Early pregnancy Flashcards
Most common site of ectopic pregnancy
ampulla and isthmus of fallopian tube
risk factors for ectopic pregnancy
Previous ectopic pregnancy
Previous pelvic inflammatory disease/ endometriosis
Previous surgery to the fallopian tubes or pathology
Intrauterine devices (coils)
POP
Older age
Smoking
presentation of ectopic pregnancy
6-8 weeks gestation
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)
Unilateral pain RIF/ LIF
Irregular PV spotting/ bleeding, dark sticky prune juice
GI symptoms: N/V, diarrhoea
dizziness/syncope
shoulder tip pain
Tubal types of ectopic
Isthmic, majority
Fimbrial
Cornual
Interstitial
Bilateral (very rare)
types of ectopic
Tubal >99%
Ovarian
Abdominal
Cervical
Uterine (rare)
Diverticulum, intramural, rudimentary horn (cornual), scar (becoming more common)
Heterotopic with IVF
USS ectopic
blob/bagel/tubal ring: empty gestational sac
gestation sac containing yolk sac or fetal pole
empty uterus, pesudogestational sac
Pregnancy of unknown location management
monitor hCG
rise in >63% 48 hrs indicates intrauterine pregnancy, hCG>1500, repeat USS 1-2 weeks
rise 63% -> ectopic
> 50% fall: miscarriage, pregnancy test after 2 weeks
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 and falling
criteria for medical management of ectopic pregnancy
HCG level must be < 5000 IU / l
Confirmed absence of intrauterine pregnancy on ultrasound
how long after methotrexate can u get pregnant?
3 months
side effects of methotrexate
vaginal bleeding
N/V
abdominal pain
stomatitis
surgical management of ectopic pregnancy
laparoscopic salpingectomy
lap salpingotomy if otther tube is damaged or low infertility
anti-D prophylaxis if rhesus negative
early and late miscarriage
Early miscarriage is before 12 weeks gestation.
Late miscarriage is between 12 and 24 weeks gestation.
aetiology of miscarriage
Sporadic in most cases, never established in most cases
Chromosomal abnormalities
Congenital abnormalities
Maternal disease:
Poorly controlled diabetes
Acute illness/ infection
Uterine abnormalities
Thrombophilia/ antiphospholipid syndrome
risk factors for miscarriage
Advanced maternal age
Previous miscarriage
Smoking
Alcohol and drug use:
NSAIDs and aspirin
Street drugs
Folate deficiency
Consanguinity
missed miscarriage
the fetus is no longer alive, but no symptoms have occurred
Failed pregnancy with no cardiac pulsations on USS
threatened miscarriage
vaginal bleeding with a closed cervix and a fetus that is alive
Bleeding and/or pain up to 24/40 with a viable ongoing pregnancy
inevitable miscarriage
vaginal bleeding with an open cervix
Cervix open, internal os
Products of conception not yet passed but they will
incomplete miscarriage
retained products of conception remain in the uterus after the miscarriage
Some products of conception have been passed
Cervix stays open until all tissues passed
Still bleeding and pain
Echogenic mass of blood clot and tissue within the uterine cavity >20mm in AP diameter
complete miscarriage
a full miscarriage has occurred, and there are no products of conception left in the uterus
All products of conception have been passed
Complete sac may be identifiable
Bleeding and pain reducing
Cervix now closed
Cannot diagnose with USS
Empty uterine cavity
Rough guide AP <20mm
anembryonic pregnancy
a gestational sac is present but contains no embryo
Failed pregnancy with empty gestation sac
No fetus present
USS features miscarriage
Mean gestational sac diameter
Fetal pole and crown-rump length
Fetal heartbeat
fetal heartbeat
When a fetal heartbeat is visible, the pregnancy is considered viable. A fetal heartbeat is expected once the crown-rump length is 7mm or more.
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 there is a crown-rump length of 7mm or more, without a fetal heartbeat, the scan is repeated after one week before confirming a non-viable pregnancy.
fetal pole
A fetal pole is expected once the mean gestational sac diameter is 25mm or more. When there is a mean gestational sac diameter of 25mm or more, without a fetal pole, the scan is repeated after one week before confirming an anembryonic pregnancy.
<6 weeks miscarriage management
expectant management
repeat urine pregnancy test after 7-10 days
> 6 weeks miscarriage management
EPAU
USS
expectant, medical, surgical
expectant management miscarriage
Expectant management is offered first-line for women without risk factors for heavy bleeding or infection.
1 – 2 weeks are given to allow the miscarriage to occur spontaneously. A repeat urine pregnancy test should be performed three weeks after bleeding and pain settle to confirm the miscarriage is complete.
Persistent or worsening bleeding requires further assessment and repeat ultrasound, as this may indicate an incomplete miscarriage and require additional management.
Must have 24 hour access to gynae services
expectant management of miscarriage advantages and disadvantages
Advantages:
Avoid risks of surgery/meds
Can be at home
Disadvantages: Pain and bleeding can be unpredictable Worries regarding being at home Takes longer May be unsuccessful
misoprostol advantages and disadvantages
Advantages:
Avoids surgery
High patient satisfaction if successful
Can be done as outpatient
The key side effects of misoprostol are: Heavier bleeding Pain Vomiting Diarrhoea
surgical management of miscarriage
Manual vacuum aspiration under local anaesthetic as an outpatient
Electric vacuum aspiration under general anaesthetic
Give misoprostol before to soften the cervix
anti-D prophylaxis
surgical management of miscarriage advantages and disadvantages
Advantages:
Planned procedure, closure
Disadvantages: Surgical (perforation, bowel/bladder damage) Damage to cervix Asherman's Cervical weakness Anaesthetic risk
complication of evacuation of retained products of conception
endometritis
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 systemic lupus erythematosus (SLE)
The risk of miscarriage in patients with antiphospholipid syndrome is reduced by using
Low dose aspirin
Low molecular weight heparin (LMWH)
hereditary thrombophilias
Factor V Leiden (most common)
Factor II (prothrombin) gene mutation
Protein S deficiency
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
investigations for 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
N/V peak in pregnancy
Nausea and vomiting in pregnancy starts in the first trimester, peaking around 8 – 12 weeks gestation.
pathophysiology of hyperemesis
Elevated HCG:
More common in twin/ molar pregnancies
Same alpha subunit TSH-> thyrotoxicosis
Elevated oestrogen/ progesterone:
Decreased gut motility
Increased liver enzymes
Decreased cardiac sphincter pressure
H, Pylori:
Sub-clinical infection activated by altered immunity in pregnancy
Psychological:
Difference in incidence in different populations and cultures
hyperemesis gravidarum diagnosis
More than 5 % weight loss compared with before pregnancy
Dehydration
Electrolyte imbalance
PUQE
Pregnancy unique quantification of emesis
< 7: Mild
7 – 12: Moderate
> 12: Severe
investigations of hyperemesis
Urine: PT/ ketonuria/ UTI
FBC: haematocrit
UE (esp K)
LFT and amylase
TFT
USS: exclude GTD/ multiple pregnancy
hyperemesis management
Prochlorperazine (stemetil)
Cyclizine
Ondansetron
Metoclopramide
if reflux is a problem: ranitidine/ omeprazole
ginger or acupressure
admission criteria hyperemesis
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
admission management hyperemesis
IV or IM antiemetics
IV fluids (normal saline with added potassium chloride)
Not with glucose as it precipitates Wernicke’s
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
Folic acid
Ranitidine
Gestational trophoblastic disease types
Pre-malignant conditions (more common):
Hydatidiform mole/ molar pregnancy
Complete mole (empty egg, 1 sperm)
Partial mole (egg and 2 sperm)- more common
Malignant conditions (rarer): Invasive mole Choriocarcinoma Placental trophoblastic site tumour Epithelioid trophoblastic tumour.
risk factors for GTD
Maternal age <20 or >35
Previous gestational trophoblastic disease (this risk is not decreased by a change of partner)
Previous miscarriage
Use of the oral contraceptive pill
clinical features of molar pregnancy
vaginal bleeding and abdominal pain
Hyperemesis – because there is an increased titre of B-hCG which is thought to be linked to nausea in pregnancy.
Hyperthyroidism – gestational thyrotoxicosis due to stimulation of the thyroid by high HCG levels.
Anaemia
Bleeding/ haemorrhage
Severe, very early PET
Uterus large for dates
investigations for molar pregnancy
urine bCHG HIGH
USS: granular/ snowstorm appearance
histology: post-treatment
mets: CT CAP, pelvic USS
management of molar pregnancy
suction curettage or
medical evacuation with urinary bHCG measured 3 weeks post-treatment
