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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
Q

Genotype for complete mole

A

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)

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26
Q

Presentation of GTD

A

Irregular vaginal bleeding
Lower abdominal pain
Hyperemesis gravidarum
Large for dates uterus
Hypertension

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27
Q

What conditions can GTD cause?

A

Hyperemesis gravidarum and hyperthryoidism

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28
Q

Why can GTD cause hyperthyroidism?

A

bHCG mimics TSH subunit stimulating release

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29
Q

Why can GTD cause hyperemesis gravidarum?

A

lots of circulating levels of bHCG

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30
Q

Investigations for GTD

A

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

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31
Q

What is the serum HCG likely to be in GTD?

A

likely to be very high for the gestational age

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32
Q

What will be seen on TVUSS of GTD?

A

Classically associated with the snowstorm or cluster of grapes appearance

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33
Q

1st like management of GTD

A

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

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34
Q

Who should GTD pateints be referred to following suction curretage?

A

Refer patients to a trophoblastic screening centre for follow-up
Usually involves monitoring serum hCG

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35
Q

What can GTD lead to?

A

Gestational Trophoblastic Neoplasia
Malignant form of gestational trophoblastic disease
Usually requires chemotherapy (e.g. methotrexate)

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36
Q

What is gestational trophoblastic neoplasia? What does it usually require?

A

Malignant form of gestational trophoblastic disease
Usually requires chemotherapy (e.g. methotrexate)

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37
Q

Definition of miscarriage

A

Spontaneous ending of a pregnancy before 24 weeks’ gestation.

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38
Q

Types of miscarraige

A

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
Q

PACES: How many pregnancies do miscarriages affect?

A

Miscarriages are very common and are thought to affect roughly 20% of pregnancies

40
Q

How can miscarriages be categorised?

A

Whether the cervical os is open or closed

Open: (THINK: 2 I’s)
Inevitable
Incomplete

Closed:
Threatened
Complete
Missed

41
Q

Causes and features of miscarriages with an open cervical os

A

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
Q

Causes and features of a miscarriage with a closed cervical os

A

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
Q

Features of a threatened miscarriage

A

Intrauterine pregnancy
Closed cervical os
Foetal heartbeat present
May resolve and the pregnancy continues without complication

44
Q

What type of miscarriage still has a foetal heartbeat present?

A

Threatened

45
Q

Features of inevitable miscarriage

A

Intrauterine pregnancy
Open cervical os
No foetal heartbeat

46
Q

Features of incomplete miscarriage

A

Retained products of conception
Open cervical os
May require procedure to evacuate the uterus

47
Q

Difference between inevitable and incomplete miscarriage

A

Incomplete miscarriage has retained products of cocneption –> may require a procedure to evacuate the uterus

Inevitable has an intrauterine pregnancy

48
Q

Features of a complete miscarriage

A

Empty uterus
Closed cervical os

49
Q

Features of missed miscarraige

A

Intrauterine pregnancy
Closed cervical os
No foetal heartbeat
Often asymptomatic

50
Q

Difference between threatened, complete, missed miscarriage (all closed cervical os)

A

Threatened - foetal heartbeat present
Complete - empty uterus
Missed - intrauterine pregnancy

51
Q

Which miscarriage is often ASx?

A

Missed

52
Q

Causes of miscarraige

A

Most cases have no clear cause
Cervical insufficiency
Antiphospholipid syndrome
Endocrine disorders (e.g. PCOS)
Uterine structural abnormality (e.g. fibroids)
Chromosomal abnormalities

53
Q

Most common cause of miscarriage in 1st trimester

A

Chromosomal abnormalities (50%)

54
Q

Most common cause of miscarriage in 2nd trimester

A

AI disorders including SLE and antiphospholipid syndrome

55
Q

antibodies for antiphospholipid syndrome

A

anti cardiolipin, anti-beta2 glycoprotein, lupus anticoagulant

56
Q

Presentation of miscarraige

A

Abdominal pain
Vaginal bleeding

57
Q

Investigations for miscarriage

A

Bedside
Urine Pregnancy Test
Speculum Examination

Bloods
Serum hCG
FBC (to check haemoglobin)

G&S
Imaging & Other
Transvaginal Ultrasound Scan

58
Q

Management of threated miscarriage

A

Continue with routine antenatal care if the bleeding stops

59
Q

Expectant managemnt of miscarriage

A

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
Q

1st line management in women with confirmed miscarriage

A

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
Q

Medical management of miscarriage

A

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
Q

When to contact a medical progressional in medical management of miscarriage?

A

Offer vaginal misoprostol
If bleeding has not started within 24 hours of treatment, contact a healthcare professional

63
Q

Surgical management of miscarriage

A

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
Q

Definition of pregnancy of unknown origin

A

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
Q

Causes of pregnancy of unknown origin

A

early intrauterine pregnancy, ectopic pregnancy or miscarriage.

66
Q

Investigations for pregnancy of unknown origin

A

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
Q

What would you expect hCG to do in an intrauterine pregnancy?

A

you would expect hCG to double every 48 hours in an intrauterine pregnancy

68
Q

HCG interpretation for pregnacny of unknown lcoaiton

A

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
Q

What does a rise of >63% in serum HCG in 48 hours suggest?

A

Rise of > 63% = Intrauterine Pregnancy
Repeat ultrasound scan in 1-2 weeks to confirm the pregnancy

70
Q

What does a rise of <63% in serum HCG in 48 hours suggest?

A

Rise of < 63% = Ectopic Pregnancy
Monitor and review regularly

71
Q

What does a rise of <50% in serum HCG in 48 hours suggest?

A

Fall of > 50% = Miscarriage
Perform urine pregnancy test in 2 weeks

72
Q

What is recurrent miscarriage defined as?

A

three consecutive miscarriages.

73
Q

How many miscarriages are needed consecutively to be defined as recurrent?

A

3 consecutive miscarriages

74
Q

Causes of recurrent miscarriage

A

Clotting Disorders (e.g. antiphospholipid syndrome)
Thyroid Disorders
Uterine Structural Abnormalities (e.g. large fibroids)
Chromosomal Abnormalities
Cervical Incompetence
Age

75
Q

Investigations for recurrent miscarriage

A

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
Q

Antiphospholioid syndrome screen consists of…

A

Checks for lupus anticoagulant and anti-cardiolipin antibodies
2 positive results at least 12 weeks apart is considered diagnostic

77
Q

Management of antiphospholipid syndrome

A

Low-dose aspirin and LMWH in future pregnancy
Reduces the risk of miscarriage

78
Q

What could be considered for patients with cervical incompetence?

A

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
Q

What can be offered to patients with recurrent first trimester miscarriage?

A

Progesterone Pessary

80
Q

What agents are used for medical termination of pregnancy?

A

Mifepristone (oral) followed 24-48 hours later by Misoprostol (vaginal, buccal or sublingual)

81
Q

When can medical termination of pregnacny be considered?

A

Can be considered at any gestation

82
Q

PACES: What advice to give if offering medical TOP?

A

The onset of contractions can be painful (recommend using simple analgesia for symptomatic relief)

83
Q

What does the follow up of medical OTP depend on?

A

Gestation

<9 weeks at home
>9 weeks in a clinical setting

84
Q

Follow up for medical TOP in less than 9 weeks gestation

A

Medications can be administered at home
Bleeding may continue for 2 weeks after abortion
Recommend urine pregnancy test 2-3 weeks later

85
Q

Follow up for medical TOP in more than 9 weeks gestation

A

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
Q

What should be offered after 21+6 weeks gestation in ALL medical TOP

A

a feticide (intracardiac potassium chloride injection) should be administered to eliminate the possibility of the foetus showing any signs of life

87
Q

Example of a feticide and when it should be offerde

A

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
Q

Types of surgical TOP

A

Vaccum aspiration (<14 weeks)
Dilation and evacuation (>14 weeks)

89
Q

What is vacuum aspiration and when should it be sued?

A

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
Q

What is dilation and evacuation and when should it be used?

A

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
Q

Risks of surgical TOP

A

Haemorrhage
Infection
Antibiotic prophylaxis may be give
Perforation

92
Q

When to offer Rhesus prophylaxis in TOP?

A

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
Q

Should rhesus prophylaxis be offered in medical TOP?

A

Yes if woman is rhesus D negative and >10 weeks gestation

94
Q
A

Gynae (8 decks)

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