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Gynae > Early Pregnancy > Flashcards

Early Pregnancy Flashcards

1
Q

What is an ectopic pregnancy?

A

Implantation of a pregnancy outside the uterus.

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2
Q

Most common site of ectopic pregnancy

A

Ampulla in the fallopian tube

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3
Q

RFs for ectopic pregnancy

A

Previous ectopic pregnancy
Pelvic inflammatory disease
Previous surgery to fallopian tube (e.g. salpingotomy)
Intrauterine device
Maternal age
Smoking

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4
Q

Important note regarding IUD’s and ectopic pregnancy

A

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

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5
Q

Presentation of ectopic pregnancies

A

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

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6
Q

What may features of peritonism in a young woman suggest?

A

ruptured ectopic pregnancy

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7
Q

What may a missed period in a young woman suggest?

A

ectopic

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8
Q

When do ectopic pregnancies tend to present?

A

round 6-8 weeks gestation

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9
Q

Investigations for ectopic pregnancy

A

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

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10
Q

When should expectant management of ectopics be considered?

A

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

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11
Q

What medication is used for medical management of ectopics?

A

IM Methotrexate

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12
Q

When should medical management of ectopics be offered?

A

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

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13
Q

What is an essential criteria that needs to be met if offering medical management of ectopics?

A

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

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14
Q

When should surgical management be offered in management of ectopics?

A

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

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15
Q

What are teh surgical approaches for ectopics?

A

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

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16
Q

When is saplingectomy considered for surgical management of ectopics? What follow up is needed?

A

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

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17
Q

When is salpingotomy considered for surgical management of ectopic? What follow up is needed?

A

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

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18
Q

PACES: what warning should be given if offering a salpingotomy for surgical management of an ectopic?

A

WARNING: 1 in 5 women who have a salpingotomy need further treatment (with methotrexate and/or salpingectomy)

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19
Q

Who should receive Anti-D if they have an ectopic?

A

Offer to all RhD-negative women who receive surgical management of an ectopic pregnancy or miscarriage

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20
Q

What should be offered to all RhD negative women who receive surgical management of an ectopic or miscarriage?

A

Anti-D Prophylaxis

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21
Q

What is Gestational Trophoblastic Disease?

A

A spectrum of tumours and tumour-like conditions characterised by proliferation of pregnancy-associated trophoblastic tissue.

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22
Q

PACES: How to describe GTD?

A

tumour made up of pregnancy-associated tissue.

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23
Q

Types of GTD and their composition

A

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)

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24
Q

Genotype for partial mole

A

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

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25
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)
26
Presentation of GTD
Irregular vaginal bleeding Lower abdominal pain Hyperemesis gravidarum Large for dates uterus Hypertension
27
What conditions can GTD cause?
Hyperemesis gravidarum and hyperthryoidism
28
Why can GTD cause hyperthyroidism?
bHCG mimics TSH subunit stimulating release
29
Why can GTD cause hyperemesis gravidarum?
lots of circulating levels of bHCG
30
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
31
What is the serum HCG likely to be in GTD?
likely to be very high for the gestational age
32
What will be seen on TVUSS of GTD?
Classically associated with the snowstorm or cluster of grapes appearance
33
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
34
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
35
What can GTD lead to?
Gestational Trophoblastic Neoplasia Malignant form of gestational trophoblastic disease Usually requires chemotherapy (e.g. methotrexate)
36
What is gestational trophoblastic neoplasia? What does it usually require?
Malignant form of gestational trophoblastic disease Usually requires chemotherapy (e.g. methotrexate)
37
Definition of miscarriage
Spontaneous ending of a pregnancy before 24 weeks' gestation.
38
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
39
PACES: How many pregnancies do miscarriages affect?
Miscarriages are very common and are thought to affect roughly 20% of pregnancies
40
How can miscarriages be categorised?
Whether the cervical os is open or closed Open: (THINK: 2 I's) Inevitable Incomplete Closed: Threatened Complete Missed
41
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
42
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
43
Features of a threatened miscarriage
Intrauterine pregnancy Closed cervical os Foetal heartbeat present May resolve and the pregnancy continues without complication
44
What type of miscarriage still has a foetal heartbeat present?
Threatened
45
Features of inevitable miscarriage
Intrauterine pregnancy Open cervical os No foetal heartbeat
46
Features of incomplete miscarriage
Retained products of conception Open cervical os May require procedure to evacuate the uterus
47
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
48
Features of a complete miscarriage
Empty uterus Closed cervical os
49
Features of missed miscarraige
Intrauterine pregnancy Closed cervical os No foetal heartbeat Often asymptomatic
50
Difference between threatened, complete, missed miscarriage (all closed cervical os)
Threatened - foetal heartbeat present Complete - empty uterus Missed - intrauterine pregnancy
51
Which miscarriage is often ASx?
Missed
52
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
53
Most common cause of miscarriage in 1st trimester
Chromosomal abnormalities (50%)
54
Most common cause of miscarriage in 2nd trimester
AI disorders including SLE and antiphospholipid syndrome
55
antibodies for antiphospholipid syndrome
anti cardiolipin, anti-beta2 glycoprotein, lupus anticoagulant
56
Presentation of miscarraige
Abdominal pain Vaginal bleeding
57
Investigations for miscarriage
Bedside Urine Pregnancy Test Speculum Examination Bloods Serum hCG FBC (to check haemoglobin) G&S Imaging & Other Transvaginal Ultrasound Scan
58
Management of threated miscarriage
Continue with routine antenatal care if the bleeding stops
59
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
60
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
61
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
62
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
63
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
64
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.
65
Causes of pregnancy of unknown origin
early intrauterine pregnancy, ectopic pregnancy or miscarriage.
66
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
67
What would you expect hCG to do in an intrauterine pregnancy?
you would expect hCG to double every 48 hours in an intrauterine pregnancy
68
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
69
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
70
What does a rise of <63% in serum HCG in 48 hours suggest?
Rise of < 63% = Ectopic Pregnancy Monitor and review regularly
71
What does a rise of <50% in serum HCG in 48 hours suggest?
Fall of > 50% = Miscarriage Perform urine pregnancy test in 2 weeks
72
What is recurrent miscarriage defined as?
three consecutive miscarriages.
73
How many miscarriages are needed consecutively to be defined as recurrent?
3 consecutive miscarriages
74
Causes of recurrent miscarriage
Clotting Disorders (e.g. antiphospholipid syndrome) Thyroid Disorders Uterine Structural Abnormalities (e.g. large fibroids) Chromosomal Abnormalities Cervical Incompetence Age
75
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
76
Antiphospholioid syndrome screen consists of...
Checks for lupus anticoagulant and anti-cardiolipin antibodies 2 positive results at least 12 weeks apart is considered diagnostic
77
Management of antiphospholipid syndrome
Low-dose aspirin and LMWH in future pregnancy Reduces the risk of miscarriage
78
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
79
What can be offered to patients with recurrent first trimester miscarriage?
Progesterone Pessary
80
What agents are used for medical termination of pregnancy?
Mifepristone (oral) followed 24-48 hours later by Misoprostol (vaginal, buccal or sublingual)
81
When can medical termination of pregnacny be considered?
Can be considered at any gestation
82
PACES: What advice to give if offering medical TOP?
The onset of contractions can be painful (recommend using simple analgesia for symptomatic relief)
83
What does the follow up of medical OTP depend on?
Gestation <9 weeks at home >9 weeks in a clinical setting
84
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
85
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)
86
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
87
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
88
Types of surgical TOP
Vaccum aspiration (<14 weeks) Dilation and evacuation (>14 weeks)
89
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
90
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)
91
Risks of surgical TOP
Haemorrhage Infection Antibiotic prophylaxis may be give Perforation
92
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
93
Should rhesus prophylaxis be offered in medical TOP?
Yes if woman is rhesus D negative and >10 weeks gestation
94

Gynae (8 decks)

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