Early Pregnancy Flashcards
What is the risk of miscarriage associated with age?
12-19 13%
20-24 11%
25-29 12%
30-34 15%
35-39 25%
40-44 51%
45 and above 93%
What are risk factors for recurrent miscarriage?
Antiphospholipid antibodies, accounts for 15%- lupus antibody has strongest association
Inherited thombophilia - Factor V Leiden, Prothrombin (no evidence for protein C or S)
Parental chromosomal translocations (3-5% vs 0/.4% of general population)
Fetal chromosomal anomalies (30-60%)
Uterine structural abnormalities - septate and bicornuate
Intrauterine adhesions
Cervical integrity
Endocrine - uncontrolled Diabetes, Hypothyroid including subclinical, prolactinaemia
Infections - Chronic endometritis, BV
What is the diagnostic criteria for anti phospholipid syndrome?
1 lab and 1 clinical criteria of the following:
Lab:
Lupus, anticardiolipin or anti-b2-glycoprotein present in serum twice, 12 weeks apart
Clinical criteria:
Thrombosis: at least one episode of arterial or venous thrombosis.
Pregnancy morbidity: at least one unexplained death of a normal-appearance fetus at or beyond the 10th week of gestation; at least one preterm birth of a neonate of normal appearance before 34 weeks of gestation, because of eclampsia or severe pre-eclampsia or with signs of placental insufficiency; three or more unexplained consecutive spontaneous miscarriages before 10 weeks of gestation where anatomical, hormonal and chromosomal causes have been excluded.
What investigations are required following second trimester miscarriage?
Thrombophilia screen
Pelvic USS
Antiphospholipid screen
After 3 consecutive early miscarriages, what is the risk of further miscarriage?
40%
What are the risks of surgical management of miscarriage?
The overall (significant) complication rate for surgical evacuation of the uterus is approx 6%
Frequent Risks
Bleeding (note heavy bleeding necessitating transfusion uncommon 0-3 in 1000)
Infection 4%
Retained placental or fetal tissue 4%
Intrauterine adhesions 19%
Serious Risks
Uterine perforation 1 in 1000
Cervical trauma <1 in 1000
What is the risk of recurrence following ectopic pregnancy?
Irrespective of method of management
RCOG quotes 18%
What is the effect of methotrexate on ovarian reserve?
There is no impact
What is the best treatment, in terms of fertility for pregnancy?
In those with history of subfertility - conservative/medical are associated with improved fertility outcomes
What are the ultrasound criteria for a cervical ectopic pregnancy?
- Empty uterine cavity.
- A barrel-shaped cervix.
- A gestational sac present below the level of the internal cervical os.
- The absence of the ‘sliding sign’ (differentiates from miscarriage)
- Blood flow around the gestational sac using colour Doppler.
What is the prevalence of caesarean scar pregnancy?
1 in 2000 pregnancies
What are the criteria for use of methotrexate in ectopic pregnancy?
no significant pain
an unruptured ectopic pregnancy with a mass smaller than 35 mm with no visible heartbeat
serum b-hCG between 1500 and 5000 iu/l
no intrauterine pregnancy (as confirmed on ultrasound
What are the ultrasound criteria for miscarriage?
If no FH and CRL 7mm or more
MSD >25mm
Need 2 scans 7 days apart
What are the criteria for expectant management of ectopic pregnancy?
HCG <1000, consider between 1000-1500
Pain free
Can return for follow up
Mass <35mm with no FH
Return for bloods Day 2,4,7 - if falling by 15% then weekly until HCG <20
Who does and who does not qualify for anti-D, in miscarriage and ectopic pregnancy?
DOES:
-surgical management of miscarriage/ectopic
DOES NOT:
-medical management for an ectopic pregnancy or miscarriage
-threatened miscarriage
-complete miscarriage
-PUL
Discuss biochemical markers in early pregnancy
HCG - single measurement not useful, change over time can be predictive of iUP or Ectopic
Progesterone - Levels <20mmol high chance of failing pregnancy, level >60mmol high chance of ongoing pregnancy
Not enough evidence for any over novel biomarker
What are associations with the following biochemical markers in the 1st trimester?
Low HCG
Low Papp-A
Low PAPP-A:
spontaneous miscarriage
low birthweight
preterm delivery
gestational hypertension/PET
Associations with low βhCG:
spontaneous miscarriage
low birthweight
What are associations with the following biochemical markers in the 2nd trimester?
Raised HCG
Raised AFP
Raised Inhibin A
Low E3
Associations with raised αFP:
preterm delivery
fetal demise after 24 weeks
fetal growth restriction
placental abruption
spontaneous miscarriage
Associations with raised βhCG or Inhibin A:
preterm delivery
fetal demise after 24 weeks
fetal growth restriction
gestational hypertension/PET pre-eclampsia
Associations with low uE3 :
Fetal demise after 24 weeks
Oligohydramnios
low birth weight
spontaneous miscarriage
What is the HCG follow up required following salpingostomy for ectopic pregnancy?
At 7 days then weekly until negative
20% chance of needing further methotrexate or surgery
What size must an ectopic pregnancy be less than in order to offer….
conservative Mx?
medical Mx?
Both <35mm (NICE guidance) and no fetal heart, no signs of rupture
Conservative HCG <1000, consider 1000-1500
Medical HCG <3000, consider 1000-5000
Must be pain free
Able to return for follow up
What is the incidence of …
gestational trophoblastic disease?
choriocarcinoma?
In the UK..
GTN incidence~1-1.5:1000 live births with higher incidence in women from Asia
Incidence of choriocarcinoma ~ 1:50,000 live births
Recurrence risk of molar pregnancy = 1:80; 1:6.5 after two previous molar pregnancies. If recurrence occurs, 68-80% will be of the same histological type
Describe features of complete molar pregnancy
46XX; Diploid and androgenic.
75-80% arise from fertilisation of anucleate oocyte by one sperm which duplicates its genetic material.
20-25% arise from di-spermic fertilisation of an anucleate ovum.
On scan:
Snowstorm appearance
No fetal parts seen
Ovarian theca-lutein cysts
Clinically:
vaginal bleeding with expulsion of hydropic vesicles
Uterus large for dates
Excessive pregnancy symptoms
Hyperemesis
Hyperthyroidism
Early onset pre-eclampsia
What is the incidence of recurrent (3 consecutive) miscarriage?
1%
What is the risk of further miscarriage after…
0
1
2
3
4
5
consecutive miscarriages?
0 - 11.3%,
1- 17.0%,
2 - 28.0%
3 - 39.6%,
4 - 47.2%
5 - 63.9%
What is the follow up for molar pregnancy?
COMPLETE:
If hCG has reverted to normal within 56 days (8 weeks) of the pregnancy event then follow up will be for 6 months from the date of uterine evacuation
If hCG has not reverted to normal within 56 days of the pregnancy event then follow up will be for 6 months from normalisation of the hCG level
PARTIAL:
2 normal HCGs, 4 weeks apart
Women who have not received chemotherapy no longer need to have hCG measured after any subsequent pregnancy event
Women are advised not to conceive until their follow-up is complete + avoid coils due to risk of perforation. COCP, POP, Progestogen implants, Depo-MPA all OK.
Women who undergo chemotherapy are advised not to conceive for 1 year after completion of treatment, as a precautionary measure
What is the best way of dating a pregnancy?
By LMP in first instance
EDD is 280 days after the LMP
CRL has an accuracy of ±5–7 days
If USS has more than 7 days discrepancy from LMP then EDD should be changed
Use CRL up to 84mm then use HC (although some sources say BPD)
EDD for IVF pregnancy should use the age of the embryo and the date of transfer.
For a day-5 embryo, the EDD would be + 261 days from the embryo transfer.
For a day-3 embryo would be 263 days from the embryo transfer
Follow up of <6 weeks and bleeding
If patients present with BLEEDING and less than 6 weeks then following scan to exclude ectopic - NICE states repeat UPT 7-10 days and then represent if remains positive to confirm IUP + FH
What is percentage chance of tubal patency following methotrexate treatment?
80%
