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OBGYN 4MB > Disorders of Early Pregnancy > Flashcards

Disorders of Early Pregnancy Flashcards

1
Q

In what part of the female reproductive tract is the oocyte fertilised?

A

The fallopian tubes

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2
Q

What are the consequences of tubal damage?

A

Impair movement of the zygote and increase risk of ectopic pregnancy

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3
Q

At what stage after fertilisation is the placenta formed?

A

Begins days 6-12 and is completed by week 12

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4
Q

At what stage of pregnancy does beta hCG peak?

A

12wks

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5
Q

At what stage of pregnancy is the heartbeat established?

A

4-5wks

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6
Q

Define spontaneous miscarriage

A

Fetus dies or delivers dead before 24 completed weeks of pregnancy

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7
Q

List the types miscarriage

A
  1. Threatened miscarriage
  2. Inevitable miscarriage
  3. Incomplete miscarriage
  4. Complete miscarriage
  5. Septic miscarriage
  6. Missed miscarriage
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8
Q

What is a threatened miscarriage?

A
  • Bleeding but fetus still alive
  • Uterus is size expected and cervical os closed
  • 25% go on to miscarry
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9
Q

What is an inevitable miscarriage?

A
  • Bleeding heavier

- Fetus may still be alive but cervical os open

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10
Q

What is an incomplete miscarriage?

A
  • Some fetal parts have been passed

- The os is usually open

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11
Q

What is a complete miscarriage?

A
  • All fetal tissue has been passed
  • Bleeding diminished
  • Uterus no longer enlarged and cervical os closed
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12
Q

What is a septic miscarriage?

A
  • Contents of the uterus infected causing endometritis
  • Vaginal loss offensive
  • Uterus tender
  • Fever can be absent
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13
Q

What is a missed miscarriage?

A
  • Fetus has not developed or died in utero
  • Not recognised until bleeding occurs or US
  • Uterus small for dates, os closed
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14
Q

Define recurrent miscarriage

A

3 or more consecutive miscarriages

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15
Q

List the clinical features of miscarriage

A
  1. Bleeding
  2. Pain from contractions
  3. Uterine size
  4. State of cervical os

3&4 depend on type of miscarriage

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16
Q

What investigations should be performed if miscarriage is suspected?

A
  1. Early pregnancy assessment unit
  2. Transvaginal US:
    - Show if fetus in uterus and if it is viable
    - may detect retained fetal tissue
    - If doubt, repeat in 1wk
  3. Bloods:
    - BhCG levels (normally increase by >63% in 48hrs)
    - If BhCg levels fall by >50% suggests non-viable pregnancy
    - Change between above level suggests ectopic
    - FBC
    - Rh status
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17
Q

Define pregnancy of unknown location

A

Sometimes it is not possible to differentiate between an early viable or failing uterine pregnancy, a complete miscarriage or an ectopic pregnancy and this is termed a PUL

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18
Q

When is conservative management considered in case of miscarriage?

A
  1. No signs of infection
  2. No excessive bleeding
  3. No pyrexia or abdominal pain
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19
Q

What are women counselled when following a conservative management plan?

A
  1. What to expect (complete resolution may take several weeks and that overall efficacy rates are lower)
  2. The likely amount of blood loss
  3. What analgesics to take
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20
Q

What is the follow up like for conservative management?

A
  • Follow up scans arranged at 2wkly intervals until diagnosis of complete miscarriage
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21
Q

When can medical management of miscarriage not be used?

A
  1. Signs of infection
  2. Excessive bleeding
  3. Pyrexia
  4. Abdominal pain
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22
Q

What is the suggested protocol of misoprostol administration?

A
  • 2 sublingual/vaginal doses 600mcg at least 3hrly (if GA <13wks)
  • Safe for use in women with previous uterine surgery
  • Follow up scan after 2wks
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23
Q

When can misoprostol administration be done in an outpatient setting?

A
  • Only if the mean gestation sac diameter (MGSD) <50mm
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24
Q

Which women should be prescribed misoprostol with caution?

A
  1. Uterine infection
  2. Severe anaemia
  3. Cardiovascular and cerebrovascular diseases
  4. Coagulopathy or current anticoagulant therapy
  5. Severe HTN or asthma
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25
Q

List the clinical indications for surgical uterine evacuation

A
  1. Persistent excessive bleeding
  2. Haemodynamic instability
  3. Evidence of infected retained tissue
  4. Suspected gestational trophoblastic disease (GTD)
  5. To women who prefer this option to medical or conservative management
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26
Q

What is the surgical procedure done to manage miscarriage?

A
  • Evacuation of retained products of conception (ERPC)

- Performed using suction curettage; preferably as day case

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27
Q

List the risks of ERPC

A
  1. Uterine perforation
  2. Cervical tears
  3. Intra-abdominal trauma
  4. Haemorrhage
  5. Infection
28
Q

How should the patient be prepared for the procedure?

A
  • Oral or vaginal cervical preparation prior to procedure - misoprostol 400mcg 3hrs before procedure
29
Q

What happens to the products of conception after surgery?

A
  • Sent for histological examination to determine if molar or ectopic pregnancy
30
Q

In what early pregnancy situations do women receive anti-D?

A
  • Non-sensitised Rh- women receive prophylactic anti-D Ig in:
    1. Ectopic pregnancy
    2. All miscarriages >12wks gestation
    3. All miscarriages evacuated surgically
  • Only given in threatened miscarriage <12wks if bleeding heavy or painful
  • Not required for complete miscarriage <12wks where no surgical evacuation
31
Q

How should the psychological aspects of miscarriage be addressed?

A
  • Be aware
  • Provide support, follow-up and access to formal counselling when necessary
  • System in place for informing all relevant primary care professionals
32
Q

List the causes of recurrent miscarriage

A
  1. Antiphospholipid antibodies
  2. Parental chromosomal defects
  3. Anatomical factors
  4. Infection
  5. Hormonal factors
  6. Others:
    - Obesity
    - Smoking
    - Excess caffeine intake
    - Older maternal age
33
Q

What is the mechanism of miscarriage in antiphospholipid antibodies and how can this be prevented?

A
  • Thrombosis in uteroplacental circulation

- Prevent with aspirin and LMWH

34
Q

How is a parental chromosomal defect determined as cause of miscarriage and what is the follow up?

A
  • Miscarried fetal tissue karyotyped and if shows abnormality parents are karyotyped
  • Refer to clinical geneticist
35
Q

What anatomical abnormalities are implicated in miscarriage and when do these miscarriages tend to occur?

A
  • Uterine abnormalities

- More common in late miscarriage

36
Q

What impact can infection have on pregnancy?

A
  • Implicated in preterm labour and late miscarriage

- Early treatment leads to decreased incidence of fetal loss

37
Q

What hormonal factors can contribute to recurrent miscarriage?

A
  1. Thyroid dysfunction

2. Polycystic ovary syndrome (PCOS)

38
Q

Define ectopic pregnancy

A

When the embryo implants outside the uterine cavity

39
Q

List the sites of ectopic pregnancy

A
  1. Fallopian tube (most common 95%)
  2. Cornu
  3. Cervix
  4. Ovary
  5. Abdominal cavity
40
Q

List the risk factors for ectopic pregnancy

A
  1. Any factor which damages fallopian tube
  2. Pelvic inflammatory disease (PID)
  3. Assisted conception
  4. Pelvic surgery
  5. Previous ectopic
  6. Smoking
41
Q

What are the clinical features of ectopic pregnancy?

A
  • Symptoms:
    1. Abnormal vaginal bleeding
    2. Abdominal pain
    3. Collapse
  • History:
    1. Lower abdominal pain followed by scanty, dark vaginal bleeding
    2. Pain variable
    3. Syncopal episodes and shoulder tip pain (intraperitoneal blood loss)
    4. Amenorrhea of 4-10wks usual
42
Q

What features are present on examination of a patient with suspected ectopic pregnancy?

A
  1. Tachycardia (blood loss)
  2. Hypotension
  3. Abdominal and rebound tenderness
  4. Movement of uterus may cause pain
  5. Uterus small for dates
  6. Cervical os closed
43
Q

List the investigations performed in suspected ectopic pregnancy

A
  1. Pregnancy test
  2. Ultrasound (preferably transvaginal)
  3. Quantitive serum hCG and 48hr hCG
  4. Laparoscopy - most sensitive but invasive
44
Q

What is it called when an ectopic pregnancy co-exists with a viable intrauterine pregnancy?

A

Heterotopic pregnancy

45
Q

Discuss expectant management of ectopic pregnancy

A
  • Used in women with probable EP
  • Must have minimal symptoms and be compliant with follow-up
  • Initial hCG <1000 IU/L and decreases by 13% in 48hrs
  • Weekly serial hCg measurements and TVUS
  • Any plateau or rise in hCG = medical or surgical management
46
Q

Discuss medical management of ectopic pregnancy

A
  • Done with systemic methotrexate
  • Used in women with minimal symptoms and initial hCG <1500 IU/L with an adnexal mass <35mm
  • Must be haemodynamically stable
47
Q

List the contraindications to medical management of ectopic pregnancy with methotrexate

A
  1. Pre-existing blood dyscrasias
  2. Serious acute or chronic infections
  3. Ulcers of the oral cavity and known active GI ulcer disease
  4. Breastfeeding
  5. Concurrent vaccination with live vaccines
  6. Hepatic or renal disease
48
Q

What is the single dose methotrexate protocol?

A
  • Single administration of MTX by IM injection with monitoring of hCG levels on day 4 and 7
  • Dose = 1mg/kg body weight
  • If less than expected 15% decrease in hCG, repeat dose of MTX
  • Surgery if still unsatisfactory reduction
49
Q

List the prerequisites for treatment of ectopic pregnancy with methotrexate therapy

A
  1. Able to return for follow up
  2. No significant pain
  3. Unruptured ectopic pregnancy
  4. Adnexal mass <35mm with no fetal heart activity seen
  5. No co-existing intrauterine pregnancy
  6. Lower level of hCG
50
Q

What else should patients be informed of if on methotrexate therapy?

A
  • Can’t conceive until after 6mths
51
Q

Discuss the surgical management of ectopic pregnancy

A
  • Preferable if hCG >1500 IU/L
  • Also use if:
    1. Visible EP sac with fetal cardiac activity
    2. IF mass >35mm
  • Leads to rapid confirmation of dx with shorter resolution time
52
Q

In what women is a salpingectomy done?

A
  1. Recurrent EP in same fallopian tube
  2. Extensive damage to involved tube
  3. Uncontrolled bleeding
  4. Women who have completed child bearing
53
Q

In what women is a salpingotomy done?

A
  1. Women who do not have a healthy contralateral tube
54
Q

Define hyperemesis gravidarum

A

Nausea and vomiting in early pregnancy so severe as to cause severe dehydration, weight loss or electrolyte disturbance

  • Seldom persists beyond 14wks
  • More common in multips
55
Q

How is hyperemesis gravidarum managed?

A
  • Exclude predisposing conditions
  • IV rehydration
  • Antiemetics (e.g. metoclopramide, cyclizine and ondansetron)
  • Give thiamine to prevent neurological complications
  • Steroids in severe cases
  • Psychological support essential
56
Q

Define gestational trophoblastic disease (GTD)

A

Trophoblastic tissue proliferates in a more aggressive way than is normal with hCg usually secreted in excess

57
Q

What is a hydatidiform mole?

A
  • Localised and non-invasive proliferation
  • Premalignant condition
  • Complete = entirely paternal in origin (one sperm fertilises empty oocyte and undergoes mitosis; diploid; no fetal tissue)
  • Partial = two sperm entering one oocyte (triploid; variable evidence of a fetus)
58
Q

What is an invasive mole?

A
  • Characteristics of malignant tissue

- Invasion present locally within the uterus

59
Q

What is choriocarcinoma?

A
  • Metastatic GTD
60
Q

What is placental site trophoblastic tumour (PSTT)?

A
  • Least common form of GTD

- Presents later after index pregnancy (~3.4yrs)

61
Q

What are the clinical features of GTD?

A
  1. Large uterus
  2. Early pre-eclampsia and hyperthyroidism
  3. Vaginal bleeding
  4. Severe vomiting
  5. May be detected on routine US
62
Q

What investigations should be done for GTD?

A
  1. US - snowstorm appearance with complete moles
  2. Dx can only be confirmed histologically
  3. Serum hCG levels very high
63
Q

How is GTD managed?

A
  • Trophoblastic tissue removed via ERPC
  • Dx confirmed histologically
  • Serial hCg levels afterwards (persistent or rising levels indicate malignancy)
  • Oral contraception must be used post ERPC when hCG levels being monitored
  • Pregnancy avoided until after surveillance period
64
Q

List the complications of GTD

A
  1. Recurrence - after every future pregnancy further hCG samples required to exclude recurrent disease
  2. Gestational trophoblastic neoplasia - follows 15% of complete moles and 0.5% of partial moles; can also follow miscarriage and normal pregnancy
65
Q

How is GTN diagnosed and managed?

A
  • Persistently elevated or rising hCG, persistent vaginal bleeding or evidence of blood borne metastasis (commonly to lungs)
  • Highly malignant; very sensitive to chemo
  • Low risk pts = methotrexate with folic acid
  • High risk pts = Combination chemotherapy

OBGYN 4MB (25 decks)

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