Early Pregnancy Flashcards
What is an ectopic pregnancy?
Implantation of a pregnancy outside the uterus.
Most common site of ectopic pregnancy
Ampulla in the fallopian tube
RFs for ectopic pregnancy
Previous ectopic pregnancy
Pelvic inflammatory disease
Previous surgery to fallopian tube (e.g. salpingotomy)
Intrauterine device
Maternal age
Smoking
Important note regarding IUD’s and ectopic pregnancy
the overall rates of pregnancy are considerably lower in patients with an IUD in place, however, if they were to become pregnant, it is more likely to be an ectopic pregnancy
Presentation of ectopic pregnancies
Lower abdominal pain (may localise to right or left iliac fossa)
Ruptured ectopic pregnancies may demonstrate features of peritonism
Missed period
Ectopic pregnancies tend to present at around 6-8 weeks gestation
Vaginal bleeding
What may features of peritonism in a young woman suggest?
ruptured ectopic pregnancy
What may a missed period in a young woman suggest?
ectopic
When do ectopic pregnancies tend to present?
round 6-8 weeks gestation
Investigations for ectopic pregnancy
Bedside
Urine pregnancy test
Urine dipstick (rule out other differentials e.g. UTI)
Bloods
FBC, Clotting and G&S (pre-operative bloods)
Serum b-hCG
Imaging & Other
Transvaginal Ultrasound Scan
When should expectant management of ectopics be considered?
Considered if:
Haemodynamically stable
Asymptomatic (i.e. no significant pain)
Ectopic < 30 mm
No foetal heart beat
Serum hCG < 200 IU/L and declining
NOTE: Patients should have serial serum hCG measurements until the levels are undetectable
What medication is used for medical management of ectopics?
IM Methotrexate
When should medical management of ectopics be offered?
Offer IM Methotrexate as first-line treatment option provided that:
Patient is able to attend follow-up
No significant pain
Ectopic < 35 mm
No foetal heart beat
Serum hCG < 1500 IU/L
No co-existing intrauterine pregnancy
What is an essential criteria that needs to be met if offering medical management of ectopics?
Patient is able to attend follow up, if unable to return for follow up –> surgical management
Follow-Up
Take 2 serum hCG measurements on day 4 and 7 after administration of methotrexate
Then take 1 serum hCG result per week until a negative test is obtained
Avoid sex during treatment
Avoid conceiving for 3 months after having methotrexate
When should surgical management be offered in management of ectopics?
Offer surgery as first-line treatment option if:
Unable to return for follow-up
Significant pain
Ectopic > 35 mm
Foetal heart beat detected on ultrasound
Serum hCG > 5000 IU/L
What are teh surgical approaches for ectopics?
Salpingectomy (removal of affected fallopian tube)
Generally considered the better option unless there are other risk factors for infertility that would warrant consideration of fertility-sparing surgery
Follow-Up: 1 serum hCG measurement per week until negative result is obtained
Salpingotomy (excision of affected portion of fallopian tube with anastomosis of loose ends)
Considered if patient has other risk factors for infertility (e.g. previous PID) or known contralateral tube damage
WARNING: 1 in 5 women who have a salpingotomy need further treatment (with methotrexate and/or salpingectomy)
Follow-Up: urine pregnancy test at 3 weeks
When is saplingectomy considered for surgical management of ectopics? What follow up is needed?
Salpingectomy (removal of affected fallopian tube)
Generally considered the better option unless there are other risk factors for infertility that would warrant consideration of fertility-sparing surgery
Follow-Up: 1 serum hCG measurement per week until negative result is obtained
When is salpingotomy considered for surgical management of ectopic? What follow up is needed?
Salpingotomy (excision of affected portion of fallopian tube with anastomosis of loose ends)
Considered if patient has other risk factors for infertility (e.g. previous PID) or known contralateral tube damage
WARNING: 1 in 5 women who have a salpingotomy need further treatment (with methotrexate and/or salpingectomy)
Follow-Up: urine pregnancy test at 3 weeks
PACES: what warning should be given if offering a salpingotomy for surgical management of an ectopic?
WARNING: 1 in 5 women who have a salpingotomy need further treatment (with methotrexate and/or salpingectomy)
Who should receive Anti-D if they have an ectopic?
Offer to all RhD-negative women who receive surgical management of an ectopic pregnancy or miscarriage
What should be offered to all RhD negative women who receive surgical management of an ectopic or miscarriage?
Anti-D Prophylaxis
What is Gestational Trophoblastic Disease?
A spectrum of tumours and tumour-like conditions characterised by proliferation of pregnancy-associated trophoblastic tissue.
PACES: How to describe GTD?
tumour made up of pregnancy-associated tissue.
Types of GTD and their composition
Partial Mole
Formed by the fusion of two normal sperm (23X) or one sperm with a diploid genotype (46XY) and a normal egg (23X) resulting in the formation of a zygote with a 69XXY genotype
Complete Mole
Formed by the fusion of two normal sperm (23X) or one normal sperm (23X) which duplicated upon fusion with an empty egg resulting in the formation of a zygote containing only male chromosomes (46XX)
Genotype for partial mole
69XXY genotype
Formed by the fusion of two normal sperm (23X) or one sperm with a diploid genotype (46XY) and a normal egg (23X) resulting in the formation of a zygote with a 69XXY genotype
Genotype for complete mole
46XX genotype
Formed by the fusion of two normal sperm (23X) or one normal sperm (23X) which duplicated upon fusion with an empty egg resulting in the formation of a zygote containing only male chromosomes (46XX)
Presentation of GTD
Irregular vaginal bleeding
Lower abdominal pain
Hyperemesis gravidarum
Large for dates uterus
Hypertension
What conditions can GTD cause?
Hyperemesis gravidarum and hyperthryoidism
Why can GTD cause hyperthyroidism?
bHCG mimics TSH subunit stimulating release
Why can GTD cause hyperemesis gravidarum?
lots of circulating levels of bHCG
Investigations for GTD
Bedside
Urine Pregnancy Test
Measurement of Symphysis Fundal Height
Bloods
Serum hCG (likely to be very high for the gestational age)
TFTs
FBC, G&S and Clotting (pre-operative bloods)
Imaging & Other
Transvaginal Ultrasound Scan
Classically associated with the snowstorm or cluster of grapes appearance
What is the serum HCG likely to be in GTD?
likely to be very high for the gestational age
What will be seen on TVUSS of GTD?
Classically associated with the snowstorm or cluster of grapes appearance
1st like management of GTD
1st Line: Suction Curettage
Performed under general anaesthesia
Perform urine pregnancy test 3 weeks after medical management of failed pregnancy
Anti-D prophylaxis should be recommended to Rhesus-negative women undergoing surgical management of molar pregnancy
Who should GTD pateints be referred to following suction curretage?
Refer patients to a trophoblastic screening centre for follow-up
Usually involves monitoring serum hCG
What can GTD lead to?
Gestational Trophoblastic Neoplasia
Malignant form of gestational trophoblastic disease
Usually requires chemotherapy (e.g. methotrexate)
What is gestational trophoblastic neoplasia? What does it usually require?
Malignant form of gestational trophoblastic disease
Usually requires chemotherapy (e.g. methotrexate)
Definition of miscarriage
Spontaneous ending of a pregnancy before 24 weeks’ gestation.
Types of miscarraige
Threatened Miscarriage
Intrauterine pregnancy
Closed cervical os
Foetal heartbeat present
May resolve and the pregnancy continues without complication
Inevitable Miscarriage
Intrauterine pregnancy
Open cervical os
No foetal heartbeat
Incomplete Miscarriage
Retained products of conception
Open cervical os
May require procedure to evacuate the uterus
Complete Miscarriage
Empty uterus
Closed cervical os
Missed Miscarriage
Intrauterine pregnancy
Closed cervical os
No foetal heartbeat
Often asymptomatic
PACES: How many pregnancies do miscarriages affect?
Miscarriages are very common and are thought to affect roughly 20% of pregnancies
How can miscarriages be categorised?
Whether the cervical os is open or closed
Open: (THINK: 2 I’s)
Inevitable
Incomplete
Closed:
Threatened
Complete
Missed
Causes and features of miscarriages with an open cervical os
Inevitable Miscarriage
Intrauterine pregnancy
Open cervical os
No foetal heartbeat
Incomplete Miscarriage
Retained products of conception
Open cervical os
May require procedure to evacuate the uterus
Causes and features of a miscarriage with a closed cervical os
Threatened Miscarriage
Intrauterine pregnancy
Closed cervical os
Foetal heartbeat present
May resolve and the pregnancy continues without complication
Complete Miscarriage
Empty uterus
Closed cervical os
Missed Miscarriage
Intrauterine pregnancy
Closed cervical os
No foetal heartbeat
Often asymptomatic
Features of a threatened miscarriage
Intrauterine pregnancy
Closed cervical os
Foetal heartbeat present
May resolve and the pregnancy continues without complication
What type of miscarriage still has a foetal heartbeat present?
Threatened
Features of inevitable miscarriage
Intrauterine pregnancy
Open cervical os
No foetal heartbeat
Features of incomplete miscarriage
Retained products of conception
Open cervical os
May require procedure to evacuate the uterus
Difference between inevitable and incomplete miscarriage
Incomplete miscarriage has retained products of cocneption –> may require a procedure to evacuate the uterus
Inevitable has an intrauterine pregnancy
Features of a complete miscarriage
Empty uterus
Closed cervical os
Features of missed miscarraige
Intrauterine pregnancy
Closed cervical os
No foetal heartbeat
Often asymptomatic
Difference between threatened, complete, missed miscarriage (all closed cervical os)
Threatened - foetal heartbeat present
Complete - empty uterus
Missed - intrauterine pregnancy
Which miscarriage is often ASx?
Missed
Causes of miscarraige
Most cases have no clear cause
Cervical insufficiency
Antiphospholipid syndrome
Endocrine disorders (e.g. PCOS)
Uterine structural abnormality (e.g. fibroids)
Chromosomal abnormalities
Most common cause of miscarriage in 1st trimester
Chromosomal abnormalities (50%)
Most common cause of miscarriage in 2nd trimester
AI disorders including SLE and antiphospholipid syndrome
antibodies for antiphospholipid syndrome
anti cardiolipin, anti-beta2 glycoprotein, lupus anticoagulant
Presentation of miscarraige
Abdominal pain
Vaginal bleeding
Investigations for miscarriage
Bedside
Urine Pregnancy Test
Speculum Examination
Bloods
Serum hCG
FBC (to check haemoglobin)
G&S
Imaging & Other
Transvaginal Ultrasound Scan
Management of threated miscarriage
Continue with routine antenatal care if the bleeding stops
Expectant managemnt of miscarriage
A 7-14 day period of expectant management is the first-line management option in women with confirmed miscarriage
If bleeding and pain resolves within 7-14 days, advise taking pregnancy test 3 weeks later
Offer repeat scan if, after a period of expectant management, the bleeding and pain:
Has not started or has persisted/is increasing
1st line management in women with confirmed miscarriage
A 7-14 day period of expectant management is the first-line management option in women with confirmed miscarriage
NOTE: If bleeding and pain resolves within 7-14 days, advise taking pregnancy test 3 weeks later
Medical management of miscarriage
Offer vaginal misoprostol
If bleeding has not started within 24 hours of treatment, contact a healthcare professional
Offer pain relief and anti-emetics, and warn patients about vaginal bleeding, pain, diarrhoea and vomiting
Advise taking pregnancy test 3 weeks later
When to contact a medical progressional in medical management of miscarriage?
Offer vaginal misoprostol
If bleeding has not started within 24 hours of treatment, contact a healthcare professional
Surgical management of miscarriage
Manual vacuum aspiration under local anaesthetic
May also be performed under general anaesthetic in theatre
Vaginal or sublingual misoprostol are often used to ripen the cervix to facilitate cervical dilatation
Definition of pregnancy of unknown origin
When a patient has a positive pregnancy test with no evidence of pregnancy on ultrasound. This could be suggestive of an early intrauterine pregnancy, ectopic pregnancy or miscarriage.
Causes of pregnancy of unknown origin
early intrauterine pregnancy, ectopic pregnancy or miscarriage.
Investigations for pregnancy of unknown origin
Serum hCG should be measured and re-checked in 48 hours
NOTE: you would expect hCG to double every 48 hours in an intrauterine pregnancy
What would you expect hCG to do in an intrauterine pregnancy?
you would expect hCG to double every 48 hours in an intrauterine pregnancy
HCG interpretation for pregnacny of unknown lcoaiton
Rise of > 63% = Intrauterine Pregnancy
Repeat ultrasound scan in 1-2 weeks to confirm the pregnancy
Rise of < 63% = Ectopic Pregnancy
Monitor and review regularly
Fall of > 50% = Miscarriage
Perform urine pregnancy test in 2 weeks
What does a rise of >63% in serum HCG in 48 hours suggest?
Rise of > 63% = Intrauterine Pregnancy
Repeat ultrasound scan in 1-2 weeks to confirm the pregnancy
What does a rise of <63% in serum HCG in 48 hours suggest?
Rise of < 63% = Ectopic Pregnancy
Monitor and review regularly
What does a rise of <50% in serum HCG in 48 hours suggest?
Fall of > 50% = Miscarriage
Perform urine pregnancy test in 2 weeks
What is recurrent miscarriage defined as?
three consecutive miscarriages.
How many miscarriages are needed consecutively to be defined as recurrent?
3 consecutive miscarriages
Causes of recurrent miscarriage
Clotting Disorders (e.g. antiphospholipid syndrome)
Thyroid Disorders
Uterine Structural Abnormalities (e.g. large fibroids)
Chromosomal Abnormalities
Cervical Incompetence
Age
Investigations for recurrent miscarriage
Bloods
Antiphospholipid Syndrome Screen
Checks for lupus anticoagulant and anti-cardiolipin antibodies
2 positive results at least 12 weeks apart is considered diagnostic
Cytogenetic Analysis
Of peripheral blood of both partners
Of products of conception from the last miscarriage
Thrombophilia Screen
Imaging
Transvaginal Ultrasound
Check for uterine anomalies
Antiphospholioid syndrome screen consists of…
Checks for lupus anticoagulant and anti-cardiolipin antibodies
2 positive results at least 12 weeks apart is considered diagnostic
Management of antiphospholipid syndrome
Low-dose aspirin and LMWH in future pregnancy
Reduces the risk of miscarriage
What could be considered for patients with cervical incompetence?
Consider cervical cerclage for patients with cervical incompetence
Ultrasound scan offered at 18-22 weeks’ gestation to assess cervical length and determine risk of preterm birth
What can be offered to patients with recurrent first trimester miscarriage?
Progesterone Pessary
What agents are used for medical termination of pregnancy?
Mifepristone (oral) followed 24-48 hours later by Misoprostol (vaginal, buccal or sublingual)
When can medical termination of pregnacny be considered?
Can be considered at any gestation
PACES: What advice to give if offering medical TOP?
The onset of contractions can be painful (recommend using simple analgesia for symptomatic relief)
What does the follow up of medical OTP depend on?
Gestation
<9 weeks at home
>9 weeks in a clinical setting
Follow up for medical TOP in less than 9 weeks gestation
Medications can be administered at home
Bleeding may continue for 2 weeks after abortion
Recommend urine pregnancy test 2-3 weeks later
Follow up for medical TOP in more than 9 weeks gestation
Should be conducted in a clinical setting due to increased risk of bleeding and discomfort
Repeated doses of misoprostol usually needed every 3 hours until expulsion (Max Doses: 5)
What should be offered after 21+6 weeks gestation in ALL medical TOP
a feticide (intracardiac potassium chloride injection) should be administered to eliminate the possibility of the foetus showing any signs of life
Example of a feticide and when it should be offerde
Intracardiac KCL injection
IMPORTANT: After 21+6 weeks’ gestation, a feticide (intracardiac potassium chloride injection) should be administered to eliminate the possibility of the foetus showing any signs of life
Types of surgical TOP
Vaccum aspiration (<14 weeks)
Dilation and evacuation (>14 weeks)
What is vacuum aspiration and when should it be sued?
Type of surgical TOP and used in pregnancies that are less than 14 weeks’ gestation
Involves gently dilation of the cervix and using vacuum suction to evacuate the uterus
May be performed under local or general anaesthetic
The cervix may be pre-treated with misoprostol
What is dilation and evacuation and when should it be used?
Type of surgical TOP and Used in pregnancy that are over 14 weeks’ gestation
Requires cervical dilatation to allow removal of large foetal parts
Misoprostol is used to ripen the cervix and allow easier dilatation
Contents of the uterus are manually extracted (e.g. using forceps)
Risks of surgical TOP
Haemorrhage
Infection
Antibiotic prophylaxis may be give
Perforation
When to offer Rhesus prophylaxis in TOP?
Rhesus Prophylaxis (For Rhesus D Negative Women)
Offer if having termination of pregnancy after 10 weeks’ gestation
Consider if having surgical termination of pregnancy
Should rhesus prophylaxis be offered in medical TOP?
Yes if woman is rhesus D negative and >10 weeks gestation
