Early pregnancy Flashcards
which region can you get an ectopic pregnancy in fallopian tube?
cornual region
what are the TVUS findings of ectopic pregnancy?
A gestational sac containing a yolk sac or fetal pole may be seen in a fallopian tube.
When a mass containing an empty gestational sac is seen, this may be referred to as the “blob sign”, “bagel sign” or “tubal ring sign”
A mass representing a tubal ectopic pregnancy moves separately to the ovary. The mass may look similar to a corpus luteum; however, a corpus luteum will move with the ovary.
An empty uterus
Fluid in the uterus, which may be mistaken as a gestational sac (“pseudogestational sac”)
what is pregnancy of unknown locations PUL?
positive pregnancy test and there is no evidence of pregnancy on the ultrasound scan.
In this scenario, an ectopic pregnancy cannot be excluded, and careful follow up needs to be in place until a diagnosis can be confirmed.
how do you investigate for pregnancy of unknown locations PUL?
Serum hCG can be tracked over time
Repeated after 48 hours, to measure the change from baseline.
what happens to the hCG level in intrauterine pregnancy, miscarriage or ectopic?
The developing syncytiotrophoblast produces hCG.
Intrauterine –> hCG x2 every 48 hours. This will not be the case in a miscarriage or ectopic pregnancy.
rise >63% over 48 hours –> intrauterine, confirm with US 1-2 weeks later
A pregnancy should be visible on an ultrasound scan once the hCG level is above 1500 IU / l
rise <63% over 48 hours –> ectopic, monitor and review
fall >50% –> miscarriage, urine pregnancy test 2 weeks later
When should A pregnancy should be visible on an ultrasound scan?
A pregnancy should be visible on an ultrasound scan once the hCG level is above 1500 IU / l
Criteria for expectant management of ectopic pregnancy
Follow up needs to be possible to ensure successful termination The ectopic needs to be unruptured Adnexal mass < 35mm No visible heartbeat No significant pain HCG level < 1500 IU / l
monitor hCG
Criteria for medical management (methotrexate) of ectopic pregnancy
Follow up needs to be possible to ensure successful termination The ectopic needs to be unruptured Adnexal mass < 35mm No visible heartbeat No significant pain
HCG level <5000 IU / l
confirmed absence of intrauterine pregnancy on US
side effects of methotrexate after ectopic pregnancy medical management
teratogenic, dont get pregnant for 3 months
Vaginal bleeding
Nausea and vomiting
Abdominal pain
Stomatitis (inflammation of the mouth)
what is surgical management for ectopic and what are indications?
don’t meet criteria for expectant or medical tx
most need surgical
Pain
Adnexal mass > 35mm
Visible heartbeat
HCG levels > 5000 IU / l
2 options Laparoscopic salpingectomy
Laparoscopic salpingotomy
what’s the difference btw Laparoscopic salpingectomy
and Laparoscopic salpingotomy
surgical management of ectopic
Laparoscopic salpingectomy
- 1st line
- under GA
- key-hole surgery with removal of the affected fallopian tube, along with the ectopic pregnancy inside the tube.
Laparoscopic salpingotomy
- may be used in women at increased risk of infertility due to damage to the other tube
- aim: avoid removing the affected fallopian tube –> cut it, take out ectopic, close tube back up
- inc risk of not removing ectopic vs other
- 20% will need methotrexate or salpingectomy after
Anti-rhesus D prophylaxis is given to rhesus negative women having surgical management of ectopic pregnancy.
Time difference btw eary and late miscarriage
eary <12 weeks
late 12-24 weeks
6 types of miscarriage
Threatened Inevitable Incomplete (RPOC) Complete Anembryonic Missed
what is a Missed miscarriage?
the fetus is no longer alive, but no symptoms have occurred
what is a threatened miscarriage?
vaginal bleeding with a closed cervix and a fetus that is alive
what is an inevitable miscarriage?
vaginal bleeding with an open cervix
what is an incomplete miscarriage?
retained products of conception remain in the uterus after the miscarriage
what is a complete miscarriage?
a full miscarriage has occurred, and there are no products of conception left in the uterus
what is an anembryonic miscarriage?
- a gestational sac is present but contains no embryo
what are the 3 featurs a sonographer looks for to diagnose a miscarriage?
Mean gestational sac diameter
Fetal pole and crown-rump length
Fetal heartbeat
these appear sequentially
what US findings make a pregnancy viable or miscarriage?
Viable if fetal heartbeat
- expected once the crown-rump length is. ..->7mm
CRL <7mm + NO FHB
- repeat scan 1 week to ensure FHB develops
CRL>7mm + NO FHB
- repeat scan 1 week to confirm non-viable pregnancy
fetal pole
- expected once the mean gestational sac diameter is >/25mm
if MGSD >/25 mm + NO FP
- repeat scan 1 week to confirm anembryonic pregnancy
how do you manaage miscarriage <6 weeks
expectant
repeat urine pregnancy test 7-10 days
how can you manage miscarriage > 6 weeks + bleeding
refer to EPAU
- US for location and viability
Expectant management (do nothing and await a spontaneous miscarriage) Medical management (misoprostol) Surgical management
what is classified as recurrent miscarriage
3 or more consecutive
risk inc with age
10% in women aged 20 - 30 years
15% in women aged 30 - 35 years
25% in women aged 35 - 45 years
50% in women aged 40 - 45 years
when can you investigate for Recurrent miscarriage?
Three or more first-trimester miscarriages
One or more second-trimester miscarriages
how do you manage recurrent miscarriages in antiphospholipid syndrome?
Test for antiphospholipid antibodies, and treatment is with low dose aspirin and LMWH.
3 key inherited thrombophilias to remember for recurrent miscarriages
Factor V Leiden (most common) Factor II (prothrombin) gene mutation Protein S deficiency
uterine abnormalities that can cause recurrent miscarriage
Uterine septum (a partition through the uterus)
Unicornuate uterus (single-horned uterus)
Bicornuate uterus (heart-shaped uterus)
Didelphic uterus (double uterus)
Cervical insufficiency
Fibroids
how do you investigate for recurrent miscarriages?
Antiphospholipid antibodies Testing for hereditary thrombophilias Pelvic ultrasound Genetic testing of the products of conception from the third or future miscarriages Genetic testing on parents
When. do you get nausea and vomiting in pregnancy?
Symptoms usually start from 4 - 7 weeks, are worst around 10 - 12 weeks and resolve by 16 - 20 weeks. Symptoms can persist throughout pregnancy.
4 criteria of hyperemesis gravidarum
“protracted” NVP plus:
More than 5 % weight loss compared with before pregnancy
Dehydration
Electrolyte imbalance
how can you assess the severity of hyperemesis gravidarum
The severity can be assessed using the Pregnancy-Unique Quantification of Emesis (PUQE) score. This gives a score out of 15:
< 7: Mild
7 - 12: Moderate
> 12: Severe
what antiemetics can be used in pregnancy?
Vaguely in order of preference and known safety, the choices are: Prochlorperazine (stemetil) Cyclizine Ondansetron Metoclopramide
Ranitidine or omeprazole can be used if acid reflux is a problem.
when do you consider admission for hyperemesis grvaidarum?
Admission should be considered when:
Unable to tolerate oral antiemetics or keep down any fluids
More than 5 % weight loss compared with pre-pregnancy
Ketones are present in the urine on a urine dipstick (2 + ketones on the urine dipstick is significant)
Other medical conditions need treating that required admission
how do you manage moderate-severe Hyperemesis Gravidarum?
may require ambulatory care (e.g. early pregnancy assessment unit) or admission for:
IV or IM antiemetics
IV fluids (normal saline with added potassium chloride)
Daily monitoring of U&Es while having IV therapy
Thiamine supplementation to prevent deficiency (prevents Wernicke-Korsakoff syndrome)
Thromboprophylaxis (TED stocking and low molecular weight heparin) during admission
what’s the difference between a complete and partial mole?
complete mole
- 2 sperm cells fertilise an empty ovum (no genetic material)
- No fetal material will form.
partial mole
- 2 sperm cells fertilise a normal ovum (containing genetic material) at the same time.
- cell has 3 sets chr (is a haploid cell)
- The cell divides and multiplies
- some fetal material may form.
Signs of molar pregnancy
More severe morning sickness Vaginal bleeding Increased enlargement of the uterus Abnormally high hCG Thyrotoxicosis (hCG can mimic TSH and stimulate the thyroid to produce excess T3 and T4)
US: snowstorm
how do you diagnose a molar pregnancy
Ultrasound of the pelvis shows a characteristic “snowstorm appearance” of the pregnancy.
Provisional diagnosis can be made by ultrasound and confirmed with histology of the mole after evacuation.
management of hydatidiform mole
- evacuation of the mole
- follow to detect any malignant changes (mole can metastasis, pt may require chemo)
- refer pt to gestational trophoblastic disease centre
- checking HCG levels every 1-2 weeks until back to prepregnancy level repeat 1-2 months for up to a yr
- No pregnancy for a yr
- need psychosocial support
