Early Pregnancy

Question 1

Causes of miscarriage

Answer 1

Chromosomal- 50%
- risk increases with advancing age
- most common is trisomies, then monosomy then triploidies

Unknown- 25%

Infection
- perinatal
- others

Uterine anomalies
- bicornuate, septate, arcuate, DES
- cervical incompetence in second trimester

Haematological
- APS
- thrombophilias

Question 2

Causes of recurrent miscarriage

Answer 2

Unknown- 50%
Advancing maternal age
Genetic factors
- parental chromosomal rearrangements
- embryonic chromosomal abnormalities
Antiphospholipid syndrome
Anatomical factors
- congenital uterine anomalies
- acquired uterine anomalies
- cervical incompetence
Endocrine factors
Inherited thrombophilias

Question 3

Summary of SPIN study

Answer 3

There is no difference in pregnancy loss in women with recurrent miscarriage (where the aetiology is not due to chromosomal, structural or endocrine causes) if given low dose LMWH + LDA + intense pregnancy surveillance vs just intense pregnancy surveillance

Question 4

Risk factors for ectopic pregnancy

Answer 4

Tubal damage
Chromosomally abnormal pregnancy
Exogenous hormones- POP, Jadelle as P decreases smooth muscle contractility
IUCD
Previous ectopic
ART

Question 5

USS features of ectopic pregnancy

Answer 5

Adnexal mass moving separate to the ovary comprising a GS containing a yolk sac OR a fetal pole

Question 6

USS features with high probability of ectopic

Answer 6

Empty extrauterine GS moving separate to ovary
A complex homogenous adnexal mass moving separate to the ovary 50-60%
Empty uterus
A fluid collection within the uterine cavity “pseudosac”

Question 7

Management of interstitial ectopic pregnancy

Answer 7

Expectant if pain- free and low/ significantly falling beta- HCGs

Medical
- not recommended if large or presence of FH
- systemic MTX
- USS- guided intrasac MTX +/- KCl
- laparoscopy- guided intrasac MTX +/- KCl

Surgical
- laparoscopic cornual/ wedge resection if >4cm, salpingoyomy <3.5cm
- hysteroscopic endometrial evacuation under lap control; corneal evacuation with polyp forceps under USS or laparoscopic guidance
- laparotomy
— cornual resection
— UA ligation and repair of ruptured cornua
— hysterectomy

Question 8

Management of CS scar ectopic

Answer 8

Counsel with regards to severe maternal morbidity and mortality
Medical + surgical measures should be considered in women with first trimester CS scar pregnancy.

Medical:
- systemic IM/ IV MTX +/- other modalities
- for stable unruptured CSP
- more likely successful if HCG <5000

Interventional radiology:
- intragestational sac MTX
— aspiration of GS with US- guidance, 50mg MTX injected into sac followed by a saline flush
- intragestational sac KCl 2ml when FH activity evident to induce asystole
- UAE either combined with local/ systemic MTX or using MTX ( chemoembolisation)

Surgical:
- suction D&C
- laparoscopic or open excision and re- suturing
- hysteroscopic resection

Follow- up:
- variable time frame for HCG resolution (up to 6 months with medical)
- weekly beta- hcg- if plateaued, offer repeat systemic MTX
- risk of haemorrhage as vascular trophoblastic tissue degenerates
- consider cs defect repair prior to next pregnancy
- early us in future pregnancy
- recommend repeat cs in future

Question 9

Pharmacology of mifepristone

Answer 9

Acts as a competitive progesterone receptor antagonist which induces decidual breakdown which leads to trophoblast detachment, resulting in decreased syncitiotrophoblast production by the corpus luteum

Question 10

Pharmacology of misoprostol

Answer 10

Prostaglandin analogue which binds and stimulates the prostaglandin E1 receptors to soften and dilate the cervix and induce uterine contractions

Question 11

Criteria for diagnosis of antiphospholipid syndrome

Answer 11

1 lab criteria (present in 2 occasions, 12 weeks apart)
- lupus anticoagulant
- anti- cardiolipin antibody
- anti- B2 glycoprotein- I antibody

PLUS

1 clinical criteria (thrombosis or pregnancy- related morbidity)

Thrombosis:
- arterial
- venous
- small vessel

Pregnancy- related morbidity:
- unexplained miscarriage > 10/40
- PTB <34 weeks due to PET or severe IUGR (placental insufficiency)
- 3 or more unexplained consecutive miscarriages <10 weeks

Question 12

Pathophysiology of APS

Answer 12

Inflammation
- increased complement activation, torrid factors and endothelial growth factor

Promotion of coagulation
- APL interfered with coagulation cascade
- placental infarction and thrombosis from spiral artery vasculopathy

Interference with trophoblast function
- aPL bind to trophoblasts and cause impaired differentiation, proliferation and invasion resulting in impaired implantation
- trophoblast apoptosis
- reduced HCG release