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Becks Gynaecology Qs > Disorders of early pregnancy > Flashcards

Disorders of early pregnancy Flashcards

1
Q

Between which days does implantation happen?

A

6th to 12th days

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2
Q

What cells secrete hCG?

A

Trophoblasts

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3
Q

Why does tubules damage increase risk of ectopic pregnancy?

A

Because the tubules use ciliary action and peristalsis to move the oocyte along. If they are damaged this movement doesn’t occur and as a result the oocyte is more likely to end in tubal implantation and ectopic.

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4
Q

What maintains a secretory endometrium for the oocyte?

A

The oocyte’s trophoblasts produce hCG which maintains the corpus luteum to keep producing eostrogen and progesterone. These hormones keep the endometrium secretory.

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5
Q

When is a heart beat established?

A

4-5 weeks

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6
Q

When is the placenta morphology complete?

A

12 weeks

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7
Q

What is the definition of a spontaneous miscarriage?

A

When the feotus died of delivers dead before 24 weeks completed pregnancy.

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8
Q

What are the types of miscarriage?

A

Threatened miscarriage - there is bleeding but the foetus is still alive and the cervical oz is closed. Only 25% go on to miscarry.

Inevitable miscarriage - bleeding is heavier. Although the foetus may still be alive, the cervical oz is open so miscarriage is about to occur.

Incomplete miscarriage - some foetal parts have been passed, but the oz is usually open.

Complete miscarriage - all foetal tissue has been passed. Bleeding has diminished, the uterus is no longer enlarged and the cervical oz is closed.

Septic miscarriage - the contents of the uterus are infected, causing endometritis. Vaginal loss is offensive, tender cervix, may or may not have a temperature. Abdominal pain and peritonism if pelvic infection occurs.

Missed miscarriage - foetus has not developed or died in utero, but this is not recognised until bleeding occurs or ultrasound is performed. The uterus is smaller than expected for gestational age and the cervical oz closed.

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9
Q

What is likely to cause a miscarriage?

A

Chromosomal abnormalities - these account for over 60% of ‘one-off’ miscarriages.

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10
Q

Does stress or emotional trauma cause miscarriage?

A

No.

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11
Q

What do you do on examination and investigations to check for miscarriage?

A

Check the patency of the cervical oz and uterine size.

Ultrasound.

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12
Q

What situations can give rise to PUL (pregnancy of unknown location)?

A

An early viable pregnancy
A failing intrauterine pregnancy
A complete miscarriage
An ectopic pregnancy

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13
Q

How does a blood test help differentiate if the pregnancy is viable/ectopic/non-viable?

A

You measure the hCG and again 48 hours later - it will have increased by 68% if the pregnancy is viable.
Between -50% and 63% is likely ectopic.
A decline of greater than 50% is non-viable.

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14
Q

What can help reduce bleeding in miscarriage if the foetus is non-viable?

A

Ergometrine.

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15
Q

When should you use anti-rhesus D?

A

Anti-D is given to women who are rhesus negative if the miscarriage is treated surgically or medically, or if there is bleeding after 12 weeks gestation.

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16
Q

90% of women with a threatened miscarriage will not miscarry if what is present at 8 weeks?

A

Foetal heart activity at 8 weeks.

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17
Q

What are the 3 broad options for treatment of non-viable intrauterine pregnancy? What need to be excluded after each?

A

Expectant management (wait).
Medical (misoprostol - prostaglandin) - pregnancy test 3 weeks later to exclude ectopic or molar.
Surgical (evacuation of retained products of conception) - sent to histology to exclude molar pregnancy.

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18
Q

Asherman’s syndrome is a risk factor after surgical management. What is this?

A

Adhesions in the uterine cavity.

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19
Q

What situations are investigations into a miscarriage reserved for?

A

When there has been 3 or more miscarriages in succession or if the miscarriage was after 12 weeks.

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20
Q

What are some of the causes of recurrent miscarriages?

A

Antiphospholipid antibodies (thrombosis is the likely mechanism - can give aspirin/low-dose low molecular weight heparin).

Parental chromosomal defects. Can offer amniocentesis and the use of donor egg/sperm.

Anatomical factors - uterine abnormality.

Infection - causes late miscarriage which is why bacterial vaginitis is important to treat.

Hormonal factors: thyroid disease can cause recurrent miscarriages. PCOS may be associated with an increased rate of miscarriage, however this is probably due to hight BMI.

Obesity, smoking and excess caffeine intake have been implicated and should all be addressed.

21
Q

What investigations should you do for a woman with recurrent miscarriages?

A

Antiphospholipid antibody screen.
Karyotying of foetal miscarriage tissue.
Thyroid blood tests.
US (and MRI or hysterosalpingogram if abnormal).

22
Q

What is the legal time limit for abortions?

A

24 weeks (unless there is grave risk to the woman’s life or risk of grave physical and mental injury to the woman).

23
Q

What is the time-frame for Rhesus-negative women to receive anti-D after termination or pregnancy?

A

Before72 hours.

24
Q

What are the surgical methods of abortion?

A 
Suction curettage (used between 7 and 12-14 weeks) 
Dilatation and evacuation (cervix is prepared with preoperative vaginal misoprostal and antibiotic prophylaxis)
25
Q

What is the medical method of abortion? When is it the best option? What happens at 22 weeks?

A

Antiprogesterone (mifepristone) followed by prostaglandin (misoprostol) 36-48 hours later. It is best before 7 weeks and between weeks 13-24, but can also be used throughout. After 22 weeks, feticide is performed first to prevent live birth using KCl.

26
Q

What is a selective abortion?

A

When there is a high-order multiple pregnancies to avoid risk or where a foetus of multiple pregnancy is abnormal, it is selectively aborted.

27
Q

What are the complications of abortion?

A 
Multiple surgical abortions can cause subsequent preterm labour.
Haemorrhage
Infection
Cervical trauma
Uterine perforation
28
Q

What is an ectopic pregnancy?

A

When the embryo implants outside the uterine cavity.

29
Q

What increases the risk of ectopic?

A 
Advancing age
Tubal damage (PID/STD/surgery)
IUD
Low socioeconomic group
Smoker
Previous ectopic
30
Q

What is the most common site for ectopic? Where else can it be?

A

95% occur in fallopian tubes.

Can occur in the ovarian, cornu, cervix and abdominal cavity.

31
Q

What happens when an ectopic is implanted in the tube?

A

The wall cannot sustain the trophoblast invasion and bleeds into the tube. It may rupture.
It may also be naturally aborted.

32
Q

Why does copper IUD have a higher chance of ectopic?

A

Because the copper IUD prevents most intrauterine pregnancies but not those destined to implant in the tube.

33
Q

What are the symptoms and signs of ectopic?

A

Lower abdominal pain followed by scanty, dark vaginal bleeding.
Pain if often colicky and then constant.
Amenorrhoea of 4-10 weeks is usual.
Syncopal episodes and shoulder tip pain suggest intra-peritoneal blood loss.
Tachycardia if blood loss and hypotension (might only be in extremities).
Cervical excitation
Abdominal pain and rebound tenderness.

34
Q

What investigations would you do to check for ectopic and how would you interpret them?

A

hCG levels.
Ultrasound.
Laparoscopy
If not seen on US it is either <5 weeks, ectopic (sometimes can visualise these) or a complete miscarriage has occurred.
You taken the hCG and then again 48 hours later. If hCG is >1000IU/mL you would be able to visualise if it were intrauterine. If the level in 48 hours rises less than 63% or declines, it is likely ectopic.
If US and hCG suggest ectopic –> laparoscopy.

35
Q

What is the management of ectopic pregnancies (both acute and subacute)?

A

Acute - if haemodynamically unstable, they have laparotomy or laparoscopy and the tube is removed.
Subacute - surgical or medical. Surgical is used if there is a lot of pain, high hCG (>5000), adnexal mass >35mm or there is a
viable heart beat. It involves laparoscopy - tube is either removed or the ectopic is removed from the tube (salpingectomy or salpingostomy).
Medical - if no pain, adnexal mass <35mm, no viable heartbeat, hCG is low (<5000, ideally <1500IU/mL) = systemic single dose methotrexate. 15% need a second dose, 10% need surgery.

36
Q

What is measured after management of ectopic?

A

hCG levels until they are <20IU/mL.

37
Q

What is hyperemesis gravidarum?

A

When nausea and vomiting in early pregnancy are so severe they cause severe dehydration, weight loss or electrolyte imbalance.

38
Q

What is the management of hyperemesis gravarum?

A

Anti-emetics –> metoclopramide, even ondansetron.
Thiamine (to prevent neurological complications of depletion)
Rehydration/fluids.

39
Q

When is morning sickness most common?

A

Up to 14 weeks.

40
Q

What is gestational trophoblastic disease?

A

When trophoblasts (which normally invade the endometrium) proliferates more aggressively than normal. hCG is normally secreted in excess.

41
Q

What are the pathologies of gestational trophoblastic disease?

A

When proliferation is:

  1. Localised and non-invasive = hydatidiform mole (partial or complete)
  2. Localised and invasive = invasive mole.
  3. Metastasis and invasive = choriocarcinoma.
  4. Placental site trophoblastic tumour (presents 3.4 years later and is the rarest).
42
Q

What is the difference between a partial and complete hydatidiform mole?

A

Complete hydatidiform mole is completely paternal in origin and is when an empty oocyte is fertilised by one sperm and it undergoes mitosis. No evidence of foetus, merely a proliferation of swollen chorionic villi.
Partial hydatidiform mole is when an oocyte is fertilised by 2 sperm and is triploid. There is variable evidence of foetus.

43
Q

Which women are gestational trophoblastic disease more common in?

A

Twice as common in Asian women.

Risk increases with extremes of reproductive ages.

44
Q

What are the clinical features of gestational trophoblastic disease?

A

Large uterus, hyperthyroidism, pre-eclampsia may occur.

Vaginal bleeding is usual and may be heavy. Severe vomiting may occur (due to high hCG).

45
Q

What is the appearance of gestational trophoblastic disease on ultrasound? How is it diagnosed?

A

Snowstorm appearance (of the swollen villi with complete moles). Diagnosed histologically and hCG is usually high.

46
Q

What is the management of gestational trophoblastic disease?

A

Trophoblastic tissue is removed by suction curettage (ERPC) and the diagnosis is confirmed histologically.
Serial blood or urine hCG is measured; persistent or rising is suggestive of malignancy.

47
Q

What are the complications of a molar pregnancy?

A

Recurrence of molar pregnancy.

Malignancy.

48
Q

How is malignancy from molar pregnancy treated?

A

Low risk = methotrexate and folic acid.
High risk = combined chemotherapy.
5 year survival rate is close to 100%.

Becks Gynaecology Qs (14 decks)

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