Early pregnancy Flashcards
6-8 wk gestation
Missed period
Constant low abdo pain in LIF/RIF
Vaginal bleeding
Cervical motion tenderness/cervical excitation
Ectopic pregnancy
what is the Ix of choice in an ectopic pregnancy ?
-Transvaginal USS
What is the normal hCG rise in an intrauterine pregnancy
-Doubles every 48 hrs
-Rise of less than 65% in 48 hrs may suggest ectoptic
-Fall of >50% is likely to indicate miscarriage
What are the 3 options for terminating an ectopic pregnancy ?
-Expectant management
-Medical (methotrexate)
-Surgical (salpingectomy or salpingotomy)
How is methotrexate given to terminate pregnancy and what is the criteria
-IM in the buttock
Criteria :
- hCG >1000 but <5000 IU/L
-No pain, unruptured and nio fetal heartbeat
-Confrimed absence of intrauterine pregnancy on USS
What is the 1st line surgical treatment for ectopic pregnancy ?
-Laparaoscopic salpingectomy -> key hole removal of affected fallopian tube
What is the criteria for surgical removal or ectopic pregnancy over medical
Pain
Adnexal mass >35mm
Visible heartbeat
hCG >5000 IU/L
When is a laparoscopic salpingotomy done ?
-Women with increased risk of infertility
-Involves cutting into fallopian tube rather than removing it
What 3 features are assessed on an USS in early pregnancy
-Mean gestational sac diameter
-Fetal pole and crown-rump length
-Fetal heartbeat : once present, pregnancy considered viable
When is a fetal heartbeat expected?
Once the crown-rump length is 7mm or more
When is a pregnancy considered non viable on USS?
-When crown-rump length is >7mm without fetal heartbeat and scan has been repeated after 1 wk
-When there is a mean gestational sac diamete of >25mm without a fetal pole and the scan has been repeated after 1 wk = anembryonic pregnancy
How is a miscarriage at <6 wks managed
-Expectantly if no pain or other complications/RF
-Repeat urine pregnancy test at 7-10 days to confirm miscarriage
How can a miscarriage at >6 wks be managed
Expectant
Medical : misoprostol
Surgical
What is misoprostal
-Prostaglandin analogue
-Activates them causing cervix to soften and stimulate uterine contractions
-Given as vaginal suppository or orally
Give 4 SE of misoprostal
-Heavier bleeding
-Pain
-D&V
What are 2 surgical management options of miscarriage
-Manual vacuum aspiration (local anaesthetic)
-Electric vacuum aspiration (general anaesthetic)
What is manual vacuum aspiration and when is it done?
-> Misoprostol given first
-> <10 wks
-> Syringe used to manual aspirate contents of the uterus
-> More appropriate for parous women.
What is given to women recieving surgical management of a miscarriage or ectpic?
Anti-rhesus D prophylaxis
What is an incomplete miscarriage and how can it be managed ?
-> Retained products of conception (fetal or placental tissue
-> Medical with misoprostol
-> Surgical with evacuation of retained products of conception (ERPC) = vacuum aspiration and curettage
What defines recurrent miscarriage ?
3 or more consecutive miscarriages
Give 7 causes of recurrent miscarriage
-Idiopathic
-Antiphospholipid syndrome
-Hereditary thrombophilias
-Uterine abnormalities
-Genetic factors
-Chronic histiocytic intervillositis
-Chronic disease : DM , thyroid, SLE
Recurrent miscarriage
Past DVT
Antiphospholipid syndrome
How is miscarriage risk reduced in antiphospholipd syndrome
-Low dose aspirin
-LMWH
Give 3 hereditary thrombophilias that can cause recurrent miscarriage
-Factor V leiden (most common)
-Factor II gene mutation
-Protein S deficiency
What are the 2 legal requirements for abotion
-2 registered medical practitioners must sign
-Must be carried out by registered medical practitioner in an NHS hospital or approved premise
What is the latest gestational age where an abortion is legal ?
-24 wks
-If continuing pregnancy involves greater risk to physical or mental health of the women or existing children of the family
What is involved in medical abortion
-Mifepristone : anti-progestogen & blocks progesterone.
-Misoprostol : prostaglandin analogue given 1-2 days later. From 10 wks gestation additional misoprostol is given until expulsion
What medications are given prior to surgical abortion to soften and dilate the cervix
-Misoprostol
-Mifeprstone
-Osmotic dilators
What are the 2 surgical options for abortion
-Cervical dilation and suction of uterus contents (up to 14 wks)
-Cervical dilation and evacuation using forceps (14-24 wks)
What is hyperemesis gravidarum and what is required for diagnosis
-> Severe N&V in pregnancy +
-> >5% weight loss compared to before pregnancy
-> Dehydration
-> Electrolyte imbalance
What are the antiemetic choices for N&V in pregnancy ?
- Prochlorperazine
- Cyclizine
- Ondansetron
- metoclopramide
When is admission required in N&V in pregnancy
-Unable to tolerate antiemetics or keep down fluids
-5% weight loss
-Ketones in urine (2+)
What is a complete hydatidiform mole?
-2 sperm cells fertilise an ovum that contains no genetic material
-Diploid cell = 46 chromosomes
-Grow into a tumour called a complete mole
What is a partial hydatidiform mole ?
-2 sperm cells fertilise a normal ovum at the same time
-3 sets of chromosomes = triploid = 69 chromosomes
-Cell divides into a tumour called a partial mole
What is seen on USS in hydatidiform mole?
‘snowstorm appearance’
How is a hydatidiform mole managed
Evacuation of uterus
hCG monitored until return to normal
What 5 features would suggest a molar pregancy over a normal pregnancy
-More severe morning sickness
-Vaginal bleeding
-Increased enlargement of uterus
-Abnormally high hCH
-Thyrotoxicosis
what is the most common location of an ectopic pregnancy
ampulla of fallopian tube
Give 5 associations with hyperemesis gravidarum
multiple pregnancies
trophoblastic disease -> vaginal spotting, uterus large for dates
hyperthyroidism
nulliparity
obesity
what kind of trophoblastic disease can cause hyperemesis gravidarum and what would be seen on investigations
-Hydatidiform mole
-Snowstorm appearance on USS
-Massively raised b-hCG
when would an ectopic pregnancy be managed with expectant management
hCG <1000
no fetal heartbeat
asymptomatic
How is ERPC done ?
-Under GA
-Cervix is dilated
-Retinaed products are manually removed using vacuum aspiration and curettage
-Complications : endometritis
What are the 6 different miscarriage definitions
-Missed : dead fetus, no sx
-Threatened : vaginla bleeding with a closed cervix and alive fetus
-Inevitable : vaginal bleeding + open cervix
-Complete : full miscarriage and no RPC
-Incomplete : RPC
-Anembryonic pregnancy : gestational sac with no embryo
Give 6 uterine abnormalities that can cause miscarriages
-Uterine septum
-Unicornuate uterus
-Bicornuate uterus
-Didelphic uterus (double uterus)
-Cervical insufficiency
-Fibroid s
What is chronic histiocytic intervillositis
-Cause of recurrent miscarriage (esp 2nd trimester)
-Also cause IUGR and intrauterine death
-Diagnosis : placental histology showing infiltrates of mononuclear cells in the intervillous spaces
When can an abortion be carried out at any time of the pregnancy
-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
what produces hCG -> human chorionic gonadotropin
placenta
when is an expectant management of miscarriage not recommened ?
-> Evidence of infection
-> Increased risk of haemorrhage
-> Previous adverse and / or traumatic experience associated with pregnancy
Give 6 RF for ectopic pregnancies
-> PID (e.g. chlamydia) causing damage to tubes
-> Previous ectopic
-> Endometriosis
-> IUD
-> POP
-> IVF
