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Obstetrics and Gynaecology > Early Pregnancy > Flashcards

Early Pregnancy Flashcards

1
Q

What is the most common site for ectopic pregnancy?

A

Fallopian tube

Or entrance to tube - cornual region
Ovary
Cervix
Abdomen

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2
Q

What are the risk factors for ectopic pregnancy?

A 
Previous ectopic pregnancy
Previous pelvic inflammatory disease
Endometriosis
Previous surgery to fallopian tubes
Intrauterine devices
Older age
Smoking
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3
Q

What is the presentation of an ectopic pregnancy?

A

Usually presents around 6-8 weeks
Ask about possibility of pregnancy, missed periods, recent unprotected sex.

Missed period
Constant lower abdominal pain in R or LIF
Vaginal bleeding
Lower abdominal or pelvic tenderness
Cervical motion tenderness - pain when moving cervix during bimanual examination

Dizziness or syncope - blood loss
Shoulder tip pain - peritonitis

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4
Q

What are the ultrasound findings in an ectopic pregnancy?

A

Transvaginal ultrasound is investigation of choice
May show gestational sac, containing yolk sac or fetal pole

Mass containing empty gestational sac can sometimes been seen known as the ‘blob sign’.

Mass in a tubal ectopic pregnancy moves separately to the ovary, may look similar to corpus luteum but corpus luteum will move with ovary.

Empty uterus, or fluid in uterus mistaken as a gestational sac.

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5
Q

What is PUL?

A

Pregnancy of unknown location
Woman has positive pregnancy test but no evidence of pregnancy on the ultrasound scan.
Ectopic cannot be excluded.

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6
Q

What is the importance of hCG levels in miscarriage or ectopic pregnancy?

A

In intrauterine pregnancy, hCG will roughly double every 48 hours - hence serum hCG repeated every 48 hours.

Rise of more than 63% after 48 hours likely to indicate intrauterine pregnancy, with a repeat USS to confirm.

Rise of less than 63% - ectopic pregnancy

Fall of more than 50% indicates miscarriage, urine pregnancy test needed after 2 weeks to confirm complete.

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7
Q

When can a pregnancy be visible on ultrasound?

A

When hCG level is above 1500 IU/I

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8
Q

What are the management options for an ectopic pregnancy?

A

Pregnancy test for all women with abdo or pelvic pain, that may be caused by an ectopic pregnancy.
Refer to early pregnancy assessment unit.

Expectant management - awaiting natural termination
Medical management - methotrexate
Surgical management - salpingectomy, salpingotomy

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9
Q

What is the criteria for expectant management of an ectopic pregnancy?

A 
Follow up needs to be possible to ensure successful 
Ectopic needs to be unruptured
Adnexal mass <35mm
No visible heartbeat
No significant pain
HCG level < 1500 IU/I

Need quick and easy access to services if condition changes

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10
Q

What is the criteria for medical management of ectopic pregnancy?

A

HCG < 5000 IU/I
Confirmed absence of intrauterine pregnancy on USS

NICE recommends systemic methotrexate as the first-line option for women who meet the following criteria:

Able to return for follow-up
No significant pain
Unruptured ectopic pregnancy with an adnexal mass <35 mm and no visible heartbeat
No intrauterine pregnancy is seen on the ultrasound scan
Serum hCG <1500 IU/L

The serum hCG level is monitored to ensure it is declining and not continuing to rise. If serum hCG levels continue to rise, a further dose of systemic methotrexate may need to be administered.

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11
Q

How is an ectopic pregnancy managed with methotrexate?

A

Methotrexate inhibits enzymes responsible for nucleotide synthesis which prevents cell division and leads to anti-inflammatory actions

It is highly teratogenic

Given as an IM injection into the buttock

Women advised not to get pregnant for 3 months following treatment as harmful effects could last this long

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12
Q

What are the common side effects of methotrexate?

A

Vaginal bleeding
Nausea and vomiting
Abdominal pain
Stomatitis - inflammation of the mouth

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13
Q

What are the options for surgical management of an ectopic pregnancy?

A

Laparoscopic salpingectomy - removal of affected fallopian tube and ectopic pregnancy inside it

Laparoscopic salpingotomy - those at increased risk of infertility due to damage of other tube, cut made in tube and ectopic removed. Increased risk of failure.

Anti rhesus D prophylaxis give to rhesus negative women having surgical management

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14
Q

What is the criteria for surgical management of an ectopic pregnancy?

A

Anyone who does not meet criteria for medical or expectant, usually most patients

Pain
Adnexal mass > 35mm
Visible heartbeat
HCG levels > 5000 IU/I

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15
Q

What is a missed miscarriage?

A

Fetus no longer alive, but no symptoms have occurred

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16
Q

What is a threatened miscarriage?

A

Vaginal bleeding with a closed cervix and fetus alive

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17
Q

What is an inevitable miscarriage?

A

Vaginal bleeding with an open cervix

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18
Q

What is an incomplete miscarriage?

A

Retained products of conception remain in uterus

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19
Q

What is a complete miscarriage?

A

Full miscarriage has occurred, no products left

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20
Q

What is an anembryonic pregnancy?

A

Gestational sac present but no embryo

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21
Q

What is the investigation of choice for miscarriage?

A

Transvaginal ultrasound

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22
Q

What three features is it important to look for on USS to assess whether the pregnancy is viable?

A

Mean gestational sac diameter
Fetal pole and crown-rump length
Fetal heartbeat

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23
Q

When is a fetal heartbeat expected?

A

Once the crown rump length is 7mm or more

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24
Q

How is a pregnancy without heartbeat assessed?

A

When the crown rump length is less than 7mm without a fetal heartbeat, the scan is repeated after at least one week to ensure a heartbeat develops.

When the crown rump length is 7mm or more, and no heartbeat, the scan is repeated after one week then confirmed to be non viable.

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25
Q

When is a fetal pole expected?

A

When the mean gestational sac is 25mm or more

If 25mm or more and no pole, then scan repeated after one week before confirming an anembryonic pregnancy.

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26
Q

What is the fetal pole?

A

The first direct imaging manifestation of the fetus, and is seen as a thickening on the margin of the yolk sac during early pregnancy.

Usually identified at 6 weeks on TV USS or 61/2 with abdominal ultrasound. But can not appear until 9 weeks.

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27
Q

What is the management of a miscarriage if less than 6 weeks?

A

Presentation with bleeding, can be managed expectantly providing they have no pain or other complications or risk factors e.g. previous ectopic.

Await miscarriage without investigations or treatment
Repeat urine pregnancy test performed 7-10 days

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28
Q

What is the management of a miscarriage if more than 6 weeks?

A

Referral to an early pregnancy unit if positive pregnancy test, more than 6 weeks and bleeding.

USS confirms location and viability of pregnancy.
Then either expectant, medical or surgical management.

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29
Q

What is expectant management of a miscarriage?

A

If no risk factors for heavy bleeding or infection
1-2 weeks allowed for miscarriage to occur, repeat urine pregnancy test performed 3 weeks after bleeding and pain settle to confirm.

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30
Q

What is the medical management of miscarriage?

A

Misoprostol - prostaglandin analogue, binds to prostaglandin receptors, softens cervix, uterus contracts/

Given as vaginal suppository or oral dose

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31
Q

What are the key side effects of misoprostol?

A

Heavier bleeding
Pain
Vomiting
Diarrhoea

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32
Q

What is the surgical management of a miscarriage?

A

Manual vacuum aspiration under local anaesthetic
Electric vacuum aspiration under general

Prostaglandins - misoprostol given before surgical management to soften cervix

Manual vacuum best for below 10 weeks, and parous

Anti Rhesus D prophylaxis given to rhesus negative women

33
Q

What is an incomplete miscarriage and the treatment?

A

Retained products of conception either fetal tissue or placental tissue remain, poses risk of infection.

Medical management with misoprostol
Surgical evacuation of retained products of conception ERPC using vacuum aspiration and curettage (scraping)

34
Q

What is a key complication of ERPC?

A

Endometritis

35
Q

What is classed as recurrent miscarriage?

A

Three or more consecutive miscarriages

36
Q

When are investigations for recurrent miscarriage initiated?

A

Three or more first trimester miscarriages

One or more second trimester miscarriages

37
Q

What are some of the causes of recurrent miscarriages?

A

Idiopathic, particularly in older women
Antiphospholipid syndrome
Hereditary thrombophilias
Uterine abnormalities
Genetic factors in parents e.g. balanced translocations
Chronic histiocytic intervillositis
Other chronic diseases e.g. diabetes, thyroid, SLE

38
Q

What is antiphospholipid syndrome?

A

Antiphospholipid antibodies, hypercoaguable state

Risk of miscarriage reduced with low dose aspirin or LMWH

39
Q

What key hereditary thrombophilias can be a cause of miscarriage?

A

Factor V Leiden
Factor II prothrombin mutation
Protein S deficiency

40
Q

What uterine abnormalities can cause miscarriage?

A 
Uterine septum - a partition through the uterus
Unicornuate uterus - single horned
Bicornuate - heart shaped
Didelphic uterus - double
Cervical insufficiency
Fibroids
41
Q

What is chronic histiocytic intervillositis?

A

Can cause IUGR and intrauterine death.
Histiocytes and macrophages build up in the placenta and cause inflammation, there are infiltrates in intervillous spaces.

42
Q

What are the investigations for recurrent miscarriage?

A 
Antiphospholipid antibodies
Testing for hereditary thrombophilias
Pelvic ultrasound
Genetic testing of products of conception of miscarriages
Genetic testing of parents
43
Q

What is the management of recurrent miscarriages?

A

Dependent on underlying cause
May be a benefit to using vaginal progesterone pessaries during early pregnancy for those who have presented in the past with bleeding.

44
Q

What are the risk factors for a miscarriage?

A 
Age
Previous miscarriages
Chronic conditions
Uterine or cervical problems; large cervical cone biopsies for e.g. cervical cancer
Smoking, alcohol, illicit drugs
Weight
Invasive prenatal testing
45
Q

What is the Abortion Act of 1967?

A

States that an abortion is legal if it is performed by a registered medical practitioner (a doctor), and that it is authorised by two doctors, acting in good faith, on one (or more) of the following grounds

Before 24 weeks
If continuing the pregnancy involves greater risk to the physical or mental health of the women, existing children of the family.

If continuing the pregnancy is likely to risk the life of the women, terminating will prevent permanent injury, or if there is a substantial risk of disability of the child.

46
Q

What is a medical abortion?

A

More appropriate earlier on in pregnancy, can be used at any time.

Mifepristone is an anti-progesterone that blocks the action of progesterone, halting pregnancy and relaxing the cervix.

Misoprostol is a prostaglandin analogue which binds to prostaglandin receptors and activates them, softens the cervix and stimulates uterine contractions.
From 10 weeks, additional misoprostol doses needed e.g. every 3 hours until expulsion.

If 10 weeks or above and rhesus negative, need anti-D prophylaxis.

47
Q

What is a surgical abortion?

A

Performed under local, local with sedation, or general anaesthetic.

Prior to surgical, medications used for cervical priming to soften and dilate cervix. e.g. misoprostol, mifepristone, osmotic dilators (expand as they absorb fluid and open the cervical canal)

Cervical dilatation and suction of contents up to 14 weeks
Cervical dilatation and evacuation using forceps up to 24

Rhesus negative women need anti-D prophylaxis

48
Q

What are the complications of an abortion?

A

May experience vaginal bleeding and abdominal cramps intermittently for up to 2 weeks after procedure.

Bleeding, pain, infection, failure of abortion, damage to the cervix, uterus or other structures

49
Q

Is nausea and vomiting in pregnancy common?

A

Common symptom early on, starts in first trimester peaking around 8-12 weeks. Usually resolve by 16-20 weeks.

It is thought hCG is responsible, therefore more severe if higher levels e.g. molar pregnancies, multiple pregnancies

Also worse in first pregnancy, overweight or obese

50
Q

What is hyperemesis gravidarum?

A

Persistent and severe vomiting during pregnancy which leads to weight loss, dehydration and electrolyte imbalances.

Prolonged and severe NVP, more than 5% pre-pregnancy weight loss.

51
Q

What are the risk factors of hyperemesis gravidarum?

A 
First pregnancy
Previous history of HG
Raised BMI
Multiple pregnancy
Hydatidiform mole
52
Q

What are the clinical features of hyperemesis gravidarum?

A 
Daily nausea and vomiting
Weight loss, dehydration
Reduced urination
Symptoms occur at any time of day
Signs of dehydration to include orthostatic hypotension, tachycardia, delayed cap refill, dry mucous membranes, decreased skin turgor
53
Q

What is the PUQE score?

A

Pregnancy Unique Quantification of Emesis Index
Scored out of 15, over past 24 hours

In last 24 hours, for how long have you felt nauseated or sick to your stomach? 1 not at all, 5 more than 6 hours

In the last 24 hours have you vomited? 1 not at all, 5 is 7 or more times

In the last 24 hours, how many times have you had retching or dry heaves without bringing anything up? 1 not at all, 5 is 7 or more times

54
Q

What are the investigations for hyperemesis gravidarum?

A

Urine dipstick - ketonuria
MSU
U&Es - hypo or hyperkalaemia, hyponatraemia, dehydration
FBC - infection, anaemia
Blood glucose monitoring
USS confirm viable pregnancy, exclude multiple pregnancy and trophoblastic disease

Metabolic hypochloraemia alkalosis

history of previous admissions; check TFTs, LFTs, amylase to exclude pancreatitis, ABG to exclude metabolic disturbances

55
Q

What are some differentials of hyperemesis gravidarum?

A

Other pathological causes of nausea and vomiting

Peptic ulcers, cholecystitis, gastroenteritis, pancreatitis, genitourinary conditions

Testing for H pylori

56
Q

What is the initial management of NVP and HG?

A

Women with mild NVP should be managed in the community with antiemetics e.g. cyclizine, ondansetron, metoclopramide.

Ambulatory daycare management should be used when primary care measured failed and PUQE score <13: IV or IM antiemetics, IV fluids, daily monitoring U&Es, thiamine supplementation to prevent deficiency, prevents Wernicke Korsakoff’s, thromboprophylaxis with TEDs and LMWH.

57
Q

What should inpatient management be considered?

A

Continued nausea and vomiting, inability to keep down oral antiemetics

Continued nausea and vomiting associated with ketonuria and/or weight loss despite oral antiemetics

Confirmed or suspected comorbidity e.g. UTI and inability to tolerate oral antibiotics

58
Q

What complementary therapies can be considered for HG?

A

Ginger

Acupressure on the wrist at the PC6 inner wrist point

59
Q

What is a hydatiform mole?

A

A type of tumour that grows like a pregnancy inside the uterus, can be a complete mole or partial mole.

60
Q

What is a complete mole in a molar pregnancy?

A

Occurs when two sperm cells fertilise an ovum that contains no genetic material.
These sperm combine, and cells divide into complete mole with no fetal material.

61
Q

What is a partial mole in a molar pregnancy?

A

Occurs when two sperm cells fertilise a normal ovum containing genetic material at the same time.

New cell now has three sets of chromosomes.
Cell divides and multiplies into a tumour, some fetal material may form.

62
Q

What are the clinical features of a molar pregnancy?

A

Behaves like a normal pregnancy, periods stop and hormonal changes occur.

More severe morning sickness
Vaginal bleeding
Increased enlargement of uterus
Abnormally high hCG
Thyrotoxicosis - hCG can mimic TSH and stimulate thyroid to produce T3 and T4
63
Q

What is seen on ultrasound in a molar pregnancy?

A

Snowstorm appearance

Provisional diagnosis is made, and then confirmed with histology following evacuation

64
Q

What is the management of a molar pregnancy?

A

Evacuation of uterus to remove
Products of conception sent for histological examination
Referred to gestational trophoblastic disease centre for follow up

hCG levels monitored
Can metastasise, and require systemic chemo

65
Q

What are the complications of hyperemesis gravidarum?

A

Hypovolaemia and electrolyte imbalances causing rhabdomyolysis.

QRS prolongation, haematocrit increase, liver cholestasis

Vitamin deficiencies
Vitamin B1 thiamine causing Wernicke’s encephalopathy

Vitamin B12 and B6 may cause anaemia and peripheral neuropathies

Mallory Weiss tears
Retinal haemorrhages
Splenic avulsion
Pneumothorax

Associated with higher incidence of low birth weight - SGA and premature babies

66
Q

What dose of mifepristone is prescribed for a medical abortion from 14 weeks gestation?

A

Mifepristone 200 mg orally, followed 12–48 hours later by misoprostol 800micrograms vaginally,

Then misoprostol 400micrograms orally or vaginally every 3 hours until abortion occurs

if after 24 hours abortion does not occur, repeat 3 hours after the last dose of misoprostol, and 12 hours later misoprostol may be recommenced.

67
Q

What is the general presentation of miscarriages?

A

Vaginal bleeding and pain worse than normal period

Visible products of conception

Haemodynamic instability - dizzy, pallor, tachycardic

68
Q

What is a threatened miscarriage and when and how does it present?

A

Still a viable pregnancy which presents with mild painless bleeding

Cervix is closed

Often 6-9 weeks

69
Q

What is an inevitable miscarriage and how does it present?

A

Heavy bleeding with clots and pain
Cervix is open

Progresses to incomplete then complete miscarriage

70
Q

How does an incomplete miscarriage present?

A

Products of conception partially expelled (can be seen in the canal)
Vaginal bleeding and pain

Cervix remain open

71
Q

How does a complete miscarriage present?

A

Empty uterine cavity - products of conception fully expelled
Heavy bleeding with cloths and pain but stops

Uterus smaller than normal
Cervix closed

72
Q

What is a missed miscarriage and how does it present?

A

Foetus dead but retained
Asymptomatic or Hx of threatened miscarriage

Light vaginal bleed or ongoing dark discharge
Don’t normally get any pain
Small for date uterus
Cervix closed

73
Q

How does a septic miscarriage present?

A

Infected products of conception

Fever, riggers, uterine tenderness, bleeding, discharge, pain

74
Q

What are the differentials for a miscarriage?

A

Ectopic pregnancy has to be excluded
Implantation bleed

Malignancy
Hydatidiform Mole

75
Q

What are the risk factors for miscarriage?

A

Mum > 30 or Dad >40yo
Obesity or low BMI

Previous miscarriage
Parental chromosomal abnormalities
Smoking and alcohol
Uterine abnormalities
Incompetent cervix
Antiphospholipid syndrome
SLE
PCOS
Diabetes
Thyroid
76
Q

How would you investigate a miscarriage?

A

Seen in EPAU

Transvaginal USS - definitive diagnosis, look for fetal heart activity
Transabdominal USS (only if transvaginal declined)
Serum HcG - rule out ectopics
77
Q

How are miscarriages managed?

A

> 12 weeks and rhesus -ve - give anti-D

Conservative - Wait 7-14 days to pass naturally
Medical - Vaginal misoprostol - stimulate cervical ripening and myocetrial contractions
Surgical - <12 weeks = manual vacuum aspiration under local
>12 weeks - evacuation of retained POC under general

78
Q

What are the side effects of misoprostol? And therefore what else do you need to prescribe

A

D&V
Pain

Bleeding
Analgesia and antiemetics

Obstetrics and Gynaecology (11 decks)

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