Early Pregnancy Flashcards
ECTOPIC PREGNANCY
i) what is it? what is the most common site? name four RFs
ii) at how many weeks gestation does it usually px? name five classic features? name two other features
iii) what is the investigation of choice? what may be seen? how does a tubal ectopic pregnancy look? name two other features on imaging that suggest ectopic
iv) what produces HCG? how quickly does it double in a uterine pregnancy? what may a rise less than this indicate?
v) when should a urine pregnancy test be done to confirm miscarriage
i) pregnancy implants outside the uterus - most common in the fallopian tube
RF - previous ectopic, previous PID, previous fallopian tube dx, IUD, older age, smoking
ii) usually 6-8 weeks gestation
missed period, constant lower aabdo pain in RIF/LIF, vaginal bleeding, lower abdo pain, pelvic tender, cervical motion tender
other featurres - dizzy/syncope (blood loss), shoulder tip pain (peritonitis)
iii) TV US is investigation
may see gestational sac cont yolk sac or fetal pole maay be seen in fallopian tube
empty gestational sac = blob sign
tubal ectopic - mass that moves seperately to the ovary
other features - empty uterus or fluid in uterus
iv) developing syncytiotrophoblast produces HCG > interuterine doubles every 48 hours
rise <63% after 48hrs maay suggest ectopic
fall of more than 50% may indiccate miscarriage
v) urine preg test after 2 weeks to confirm
ECTOPIC PREGNANCY MX
i) who should pt with abdo/pelvic pain and positive pregnancy test be referred to? what are the three tx options for termination?
ii) name three things that may allow for expectant mx
iii) name two things that allow medical mx? what drug is given? how is it given and how does it work? how long after must a woman not get pregnant
iv) name three reasons for surgical management? what are the two options? what is first line?
v) what is given to rhesus negative mothers that have sx mx
i) refer to early preg asasess unit
expectant - wait for natural termination
medical - MTX
surgical - salpingectomy or salpingotomy
ii) expectant - folllow up possible, unrupturred, adnexal mass <35mm, no visible heart beat, no pain, HCG <1500
iii) medical - HCG <5000 and confirmed absnce of intrauterine pregnancy on US
give methotrexate - highly teratogenic by intramusc injection
dont get pregnaant for 3 months
iv) surgical mx if pain, adnexal mass >35mm, visible heart beat, HCG >5000
lap salpingectomy is first line - key hole to remove the affected fallopian tube
lap salpingotomy - dont removed fallopian tube > remove ectopic then close
v) give anti rhesus D prophylaxis
MISCARRIAGE
i) what is early/late?
ii) what is missed, threatened, inevitable, incomplete, complete, anembryonic?
iii) what is first ix of choice? what three things are recorded?
iv) when is a fetal heartbeat expected to be present?
i) early is pre 12 weeks and late is 12-24 weeks
ii) missed - fetus no longer alive but asymptomatic
threatened - vaginal bleed with closed cervix and alive fetus
inevitable - vaginal bleed with open cervix
incomplete - retained products of conception remain in utero after miscarriage
complete - no products of conception left in utero
anembryonic - gestational sac is present but no embryo
iii) TV US - look at mean gestational sac diameter, fetal pole and crown rump length and fetal heartbeat
iv) expect fetal heartbreat when crown rump length is 7mm or more
MISCARRIAGE MX
i) how can women be managed at less than 6wks gestation if they have no pain or RF? after how many days is repeat urine pregnancy test done? is US helpful?
ii) where are pts referred if over 6 weeks gestation? what imaging is done? what needs to be excluded? what are the three options for mx?
iii) what does expectant mx involve? when is a repeat urine preg test done?
iv) which medication is given in medical mx? how does it work? how is it given? name two SEs
v) name two options for surgical mx? what is given before surgery?
vi) name two ways to treat incomplete miscarriage
i) less than 6wks - expectant mx then repeat urine 7-10 days later
US not useful as cant vis
ii) over 6 weeks refer to EPU and do US to confirm location and viability - want to rule out ectopic
expectant, medical, surgical
iii) expectant - first line for no RF for bleeding and infection - allow MC to occ spont for 1-2 weeks
repeat urine at 3 weeks
iv) medical - misoprostol = PG analogue > PGs soften cervix and stimulate uterine contractions
give vaginal or oral
SEs are heavy bleeding, pain, vomiting, diarrhoea
v) surgical = manual vacuum aspiration under local (more approp if prev given birth)
electric vacuum aspiration under general
give misoprostol before sx to soften cervix
vi) incomplete - retained products of concetpion with inc risk of infection
medical or surgical mx
RECURRENT MISCARRIAGE
i) what is it defined as? when are investigations initiatied? (2)
ii) name four potential causes?
iii) which syndrome is particularly associated with it? why? how can risk be reduced in these patients? (2)
iv) which three inherited thrombophilias increase risk? name two uterine abnormalities
v) name four investigations that may be done
i) defined as three or more consecutive
initiate ix when 3+ in first trimester or 1+ in second trimester
ii) idiopathic (older age), anti phoslip syndrome, hereditiary thrombophilia, uterine abnorms, genetic factors, chronic disease eg diabetes, thyroid, SLE
iii) assoc with anti phospholipid syndrome > hyper cogaulable state assoc with thrombosis and miscarriage
mx in pregnancy with low dose aspirin and LMWH
iv) inherited thrombophilia - factor V leiden, factor II prothrombin gene mutation, protein S deficiency
uterine abnorms - uterine septum, unicornuate uterus, bicornuate uterus, didelphic uteris
v) ix with antiphospholipid antibodies, hereditary thrombophilias, pelvic ulltrasound, genetic testing the products of conception
TERMINATION OF PREGNANCY
i) what is the legal framework? what is the legal age limit gestation? how many people need to agree abortion is indicated?
ii) under how many weeks can service be remote? which two medications are given? what does each do?
iii) what do rhesus negative women with gestation over 10 weeks need?
iv) what needs to be given before surgical abortion? (3) what do they do? what are the two options for surgical abortion?
v) how long may women have bleeding/cramps post abortion? when is urine pregnancy test done? name three complications
i) 1967 abortion act
1990 human fert and embryology act made GA 24 weeks
2 people need to agree
ii) under 10 weeks - remote consultation
mifepristone - anti progestogen (halts pregnancy and relaxes the cervix)
misoprostol is a PG analog (softens cervix and stimulats uterine contracs) over 10 weeks give multiple doses until expulsion
iii) rhesus neg have anti d prophylaxis
iv) before surgical - give misoprosol, mifepristone or osmotic dilators to soften and dilate the cervix
two options - cervical dilatation and suction (up to 14 weeks)
cervical dilatation and evac using forceps (14-24 weeks)
v) 2 weeks bleed and cramp
do repeat ruine 3 weeks later
complications - bleed, pain, infection, failed abortion, damage to cervix/uterus
NAUSEA AND VOMITING IN PREGNANCY
i) when do symptoms usually start? when are they usually worse? when do they resolve by?
ii) name two types of pregnancy it may be more severe in? what are the three criteria for hyperemesis gravidarum dx?
iii) which score assess HG? what is classed as severe?
iv) what is usual first line anti emetic? name three others? what can be given in acid reflux is a problem? name two complimentatry therapies?
i) start from 4-7 weeks, peak st 10-12 weeks and resolve by 16-20 weeks
ii) more sever in molar preg or multiple preg due to higher HCG
HG: more than 5% weight loss, dehydration, electo imbalance
iii) pregnancy unique quantification of emesis (PUQE) score out of 15 (>12 is severe)
iv) first line is prochorperazine, then cyclizine, ondansetron, metoclopramide
acid reflux - ranitidine or omeprazole
complimetary - ginger or acupressure on inner wrist
MX OF N+V IN PREGNANCY
i) how can mild cases be managed? name three reasons for admission?
ii) what type of care do mod/severe need?
iii) name three things that may be given to mod/severe
i) mild - oral anti emetic at home
admit if unable to tolerate oral anti emetic, 5% weight loss, ketones on urine dipstick
ii) mod/severe need ambulatory care or admission
iii) give IV or IM anti emetic
IV fluid ( normal saline + potassium chloride),
daily U+Es
thiamine supplements to prevent werenicke korsakoffs
thromboprophylaxis
MOLAR PREGNANCY
i) what is it? what is it aka?
ii) what are the two types and what happens in each?
iii) name three things that may indicate molar pregnancy rather than normal pregnancy?
iv) what US appearance may be seen?
v) how is it managed? where should patient be referred? what blood levels are monitored?
i) tumour that grows like a pregnancy in the uterus = hydatidiform mole
ii) complete mole - two sperm fertilise an empty ovum > sperm combine genetic materal that divdes and grows
partial mole - two sperm fertilise a normal ovum (three sets of chromos) - some fetal material may form
iii) more severe morning sickness, vaginal bleeding, increased enlarge of uterus, abnormally high HCG, thyrotoxicosis (HCG can mimic TSH)
iv) US = snowstorm appearance
v) mx with evacuation of uterus to remove the mole > histology
refer to gestational trophoblastic disease centre
monitor HCG until normal
