Early Pregnancy Flashcards
Antibodies tested for anti phospholipid syndrome?
- Anticardiolipin
- Beta-2 glycoprotein
- Lupus anticoagulant
It is recommended the woman should have 2 positive tests 12 weeks apart.
Investigations following third first trimester miscarriage:
- Pelvic US
- Antiphospholipid antibodies (anticardiolipin, lupus anticoagulant, beta-2 glycoprotein)
- Screen for inherited thrombophilias including factor V Leiden, factor II (prothrombin) gene mutation and Protein S
** Lupus anticoagulant has the strongest association with recurrent miscarriage !
Rate of antiphospholipid antibodies in recurrent miscarriage?
15%
In women with low risk obstetric histories, antiphospholipid antibodies are present in <2%.
Incidence of recurrent miscarriage?
1 - 3%
Incidence of Ectopic Pregnancy?
11.1/1000
(Account for 7.5% of all maternal deaths)
Location of ectopic Pregnancy + incidence:
1. Tubal
2. Cornual
3. Ovarian
4. Intra abdominal
- Tubal - 97.6%
- Ampulla 55%
- Fimbral end 17%
- Isthmus 25% - Cornual - 2%
- Ovarian - 0.5%
- Intra abdominal - 0.1%
Ectopic Pregnancy - to whom do you offer Expectant management?
- Clinically stable and pain free
- Tubal ectopic measuring < 35mm with no visible heart beat on TV scan
- Serum HCG < 1000 (consider 1000-1500)
- Are able to return to follow up
Ectopic Pregnancy - medical management ?
- Pain free
- Tubal ectopic < 35mm on TVUS without heart beat
- HCG 1500-5000
- No IUP
- Able to attend follow up
Need for further treatment following salpingotomy for ectopic pregnancy?
1/5
(This may include surgery/methotrexate)
Ipsilateral tubal patency rates following treatment for ectopic pregnancy?
80%
Among women trying to become Pregnant:
1. IUP rate 54%
2. Recurrent ectopic pregnancy rates 8-10%
What % of women experience tubal rupture during follow up for medical management of ectopic pregnancy?
7%
About 75% will experience pain during treatment.
Incidence of cervical ectopic pregnancy?
Ultrasound diagnosis?
- 1/8600-12,400 pregnancies
- US diagnosis:
- Empty endometrial cavity
- Barrel shaped cervix
- GS implanted below the level of the uterine arteries (below int Os)
- Absence of ‘sliding sign’ (when pressure is applied to the cervix using the probe in a miscarriage, the GS slides against the endo cervical canal)
Caesarean section scar ectopic:
- Incidence
- Incidence in women with prev CS diagnosed w ectopic
- 1/1800-2200
- 6.1%
About 19% of women have a defect in the anterior myometrium at the level
of the previous caesarean scar
Caesarean scar ectopic recurrence rate?
3.2 - 5%
Heterotopic Pregnancy:
1. Incidence
2. Incidence after ART
- 1/ 8,000 - 30,000
- Incidence as high as 1% after ART
Risks of SMM?
Frequent:
1. Bleeding (heavy bleeding necessitating transfusion 0-3/1000)
2. Infection 4%
3. RPOC 4%
4. Intrauterine adhesions 19%
Serious:
1. Uterine perforation 1/1000
2. Cervical trauma <1/1000
Describe Complete Molar Pregnancy
- 46XX
- Diploid and androgenic
- 75-80% arise from fertilisation of anucleate ovum by one sperm which duplicates is genetic material.
- 20-25% arise from di-spermic fertilisation of an anucleate ovum
Describe a partial molar pregnancy.
- 90% are triploid
- Fertilisation of haploid oocyte by 2 sperm
- 10% are tetraploid or mosaics and there is usually evidence of fetal parts or fetal red blood cells.
Gestational Trophoblastic Disease (GTD).
Risk factors
Extremes of age (<15 or >50)
Previous molar
Recurrence risk of molar pregnancy?
1. After 1
2. After 2
- After 1 - 1/80
- After 2 - 1/6.5
If recurrence occurs, 60-80% will be the same histological subtype
Proportion of couples presenting with recurrent miscarriage who have a chromosomal anomaly?
3-5%
Incidence of GTD in the UK is?
1.0 - 1.5 per 1000 live births
Incidence of choriocarcinoma in the UK is?
1 in 50,000 live births
Incidence of ectopic pregnancy in the UK?
9-12/1000
TV scan signs indicating a tubal ectopic pregnancy ?
- Adnexal mass moving separate to the ovary, comprising a GS containing a YS
- An adnexal mass, moving separately to the ovary, comprising a GS or fetal pole
High probability:
1. Adnexal mass moving separate to the ovary with an empty GS (tubal ring or bagel sign)
2. A complex, inhomogenous mass, moving separate to the ovary
Follow up following diagnosis of GTD
1 Complete molar pregnancy
a)if HCG normal within 56 days of the pregnancy event then follow up 6 months from the date of uterine evacuation.
b)If HCG has not reverted to normal within 56 days of the pregnancy even then follow up will be 56 days from normalisation if HCG level
- Partial Mole
a) follow up has concluded once the HCG has returned to normal on 2 separate samples 4 weeks apart
The proportion of women who need chemotherapy following:
- Complete Molar Pregnancy
- Partial molar pregnancy
- Complete Mole - 13-16%
- Partial Mole - 0.5 - 1%
HCG required to see pregnancy location on:
1. TVUS
2. TAUS
- TVUS - 1500-1800 (up to 2300 with multiples)
- TAUS - 6000-6500
HCG monitoring for women undergoing expectant management of Ectopic Pregnancy?
Rpt HCG on day 2, 4 and 7 after the original test and:
- If HCG drops by 15% or more from the previous values on days 2, 4 and 7 then rpt weekly until a negative result (<20 IU/L)
OR
- If HCG does not fall by 15%, stays the same or rises from the previous value, review the clinical condition
Risk of needing further treatment if Salpingotomy performed for Ectopic Pregnancy?
1/5 - methotrexate or salpingectomy
Anti D dose for women who have had surgical mgmt for Ectopic ?
250 IU
Do not offer if they have received only medical mgmt, threatened m/c, complete m/c, or PUL
Do NOT use Kleihaur test to quantify FMH.
Ipsilateral tubal patency rates following medical mgmt for ectopic?
Approx 80%
What % of women will experience tubal rupture during following medical mgmt for Ectopic Pregnancy?
7%
IUP rate following medical mgmt for Ectopic?
54%
Recurrent ectopic 8-10% - comparable to those following lap salpingostomy
Methotrexate SE’s?
Stomatitis
Alopecia
Haematosalpinx
Neutropenia
Pneumonitis
Multiple ovarian cysts
Failed therapy
Classification of caesarean scar ectopic pregnancy:
1. Type 1 or endogenic
2. Type 2 or exogenic
- Implantation occurs on the scar and the GS grows towards the cervico-isthmic or uterine cavity
- The GS grows towards the bladder, a layer of myometrium may be seen between the GS and the bladder at an earlier stage and becomes thin and eventually disappears as the pregnancy progresses - greater risk of rupture
Caesarean section scar ectopic - risk of recurrence ?
3.2 - 5.0% in women with one previous caesarean scar ectopic
US criteria for diagnosis of caesarean scar ectopic?
- Empty uterine cavity and closed and empty cervical canal
- Placenta and / or GS embedded in the scar of a previous caesarean section
- A triangular /round or oval shaped GS that fills the niche of the scar
- Thin or absent myometrial layer between the GS and the bladder
- Yolk sac, embryo and cardiac activity may or may not be present
- Negative ‘sliding organs’ sign
Caesarean section scar ectopic treatment options?
- Expectant management not recommended
- Medical mgmt should be considered for HD stable women with minimal or no symptoms
- Methotrexate is the drug of choice for medical mgmt and works well if < 8/40 and where HCG < 5000
- Intralesional injection of methotrexate with sac aspiration has a higher success rate and should be considered as an option for stable women
- For women with endogenous caesarean scar ectopic, surgical evacuation or hysteroscopic resection carries less risk of perforation
Incidence of heterotopic pregnancy?
1/8000 - 30,000 spontaneous conceptions
Increases by up to 1% after ART following multiple embryo transfer.
Age related risk of miscarriage ?
1. 12 - 19y
2. 20 - 24y
3. 25 - 29y
4. 30 - 34y
5. 35 - 39y
6. 40 - 44y
7. > 45y
- 12 - 19y = 13%
- 20 - 24y = 11%
- 25 - 29y = 12%
- 30 - 34y = 15%
- 35 - 39y = 25%
- 40 - 44y = 51%
- > 45y = 93%
Risk of further miscarriage following:
1. One
2. Two
3. Three
4. Four
5. Five and six
- 11.3%
- 17.0%
- 28.0%
- 47.2%
- 63.9%
APLS and VTE recommendation?
Aspirin and Heparin should be offered from +ve test until 34/40 of gestation.
Progesterone supplementation in early pregnancy?
Progesterone supplementation should be considered in women with recurrent miscarriage who present with bleeding in early pregnancy
- 400mg BD at the time of bleeding until 16/40
Incidence of N+V in Pregnancy?
Incidence of HG?
90%
HG - 0.3 - 3.6% of women
HG recurrence rates?
15.2 - 89%
LFTs are abnormal in what % of women with HG?
40%
First line Rx for NVP?
- Doxylamine and Pyrdoxine (vitamin B6) 20/20mg at night (Xonvea)
- Cyclizine 50mg
- Prochlorperazine
- Promethazine
- Chlorpromazine
Second line Rx NVP?
- Metoclopramide (risk of EP side effects)
- Domperidone
- Ondansetron (risk of constipation)
Biochemical abnormalities seen in refeeding syndrome?
- Hypokalaemia
- Hypophosphatemia
- Hypomagnesaemia
- Hypernatraemia - if pt is fed protein rich diet
- Hyponatraemia - if pt is fed carb rich diet
GTN
1. Cure rate
2. Chemotherapy rate
- partial mole
- complete mole
- 98 - 100%
- Chemo for partial mole 0.5 - 1%
Chemo for complete mole 13-16%
Where does choriocarcinoma metastasise to?
Lungs - cannonball mets
Brain
Liver
When can the GS first be seen on:
1. TVUS - what does it measure?
2. TAUS
By how much does it grow per day?
- The GS can be visualised at 31 days or 4+3 from the LMP. Measures 2-3mm.
- TAUS - 5+3
Typically centrally located within the fundus. - Grows by 1mm/day at this stage and becomes elliptical in shape with diameter exceeds 10mm.
MSD at 6/40?
Range?
16mm (6 - 26mm)
TVUS landmarks:
- 5+1 - 5+5
- 5+2 - 6+0
- 6+1 - 6+6
- 7+0 - 7+6
- 9 -10
- 5+1 - 5+5: YS should be detectable in all viable pregnancies with MSD > 12mm.
- 5+2 - 6+0: the embryonic pole is detectable at 2-4mm with cardiac pulsation. Embryo detectable with MSD > 18mm.
- 6+1 - 6+6: the embryo is kidney shaped, CRL 4-10mm.
- 7+0 - 7+6: CRL 11-16mm.
- 9 - 10 weeks: CRL 23 - 32mm and the embryonic HR peaks 170-180bpm.
The yolk sac:
1. First detected
2. Maximum diameter
3. Not detectable after..?
- TVUS @ 35 days from LMP at 3-4mm
- Max diameter reached at 10 weeks (6mm)
- Compressed again the wall of the chorionic cavity by the expanding amniotic cavity and not detectable after 12/40.
The embryo:
1. First detectable
2. Rate of growth
3. CRL > ? Should demonstrate cardiac activity
- Embryo first detected 37 days from LMP by TVUS.
- Embryo grows at 1mm/day.
- In multiple pregnancies, the larger CRL should be used for assigning gestational age. - All viable embryo’s > 7mm should demonstrate cardiac activity.
How to measure an accurate CRL for dating?
- Mean of 3 discrete CRL measurements.
- True midsagittal plane - genital tubercle and fetal spine longitudinally in view
When to offer micronised progesterone in first trimester?
Offer progesterone 400mg BD to women with IUP confirmed on dating scan if they have vaginal bleeding and have previously had a miscarriage.
Management of missed miscarriage?
Single dose of 800mcg Misoprostol.
If bleeding has not started 24 hours after treatment, woman should contact her healthcare professional.
Management of incomplete miscarriage ?
Single dose of 600mcg Misoprostol (800 micrograms can be used as an alternative)
Risk of needing blood transfusion following SMM?
0 - 3/1000
Most common perforation sites during TOP?
- Anterior Wall - 40%
- Cervical Canal - 36%
- Right lateral wall - 21%
- Left lateral wall - 17%
- Posterior wall - 13%
- Fundus - 13%
Most effective route of Misoprostol used for medical management of miscarriage ?
Sublingual
When would you test for antiphospholipid antibodies to investigate recurrent miscarriage ?
6 weeks after miscarriage, then 18 weeks after miscarriage.
Anti D for complete and partial molar pregnancies?
Not required for complete molar pregnancies.
Required for partial molar pregnancies.
Incidence of GTD at extremes of age?
1. < 15
2. > 50
- < 15 years = 1/500
- > 50 years = 1/8
What scoring system is used for women with GTN?
FIGO 2000
GTN - FIGO score <6 treatment?
Women with scores of 6 or less are considered low risk.
Treated with single agent methotrexate - 67% success.
Treatment should be continued for 3 cycles (6 weeks) after HCG has normalised.
% success of single agent methotrexate treatment for GTN with FIGO 2000 <6
67%
% success of single agent Methotrexate for GTN with FIGO 2000 > 7
31%
Recommended treatment for GTN FIGO > 7
Cure rate?
Treatment with 5 Chemotherapeutic agents: Topside, Methotrexate, Actinomycin, Cyclophosphamide, Vincristine.
Continue for 6 weeks after HCG has normalised.
Cure rate 86%
What is the overall risk of significant complications from surgical evacuation of the Uterus following a miscarriage for a woman with a normal BMI?
6%
After salpingotomy for ectopic pregnancy, how many women will require further treatment ?
20%
Risk of requiring chemotherapy for GTN?
- complete mole
- partial mole
- Complete mole: 13-16%
- Partial mole: 0.5-1%
Incidence of GTN after a live birth?
1/50,000
By what proportion to IVF and IVF with OHSS increase VTE risk in early pregnancy?
- IVF - 5 fold
- IVF + OHSS - 100 fold
