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Year 4 - Reproductive Health > 1.04 - Early Pregnancy > Flashcards

1.04 - Early Pregnancy Flashcards

1
Q

Define miscarriage.

a) early miscarriage

b) late miscarriage

A

A loss of pregnancy at less than 24 weeks’ gestation.

a) before 12 weeks

b) 13-24 weeks

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2
Q

Risk factors for miscarriage.

A
  • maternal age >30
  • previous miscarriage
  • obesity
  • smoking
  • coagulopathies
  • anti-phospholipid syndrome
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3
Q

Clinical features of miscarriage (history).

A
  • vaginal bleeding
  • suprapubic, cramping pain
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4
Q

Clinical features of miscarriage (examination).

A

Haemodynamic instability (pallor, tachycardia, hypotension, tachypnoea).

Abdominal distension / tenderness.

Bleeding and dilated cervix on speculum examination.

Uterine tenderness on bimanual examination.

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5
Q

What are the main differentials to a suspected miscarriage?

A
  • ectopic pregnancy
  • hyatidiform mole
  • cervical / uterine malignancy
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6
Q

How can suspected miscarriage be investigated?

A
  • transvaginal ultrasound scan (fetal heartbeat absent vs present)
  • serum b-hCG
  • FBC
  • blood group / rhesus status
  • triple swabs and CRP (if pyrexic)
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7
Q

What are the categories of miscarriage management?

A

1) Conservative (expectant) management: allows products of conception to pass naturally.

2) Medical management: uses vaginal misoprostol to stimulate cervical ripening and myometrial contractions.

3) Surgical management: manual vacuum aspiration with local anaesthetic (<12 weeks), or evacuation of retained products of conception (ERPC).

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8
Q

When is anti-D prophylaxis indicated in miscarriage management?

A

Patient RhD-ve and >12 weeks gestation.

Patient RhD-ve and surgically managed (regardless of gestation).

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9
Q

What are the

a) clinical features

b) transvaginal USS findings

c) management

of a threatened miscarriage?

A

a) mild bleeding; pain; cervix closed

b) viable pregnancy

c) if heavy bleeding admit/observe, if not reassure and back to GP/midwife; if >12 weeks and RhD-ve, anti-D prophylaxis.

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10
Q

What are the

a) clinical features

b) transvaginal USS findings

c) management

of an inevitable miscarriage?

A

a) heavy bleeding, clots, pain, cervix open

b) internal cervical os opened; fetus can be viable or non-viable

c) if heavy bleeding admit/observe; offer conservative/medical/surgical options (likely to proceed to incomplete/complete miscarriage); if >12 weeks and RhD-ve, anti-D prophylaxis.

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11
Q

What are the

a) clinical features

b) transvaginal USS findings

c) management

of a missed miscarriage?

A

a) asymptomatic or hx of threatened miscarriage

b) no fetal heart pulsation in a fetus where crown-rump length is >7mm

c) manage conservatively/medically/surigcally; if >12 weeks and RhD-ve, anti-D prophylaxis.

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12
Q

What are the

a) clinical features

b) transvaginal USS findings

c) management

of an incomplete miscarriage?

A

a) POC partially expelled; sx of missed miscarriage or bleeding/clots.

b) retained POC, with endometrial diameter >15mm AND proof of previous intrauterine pregnancy (e.g. USS).

c) expectant/medical/surgical management; if >12 weeks and RhD-ve, anti D prophylaxis.

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13
Q

What are the

a) clinical features

b) transvaginal USS findings

c) management

of a complete miscarriage?

A

a) hx of bleeding, passing clots and POC and pain. Sx now settling/settled.

b) no POC seen in uterus, with endometrium <15mm diameter AND previous proof of intrauterine pregnancy (ie. scan).

c) discharge to GP; if >12 weeks and RhD-ve, anti-D prophylaxis.

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14
Q

What are the

a) clinical features

b) transvaginal USS findings

c) management

of a septic miscarriage?

A

a) infected POC (fever, rigor); uterine tenderness; bleeding, discharge and pain.

b) leucocytosis and raised CRP; USS findings of complete or incomplete miscarriage.

c) medical/surgical management; if >12 weeks and RhD-ve, anti-D prophylaxis; IV abx and fluids.

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15
Q

Define recurrent miscarriage.

A

The occurrence of three or more consecutive pregnancies that end in miscarriage of the fetus before 24 weeks of gestation.

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16
Q

What are the genetic factors contributing towards the risk of recurrent miscarriage?

A

Parental chromosomal rearrangements - either mother or father carries a balanced reciprocal or Robertsonian I chromosomal translation.

Embryonic chromosomal abnormalities (e.g. Trisomy 21).

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17
Q

What are the endocrine factors contributing towards the risk of recurrent miscarriage?

A
  • diabetes mellitus
  • thyroid disease
  • PCOS
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18
Q

What are the anatomical factors contributing towards the risk of recurrent miscarriage?

A
  • uterine malformations (septate, bicornuate or arcuate uterus)
  • cervical weakness (dilation before pregnancy reaches term)
  • acquired uterine abnormalities (e.g. adhesions in Asherman’s syndrome)
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19
Q

What are the infective factors contributing towards the risk of recurrent miscarriage?

A

Infection is a rare cause - any overwhelming infection could cause miscarriage.

Notably, BV in first trimester is a risk factor for second trimester miscarriage, so screening and treatment in first trimester.

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20
Q

What are the inherited thrombophilias contributing towards the risk of recurrent miscarriage?

A
  • Factor V Leiden
  • prothombin gene mutation
  • deficiencies of Protein C/S and antithrombin III
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21
Q

Obstetric complications of APS.

A
  • inhibition of trophoblastic function and differentiation
  • activation of complement pathways at the maternal-fetal interface
  • thrombosis of uteroplacental vasculature

Results in recurrent miscarriage.

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22
Q

What is antiphospholipid syndrome (APS)?

A

Autoimmune condition where antibodies target against phospholipid-binding proteins.

This induces a procoagulant state.

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23
Q

Clinical features of APS.

A
  • thrombosis (arterial, venous, microvascular)
  • recurrent pregnancy loss
  • pre-eclampsia
  • intrauterine growth restriction
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24
Q

What is catastrophic APS?

A

Acute formation of microthromboses, causing infarction of multiple organs.

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25
Q

Differential diagnoses to APS.

A

protein C / protein S deficiency.

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26
Q

What are the blood tests used to diagnoses APS?

A
  • anticardiolipin
  • lupus anticoagulant*
  • anti-B2-glycoprotein I

*measures clotting ability of the blood. In vitro, APS inhibits coagulation so prolonged clotting time.

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27
Q

What are the risk factors for recurrent miscarriage?

A
  • advancing maternal age
  • previous miscarriages

Lifestyle factors:
- maternal cigarette smoking
- maternal alcohol intake
- maternal caffeine consumption

28
Q

How should recurrent miscarriage be investigated?

A

Exclude APS with blood tests.

Inherited thrombophilia screen.

Karyotyping.

Pelvic ultrasound scan to assess uterine anatomy.

29
Q

How should recurrent miscarriage secondary to APS be managed?

A

Aspirin (low-dose) plus heparin

30
Q

How should recurrent miscarriage secondary to inherited thrombophilias be managed?

A

Heparin therapy during pregnancy.

31
Q

How should recurrent miscarriage secondary to genetic abnormalities be managed?

A

Refer to clinical geneticist for genetic counselling, familial chromosome studies and pre-implantation genetic screening.

32
Q

How should recurrent miscarriage secondary to anatomical abnormalities be managed?

A

In cervical weakness, cervical cerclage (suture to close the cervix).

No randomised trials to assess the benefit of surgical correction of uterine anomalies on pregnancy outcome.

33
Q

Wha are the most common sites for ectopic pregnancy?

A

Ampulla and ithmus of the Fallopian tube.

Less commonly, the ovaries, cervix or peritoneal cavity can be involved.

34
Q

What are the risk factors for ectopic pregnancy?

A

PMHx:
- previous ectopics
- PID (adhesions)
- endometriosis (adhesions)

Contraception:
- IUD / IUS
- POP / implant (ciliary dysmotility)
- tubal ligation

Iatrogenic:
- pelvic surgery
- assisted reproduction

35
Q

What are the clinical features of ectopic pregnancy (history)?

A
  • lower abdominal/pelvic pain
  • vaginal bleeding
  • shoulder tip pain (referred pain by phrenic nerve)
36
Q

What are the clinical features of ectopic pregnancy (examination)?

A
  • abdominal tenderness
  • brown vaginal discharge

Suspect rupture of ectopic pregnancy if haemodynamically unstable and peritonitic.

37
Q

Differential diagnoses for ectopic pregnancy.

A
38
Q

Investigations for ectopic pregnancy.

A
  • b-hCG (>1500 iU)

If pregnancy test positive, pelvic USS can determine the presence or absence of intrauterine pregnancy.

If intrauterine pregnancy is not seen on transabdominal USS, a transvaginal ultrasound scan should be offered.

39
Q

What are the differential diagnoses of pregnancy of unknown location?

A

Definition: b-hCG >1500 iU AND pregnancy not identified on transvaginal USS.

  • very early intrauterine pregnancy
  • miscarriage
  • ectopic pregnancy
40
Q

How can b-hCG discriminate the differentials of pregnancy of unknown origin?

A

b-hCG >1500 iU = ectopic pregnancy until proven otherwise.

b-HCG <1500 iU, repeat after 48 hours:
a) very early intrauterine pregnancy will see HCG double
b) miscarriage will see HCG halve
c) if increase or drop not >50%, ectopic pregnancy cannot be excluded

41
Q

How can ectopic pregnancy be managed?

A

Medical: IM methotrexate (repeat if b-hCG does not decline when repeated).

Surgical: laparoscopic salpingectomy (salpingotomy if need to preserve fertility).

42
Q

When is medical management of ectopic pregnancy indicated?

A
  • stable patients
  • b-hCG <1500 iU
  • unruptured
  • no viable heartbeat
43
Q

When is surgical management of ectopic pregnancy indicated?

A
  • serve pain
  • b-hCG >5000mIU/ml
  • adnexal mass >34mm (USS)
  • fetal heartbeat

NOTE all RhD-ve women require anti-D prophylaxis if surgically managed.

44
Q

What are the complications of ectopic pregnancy?

A
  • fallopian tube rupture
  • hypovolaemic shock
  • organ failure
  • fatality
45
Q

What is gestational trophoblastic disease?

A

A group of pregnancy-related tumours:

1) Pre-malignant conditions (more common): such as partial molar pregnancy and complete molar pregnancy.

2) Malignant conditions (rarer): such as invasive mole, choriocarcinoma, placental trophoblastic site tumour and epithelioid trophoblastic tumour.

46
Q

What is the pathophysiology of a molar pregnancy?

A

In normal conception, the fetus is formed from 23 maternal chromosomes and 23 paternal chromosomes. A molar pregnancy arises from an abnormality in chromosomal number during fertilisation.

47
Q

What is the pathophysiology of a

a) partial

b) complete

molar pregnancy?

A

a) one ovum with 23 chromosomes is fertilised by two sperm, producing a cell with 69 chromosomes.

b) one ovum without any chromosomes is fertilised by one sperm which duplicates, leading to 46 chromosomes of paternal origin alone.

NOTE these tumours are benign, but can become malignant if they invade into the uterine myometrium (invasive moles).

48
Q

What are the risk factors for gestational trophoblastic disease?

A
  • maternal age <20 or >35
  • previous GTD
  • previous miscarriage
  • use of COCP
49
Q

Clinical features of molar pregnancy (history).

A
  • vaginal bleeding
  • abdominal pain
  • hyperemesis
50
Q

Clinical features of molar pregnancy (examination).

A
  • uterus large than expected for gestation
  • uterus of soft, boggy consistency
51
Q

How is suspected GTD investigated?

A
  • urine / blood b-hCG
  • ultrasound scan (snowstorm appearance)
  • histological examination of the products of conception

NOTE increased titre of b-hCG can cause gestational thyrotoxicosis and anaemia.

52
Q

How should molar pregnancy be managed?

A

Suction curettage is the most effective treatment for complete moles and non-viable partial moles.

If the partial mole is of a greater gestation with fetal development, medical evacuation should be recommended.

If RhD-ve, anti-D prophylaxis is recommended post-evacuation.

53
Q

What is hyperemesis gravidarum?

A

Persistent and severe vomiting during pregnancy, leading to:
- weight loss
- dehydration
- electrolyte imbalances

54
Q

What is the timeframe of nausea and vomiting of pregnancy (NVP)?

A

Starts between 4-7 weeks’ gestation.

Peaks in week 9.

Settles by week 20.

55
Q

What criteria must be met to diagnose hyperemesis gravidarum?

A

Prolonged and severe NVP with:
- >5% pre-pregnancy weight loss
- dehydration
- electrolyte imbalances

56
Q

Pathophysiology behind hyperemesis gravidarum.

A

Rapidly increasing levels of b-hCG are released by the placenta, which stimulates the chemoreceptor trigger zone in the brain stem, stimulating the vomiting centre of the brain.

57
Q

Risk factors for hyperemesis gravidarum.

A
  • first pregnancy
  • previous history
  • raised BMI
  • multiple pregnancy
  • molar pregnancy
58
Q

Clinical features of hyperemesis gravidarum.

A
59
Q

Which objective scoring system can be used to classify the severity of NVP?

A

Pregnancy-Unique Quantification of Emesis (PUQE).

A score >6 indicates moderate to severe symptoms.

60
Q

What are the differentials for NVP?

A
  • gastroenteritis
  • cholecystitis
  • hepatitis
  • pancreatitis
  • peptic ulcers
  • UTI / pyelonephritis

NOTE alternative diagnosis to NVP particularly considered if symptoms start after 10+6 weeks gestation.

61
Q

How should hyperemesis gravidarum be investigated?

A

Bedside:
- weight
- urine dipstick (ketonuria)

Labatory tests:
- MSU
- FBC
- U&Es
- blood glucose (exclude DKA)

Severe cases:
- LFTs
- amylase
- TFTs
- ABG

Imaging:
- USS

62
Q

Broad management of hyperemesis gravidarum.

A

Mild: oral antiemetics, oral hydration, dietary advice and reassurance.

Moderate: ambulatory daycare with IV fluids, parenteral antiemetics and thiamine.

Severe: inpatient management.

63
Q

Why is thiamine prescribed for women with moderate/severe hyperemesis gravidarum?

A

Prevent thiamine deficiency secondary to vomiting, which could cause Wernicke’s encephalopathy.

64
Q

What are some recommended antiemetic therapies for hyperemesis gravidarum?

A
  • cyclizine
  • prochlorperazine
  • promethazine

Second line could be metoclopramide or domperidone.

65
Q

What does the Abortion Act (1967) do?

A

States that abortion is legal if it is performed by a doctor, and that it is authorised by two doctors, acting in good faith on at least one of the following grounds:

a) pregnancy has not exceeded its 24th week;

b) termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman;

c) continuance of pregnancy would involve risk to the life of the pregnant woman;

d) substantial risk that if the child was born it would suffer from physical or mental abnormalities as to be seriously handicapped.

Year 4 - Reproductive Health (12 decks)

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