Early pregnancy Flashcards
ectopic pregnancy definition
when a pregnancy is implanted outside the uterus. The most common site is a fallopian tube. An ectopic pregnancy can also implant in the entrance to the fallopian tube (cornual region), ovary, cervix or abdomen.
risk fx ectopic pregnancy
Previous ectopic pregnancy
Previous pelvic inflammatory disease
Previous surgery to the fallopian tubes
Intrauterine devices (coils)
Older age
Smoking
presentation ectopic prg
6-8 weeks gestation
Missed period
Constant lower abdominal pain in the right or left iliac fossa
Vaginal bleeding
Lower abdominal or pelvic tenderness
Cervical motion tenderness (pain when moving the cervix during a bimanual examination)
dizziness
shoulder tip pain
first line ix ectopic preg
transvaginal USS-
ectopic preg what seen on imaging
gestational sac containing a yolk sac or fetal pole may be seen in a fallopian tube
or mass containing empty gestational sac - ‘blob sign’
tubal ectopic pregnancy moves separately to the ovary. The mass may look similar to a corpus luteum; however, a corpus luteum will move with the ovary
empty uterus
fluid in uterus
definition pregnancy of unknown location
when the woman has a positive pregnancy test and there is no evidence of pregnancy on the ultrasound scan. In this scenario, an ectopic pregnancy cannot be excluded
how monitor pregnancy of unknown location
serum hCG -should double every 48 hours…not in miscarriage or ectopic preg
A rise of more than 63% after 48 hours is likely to indicate an intrauterine pregnancy - any less = ectopic preg or if <50 = miscarriage
>1500 - pregnancy
mx of ectopic preg
preg test
referral to early pregnancy assessment unit or gynaecological service
termination - expectant (wait natural), medical (methotrexate), surgery (salpingectomy, salpingotomy)
criteria for expectant mx
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
criteria for methotrexate termination
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
confirmed basence of intrauterine preg on USS
advise following methotrexate mx
advised not to get pregnant for 3 months following tx
s/e - Vaginal bleeding
Nausea and vomiting
Abdominal pain
Stomatitis
pros and cons of surgical options of ectopic preg
laprascopic salpingectomy - 1st line
laparasopic salpingotomy - avoid removing affected fallopian tube if increased risk of infertility, increased risk of failure
given alongside surgical tx of ectopic preg
if rhesus neg = anti rhesus D prophylaxis
early miscarriage
<12 weeks gestation
late miscarriage
12-24 weeks gestation
missed miscarriage def
the fetus is no longer alive, but no symptoms have occurred
threatened miscarriage def
vaginal bleeding with a closed cervix and a fetus that is alive
inevitable miscarriage def
vaginal bleeding with an open cervix
incomplete miscarriage def
retained products of conception remain in the uterus after the miscarriage
complete miscarriage def
a full miscarriage has occurred, and there are no products of conception left in the uterus
anembryonic preg def
a gestational sac is present but contains no embryo
ix for miscarriage diagnosis
transvaginal USS
how assess if miscarriage
- Mean gestational sac diameter (>25mm)
- Fetal pole and crown-rump length (>7mm)
- Fetal heartbeat (visible = viable)
mx of miscarriage
<6 weeks - expectant mx and repeat preg test 7-10 days after
>6 weeks - early pregnancy assessment service for USS for expectant mx, medical mx (misoprostol), surgical mx
indications for expectant mx of miscarriage
first line for women without risk fx for heavy bleeding or infection
medical mx of miscarriage
a prostaglandin analogue, meaning it binds to prostaglandin receptors and activates them. Prostaglandins soften the cervix and stimulate uterine contractions
s/e - heavy bleeding, pain, vomit, diarrhoea
surgical tx of miscarriage
Manual vacuum aspiration under local anaesthetic as an outpatient (<10 weeks and good for women who have previously given birth)
Electric vacuum aspiration under general anaesthetic
+antirhesus d prophylaxis is rhesus -ve after
options for incomplete miscarriage
Medical management (misoprostol)
Surgical management (evacuation of retained products of conception)
complication of ERPC
endometritis (infection of the endometrium)
recurrent miscarriage definition
3 or more consecutive miscarriages
when ix recurrent miscarriages
Three or more first-trimester miscarriages
One or more second-trimester miscarriages
causes of recurrent miscarriage
Idiopathic (particularly in older women)
Antiphospholipid syndrome
Hereditary thrombophilias
Uterine abnormalities
Genetic factors in parents (e.g. balanced translocations in parental chromosomes)
Chronic histiocytic intervillositis
Other chronic diseases such as diabetes, untreated thyroid disease and systemic lupus erythematosus (SLE)
antiphospholipid syndrome definition
a disorder associated with antiphospholipid antibodies, where blood becomes prone to clotting. The patient is in a hyper-coagulable state. The main associations are with thrombosis and complications in pregnancy, particularly recurrent miscarriage.
antiphospholipid syndrome primary or secondary
both
can occur due to autoimmune such as SLE
how lower risk of miscarriage with antiphospholipid syndrome
LMWH
low dose aspirin
inherited thrombophilias causing recurrent miscarriage
Factor V Leiden (most common)
Factor II (prothrombin) gene mutation
Protein S deficiency
uterine abnormalities causing recurrent miscarriage
Uterine septum (a partition through the uterus)
Unicornuate uterus (single-horned uterus)
Bicornuate uterus (heart-shaped uterus)
Didelphic uterus (double uterus)
Cervical insufficiency
Fibroids
define chronic histiocytic intervillositis
a rare cause of recurrent miscarriage, particularly in the second trimester
CHI patho
Histiocytes and macrophages build up in the placenta, causing inflammati
CHI diagnosis
placental histology showing infiltrates of mononuclear cells in the intervillous spaces
ix for recurrent miscarriage
Antiphospholipid antibodies
Testing for hereditary thrombophilias
Pelvic ultrasound
Genetic testing of the products of conception from the third or future miscarriages
Genetic testing on parents
mx of recurrent miscarriage
depends on underlying cause
?vaginal progesterone pessaries during early pregnancy for women with recurrent miscarriages presenting with bleeding
legal number of weeks for abortion
24 weeks
abortion indications before 24 weeks
An abortion can be performed before 24 weeks if continuing the pregnancy involves greater risk to the physical or mental health of:
The woman
Existing children of the family
abortion indications any time during pregnancy
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
legal requirements for abortion to be carried out - who there and where
Two 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
<10 weeks abortion
telephone consultations and medication
medical abortion
Mifepristone (anti-progestogen)
Misoprostol (prostaglandin analogue) 1 – 2 day later
surgical abortion
Prior to surgical abortion, medications are used for cervical priming. This involves softening and dilating the cervix with misoprostol, mifepristone or osmotic dilators.
options:
Cervical dilatation and suction of the contents of the uterus (usually up to 14 weeks)
Cervical dilatation and evacuation using forceps (between 14 and 24 weeks)
post abortion care
vaginal bleeding and abdo cramps up to 2 weeks after
preg test 3 weeks after to confirm
contraception
counselling
complications of abortion
Bleeding
Pain
Infection
Failure of the abortion (pregnancy continues)
Damage to the cervix, uterus or other structures
when N+V peaks
8-12 weeks gestation
severe form of N+V
hyperemesis gravidarum
cause of N+V
hCG
worse N+V when
molar pregnancies
multiple pregnancies
first preg preg
overweight or obese
hyperemesis gravidarum diagnosis
“protracted” NVP plus:
More than 5 % weight loss compared with before pregnancy
Dehydration
Electrolyte imbalance
how N+V assessed
Pregnancy-Unique Quantification of Emesis (PUQE)
>12 = severe
<7 = mild
mx of N+V
Prochlorperazine (stemetil)
Cyclizine
Ondansetron
Metoclopramide
Ginger
Acupressure on the wrist at the PC6 point (inner wrist) may improve symptoms
reflux tx
Ranitidine or omeprazole
when N+V require admission
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
moderate-severe cases of N+V tx
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)
molar pregnancy definition
A hydatidiform mole is a type of tumour that grows like a pregnancy inside the uterus
either complete or partial
complete mole why happens
when two sperm cells fertilise an ovum that contains no genetic material (an “empty ovum”). These sperm then combine genetic material, and the cells start to divide and grow into a tumour called a complete mole. No fetal material will form.
partial mole why happens
two sperm cells fertilise a normal ovum (containing genetic material) at the same time. The new cell now has three sets of chromosomes (it is a haploid cell). The cell divides and multiplies into a tumour called a partial mole. In a partial mole, some fetal material may form.
diagnosis molar 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)
molar pregnancy presentation
diagnostic fx
but appears like normal preg = periods stop and hormonal changes will occur
Ix of molar preg
USS = snowstorm appearance
histology of mole after evacuation
mx of molar preg
evacuation of uterus
histology to confirm
referred to gestational trophoblastic disease centre for f/u
hCG level monitored
complication of molar preg
mole can metastasise…chemo
