Early Pregnancy Flashcards
Give 6 RF for an ectopic pregnancy
- Previous ectopic
- Damage to tubes (surgery, PID)
- IUCD
- Older age
- Smoking
- Endometriosis
How does an ectopic pregnancy present ?
- Missed period (6-8 wks since)
- Constant lower abdominal pain in the right or left iliac fossa
- Vaginal bleeding
What is seen on examination in an ectopic pregnancy ?
- Lower abdominal or pelvic tenderness
- Cervical motion tenderness (pain when moving the cervix during a bimanual examination)
What is the investigation of choice for diagnosing an ectopic pregnancy
- Transvaginal USS
What are the 3 options for managing an ectopic pregnancy ?
- Expectant management (awaiting natural termination)
- Medical management (methotrexate)
- Surgical management (salpingectomy or salpingotomy)
What criteria needs to be met for expectant management of ectopic ?
- 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
What is the criteria for methotrexate as the management of an ectopic ?
Same as expectant, EXCEPT :
- HCG level must be < 5000 IU / l
- Confirmed absence of intrauterine pregnancy on ultrasound
What is the criteria for surgical management of an ectopic pregnancy ?
- Pain
- Adnexal mass > 35mm
- Visible heartbeat
- HCG levels > 5000 IU / l
How is methotrexate given for an ectopic pregnancy ?
IM into the buttock
How long is a woman advised to wait before getting pregnant after the use of methotrexate ?
3 mnths
Give 4 SE of methotrexate
Vaginal bleeding
Nausea and vomiting
Abdominal pain
Stomatitis (inflammation of the mouth)
What is the first line surgical option for ectopic and what must be given to women following this ?
- Laparoscopic salpingectomy
- Anti-rhesus D prophylaxis if rhesus negative
What surgical option is used in an ectopic if increased risk of infertility
- Laparoscopic salpingotomy
- 1 in 5 (20%) will need further treatment.
In an intrauterine pregnancy, when will the hCG level double ?
Every 48 hours
A rise of what in the hCG suggest an ectopic ?
<63% after 48 hts
A fall of what in the hCG suggest a miscarriage
more than 50%
Define a missed miscarriage
Fetus is no longer alive, but no symptoms have occured
Define a threatened miscarriage
Vaginal bleeding with a closed cervix and fetus is alive
Define an inevitable miscarriage
Vaginal bleeding with an open cervix
Define an incomplete miscarriage
RPOC remain in the uterus after miscarriage
Define a complete miscarriage
Full miscarriage and no products of conception are left in the uterus
Investigation of choice for a miscarriage
Transvaginal USS
What are the features assessed on an USS in early pregnancy in sequential order
- Mean gestational sac diameter
- Fetal pole (once gestational sac is 25mm or more)
- Crown rump length
- Fetal HB (Expected when crown rump lenth is 7mm or more)
what USS findings suggest an anembryonic pregnancy
- Mean gestational sac diameter of 25mm or more WITHOUT a fetal pole
- Repeated after 1 wk to confirm
Explain the 3 ways of managing a miscarriage at >6wks
- Expectant management
- Medical management (misoprostol)
- Surgical management
What USS findings suggest a non-viable pregnancy ?
- When the crown rump length is 7mm or more with no fetal HB
How is a miscarriage at <6 wks managed
- Expectantly (as long as there is no pain or other complications)
- Repeat urine pregnancy at 7-10 days to confirm
What is involved in the medical management of a miscarriage
Misoprostol (vaginal suppository or orally)
How does misoprotol work
- Prostoglandin analogue
- Leads to release of prostaglandins with soften cervix and stimulate uterine contractions
4 SE of misoprostol
Heavier bleeding
Pain
Vomiting
Diarrhoea
what are the 2 surgical options for managing a miscarriage and what is given prior to them
- Manual vacuum aspiration (local)
- Electrical vacuum aspiration (general)
- Misoprostol is given prior
- Anti-rhesus D prophylaxis
What is the criteria for manual vacuum aspiration of a miscarriage
-> <10 wks gestation
what are the 2 management options for RPOC ?
- Medical with misoprostol
- Surgical with evacuation of RPOC - general anaesthetic
What is involved in evacuation of RPOC and a key complication
- Vacuum aspiration and curettage
- Complication : endometritis (infection of endometrium).
what is considered as recurrent miscarriage and when are investigations initiated ?
-> 3 or more
-> Three or more first-trimester miscarriages
-> One or more second-trimester miscarriages
Give 7 causes of recurrent miscarriages
- Idiopathic
- Antiphospholipid syndrome
- Hereditary thrombophilias
- Uterine abnormalities
- Genetic factors
- Chronic histiocytic intervillositis
- Chronic diseases : DM, untreated thyroid, SLE
what is given to women with antiphospholipid syndrome to reduce risk of recurrent miscarriages
- Low dose aspirin
- LMWH
Give 3 inherited thrombophilias that can cause recurrent miscarriages
- Factor V Leiden (most common)
- Factor II (prothrombin) gene mutation
- Protein S deficiency
what uterine abnormalities can cause recurrent miscarriages
- Uterine septum (a partition through the uterus)
- Unicornuate uterus (single-horned uterus)
- Bicornuate uterus (heart-shaped uterus)
- Didelphic uterus (double uterus)
- Cervical insufficiency
- Fibroids
what is a rare cause of recurrent miscarriage, particularly in the 2nd trimester
Chronic Histiocytic Intervillositis
when can an abortion be carried out before 24 wks
- If continuing pregnanct involve sgreater risk to physical or mental health of :
- The woman
- Existing children of the family
When can an abortion be carried out at any time ?
- 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 are the legal requirements for an abortion to be carried out ?
- 2 registered medical practitioners must sign to agree abortion is indicated
- It must be carried out by a registered medical practitioner in an NHS hospital or approved premise
what is involved in a medical abortion ?
- Mifepristone (anti-progestogen)
- Misoprostol (prostaglandin analogue) 1 – 2 day later -> from 10wks gestation, additional doses are given until expulsion
when would women having a medical aortion require anti-D prophylaxis
Rhesus negative women with gestational age of 10 wks or above
What are the two surgical options for abortion and what determines the choice ?
- Cervical dilation and suction (up to 14 wks)
- Cervical dilation and evacuation with forceps (from 14-24 wks)
when is a urine pregnancy test done following an abortion ?
3 wks after
Give 5 complications of an abortion
- Bleeding
-Pain
-Infection - Failure of the abortion (pregnancy continues)
- Damage to the cervix, uterus or other structures
when does N&V develop in pregnancy, when does it peak and when does it resolve
- Starts 4-7 wks
- Peaks 10-12 wks
- Resolve 16-20 wks (can persist)
how is hyperemesis gravidarum diagnosed ?
- “Protracted NVP” +
~ More than 5% weight loss compared to before pregnancy
~ Dehydration
~ Electrolyte imbalance
How is the severity of NVP assessed ?
-> Pregnancy-Unique Quantification of Emesis (PUQE) :
- <7 : mild
- 7-12 : moderate
- > 12 : severe
How can mild cases NVP be managed ?
- Oral antiemetics admission
- Prochlorperazine (stemetil)
- Cyclizine
- Ondansetron
- Metoclopramide
when would admission for NVP be considered ?
- 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
What might moderate-severe cases of NVP require ?
- 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 stocking and low molecular weight heparin) during admission
what is a complete hydatidiform molar pregnancy
- Two sperm cells fertilise an ovum containing no genetic material
- No fetal material forms
what is a partial hydatidiform molar pregnancy ?
- Two sperm fertilise a nomral ovum
- 3 sets chromosomes (Haploid cell)
- Some fetal material forms
what features suggest a molar pregnancy over 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)
what is seen on USS in a molar pregnancy
“Snowstorm appearance” of the pregnancy
How is a molar pregnancy managed
- Evacuation of the uterus
- Products of conception are sent for histological examination
- hCG levels monitored until they return to normal
- Occasionally metastasise requiring systemic chemo
Typical presentation of ovarian hyperstimulation syndrome
- Ascites
- Vomiting
- Diarrhoea
- High haematocrit
Possible cause of ovarian hyperstimulation syndrome
Ovulation induction (Gonadotropin therapy)
risk of ondansetron in
pregnancy
associated with a small increased risk of cleft lip / palate if used in first trimester
Management of thrush in pregnancy
Clotrimazole pessary (oral fluconazole is CI)
Most likely location of ectopic pregnancy
Ampulla of fallopian tube
with surrogacy, at birth who is the child’s legal mother
Whomever gives birth to the child
What is required following a medical termination of pregnancy ?
‘Multi-level pregnancy test’ two weeks later
When should a woman take aspirin to reduced the risk of hypertensive disorders in pregnancy
women with the following should take aspirin 75-150mg daily from 12 weeks gestation until the birth
≥ 1 high risk factors
≥ 2 moderate factors
High risk factors for HTN in pregnancy
- Hypertensive disease in a previous pregnancy
- Chronic kidney disease
- Autoimmune disease, such as systemic lupus erythematosus or
antiphospholipid syndrome - Type 1 or type 2 diabetes
- Chronic hypertension
Moderate risk factors for HTN in pregnancy
- First pregnancy
- Age 40 years or older
- Pregnancy interval of more than 10 years
- Body mass index (BMI) of 35 kg/m² or more at first visit
- Family history of pre-eclampsia
- M ultiple pregnancy
