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Obstetrics and Gynaecology > Disorders of early pregnancy > Flashcards

Disorders of early pregnancy Flashcards

1
Q

When is a heartbeat established?

A

It is established at 4-5 weeks and is visible on TVS a week later

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2
Q

What is the definition of spontaneous miscarriage?

A

The fetus dies or delivers dead before 24 complete weeks of pregnancy

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3
Q

What are the different types of miscarriage?

A 
Threatened miscarriage
Inevitable miscarriage
Incomplete miscarriage
Complete miscarriage
Septic miscarriage
Missed miscarriage
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4
Q

What is a threatened miscarriage?

A

There is bleeding but the fetus is still alive, the uterus is the size expected from the dates and the os is closed. Only 25% will go on to miscarry.

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5
Q

What is an inevitable miscarriage?

A

Bleeding is usually heavier than threatened miscarriage. Although the fetus may still be alive, the cervical os is open. Miscarriage is about to occur

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6
Q

What is an incomplete miscarriage?

A

Some fetal parts have been passed, but the os is usually open.

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7
Q

What is a complete miscarriage?

A

All fetal tissue has been passed. Bleeding has diminished, the uterus is no longer enlarged and the cervical os is closed.

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8
Q

What is a septic miscarriage?

A

The contents of the uterus are infected, causing endometritis. Vaginal loss is usually offensive, the uterus is tender, but a fever can be absent. If pelvic infection occurs, there is abdominal pain and peritonism

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9
Q

What is a missed miscarriage?

A

The fetus has not developed or died in utero, but this is not recognised until bleeding occurs or US is performed. The uterus is smaller than expected from the dates and the os is closed.

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10
Q

What are the clinical features of spontaneous miscarriage?

A

Bleeding is usual unless a missed miscarriage is found incidentally at US. Pain from uterine contractions can cause confusion with an ectopic pregnancy.

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11
Q

What would you find on examination of a spontaneous miscarriage?

A

Uterine size and the state of the cervical os are dependent on the type of miscarriage. Severe tenderness is usual.

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12
Q

What investigations would you perform for a spontaneous miscarriage?

A

US will show if a fetus is in the uterus and if it is viable, and it may detect retained fetal tissue products. If in doubt, repeat in a week. hCG in the blood normally increases by 66% in 48h with a viable intrauterine pregnancy.

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13
Q

How would you manage a spontaneous miscarriage?

A

IM ergometrine will reduce bleeding by the contracting uterus, but is only used if the fetus is non-viable.

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14
Q

What are the options for a non-viable intrauterine pregnancy?

A

Expectant management (as long as no infection); medical management (prostaglandin); surgical management (ERPC).

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15
Q

What is recurrent miscarriage?

A

When three or more miscarriages occur in succession

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16
Q

What investigations do you need to do in recurrent miscarriage?

A

Antiphospholipid antibody screen (repeat after 6 weeks if positive)
Karyotyping of both parents
Pelvic ultrasound.

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17
Q

What are the risk factors for recurrent miscarriage?

A

Obesity, smoking, PCOS, excess caffeine intake and higher maternal age

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18
Q

What are the statutory grounds for termination of pregnancy in England (long answer, sorry!)?

A

A: continuance of pregnancy would involve more risk to woman’s life than termination
B: termination is necessary to prevent physical or mental harm to the woman
C: pregnancy before 24 weeks and continuance would involve risk of physical or mental harm to existing children or family
D: there is a substantial risk that the child would be born with physical or mental abnormalities as to be seriously handicapped

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19
Q

What are the surgical methods of abortion?

A

Suction curettage

Dilatation and evacuation

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20
Q

When is surgical curettage performed?

A

Usually between 7 and 13 weeks.

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21
Q

When is dilatation and evacuation performed?

A

Above 13 weeks.

22
Q

What are the medical methods of abortion before 22 weeks?

A

Misoprostol. Can be performed between 7 and 24 weeks gestation.

23
Q

What are the medical methods of abortion after 22 weeks?

A

Beyond 22 weeks, feticide is performed first to prevent live birth, using KCl into the umbilical vein or fetal heart. Such later terminations are usually only performed where a fetal abnormality is present.

24
Q

What are the complications of an abortion?

A

Haemorrhage, infection, uterine perforation, cervical trauma and failure. Multiple abortions are associated with an increased risk of subsequent preterm delivery.

25
Q

What is an ectopic pregnancy?

A

When the embryo implants outside the uterine cavity and occurs in 1 in 60-100 pregnancies.

26
Q

In which women is ectopic pregnancy more common?

A

Advanced maternal age and lower socioeconomic class.

27
Q

Where are the most common sites of ectopic pregnancy?

A

The most common side is in the fallopian tube (95%), although implantation can occur in the cornu, the cervic, the ovary and the abdominal cavity.

28
Q

What are some risk factors for ectopic pregnancy?

A

PID, assisted conception and pelvic, particularly tubal, surgery are additional risks as is having a previous ectopic and being a smoker.

29
Q

What are the clinical features of an ectopic pregnancy?

A
  • lower abdominal pain: typically the first symptom. Pain is usually constant and may be unilateral. Due to tubal spasm
  • vaginal bleeding: usually less than a normal period, may be dark brown in colour
  • history of recent amenorrhoea: typically 6-8 weeks from start of last period; if longer (e.g. 10 wks) this suggest another causes e.g. inevitable abortion
  • peritoneal bleeding can cause shoulder tip pain and pain on defecation / urination
30
Q

What would you find on examination of an ectopic pregnancy?

A

tachycardia suggests blood loss, and hypotension and collapse occur only in extremis. There is usually abdominal and often rebound tenderness. On pelvic examination, movement of the uterus may cause pain (cervical excitation) and either adnexum may be tender. The uterus is small than expected from the gestation and the cervical os is closed.

31
Q

What investigations would you perform when investigating an ectopic pregnancy?

A

A pregnancy test (urinary hCG), US (doesn’t always detect ectopic but can see if it is intrauterine), quantitive serum hCG

32
Q

What pattern of serum hCG would suggest an ectopic pregnancy?

A

Declining or slower rising levels (plateauing).

33
Q

How would you manage a suspected ectopic pregnancy?

A 
NBM
FBC and cross-match
Pregnancy test
US
IV access
Potential laparoscopy or medical management
34
Q

What would be performed during a laparoscopy due to ectopic pregnancy?

A

The ectopic is either removed from the tube (salpingostomy) or a salpingectomy is performed.

35
Q

What medical management would be used to treat an ectopic pregnancy?

A

If the ectopic pregnancy is enraptured with no cardiac activity and an hCG level <1500IU/mL, systemic single-dose methotrexate can be used. A second dose or surgery may be required.

36
Q

What is hyperemesis gravidarum?

A

When nausea and vomiting in early pregnancy are so severe as to cause:
5% pre-pregnancy weight loss
dehydration
electrolyte imbalance

37
Q

How long does hyperemesis gravidarum usually last for?

A

It rarely persists beyond 14 weeks

38
Q

Is hyperemesis gravidarum more common in nulliparous or multiparous women?

A

Multiparous

39
Q

How do you treat hyperemesis gravidarum?

A

antihistamines should be used first-line (BNF suggests promethazine as first-line). Cyclizine is also recommended by Clinical Knowledge Summaries (CKS)
ondansetron and metoclopramide may be used second-line
ginger and P6 (wrist) acupressure: CKS suggest these can be tried but there is little evidence of benefit
admission may be needed for IV hydration

40
Q

What is gestational trophoblastic disease?

A

Trophoblasts proliferate in a more aggressive way the. normal. hCG is normally secreted in excess.

41
Q

What is a hydatidiform mole?

A

Trophoblast proliferation is localised and non-invasive

42
Q

What is a complete mole?

A

A mole entirely from paternal origin, usually when one sperm fertilises an empty oocyte and undergoes mitosis. There is no fetal tissue, merely a proliferation of swollen chorionic villi.

43
Q

What is a partial mole?

A

Usually triploid, derived from two sperms entering one oocyte. There if variable evidence of a fetus.

44
Q

What is an invasive mole?

A

Invasion is locally within the uterus

45
Q

What is choriocarcinoma?

A

An invasive mole that has metastasised

46
Q

What are the clinical features of gestational trophoblastic disease?

A

Vaginal bleeding is usual and may be heavy. Severe vomiting may occur.

47
Q

What would you find on examination of gestational trophoblastic disease?

A

The uterus is often large. Early PE and hyperthyroidism may occur

48
Q

What would you find on US of gestational trophoblastic disease?

A

A ‘snowstorm’ appearance of the swollen villi with complete moles, but the diagnosis can only be confirmed histologically.

49
Q

How do you treat gestational trophoblastic disease?

A

urgent referral to specialist centre - evacuation of the uterus is performed
effective contraception is recommended to avoid pregnancy in the next 12 months
Suction curettage and the diagnosis is confirmed histologically. Follow up of repeated hCG levels to check for persisting malignancy

50
Q

What are the complications of gestational trophoblastic disease?

A

Recurrence of molar pregnancy occurs in about 1 in 60 subsequent pregnancies. Gestational trophoblastic neoplasia, as an invasive mole or choriocarcinoma may follow.

51
Q

How is gestational trophoblastic neoplasia diagnosed?

A

Persistently elevated or rising hCG levels, persistent vaginal bleeding or evidence of blood-borne metastasis, commonly to the lungs.

52
Q

How do you treat gestational trophoblastic neoplasia?

A

The tumour is highly malignant, but is normally sensitive to chemotherapy.

Obstetrics and Gynaecology (27 decks)

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