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MBBS VI: O&G > Disorders of early pregnancy > Flashcards

Disorders of early pregnancy Flashcards

1
Q

Definition of miscarriage

A

Miscarriage is defined as pregnancy loss before 20th week of gestation
* Replaces the term spontaneous abortion
* WHO defines it as expulsion or extraction of an embryo or fetus weighing ≤ 500 g

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2
Q

Definition of stillbirth

A

Stillbirth is defined as pregnancy loss after 20th week of gestation

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3
Q

Defintion of ‘Pregnancy of unknown location’

A

Serum or urine pregnancy test is positive and there is no intrauterine or ectopic pregnancy seen on transvaginal USG (TVS)

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4
Q

Different types of miscarriage:
- Terms
- Definition
- Pain
- Uterine size
- Cervical Os

A
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5
Q

What is a septic abortion?

A
  • Miscarriage with sepsis
  • Incomplete miscarriage associated with ascending infection of the endometrium, parametrium, adnexa uteri or peritoneum
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6
Q

When do most miscarriages occur? How common are recurrent miscarriages?

A

General epidemiology
- 10 – 20% of all clinical recognized pregnancy ended up in miscarriage and the majority of these miscarriage occur in the 1st trimester
- Incidence of recurrent miscarriage = ~1%

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7
Q

Causes of recurrent miscarriages

A
  • Chromosomal abnormalities
  • Anatomical defects of uterus
  • Endocrine disturbances
    – Polycystic ovarian syndrome (PCOS)
    – Poorly-controlled DM
    – Untreated thyroid dysfunction
  • Autoimmune diseases
    – Antiphospholipid syndrome
  • Cervical incompetence
  • Maternal infection
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8
Q

Biochemical tests for miscarriage

A
  • CBC with differentials
  • Type and screen
    – Rhesus group if not already known
  • Pregnancy test
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9
Q

Radiological tests for miscarriage

A

Transvaginal/ Transabdominal USG
* Transvaginal USG is preferred
* Patient should be informed that the diagnosis of miscarriage using 1 USG scan cannot be guaranteed to be 100% accurate

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10
Q

Features to look for in USG scan for incomplete miscarriage

A
  • Heterogeneous material with or without a gestational sac with a thickness > 15 mm inside the uterine cavity
  • Diagnosis of incomplete miscarriage
    – Diagnosed when there is a positive pregnancy test, history of passage of tissue and blood and USG findings mentioned above
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11
Q

Features to look for in USG scan for silent miscarriage

A
  • Measure the mean gestational sac diameter (MSD) which is measured by the height, length and width divided by 3. If it is more than 25, you should see the fetal pole (fetus)
  • Than identify the fetal pole. Once identified measure the crown rump length. When CRL >7mm there should be fetal heartbeat
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12
Q

What is the dx and management for these transvaginal ultrasound findings

A

The below Mx is to confirm silent miscarriage

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13
Q

Managment for these transabdominal USG findings

A
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14
Q

What is the 1st Ix done for suspected silent miscarriage?
What is the criteria?

A

Transvaginal scan

mean sac diameter <25mm with no visible fetal pole –> perform 2nd scan a minimum of 7 days after the frist scan
mean sac diameter >25mm with no visible fetal pole: seek a second opinion on viability or perform a second scan minimum of 7 days after the first scan

CRL <7mm with no visible heart beat: perform second scan a minimum of 7 days after the first scan
CRL >7mm with no visible heart beat: seek a second opinion on viability or perform a second scan a mininum of 7 days after the 1st scan

If previous TVS had heart beat than 7 days later no heart beat than silent miscarriage

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15
Q

What is order of treatment for miscarriage in 1st and 2nd trimester?

A

1st trimester: 1st line is always expectant mx, 2nd line is medical Mx, 3rd line is surgical Mx. TOP: surgical Mx
2nd trimester is medical management

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16
Q

What is Anti-D prophylaxis and when is it needed?

A

Anti-D prophylaxis for non-sensitized Rh(D)-negative women
* One dose of anti-D antibody (1500 IU prefilled syringe)
* Indications o Medical or surgical treatment for spontaneous miscarriage at any gestation
o Spontaneous miscarriage ≥ 12 weeks not requiring any interventions
o Threatened miscarriage < 12 weeks with heavy bleeding or abdominal cramps
o Threatened miscarriage ≥ 12 weeks
– Consider 6-weekly injection if recurrent bleeding
– In the event of further intermittent uterine bleeding after 20 weeks, estimation of fetomaternal hemorrhage (FMH) by Kleihauer’s test should be carried out at 2-weekly interval

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17
Q

Management of 1st trimester miscarriage

A
  • Offer expectant management for 7 – 14 days as the 1st line management strategy for women with a confirmed diagnosis of miscarriage unless contraindicated
    o Most cost-effective strategy
    o Negates the risk of intervening and accidentally terminating a viable pregnancy
  • If expectant management is not acceptable, offer medical treatment since it is the next most cost-effective treatment
  • If neither expectant nor medical treatment is acceptable, offer surgical treatment
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18
Q

What is expectant, medical and surgical management of 1st trimester miscarriage?

A
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19
Q

Expectant management of 1st trimester miscarriage:
- Indications
- What explanation must be given?
- What is the time course of expectant management?
- Success rate?

A
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20
Q

Nature of procedures in expectant management of 1st trimester miscarriage

A
  • Awaits spontaneous complete emptying of uterus without medical or surgical interventions
  • Pain killers can be provided
  • Vaginal bleeding and pain can occur prior to passage of tissue mass
  • Suction evacuation may be required in case of retained tissue mass or incomplete miscarriage with heavy bleeding or severe pain
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21
Q

Complications of expectant management of 1st trimester miscarriage

A
  • Pelvic infection (and associated adverse effect on future fertility)
  • Excess bleeding requiring blood transfusion
  • Failed expectant management
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22
Q

Medical management of 1st trimester miscarriage:
- Indications
- Regimen
- Procedure

A
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23
Q

FU after medical management of 1st trimester miscarriage

A
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24
Q

Complications of medical management of 1st trimester miscarriage

A
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25
Q

Surgical management of 1st trimester miscarriage
- When can it be performed?

A
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26
Q

Preoperative preparation for surgical management of 1st trimester miscarriage

A
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27
Q

Procedures for surgical management of 1st trimester miscarriage

A
  • Performed under LA with conscious sedation or GA
  • Insertion of the suction tube
  • Uterine content evacuated under negative pressure
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28
Q

Follow-up for surgical management of 1st trimester miscarriage

A
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29
Q

Complications of surgical management of 1st trimester miscarriage?

A
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30
Q

Management of 2nd trimester miscarriage
- Regimen
- Success rate
- Route of administration
- MOA
- Side effects

A
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31
Q

Procedures in management of 2nd trimester miscarriage

A
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32
Q

Alternatives to misoprostol in management of 2nd trimester miscarriage

A
33
Q

Precautions of management of 2nd trimester miscarriage

A
  • Cervical dilatation and uterine contraction and retraction may not be coordinated. A ballooned-out cervix is suggestive of prostaglandin overdose and it is an indication to stop further administration
  • Presence of uterine scar is NOT a contraindication to the use of misoprostol but the patient should be monitored closely for signs and symptoms of uterine rupture
  • Patients with high risk of scar rupture should be pretreated with mifepristone 200 mg 24 – 48 hours before starting misoprostol
  • Caution should be exercised if a combination of prostaglandins and oxytocin infusion is used as overstimulation of uterus may lead to tis rupture
  • Hysterectomy may be indicated in patients who develop severe intrauterine infection or who are bleeding profusely and yet cervices have not dilated sufficiently for surgical evacuation
34
Q

Follow-up in management of 2nd trimester miscarriage

A
35
Q

Frequent complications in management of 2nd trimester miscarriage

A

Frequent complications
* Vaginal bleeding and abdominal cramps within 2 weeks
* Breast engorgement a few days after procedures
* Incomplete miscarriage requiring suction evacuation (10%, common)
* Side effects of misoprostol = Nausea/ Vomiting/ Diarrhea/ Fever/ Abdominal pain/ Headache/ Vaginal bleeding

36
Q

Serious complications in management of 2nd trimester miscarriage

A
  • Excessive bleeding requiring blood transfusion (< 1%, uncommon)
  • Cervical tear resulting in cervical incompetence (< 1%, uncommon)
  • Uterine rupture necessitating laparotomy or hysterectomy (< 0.01%, rare)
  • Failure of procedure requiring alternative medications (< 1%, uncommon)
  • Pelvic infection
  • Congenital abnormality if procedure was stopped and pregnancy continues
  • Anaphylaxis caused by drug
37
Q

Management of recurrent miscarriage

A
38
Q

What is ‘Termination of Pregnancy (TOP)’?

A

Induced abortion which is a procedure to discontinue a live pregnancy by evacuation of uterus before 24 weeks of gestation

39
Q

What is ‘viability’? Why is the concept of viability important in TOP?

A
  • Viability refers to the ability to survive
  • Fetuses with maturity ≥ 24 weeks are regarded as potentially viable and thus maturity of 24 weeks of gestation is set as the cutoff of abortion
  • Although the laws in HK allow TOP up to 24 weeks but is not advisable to terminate pregnancy after 20th week since the fetuses may be viable with the exception of pregnancies with significant fetal abnormalities
40
Q

Legal aspects of abortion in Hong Kong
- Time frame
- Conditions
- Location

A
41
Q

Investigations for TOP: History taking

A
42
Q

Investigations for TOP: Biochemical tests

A
  • CBC with differentials
  • Blood group and Rh(D)
    ** ALL women with threatened or spontaneous miscarriage, ectopic pregnancy or undergoing TOP should have Rh (D) blood group checked
43
Q

Investigations for TOP: Fetal USG

A

When there is doubt about the gestational age, USG should be performed

44
Q

Method of TOP in 1st trimester

A
45
Q
  • Method of TOP in 2nd trimester
  • When is the 2nd trimester?
A
46
Q

Importance of future contraception for women receiving TOP

A
47
Q

What must be given to a non-sensitized Rh(D)-negative women during TOP?

A
48
Q

Suction evacuation
- Time frame
- Under what condition may a suction evacuation be contraindicated?
- What are alternatives if suction evacuation cannot be performed?

A
49
Q

Preoperative preparation for suction evacuation

A
50
Q

Follow-up for suction evacuation

A
51
Q

Frequent complications + serious complications of suction evacuation

A
52
Q

What is the 2nd trimester TOP method, MoA and AE?

A
53
Q

What is the medical termination of pregnancy during 2nd trimester algorithm?

A
54
Q

What are alternative options for medical TOP instead of misoprostol?

A
55
Q

What and when is the FU for management of miscarriage?

A
56
Q

What is the complications of medical TOP during 2nd trimester?

A
57
Q

What is a heterotopic pregnancy?

A
  • Combination of an intrauterine pregnancy and a concurrent pregnancy at an ectopic location
58
Q

What are the anatomical sites of ectopic pregnacy?

A
59
Q

What are the RF for ectopic pregnancy?

A
60
Q

What is the classical triad for ectopic pregnancy?
What is SS of ruptured ectopic pregnancy?

A
61
Q

What is important history taking and PE for suspected ectopic pregnancy?

A
62
Q

What are the biochemical tests done for suspected ectopic pregnancy and why?

A
  • CBC with DC (anemia)
  • Type and screen and Rh blood group: non sensitized Rh negative patients should recieve anti-D immunoglobulin
  • Clotting profile
  • LFT: pretreatment workup for MTX. MTX is hepatotoxic. Liver and renal disease may slow metabolism of MTX resulting in pancytopenia
  • Pregnancy test: negative test effectively rules out ectopic pregnancy
  • Serial serum hCG monitoring
63
Q

What is the use of serial serum hCG monitoring in suspected ectopic pregnancy?

A
64
Q

What is the serum hCG threshold for when gestational sac should be seen by TVUS?
At what hCG level is ectopic pregnancy suspected?

A

1500IU/L should be visualized by TVUS if an intrauterine preganncy is present
Suspect ectopic pregnancy when hCG >1500IU/L but yet no intrauterine gestational sac is identified

65
Q

What must you look for in transvaginal ultrasound for suspected ectopic pregnancy?

A
66
Q

What are the indications for expectant management in ectopic pregnancy?

A
67
Q

What is medical management for ectopic pregnancy?
What is the MoA?
Who is it offered?

A
68
Q

For medical management of ectopic pregnancy what route of admin is given depending on location of ectopic pregnancy?

A

IM injection into muscle

Intralesional injection indicated in caesarean scar pregnancy, interstitial pregnancy or cervical pregnancy

69
Q

What is patient selection and contraindications for medical management of ectopic pregnancy?

A
70
Q

What is pretreatment workup for medical management of ectopic pregnancy and why are they done?

A
71
Q

What is the procedures done in medical management of ectopic pregnancy?

A
72
Q

What are the complications of medical Mx of ectopic pregnancy?

A
73
Q

What is counselling and advice for medical Mx for ectopic pregnancy?

A
74
Q

What is the surgical treatment options for ectopic pregnancy?

A
75
Q

What are the indications for salpingotomy and salpingectomy in ectopic pregnancy?

A
76
Q

What are the indications for surgical intervention in ectopic pregnancy?
What are the complications?

A
77
Q

Early pregnancy bleeding, LMP 5 weeks ago but cannot see anything on TVS, what are the causes?

A
  • Intrauterine pregnancy (but too small to be seen)
  • Ectopic pregnancy (but too small to be seen)
  • Complete miscarriage (has expelled all of the products of gestation)
78
Q

Early pregnancy bleeding, LMP 5 weeks ago and has done TVS, what is the next Ix and how does this help with the diagnosis?

A

Serial hCG monitoring
* If increases optimally it is intrauterine pregnancy: >63% rise in 48 hours. Repeat TVS 7-14 days later or earlier if hCG >1500IU/L to confirm a viable intrauterine pregnancy
* If suboptimal increase it is etopic pregnancy: <63% rise in 48 hours
* If decreases it is likely complete miscarriage

79
Q
A

MBBS VI: O&G (109 decks)

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