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Problems of early pregnancy Flashcards

(50 cards)

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1
Q

Define miscarriage

A

Pregnancy loss at <20wks gestation or loss of foetus/embryo <500g

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2
Q

Risk factors for miscarriage

A 
Hx miscarriage
Smoking
Alcohol
Increasing maternal age
BMI <18.5 or >25
Fever
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3
Q

Epidemiology of miscarriage

A

20% of all pregnancies

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4
Q

Aetiology of miscarriage - foetal factors

A

Chromosomal abnormalities (50%)

Congenital abnormalities

  • genetic e.g. anencephaly
  • teratogen exposure
  • extrinsic factors

Trauma

  • amniocentesis or chorionic villus sampling
  • trauma to abdomen
  • DV
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5
Q

Aetiology of miscarriage - maternal factors

A

TORCH infection

  • toxoplasmosis
  • syphilis, parvovirus, varicella, listeria
  • rubella
  • CMV
  • HSV2

Medical conditions

  • hypothyroid
  • DM
  • PCOS

Hypercoagulable states

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6
Q

Ix for ?miscarriage

A

B-hcg
Pelvic US
Group and hold (Ab status)

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7
Q

List the different types of miscarriage

A 
Complete
Incomplete
Inevitable
Threatened
Missed
Septic
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8
Q

What is a threatened miscarriage? And what are the distinguishing features?

A

Threatened MC = any bleeding/spotting before 20wks. Does not necessarily mean actual MC.

Features:

  • No pain
  • minimal bleeding
  • no POC passed
  • no cervical dilation, closed os
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9
Q

Management for threatened miscarriage

A 
Expectant management: symptoms will either resolve or progress to MC.
Avoid strenuous activity and stress.
Rest
Weekly pelvic US
Refer to EPC
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10
Q

Features of complete miscarriage

A

Full expulsion of POC
PV bleeding and pain - usually resolves after passing POC
Cervical dilation, os open or closed.

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11
Q

Management of complete miscarriage

A

Confirm cervical os has closed
TV US to exclude retained POC
Monitor b-hcg weekly to ensure it’s dropping

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12
Q

Features of incomplete miscarriage

A

Heavy PV bleeding with clots
Passage of some POC
Abdo pain
Cervical os open

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13
Q

Management of incomplete miscarriage

A

Expectant vs medical vs surgical management

b-hcg
pelvic US

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14
Q

Features of inevitable miscarriage

A 
Heavy bleeding
Abdo pain
Cervical dilation, open os
Visible or palpable POC not yet passed
\+/- foetal cardiac activity
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15
Q

Define inevitable miscarriage

A

PV bleeding + open os with passage of POC expected to occur imminently

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16
Q

Management of inevitable miscarriage

A

Expectant or medical or surgical.

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17
Q

What is a missed miscarriage

A

US diagnosis of a non-viable IUP in the absence of PV bleeding

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18
Q

Features of missed miscarriage

A 
No bleeding (may have spotting)
No pain
No cervical changes
No foetal HR
Empty gestational sac
Incidental US finding
No expulsion of POC
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19
Q

Management of missed miscarriage

A

Expectant vs medical vs surgical

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20
Q

Features of septic miscarriage

A 
Vaginal bleeding 
Offensive PV discharge
Abdo pain
Fever
Complication of an inevitable/missed/incomplete miscarriage
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21
Q

Management of septic miscarriage

Study These Flashcards
A

Broad spectrum IV abx

Surgical D&C

22
Q

What is involved in expectant management of miscarriage?

Study These Flashcards
A
  1. education
    - 60% success rate
    - 1-2 wks duration
    - Sx should resolve as the POC is passed
    - more bleeding than a normal period
    - return if malodourous d/c, fever, severe abdo pain, N&V
  2. analgesia - NSAIDs, paracetamol
  3. Review in 1-2 wks (repeat b-hcg)
23
Q

Explain the process of medical management of miscarriage

Study These Flashcards
A
  1. misoprostol PO or PV (prostaglandin analogue for cervical ripening)
  2. mifepristone PO (blocks progesterone)
  3. analgesia
  4. return if worsened Sx
  5. follow up in 1-2 wks
    (70% have complete MC in 3 days)
24
Q

Explain the surgical management of miscarriage.

When would you opt for surgical management?

Study These Flashcards
A
  1. prime cervix 4hrs before surgery with misoprostol.
  2. D&C

Management choice for: persistent heavy bleeding, sepsis, larger foetal pole, unsuccessful medical Rx.

25
Education and counselling after a miscarriage
No sex or tampons for 2 wks Periods will return in 4-8 wks Can attempt to conceive after 2 normal periods reassurance that she didn't cause the MC risk recurrance after 1 MC is not substantial
26
Define recurrent miscarriage
>3 consecutive miscarriages
27
Risk factors for recurrent miscarriage
``` Prev miscarriages Uterine anomalies, leiomyomas, adhesions Antiphospholipid syndrome PCOS Poorly controlled DM Hyperprolactinaemia Inc parity ```
28
Investigations for recurrent miscarriage
Lupus anticoagulant Parental chromosomes Pelvic US
29
Management of recurrent miscarriage
Progesterone pessaries Low does aspirin Early pregnancy surveillance
30
Describe management of a medical termination of pregnancy
``` MS 2-step: 1. Mifepristone Two days later... 2. Misoprostol 3. Ibuprofen Plus prn panadeine forte and antiemetics ``` ``` Follow up: 2 wks after MTOP to confirm termination is complete: - declining b-hcg - hx of passing POC - US Discuss contraception Review STI results ```
31
Advantages and disadvantages of MTOP
Advantages: - safe and effective - avoids hospital admission - avoids surgical and anaesthetic risks Disadvantages: - takes longer than STOP (2 wks) - usually more blood loss - failure rate is 1 in 100, which is higher than in STOP - more likely to have retained products
32
Describe the management of a surgical termination of pregnancy (STOP)
``` Day procedure Anti-D Misoprostol 4 hrs before surgery GA suction and curettage if <14 wks, dilation and evacuation if >14wks. Abx: doxy +/- metronidazole +/- IUD insertion in theatre ```
33
Risks and benefits of STOP
Risks: - 0.2% failure rate - retained POC - infection - cervical trauma - uterine perforation - Asherman's syndrome (intrauterine adhesions) - anaesthetic risks Benefits: - higher success rate than MTOP - less bleeding ('over and done with')
34
DDx for bleeding in pregnancy
Pregnancy-related: - miscarriage: complete, incomplete, inevitable, theatened. - ectopic pregnancy - endometrial implantation bleed - molar pregnancy Not pregnancy related: - endometritis - STI - cervical polyps - cervical cancer If haemodynamically unstable: ruptured ectopic, incomplete miscarriage with cervical shock.
35
Risk factors for ectopic pregnancy
``` Previous ectopic Tubal pathology or surgery (strictures, adhesions) PID Prev STI IUD POP ```
36
Indications for expectant management of ectopic pregnancy
``` Hemodynamically stable No evidence of rupture Tubal mass <3cm No free fluid in pelvis b-hcg <5000 Pain free woman can access follow up ```
37
Outline the components of expectant management of ectopic pregnancy
``` Monitor Sx Refer to EPC serial b-hcg every 2 days US avoid conception until sonographic resolution advise of red flags ```
38
Indications for medical management of ectopic pregnancy
``` hemodynamically stable no evidence of rupture normal FBC, no signs of active bleeding reliable with treatment and follow up b-hcg <5000 mass size <3cm no FHR ```
39
What is involved in medical management of ectopic pregnancy
- Methotrexate IM or IV (absorption and resolution of pregnancy) - Admit to hospital for the 1st few days (the risk of rupture will inc for a few days after MTX as the mass swells before resolving) - serial b-hcg until -ve - US in 1 wk - avoid conception for 4 months (MTX is teratogenic) - avoid NSAIDS (BM suppression)
40
What is the success rate of medical management of ectopic pregnancy
90%
41
Indications for surgical management of ectopic pregnancy
Signs of rupture, peritonism or unstable. any b-hcg level persistent excessive bleeding heterotopic pregnancy contraindication to medical or expectant management
42
Management of ruptured ectopic
If stable --> laparoscopy | If unstable --> laparotomy
43
DDx for pain in early pregnancy
ectopic pregnancy miscarriage UTI Non-pregnancy related (appendicitis, cholelithiasis)
44
Aetiology of nausea and vomiting in pregnancy
Primary (most common): attributed to pregnancy and rising b-hcg levels. Secondary: - inc ICP - thyrotoxicosis, DKA, hyperglycaemia - iron supplements, abx - appendicitis, cholecystitis, bowel obstruction, PUD, pancreatitis - UTI, pyelo - Pregnancy specific: HELLP syndrome, acute fatty liver of pregnancy
45
Aetiology of hyperemesis gravidarum
Molar pregnancy Multiple pregnancy Hyperthyroidism
46
Complications of hyperemesis gravidarum
``` Maternal complications: Dehydration Ketosis and ketonuria Mallory weiss tear Wernicke's encephalopathy Malnutrition and weight loss Hyponatremia Thrombosis (inc blood viscosity) ``` Foetal complications: SGA Foetal death
47
Ix for hyperemesis gravidarum
``` Urinalysis - ketonuria b-hcg TSH UEC LFTs FBC BSL US - molar pregnancy or multiple pregnancy ```
48
Management of hyperemesis gravidarum
Mild: pyridoxine or ginger powder, PO fluids, small frequent meals Moderate: - metoclopramide or ondansetron - H2 anatagonist - IV fluids Severe: - admit to hospital - ondansetron, metoclopramide and prednisone - switch H2 anatgonist for a PPI - IV fluids - electrolyte replacement - IV thiamine - VTE prophylaxis
49
Management of gestational trophoblastic disease
Suction evacuation Anti-D COCP for 6/12 Refer to QTC (Queensland Trophoblastic Centre) - they will organise serial b-hcgs.
50
Diagnosis of GTD
Pelvic US: grape-like vesicles or snow storm appearance b-hcg super high hyperthyroidism

Obstetrics (7 decks)

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