Early pregnancy

Question 1

Miscarriage:

• Definition
• Risk factors
• Causes
• Symptoms + signs
• Investigations
• Management
• Complications
• Types

Answer 1

Miscarriage:

• Definition: loss fetus <24 weeks
• Risk factors: previous, uterine abnormalities such as fibroids, smoking, mat age >30, obesity, antiphospholipid syndrome, coagulopathies
• Causes: chromosome abnormal, incompetent cervix (large cervical cone biopsy), uterine structure abnormalities, infection, alc + drugs
• Symptoms + signs: bleeding, pain
• Investigations: preg test, transvag uss, serial beta hcg falls >50% 48 hours
• Management:
  1. expectant for 7-14 days (although not if infection, previous trauma, inc risk haemorrhage (late t1, coagulopathies)
  2. medical: if incomplete just misoprostolol. If missed then mifepristone then misoprostolol 48 hours after. Also antiemetics + analgesia
  3. manual vacuum or evacuation in theatre
  Preg test after 3 weeks
• Complications: retained products, asherman, anxiety
• Types
  1. threatened: bleeding but fetus alive, os closed
  2. missed: empty (anembryonic) or dead fetus in sac, closed os
  3. inevitable: heavy bleeding, os open
  4. incomplete: retained products, os open
  5. complete: no retained products, os closed

Question 2

Recurrent miscarriages:

• Definition
• Causes
• Investigations
• Management

Answer 2

Recurrent miscarriages:

• Definition: >3 conseq with same partner
• Causes : antiphospholipid syndrome, endocrine (diab, thyroid, pcos), uterine abnormal, parent chromo abnormal, smoking, structural, thrombophilia
• Investigations
• Management

Question 3

Ectopic pregnancy:

• Definition
• Risk factors
• Complications
• Symptoms and signs
• Investigations
• Management
• Salpingectomy vs salpingotomy

Answer 3

Ectopic pregnancy:

• Definition: non uterine pregnancy, most common in ampulla but most dangerous in isthmus
• Risk factors : previous, iud/ius, pid, fibroids, ivf, endometriosis
• Complications: haemorrhage
• Symptoms and signs: rif/lif radiating to shoulder week 5, amenorrhoea, n+v, bleeding/prune juice, dizzy/syncope
• Investigations: preg test +, urine dip, beta serum hcg, fbc/crp/coag, transvag uss, DO NOT DO BIMANUAL BC INC RISK RUPTURE
• Management: table on passmed
  1. expectant where hcg monitoring over 48 hours: if hcg <1000
  2. medical with methotrexate (terat for 3 months post)
  3. surgical Salpingectomy (if no risk factors for infertility) vs salpingotomy

Question 4

Pregnancy of unknown location:

• Causes (3)
• BHCG levels

Answer 4

• causes: miscarriage, ectopic, intrauterine
• if >63% inc every 48 hours then intrauterine. If slightly less maybe ectopic. If fall >50% miscarriage

Question 5

Molar pregnancy:

• Definition + types
• Risk factors
• Symptoms and signs
• Investigations
• Management

Answer 5

Molar pregnancy:

• Definition + types : complete (2 sperm, empty ovum - choriocarcinoma risk), partial (2 sperm, 1 ovum)
• Risk factors: previous, miscarriages, age >40
• Symptoms and signs: severe n+v, bleeding, enlarged uterus (shouldnt be able to palpate if <12 weeks), v high thyrotoxicosis (hcg mimics tsh)
• Investigations: hbcg, pelvic uss shows snowstorm - high hcg, low tsh, high t4
• Management: evac + histology, monitor hcg, anti d proph

Question 6

Hyperemesis gravidarum:

• Definition
• Risk factors
• Assessment - hx, ex, ix
• DD
• Management
• Complications

Answer 6

Hyperemesis gravidarum:

• Definition: up to 20 weeks (but most common 8-12) severe sickness associated with dehydration, electrolyte imbalance (hypochlor met alk) and >5% weight loss
• Risk factors: multiple preg, fx, previous, first preg, molar, obese
• Assessment - hx, ex, ix
  ex: abdo ex, fluid, weight, fetal (ctg if >23 weeks)
• DD: gastroent, dka, cholecystitis, appendicitis
• ix: PUQE preg unique quantification of emesis calcs severity
• Management: promethazine/cyclizine, nacl + kcl (not dextrose bc inc bodys needs for thiamine), thiamine, vte prophylaxis
  Cons: avoid triggers, bland foods, ginger p6 wrist acupuncture
• Complications : wernickes encephalopathy, mallory weis, preterm, aki

Question 7

Abortion:

• Definition + acts
• Types: medical, surgical
• Complications
• Retained products of conception: management

Answer 7

Abortion:

• Definition + acts: before 24 weeks. based on 1967 abortion act - needs 2 practitioners to sign the document (if emergency 1)
• Types: medical, surgical:
  medical: oral mifepristone then vaginal misoprostolol 48 hours after, if >10 weeks antid
  surgical: cervical dilatation + suction t1, t2 forceps evacuation, can inset ius/iud immediately after
  Preg test multi level 2 weeks after
• Complications: infection, uterine perforation, cervical trauma, failure, haemorrhage
• Retained products of conception: management

Question 8

Infertility:

• Definition
• Causes: male problems, female causes
• Investigations - ex, primary care
• Normal semen analysis
• Management

Answer 8

Infertility:

• Definition : >12 months
• Causes: male problems, female causes
  male: coital, obstructive (prostatitis), non obstructive (genetics, hyperprolactin), sperm
  fem: ovulation (pcos, tumours, ovarian failure), tubal (pid, endomet, surgery), uterine (endometriosis, ashermans)
• Investigations - ex, primary care
  lh/fsh day 2-5, test/oest, prog day 21 (or 7 days before period), sti screen, sperm sample, uss pelvis, hysterosalpingogram
• Normal semen analysis
• Management : ovarian hyperstim syndrome, multiple preg, ectopic
  constipation: every 2-3 days, folic acid, bmi 20-25, smoking/drink stop
  intrauterine insertion, ivf, surrogacy

Question 9

Ovarian hyperstimulation syndrome OHSS:
- Mx for ovulation induction
- definition
- symptoms
- mx

Answer 9

Ovarian hyperstimulation syndrome OHSS:
- Mx for ovulation induction: exercise, weight loss, letrozole if pcos (aromatase inhibitor reduces neg fb of oest hence inc fsh hence follicle development but dizzy/fatigue). Or clomiphene citrate which is SERM (blocks oest neg fb therefore inc gnrh but hot flushes, abdo pain, n+v). Or gonadotropin therapy where giving gnrh (inc OHSS risk)

• definition: ovarian enlargement + cysts inc perm of caps leading to fluid from intravasc -> extravasc leading to hypovol shock, renal failure, vte
• symptoms: n+v, abdo pain, bloating, diarrhoea, sob, fever, oligouria, peripheral oedema, hyponat
• mx: fluids + electrolyte replacement, anticoag, abdominal ascitic paracentesis

Question 10

Bleeding in t1 causes
- red flags

Answer 10

ectopic
miscarriage
implantation bleeding
cervical ectropion
trauma
vaginitis
polyps
- red: pain, tender
- mx: if >6 weeks then EPAU for transvag uss. If <6 weeks + no pain then return if doesnt stop and repeat preg test in 7-10 days and return if +

Question 11

Mifepristone
Misoprostol

Answer 11

mifepristone: oral, progesterone rec antag so weakens attachment to endometrial wall + cervical softening + dilatation + induces uterine contractions
misoprostol: vaginal or oral, prostaglandin analogue binds myometrial cells causing contractions causing expulsion products