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Gynaecology > Disorders of early pregnancy > Flashcards

Disorders of early pregnancy Flashcards

1
Q

1st

A

1st

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2
Q

What produces hCG?

A

The trophoblast produces the hCG - this maintains the corpus luteum which produces the oestrogen and progesterone to maintain the endometrium

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3
Q

What is the definition of spontaneous miscarriage?

A

Fetus dies or is delivered dead before 24 weeks completed gestation

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4
Q

When do you the majority of spontaneous miscarriages occur?

A

Before 12 weeks

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5
Q

What % of clinically recognised pregnancies miscarry

A

15%

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6
Q

What is threatened miscarriage?

A

There is bleeding but the fetus is still alive, the uterus is the expected size for dates and the os is shut

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7
Q

What % of threatened miscarriages actually miscarry?

A

25%

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8
Q

What is inevitable miscarriage?

A

Bleeding usually heavier than threatened, although fetus is still alive the os is open and miscarriage is about to occur

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9
Q

What is incomplete miscarriage?

A

Some fetal parts have been passed but os is usually still open

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10
Q

What is complete miscarriage?

A

All fetal tissue has been passed, bleeding has diminished, uterus is no longer enlarged and os is closed

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11
Q

What is septic miscarriage

A

Contents of the uterus are infected causing endometritis - vaginal loss is usually offensive and uterus is tender. Fever can be absent

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12
Q

Signs of septic miscarriage with pelvic infection

A

There is abdominal pain and peritonism

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13
Q

What is missed miscarriage?

A

Fetus has not developed or died in utero - but its not recognised until bleeding occurs or ultrasound is performed - uterus is smaller than expected from dates and os is closed

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14
Q

What is the cause of >60% of one-off or sporadic miscarriages?

A

Isolated non-recurring chromosomal abnormalities

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15
Q

When are miscarriages considered to be “recurrent miscarriages”

A

3 or more

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16
Q

Signs of miscarriage

A

Bleeding!!

Pain from uterine contractions can cause confusion with ectopic pregnancy

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17
Q

Management of miscarriage

A

Admission if septic of heavy bleeding
Anti-D if rhesus negative if surgical/medical treatment or if bleeding after 12 weeks
Ergometrine IM reduces bleeding by contracting uterus but only if fetus not viable

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18
Q

Management of threatened miscarriage

A

Bed rest or hormone treatment with progesterone or hCG do not prevent miscarriage

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19
Q

When is expectant management okay for non-viable intrauterine pregnancy and how long does it usually take

A

If no infection and if woman is willing

Usually takes 2-6 weeks

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20
Q

What is medical management of non-viable intrauterine pregnancy

A

Prostaglandin (oral, sublingual or vaginal) sometimes preceeded by oral antiprogesterone mifepristone

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21
Q

What is the surgical management of non-viable intrauterine pregnancy?

A

Evacuation of retained products of conception under anaesthetic using vacuum - suitable if woman prefers it, if heavy bleeding or signs of infection

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22
Q

Chance of miscarriage a 4th time after 3 miscarriages

A

40%

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23
Q

What systemic disease can cause recurrent miscarriages and management?

A

Anti-phospholipid syndrome - managed with aspirin and low-dose LMWH

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24
Q

When do uterine abnormalities cause miscarriage?

A

Usually late miscarriage

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25
Q

Legal time limit for abortion in the UK

A

24 weeks gestation

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26
Q

When are abortions allowed after the legal time limit?

A

If grave risk to womans life/physical or mental health or severe fetal abnormality

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27
Q

What should be given within 72h of TOP

A

Anti-D to rhesus neg women

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28
Q

When can contraception be administered following TOP?

A

Either with misoprostol (oral pills, condoms. injections or implants) or following next menstrual cycle (IUD or sterilisation)

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29
Q

What surgical method is used for TOP between 7-13 weeks

A

Suction curettage

30
Q

What surgical method is used for TOP after 13 weeks

A

Dilatation and evacuation

31
Q

What is medical TOP?

A

Mifepristone followed by misoprostol 36-48hr later

32
Q

What is needed with TOP after 22 weeks?

A

Feticide - KCl injected into umbilical vein or fetal heart - normally only performed when fetal abnormality is present

33
Q

Complications of TOP

A 
Haemorrhage
Infection
Uterine perforation 
Cervical trauma 
Failure
34
Q

Incidence of ectopic pregnancy

A

1 in 60-100 pregnancies

35
Q

Where is the most common site for ectopic pregnancy?

A

Fallopian tube (95%)

36
Q

What is the risk with ectopic pregnancy?

A

Thin-walled fallopian tube may bleed into lumen or rupture with trophoblastic invasion - intraperitoneal blood loss can be catastrophic

37
Q

Risk factors for ectopic pregnancy

A 
Damage to fallopian tubes 
PID usually from SIT 
Assisted conception 
Pelvic surgery 
Previous ectopic
Smoking
38
Q

When does ectopic pregnancy need to be excluded urgently?

A

In a woman who conceives with copper-IUD because prevents intrauterine pregnancy but not those destined to implant in tube

39
Q

Presentation of ectopic pregnancy?

A

Lower abdominal pain followed by scanty, dark vaginal bleeding

40
Q

Type of pain in ectopic pregnancy

A

Initially colicky as tube tries to extrude the sac and then constant

41
Q

Signs of intraperitoneal bleeding in ectopic pregnancy x2

A

Syncopal episodes

Shoulder tip pain

42
Q

Examination in ectopic pregnancy

A

Abdominal tenderness and rebound tenderness
Moving cervix may cause pain (cervical excitation) and either adenexum may be tender
Uterus is smaller than expected and os is closed

43
Q

Investigations in suspected ectopic pregnancy

A

Urine hCG (in all women of reproductive age who present with pain, bleeding or collapse)
Ultrasound
Quantitative serum hCG - if uterus is empty on US

44
Q

Serum hCG and early pregnancy

A

If >1000 then intrauterine pregnancy should be visible on TV USS
Declining or slow rising (plateauing) levels suggest ectopic or non-viable intra-uterine pregnancy

45
Q

When can pregnancy be seen on TV US?

A

5 weeks

46
Q

Surgical management of ectopic pregnancy

A

Either salpingostomy (higher change of recurrence) or salpingectomy (not done if other tube is gone)

47
Q

When can you do medical management of ectopic pregnancy

A

If unruptured, no cardiac activity, hCG below 3000, no symptoms

48
Q

What is medical management of ectopic pregnancy

A

Single-dose methotrexate - followed by monitoring of hCG levels

49
Q

When can you do conservative management of ectopic pregnancy

A

If small, unruptured and hCG levels are low

50
Q

Rate of second ectopic pregnancy

A

up to 10%

51
Q

What is hyperemesis gravidarum?

A

Nausea and vomiting in early pregnancy that is so severe that it causes severe dehydration, weight loss or electrolyte disturbance

52
Q

Incidence of hyperemesis gravidarum

A

1 in 750 women

53
Q

When does hyperemesis gravidarum occur

A

Seldom persists beyond 14 weeks

54
Q

In whom in hyperemesis gravidarum common

A

Multiparous women

55
Q

Management of hyperemesis gravidarum

A

Antiemetics such as metoclopramide, cyclzine and ondansetron

Thiamine - to prevent Wernickes

56
Q

Conditions which predispose to hyperemesis gravidarum x3

A

Urinary infection and multiple or molar pregnancy

57
Q

What is gestational trophoblastic disease?

A

Proliferation of the trophoblastic tissue - causing a molar pregnancy (not formation of a fetus)

58
Q

What is hCG like in trophoblastic disease

A

Very high

59
Q

What is a hydatidiform mole

A

When proliferation of trophoblastic tissue is localised and non-invasive

60
Q

What are the invasive types of trophoblastic disease

A

Have characteristics of malignant tissue - if only locally within uterus then invasive mole - but if metastasis then choriocarcinoma

61
Q

What is gestational trophoblastic neoplasia?

A

Persistence of gestational trophoblastic disease and elevated hCG

62
Q

When is gestational trophoblastic disease more common

A

Extremes of reproductive age and twice as common in asians

63
Q

Examination findings in GTD

A

Uterus is often large

Early preeclampsia and hyperthyroidism may occur

64
Q

Signs of GTD

A

Vaginal bleeding and may be heavy

Severe vomiting

65
Q

Investigations in GTD

A

USS shows snowstorm appearance of swollen villi

66
Q

Management of GTD

A

Trophoblastic tissue is removed by suction curettage - bleeding is often heavy

67
Q

How is definitive diagnosis of GTD made

A

Histologically

68
Q

Monitoring post removal of GTD

A

hCG - to check for malignancy persistence

Wait for hCG levels to be normal before conception because may need chemotherapy

69
Q

Recurrence of molar pregnancy

A

1 in 60

70
Q

Treatment of tumour following GTD

A

Chemotherapy and is very sensitive to it - 5 year survival rates approach 100%

Gynaecology (8 decks)

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