Early Pregnancy Flashcards
Definition of a miscarriage
TVS: MSD > 20mm w no FP
FP > 7mm w no FH
TAS: MSD >25mm w no FP
FP >8mm w no FH
Difference between complete and incomplete miscarriage
ETT <15 = complete, >15mm =incomplete
PUV vs PUL
PUV: MGSD </=20mm, no FP OR FP <7mm w no FH
PUL no IUGS seen OR IUGSw no YS
Management of miscarriage
Conservative - rpt USS 2/52
Medical: 80=91% effective. Mife 200mcg+ miso 800mcgx 2, rpt USS 2/52. ADRS: N&V, diarrhoea, PVB. Admit if MGSD >50mm
Surgical: ERPC, PT 2/52 later, Anti-D
Risk factors for recurrent miscarriage
Maternal age
Smoking
Caffeine
ETOH
Causes of recurrent miscarriage
ChAII TEA
Chromosomal - parental rearrangements + embryonic abnormalities
Antiphospholipidsyndrome
Immune
Infective
Thrombophilia
Endocrine
Anatomical
Role & effect of antiphospholipid syndrome
Includes lupus anticoagulant, antiB2 gylcoprotein ab, anticardiolipin abb
Adverse outcomes: early pregnancy loss, MTL, PTB
Inhibits trophoblastic function and differentiation. Activates complement pathways at mat/fet interface –> inflammatory response; thrombosis of uteroplacental vasculature in later pregnancy
Effects reversed with LMWH
Diagnosis of ectopic pregnancy
Serial HCG measurement
TAS/ TVS:
No IUGS + YS
60% homogenous adnexal mass adjacent to ovary
20% hypoechoic ring/ bagel sign
13% GS+FP
Types of ectopics
Tubal - bagel sign/ homogenous adnexal mass
Cervical - empty uterus, barrel-shaped cervix, GS below level of internal os, absence of sliding sign
Scar - GS low in uterine cavity. MRI 2nd line
Interstitial - empty uterine cavity, POC/GS in intramural part of tube + surrounded by <5mm myometrium
Cornual - visualisation of single interstitial portion of fallopian tube in main uterine body, GS/ POC seen mobile and separate fro uterus + completely surrounded by myometrium + vascular pedicle adjoining GS to unicornuate uterus
MTX candidate
- haemodynamically stable
- low HCG, ideally <1500 (NICE 1500-5000)
- No FH
- certainty of no viable IUP
- willingness to attend for F/U
- no known sensitivity to MTX
NICE: - no significant pain
- unruptured, w mass <35mm and no visible FH
R/F for ectopic pregnancy
- infertility (x2)
- tubal pathology (x3)
- documented salpingitis (x4)
- prev TL ( 1/3)
- pregnancy w IUCD (1/2)
- prev ectopic( 1 prev - >10%, 2 prev >25%)
MTX MOA & mx plan
MOA : Folic acid antagonist –> inhibits RNA & DNA synthesis by deactivating dihydrofolate reductase
Dose : 1mg/kg
HCG D0, D4 & D7
Monitor LFTs (hepatotoxic)
If decrease <15%, rpt MTX dose
USS appearance molar pregnancy
Complete: snowstorm appearance, no embryo, bilateral thecal cystrs
Partial: embryo, cystic spaces in placenta
Pre-op management molar pregnancy
Ix: FBC, LFTs, U&E, CXR
F/U post molar pregnancy
Evacuation (12mm catheter) + anti-D if required
Monitor serum hcg weekly until normalised x 3/52
Normalisation <8/52 —> monitor for 6/12post ERPC
Normalisation > 8/52 –> monitor for 6/12 post normalisation
Complete vs partial molar pregnancy
Complete: diploid empty ovum ( 2x sperm); uniparental disomy
Partial: triploid (1x ovum, 2x sperm)
Treatment - choriocarcinoma - indications
- plateau or increasing bhcg
- heavy PVB
- mets
- chorio on histo
- bhcg >/= 20000
- increase bhcg at 6/12 post ERPC
Investigations of patients with GTN
Pelvic USS
CXR and CT A-P
–> normal –> no further radiological ix
—> metastases –> CT chest, MRI brain
Symptoms of invasive choriocarcinoma & Mx
Sx: dyspnoea, haemoptysis, seizures
Ix: TFTs, hcg, U&E, LFT, FBC, CXR, CT TAP w MRI brain if lesions >2mm, USS abdo pelvis
If suspicious, run bhcg
ERPC –> histo diagnosis
Refer to GTD centre
Chemo required: complete - 15%, partial 0.5-1%
No anti-D required if complete (no fetal cells)
Features of hyperemesis
Weight loss
Ketonuria
Electrolyte imbalance/ dehydration
Vitamin and mineral deficiency
thyroid/ renal/ hepatic impairment
Main vitamin deficiency in HG and rx
Thiamine deficiency (vitamin B1) –> Wernicke’s encephalopathy –> irreversible neuro impairment
Rx w IV pabrinex (contains thiamine hydrochloride, riboflavin, pyridoxine
hydrochloride and nicotinamide (B vitamins); ascorbic acid (vitamin C); and glucose)
HG presents as a complication of which conditions
- UTI
- multiple pregnancy
- GI conditions
- Neuro conditions
- Molar preg
- endocrine - addisons, hypercalcaemia, uraemia, TFT
- Psych conditions
Assessment tool for HG
PUQE score:
- /15
- 3 Q’s: how often nauseated, how many times vomited, how many times dry wretched
Aims to guide clinical decision making
Definition and management of severe HG
PUQE >/= 13
Ketonuria
Clinically dehydrated
Mx:
Admit
Cariban
Promethazine / prochlorperazine (po/ IM/ buccal) / cyclizine
IV fluids
Pabrinex
COnsider potassium replacement
No improvement: consider mteoclopramide
No improvement: consider ondansetron or hydrocortisone
Section 12 TOP act
<12/40 for maternal choice (from LMP)
Primary: <9+6, 48 hour cool off period
- mife + miso, low sensitivity PT 2/52 later
- last day to be given D69
If unsure of dates –> USS
>9/40 - hospital mTOP, 2 consultant sign off
Hospital - if failed MTOP, unsure of dates, R/O ectopic
12/40 = 63mm
Section 11 TOP act
Fatal fetal anomalies
2-3% pregnancies have congenital anomalies
— 15% fatal/ life-limiting
Fetal med referral
Feticide can be performed no ensure no signs of life at delivery
Indications include: B/L renal agenesis, severe skeletal dysplasia, anencephaly, T13, T18, hydrancephaly
Section 9 & 10 TOP act
Pertain to risk of life/ health of pregnant woman
- 2 consultants to assess pt
- women w mental health diagnoses/ medical diagnoses should have priority access
RCOG TOP guidelines
Cannot be reversed: <3% ongoing pregnancies, r/o congenital malformation 4.2%
No need for USS if approp tissue passed
If little/ no bleeding - r/o ectopic
Haemodynamic instability - ERPC
Offer LARC
TOP treatment algorithm - first trimester mTOP
Mife in clinic and admitted >24 hours to ward to commence med mx
- 800mcg buccal miso stat, then 400mcg 3 hourly x 4 doses
Pregnancy tissue passed –> visually inspect –> complete + no concern re GTD –> discharge
No pregnancy tissue passed –> obstetrics review : ensure stable vitals, confirm correct administration of meds, US if uncertainty re all pregnancy tissue passed
–> repeat medical regimen (400mcg buccal miso 3 hourly x 5doses)
- OR sTOP
if no pregnancy tissue passed after second round medical management –> sTOP
Complications TOP
Medication side effects: N&V, heavy bleeding, abdo pain
Treatment failure - repeat mTOP/ sTOP
Infection - rx w broad spectrum Abx
sTOP complications: bleeding, perforation, cervical laceration
Management algorithm: acute haemorrhage following TOP
HISTORY
- LMP
- when were mife/ miso taken
- duration of bleeding/ how much blood loss
- ? passage of pregnancy tissue
- ? discharge/ abdo pain
- ? previous uterine surgery
- PMHx
EXAM
- vitals/ abdo/ bimanual/ sse
UNSTABLE PT
- call for help - senior obstetrician/ anaesthetics
- ABCs
- 2x 14G IVC, FBC, LFT, U&E, CRP, coag, GXM, VBG
- IV fluids, high flow O2, UC, blood products
- T/F to theatre
Management ongoing/ incomplete termination (rx algorithm) in acute haemorrhage
- FBC, U&E, LFT, CRP, GXM
- Consider theatre - ERPC (T1), MROP (T2)
- consider abx
- bimanual compression
- consider uterotonics: IM/ IV oxytocin/ IM syntometrine/ IM carboprost
- consider IV TXA/ fibrinogen/ clotting factors
Management infection in acute haemorrhage post TOP
FBC, U&E, LFT, CRP, GXM
HVS, MSU, +- blood cultures
IV broad spectrum antibiotics
Consider ultrasound to r/o RPOC
Management uterine rupture in acute haemorrhage post TOP
FBC, U&E, LFT, CRP, GXM
Emergency laparotomy
Abx/ blood products
Algorithm for investigations recurrent miscarriage
Detailed hx from woman + partner
After 2 consecutive losses:
- TFTs, thyroid antibodies (thyroid peroxidase, thyroglobulin), FBC, ANA, thrombophilia (APL- lupus anticoagulant, anticardiolipin ab, B2 glycoprotein 1), consider HBA1c, TVUS
If <35yo and 2 consecutive losses - perform cytogenetics. If no tissue for cytogenetics, perform parental karyotypes
If >35yo and 3 consecutive losses, cytogenetics. Karyotype if no tissue available for cytogenetics
Modifiable risk factors for recurrent miscarriage
Smoking
BMI
Drugs
Alcohol
Diet (caffeine <200mg/d)
FA
Vit D
Treatment for unexplained recurrent miscarriage
Progesterone PV 400mcg bd
Aspirin 75mg if at risk for placental insufficiency
Address modifiable risk factors
Treatment for recurrent miscarriage by cause
Anatomy - reconstruction not recommended
Thombophilia (hereditary) - aspirin 75mg preconception and LMWH once PT +ve
Endocrine - rx hypothyroidism w eltroxin; progesterone 400mcg PV; hyperprolactinaemia - bromocriptine
Genetics - gamete donor, PIGT
