Disorders of early pregnancy

Question 1

when is a heartbeat established with an early pregnancy

Answer 1

22 days

Question 2

what is defined as a spontaneous miscarriage

Answer 2

fetus delivers or dies <24 weeks old

Question 3

when does spontaneous miscarriage normally occur

Answer 3

<12 weeks

Question 4

what is the cause of >60% of spontaneous miscarriages?

Answer 4

isolated chromosomal defects

Question 5

how does a spontaneous miscarriage usually present

Answer 5

bleeding

pain

Question 6

during a suspected spontaneous miscarriage, how does bHCG levels help inform diagnosis

Answer 6

in a viable pregnancy bHCG levels increase by >65%, whereas in a non-viable pregnancy they decrease >50%

anywhere inbetween suggests an ectopic

molar pregnancy will show >100,000 IU (dramatically raised)

Question 7

what should happen if someone presents with spontaneous miscarriage symptoms + fever

Answer 7

swabs + Abx

Question 8

what is useful in a spontaneous miscarriage of a non-viable foetus

Answer 8

IM ergometrine as it prevents bleeding by contracting the uterus

Question 9

when should rhesus -ve women be given anti D in the context of a spontaneous miscarriage

Answer 9

if there has been bleeding >12 weeks or if medical/surgical treatment has been performed

Question 10

what are the types of spontaneous miscarriage

Answer 10

threatened miscarriage 
inevitable miscarriage 
complete miscarriage
incomplete miscarriage 
septic miscarriage
missed miscarriage

Question 11

what are features of threatened miscarriage

Answer 11

there is bleeding but the foetus is alive
cervical os is closed
uterus is of the expected size

Question 12

what % of threatened miscarriages go on to miscarry

Answer 12

25%

Question 13

what are the features of an inevitable miscarriage

Answer 13

heavy bleeding
foetus may still be alive
cervical os is open

Question 14

what are the features of an incomplete miscarriage

Answer 14

some foetal parts have already passed

os is open

Question 15

what are the features of a complete miscarriage

Answer 15

all foetal parts have been passed
bleeding has diminished
uterus is no longer enlarged
cervical os closed

Question 16

what are features of septic miscarriage

Answer 16

contents of the uterus causing endometritis
offensive vaginal discharge
tender uterus
not necessarily feverish

Question 17

what features make you think a septic miscarriage has caused a pelvic infection

Answer 17

peritonism

abdominal pain

Question 18

what are the features of a missed miscarriage

Answer 18

foetus died in utero with no symptoms
not noticed until bleeding/USS
uterus smaller than expected
os is closed

Question 19

how should you manage a non-viable intrauterine pregnancy

Answer 19

expectant management: watch and wait

medical management: vaginal/oral misoprostol

surgical: evacuation of retained products of conception , essentially vacuuming the non-viable pregnancy out under GA

Question 20

what are complications of surgical management of a non-viable intrauterine pregnancy (ERPC)

Answer 20

Excessive vaginal bleeding may occur with expectant or medical management – may require surgical intervention (10-40%)

Infection (3%) - similar across all managements

Surgical management may remove some endometrium causing Asherman’s syndrome (excessive scarring in the uterus causing adhesions/the walls to stick to each other)

Surgical management may also perforate the uterus (<1%)

Question 21

what are the success rates for incomplete miscarriages for each intervention

Answer 21

> 80% - expectant

>95% - surgical

Question 22

what are the success rates for missed miscarriages for each intervention

Answer 22

expectant - 30-70%
medical - 40-90%
surgical - 95%

Question 23

what qualifies as recurrent miscarriage

Answer 23

3 successive miscarriages

Question 24

whats the prevalence of recurrent miscarriage

Answer 24

1%

Question 25

is someone has had 3 successive miscarriages what is the risk of miscarriage for the 4th pregnancy

Answer 25

40%

Question 26

what are causes of recurrent miscarriages

Answer 26

Antiphospholipid antibodies Parental chromosomal defects Anatomical defects Infection Hormonal Issues (PCOS, thyroid) Obesity Smoking Excess Caffeine Older maternal age

Question 27

why does antiphospholipid syndrome cause miscarriages and what tends to be the treatment

Answer 27

thrombosis in uteroplacental circulation asprin + LMWH

Question 28

What are the statutory grounds for abortion in England

Answer 28

There is a risk to the physical or mental health of the woman if the pregnancy was continued There is a risk of death to the pregnant women The foetus is <24 weeks Substantial risk of severe mental/physical abnormalities causing a handicap

Question 29

when should rhesus -ve women receive anti-D in reference to planned abortions

Answer 29

within 72 hours

Question 30

what gestation should surgical abortions be used

Answer 30

7-14 weeks gestation

Question 31

how is a surgical abortion carried out

Answer 31

cervix is prepared with topical misoprostol and antibiotic prophylaxis is given vacuum is used to evacuate foetus

Question 32

what gestation should medical abortions be used at

Answer 32

<7 weeks, 12-24 weeks, but can be used whenever

Question 33

how is a medical abortion carried out

Answer 33

mifeprostone + prostaglandin 36-48 hours later

Question 34

what method for medical abortions tends to be used >22weeks gestation if there is a foetal abnormality present

Answer 34

feticide via injection of KCL into the foetal heart/umbilical vein

Question 35

what are the complications of a surgical abortion

Answer 35

Haemorrhage - 1 in 1000 Infection – 10% (reduced by prophylactic antibiotics) Uterine perforation Cervical trauma Failure (<5% surgical/medical require further intervention – <1% risk of total failure) Preterm delivery Associated with multiple surgical terminations Unsafe abortion

Question 36

whats the definition of an ectopic pregnancy

Answer 36

foetus implants outside the uterine cavity

Question 37

where are the majority of ectopic pregnancies

Answer 37

fallopian tube

Question 38

what is the major worry with ectopic pregnancy

Answer 38

rupture of the fallopian tubes, massive blood loss and death

Question 39

what are some risk factors for ectopic pregnancy

Answer 39

``` assisted conception pelvic surgery PID previous ectopics smoking ```

Question 40

how does an ectopic pregnancy present

Answer 40

Lower abdominal pain, starts colicky but becomes constant Vaginal bleeding Shoulder tip pain/syncopal episodes (intraperitoneal bleeding) Amenorrhoea for 4-10 weeks previously Rebound tenderness (peritonitis) Cervical excitation (extremely painful cervix on bimanual examination) Adexum tenderness Uterus is smaller than expected Cervical os closed

Question 41

how should you investigate any ?ectopic pregnancy

Answer 41

Pregnancy test USS – may not detect ectopic but absence of intrauterine pregnancy + +ve pregnancy test = high suspicion Quantitative serum bHCG – >1000 IU/ml = viable intrauterine pregnancy >63% rise in 48 hours = early viable intrauterne pregnancy Outside of these parameters suggests ectopic/non-viable pregnancy Laparoscopy

Question 42

what is the overall management for ectopic pregnancy

Answer 42

for all: IV access, cross match, anti-D if Rh- medical: single dose of methotrexate surgical: salpingostomy/salpingectomy

Question 43

when is surgical management appropriate in ectopic pregnancy

Answer 43

Woman in severe pain Adnexal mass >35mm Visible foetal heart activity BHCG >5000 IU/ml

Question 44

when is medical management appropriate in ectopic pregnancy

Answer 44

Patient able to attend follow up Has no significant pain Adnexal mass <35mm No foetal heart activity No co-existing intrauterine pregnancy

Question 45

what is correlated with success rate with medical management of an ectopic pregnancy

Answer 45

bHCG level

Question 46

how often is a follow up dose required for medical management of ectopic pregnancy

Answer 46

15%

Question 47

how often is surgical mangagement required in medical management of ectopic pregnancy

Answer 47

10%

Question 48

what are complications of hyperemesis gravidarum

Answer 48

metabolic disturbance malnutrition dehydration

Question 49

what gestational period is hyperemesis gravidarum mostly active for

Answer 49

first 14 weeks

Question 50

what patient population is hyperemesis gravidarum more common in

Answer 50

multiparous women

Question 51

what are predisposing conditions for hyperemesis gravidarum

Answer 51

UTI molar pregnancy multiple pregnancy

Question 52

what is the treatment for hyperemesis gravidarum

Answer 52

IV hydration Antiemetics (cyclizine 1st line) Thiamine given (B12) to prevent neurologial complications Steroids used in severe cases