17
Q
What is the most common inherited thrombophilia and how is it inherited?
A
- Factor V Leiden (activated protein C resistance)
- Autosomal dominant
18
Q
Chorionic histiocytic intervillositis?
A
- Rare but most common in T2
- Histiocyte and macrophage buildup in placenta
- This causes inflammation and poor outcomes
- Diagnosis: placental histology showing mononuclear cell infiltrate
19
Q
How do you investigate the possible causes of recurrent miscarriage?
A
- Antibodies (antiphospholipid syndrome)
- Pelvic USS (uterine abnormalities)
- Genetic testing of foetus or parents with consent (chromosomal abnormality, Factor V Leiden)
20
Q
What 2 acts are relevant to TOP?
A
- 1967 Abortion Act
- 1990 Human Fertilisation and Embryo Act (reduced legal age from 28 to 24 weeks)
21
Q
What is the criteria for allowing abortion before 24 weeks?
A
Continuing must present cause of significant harm to physical or mental health of the mother or unborn child
22
Q
What is the criteria for abortion after 24 weeks?
A
- Significant risk to life of woman
- Child likely to be born with severe disability
- Prevent significant harm to woman’s physical or mental health
23
Q
What are the aspects of pre-abortion care?
A
- Can be referred by self, GP, or GUM clinic
- Marie stopes is UK charity that offer remote service pre-10 weeks
- Offer counselling
24
Q
What its the medical management of abortion?
A
- Mifepristone (anti-progesterone; halts pregnancy)
- Misoprostol 2 days later (prostaglandin analogue that softens cervix and causes contractions)
- Must give anti-D prophylaxis if before week 10
25
What is the surgical management of abortion?
- Priming with mifepristone, misoprostol, and dilation
- <14 weeks: dilation and suction
- >14 weeks: dilation and forced evacuation
- Must give anti-D regardless of gestation
26
Post-abortion?
- Bleeding and cramps for 2 weeks
- Pregnancy test at 3 weeks
- Bleeding, pain, infection, TOP failure and damage to structures are risk
27
Where are most ectopic pregnancies?
- 97% are tubal
- Most are in the ampulla
- Isthmus is most dangers
28
What are the risk factors for ectopic pregnancy?
- Previous ectopic, PID, STI or Fallopian tube surgery
- Intrauterine coil
- Smoking
- IVF
- Old age
29
Presentation of ectopic?
- 6-8 weeks gestation (missed LMP
- Lower abdo pain in IF
- Bleeding
- CMT
- Shoulder tip pain
- Syncope and dizziness from bleeding
30
Investigation of ectopic pregnancy?
- TVUS will show gestational sac outside of uterus (if can't be seen this pregnancy of unknown location)
- Ectopic moves independently to ovary (if move together will be corpus luteum)
31
What is the management of ectopic?
- Expectant
- Medical
- Surgical
32
What is the medical management of ectopic pregnancy?
- Methotrexate IM buttock
- Can't get pregnant for 3 months
33
What are the surgical options for ectopic?
- Salpingectomy (better, removal of whole tube)
- Salpingotomy (less definitive, ⅕ women will need methotrexate;
done if other tube damaged/ removal of tube leaves infertile)
- Need anti-D phophylaxis
34
What criteria must be met for an expectant TOP of ectopic?
- Unruptured
- No pain
- Sac <35mm
- No heartbeat
- HCG <1500
35
What criteria must be met for medical TOP of ectopic?
- Unruptured
- No pain
- Sac <35mm
- No heartbeat
- HCG <5000
- USS evidence of non-intrauterine pregnancy
36
What criteria must be met for medical TOP of ectopic?
- If ruptured
- If painful
- >35mm
- Heartbeat present
- HCG >5000
37
What is pregnancy of unknown location?
When gestational sac can't be seen on TVUS
38
How is pregnancy of unknown location investigated?
- 2 HCG tests 48 hours apart
- Rise of >63% suggests intrauterine pregnancy
- Rise <50% is likely ectopic, admit
- Fall <50% likely miscarriage, recheck in 2 weeks
