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Early Pregnancy Flashcards

1
Q

Risk factors for ectopic pregnancy

A

Previous ectopic pregnancy

Previous pelvic inflammatory disease

Previous surgery to the fallopian tubes

Intrauterine devices (coils)

Older age

Smoking

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2
Q

When do ectopic pregnancies typically present?

A

6-8 weeks

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3
Q

Classic features of ectopic pregnancy

A

Missed period

Constant lower abdominal pain in the right or left iliac fossa

Vaginal bleeding

Lower abdominal or pelvic tenderness

Cervical motion tenderness (pain when moving the cervix during a bimanual examination)

Dizziness/syncope (blood loss)

Shoulder tip pain (peritonitis)

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4
Q

US findings in ectopic

A

TV USS

Yolk sac may be seen in tube

Empty uterus

Fluid in uterus

Empty sac -> blob/bagel/tubal ring sign

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5
Q

What is a pregnancy of unknown location (PUL)?

A

Positive pregnancy test but no evidence of pregnancy on USS

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6
Q

Follow up test for PUL

A

Serum hCG

Repeat after 48hrs to measure change from baseline

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7
Q

Serum hCG levels after 48hrs in:

Intrauterine pregnancy

Ectopic pregnancy

Miscarriage

A

Intrauterine pregnancy: rise of more than 63%

Ectopic pregnancy: rise of less than 63%

Miscarriage: fall of more than 50%

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8
Q

Management of ectopic pregnancy

A

Expectant management (awaiting natural termination)

Medical management (methotrexate)

Surgical management (salpingectomy or salpingotomy)

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9
Q

Criteria for expectant management of ectopic pregnancy

A

Follow up needs to be possible to ensure successful termination

Ectopic needs to be unruptured

Adnexal mass <35mm

No visible heartbeat

No significant pain

HCG level <1,500 IU/l

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10
Q

Criteria for methotrexate (medical management) of ectopic pregnancy

A

Follow up needs to be possible to ensure successful termination

Confirmed absence of intrauterine pregnancy on USS

Ectopic needs to be unruptured

Adnexal mass <35mm

No visible heartbeat

No significant pain

HCG level must be <5,000 IU/l

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11
Q

Outline methotrexate management of ectopic pregnancy

A

IM injection into buttock

Advise patient not to get pregnant for 3 months following treatment

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12
Q

Methotrexate side effects

A

Vaginal bleeding

Nausea and vomiting

Abdominal pain

Stomatitis (inflammation of the mouth)

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13
Q

Surgical management of ectopic pregnancy is indicated in patients with what symptoms?

A

Pain

Adnexal mass >35mm

Visible heartbeat

HCG levels >5,000 IU/l

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14
Q

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

A

Laparoscopic salpingectomy (first-line)

Laparoscopic salpingostomy (women at increased risk of infertility due to damage of other tube)

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15
Q

What is an early miscarriage?

A

Miscarriage before 12 weeks

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16
Q

What is a late miscarriage?

A

Miscarriage between 12 and 24 weeks

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17
Q

Define missed miscarriage

A

Foetus is no longer alive, but no symptoms have occurred

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18
Q

Define threatened miscarriage

A

Vaginal bleeding with a closed cervix and a foetus that is alive

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19
Q

Define inevitable miscarriage

A

Vaginal bleeding with an open cervix

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20
Q

Define incomplete miscarriage

A

Retained products of conception remain in the uterus after the miscarriage

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21
Q

Define complete miscarriage

A

A full miscarriage has occurred, and there are no products of conception left in the uterus

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22
Q

Define anembryonic miscarriage

A

A gestational sac is present but contains no embryo

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23
Q

What key features does a sonographer look for in early pregnancy?

A

Mean gestational sac diameter

Foetal pole and crown-rump length

Foetal heartbeat

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24
Q

What does the crown-rump length need to be in order to detect foetal heartbeat?

A

> 7mm

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25
When is a foetal pole expected to be visible on USS?
Once mean gestational sac diameter is 25mm or more
26
Management of miscarriage at less than 6 weeks gestation
Can be managed expectantly if no pain/complications/risk factors Repeat urine test after 7-10 days
27
Management of miscarriage at more than 6 weeks gestation
Expectant management (do nothing and await a spontaneous miscarriage) Medical management (misoprostol) Surgical management
28
Management of women with positive pregnancy test (>6/40) bleeding
Refer to early pregnancy assessment service USS to confirm location/viability
29
Outline expectant management of miscarriage
Women without risk factors for heavy bleeding or infection 1-2 weeks to allow miscarriage to occur spontaneously Repeat urine pregnancy test at 3 weeks
30
Persistent or worsening bleeding during expectant management of miscarriage
Further assessment required Repeat USS May indicate incomplete miscarriage and require additional management
31
Outline medical management of miscarriage
Misprostol (prostaglandin analogue) Binds to prostaglandin receptors and activates them Softens cervix and stimulates uterine contractions Vaginal suppository or oral dose
32
Key side effects of misoprostol
Heavier bleeding Pain Vomiting Diarrhoea
33
Surgical management of miscarriage options
Manual vacuum aspiration under local anaesthetic as an outpatient Electric vacuum aspiration under general anaesthetic
34
What is classed as "recurrent miscarriage"
Three or more consecutive miscarriages
35
When are investigations for recurrent miscarriage initiated?
Three or more first-trimester miscarriages One or more second-trimester miscarriages
36
Causes of recurrent miscarriage
Idiopathic (particularly in older women) Antiphospholipid syndrome Hereditary thrombophilias Uterine abnormalities Genetic factors in parents (e.g. balanced translocations in parental chromosomes) Chronic histiocytic intervillositis Other chronic diseases such as diabetes, untreated thyroid disease and SLE
37
Patient presents with recurrent miscarriages and a history of DVT. Which investigations would you do? What is the management for the likely diagnosis?
Antiphospholipid syndrome Tets for antiphospholipid antibodies Treat with aspirin and LMWH
38
Managing risk of miscarriage in patients with antiphospholipid syndrome
Low dose aspirin LMWH
39
Which hereditary thrombophilias increase risk of recurrent miscarriage?
Factor V Leiden (most common) Factor II (prothrombin) gene mutation Protein S deficiency
40
Uterine abnormalities causing 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
41
Investigations in recurrent miscarriage
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
42
Medical abortion options
Mifepristone (anti-progestogen) Misoprostol (prostaglandin analogue) 1-2 days later
43
Which type of anaesthetic is used in surgical abortions?
Can be under local, local + sedation, or general
44
Medications used for cervical priming prior to surgical abortion
Misoprostol Mifepristone Osmotic dilators (devices inserted into the cervix that gradually expand as they absorb fluid, opening the cervical canal)
45
What are the options for surgical abortion?
Cervical dilatation and suction of the contents of the uterus (usually up to 14 weeks) Cervical dilatation and evacuation using forceps (between 14 and 24 weeks)
46
Post-abortion care
Women may experience vaginal bleeding and cramps intermittently for up to 2 weeks post-procedure Pregnancy test 3 weeks after abortion to confirm complete Discuss contraception Support and counselling offered
47
Abortion complications
Bleeding Pain Infection Failure of the abortion (pregnancy continues) Damage to the cervix, uterus or other structures
48
Latest gestational age for abortion
24 weeks
49
An abortion can be performed at any time during pregnancy if...
Continuing the pregnancy is likely to risk the life of the woman Terminating the pregnancy will prevent “grave permanent injury” to the physical or mental health of the woman There is “substantial risk” that the child would suffer physical or mental abnormalities making it seriously handicapped
50
What is hyperemesis gravidarum?
Severe form of nausea and vomiting during pregnancy
51
Hyperemesis gravidarum diagnostic criteria
Protracted NVP plus: More than 5% weight loss compared with before pregnancy Dehydration Electrolyte imbalance
52
Assessing severity of vomiting
Pregnancy-Unique Qualification of Emesis score (out of 15) <7: Mild 7-12: Moderate >12: Severe
53
Antiemetics for hyperemesis gravidarum
Prochlorperazine (stemetil) Cyclizine Ondansetron Metoclopramide
54
When to consider admission in mild cases of hyperemesis gravidarum
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
55
When to consider admission/ambulatory care in moderate to severe cases of hyperemesis gravidarum
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 stockings and low molecular weight heparin) during admission
56
What is a molar pregnancy?
A hydatidiform mole (type of tumour) growing inside the uterus
57
What are the types of molar pregnancy?
Complete mole Partial mole
58
What is a complete mole and how does it occur?
Two sperm cells fertilise an ovum that contains no genetic material (an “empty ovum”) Sperm then combine genetic material, and cells start to divide and grow into a tumour called a complete mole. No foetal material will form
59
What is a partial mole and how does it occur?
Two sperm cells fertilise a normal ovum (containing genetic material) at the same time New cell now has three sets of chromosomes (it is a haploid cell) Cell divides and multiplies into a partial mole Some fetal material may form
60
What indicates a molar pregnancy rather than a normal 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)
61
What is the USS finding in molar pregnancy?
Snowstorm sign
62
Management of molar pregnancy
Evacuation of uterus to remove mole Products of conception need to be sent for histological examination to confirm a molar pregnancy Referred to gestational trophoblastic disease centre for management and follow up hCG levels monitored until they return to normal Occasionally mole can metastasise, and patient may require systemic chemotherapy

Obstetrics & Gynaecology (13 decks)

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