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RANZCOG -Gynaecology 2024 Edward > Early pregnancy > Flashcards

Early pregnancy Flashcards

1
Q

Discuss gestational trophoblastic disease:
-Definition
-Composition
-Incidence
-Risk factors (5)

A
  1. Spectrum of tumours of placental tissue that develop from abnormal fertilisation. Premalignant condition
  2. Made entirely of fetal material including syncitiotrophoblasts and cytotrophoblasts. Produces tHCG
  3. 1:200-1000 pregnancies
  4. Risk factors
    -Extremes of age >15 yrs RR - 20, >45 RR = 10
    -Diet deficient in protein
    -Asian ethnicity
    -Women with blood group A or whose partners are blood group 0 (RR 10)
    -Previous GTD 1:70
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2
Q

How does GTD present during pregnancy (with percentages) (6)

A
  1. Vaginal bleeding (90%)
  2. Suspicious USS findings
  3. Hyperemesis (15-30%)
  4. Theca lutein cysts (15-30%) more likely to progress to GTN
  5. Hyperthyroidism (10%)
  6. PET (10%)
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3
Q

What is the presentation of GTD on USS and histo
1. Partial mole
2. Complete mole

A
  1. Partial mole
    USS - focal vesicular areas, abnormal MSD, if fetus may be IUGR or multiple abnormalities
    Histo- trophoblastic hyperplasia, hydropic villi +/- fetal tissue
  2. Complete mole
    USS - multiple large vesicular structures, enlarged cystic ovaries. No fetus. Snow storm
    Histo-No fetal material, Marked villous hyperplasia. Hydropic swollen chorionic villi
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4
Q

Describe the management of molar pregnancy

A

Baseline: FBC, G&H, LFT, TFT, Cr, CXR
1. Suction evacuation
-Can use priming miso
-Avoid uterotonics
-Anti D if Rh-ve
-Histo to lab for confirmation on dx ( karyotype, p57 staining + in partial mole)
2. Weekly HCG until 3 consecutive normal
-Partial mole - stop once 3 x normal
-Complete mole - monthly for 6 months once 3 x normal
3. Counselling to patient and GP
-1:70 repeat
-No impact on fertility
-Contraception till cleared - COC OK. Avoid IUD until HCG normal. (increased risk perforation + dissemination)
-Early USS and HCG 6 weeks PP in following pregnancies
4. Discuss at MDM and ref to National registry

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5
Q

How should ongoing PVB of GTD be managed (3)

A
  1. Needs to suspect GTN or RPOC
  2. Consider repeat evacuation if
    -Molar pregnancy was dx on histo only
    -Persistently elevated HCG
    -No evidence of mets on CXR
    -Risk score 0-4
  3. Don’t do repeat evacuation if HCG >5000
  4. If repeat evacuation do with hysteroscopy
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6
Q

Describe miscarriages
-Definition
-Incidence
-Causes (5)
-Types (5)

A
  1. Pregnancy which spontaneously ends <20 weeks and <400g
  2. Incidence
    -10-15% of clinically recognised pregnancies
    -<5% after 9 weeks gestation
    -10% at 30yrs. 50% by age 45
  3. Causes
    -Chromosomal - 50%.
    -Increases with age
    -Less common cause as gestation increases
    -Mostly Trisomies (22%) Monosomy (8%), Triploidy (8%)
    -Infection - rarely
    -Listeria, campylobacter, rubella, cocksackie, CMV.
    -BV in second trimester
    -Uterine abnormalities
    -Bicornuate, septate, arcuate, DES
    -Cx incompetence in 2nd trimester
    -Haemoatological
    -Antiphospholiid syndrome
    -Thrombophillias
    -Unexplained 25%
  4. Types
    -Threatened - PVB before 20/40
    -Inevitable - PVB open Cx no passage of products
    -Incomplete - Passage of some products
    -Complete - products passed
    -Septic - infected POC
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7
Q

Describe expectant management for miscarriage
-When to offer
-Advantages
-Disadvantages
-Success rates

A

-Offer if <6 weeks as first line
-Offer alternative if has condition where excessive PVB is an issue, Sx of infection, previous Obstetric related trauma
-Can wait up to 2 weeks
-FU at 14/7 if woman wants to continue expectant management
-Do PT in 3/52 to check miscarried
Advantage: non-invasive, avoid anaesthetic
Disadvantage: unpredictable, can take days to weeks, prolonged PVB and pain. Highest risk of unscheduled PVB
Success: By D7 25-50% By D14 50-80%. Most successful if incomplete 75-96%
Repeat UPT in 3 weeks if still Positive for review

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8
Q

Describe medical management for miscarriage
-Regimens
-Advantages
-Disadvantages
-Success rates

A
  1. Regimens
    If <13 weeks
    -Don’t give mife (Recent Meta analysis suggests Mife + miso better cf miso RR1.5)
    -PO or PV miso is acceptable. Base on woman’s preference
    -Missed miscarriage 800mcg miso can give second dose
    -Incomplete miscarriage 600mcg PO
    If >13 weeks
    -Missed miscarriage - 200mcg PV/SL every 4-6 hrs
    -Incomplete miscarriage - 200mcg PV/SL every 6 hrs
  2. Advantages: Non invasive, avoids anaesthetic
  3. Disadvantage: Heavier longer PVB, May still need surgery -16%
    Meta analysis suggests do difference between medical and surgical management
  4. Success:
    Overall 84%, Incomplete 93%
    Mife + miso most effective form of managing miscarriage - but inconsistent data. More research needed
  5. UPT in 3/52
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9
Q

Describe surgical management for miscarriage
-When to offer
-Advantages
-Disadvantages
-Success rates
-Risks (7)

A
  1. First line if haemodynamically unstable, sepsis, Heavy PVB or suspicious for GTD
  2. Advantages: Predictable time frame, faster resolution, shorter bleeding
    Less analgesia requirement cf Miso RR 0.43 (Meta ana)
    3: Disadvantages: Anaesthetic required, perforation, Ashermanns, uterine adhesions.
  3. Success - 95-97%
  4. Risks:
    -Overall significant risk 6%
    -Bleeding - Tx 3:1000
    -Infection 40:1000
    -Uterine adhesions 19:1000 - mostly mild. Worse with more procedures.
    -Repeat surgery 3-18:1000
    -Perforation: 1:1000
    -Cx trauma : <1:1000
    -PTB RR 1.29
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10
Q

When should anti-D be prescribed post miscarriage
-When
-Dose
-Timing

A

When:
-Threatened miscarriage >12 weeks
-Spontaneous miscarriage >10 weeks
-Surgical management <10 weeks
-No clear evidence for spont miscarriage <10 weeks
Dose:
-Singleton up to 12 weeks - 250IU
-Multiple or >12 weeks 625 IU
Timing:
-By 72hrs
-Can have benefit up to 10 days

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11
Q

What is the risk of further miscarriages

A

After 1 miscarriage - 20% risk of repeat
After 2 miscarriages - 30% risk of repeat
After 3 or more miscarriages - 40-50% risk of repeat

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12
Q

Discuss the PRISM trial
-Type
-Aim
-Inclusion
-Intervention
-Primary outcome
-Results

A
  1. RCT multicentre and double blinded
  2. To determine if progesterone in women with threatened miscarriage improves live birth rates
  3. Women <12 weeks with PVB and known IUP
  4. 400mg BD PV progesterone vs placebo till 16/40
  5. Live birth >34 weeks
  6. Results
    -Number included 4150 (~2080 each arm)
    -No previous miscarriage - RR 0.99
    -1-2 previous miscarriage - RR 1.05 ( CI 1.0-1.12)
    -3 or more miscarriages - RR 1.28 ( CI 1.08 - 1.51)
    -Any previous miscarriages RR 1.09 (CI 1.03 - 1.15)
    -NNT 29 for 1 live birth
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13
Q

Discuss the MIST trial
-Type
-Aim
-Inclusion
-Primary outcome
-Results

A
  1. RCT
  2. To compare expectant, medical and surgical management of first trimester miscarriage in terms of gynaecological infection
  3. Women with dx missed or incomplete miscarriage <13 weeks
  4. Outcomes
    -Primary outcome - Gynae infection at 2 weeks and 8 weeks
    -Secondary outcome - Unplanned admission to hospital, unplanned surgical evacuation
  5. Results:
    -No difference with infection rates
    -Significantly higher rates of unplanned admission and surgical management with expectant and medical management
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14
Q

Discuss the Zhang trial
-Type (2)
-Aim (1)
-Inclusion criteria (1)
-Primary outcomes (1)
-Results (4)

A
  1. Study type
    -RCT to 800mcg misoprostol or Surgical ERPOC
    -Randomised 3:1
  2. Aim
    -To assess the efficacy, safety and acceptability of medical management
  3. Inclusion criteria
    -Women (n = 652) - first trimester pregnancy failure (missed miscarriage, fetal death, incomplete or inevitable miscarriage)
  4. Primary outcome
    -Treatment failure = repeat or evacuation by 30 days
  5. Results:
    -n = 650 500 to miso 160 to surgical
    -84% success with medical management 71% after first dose.
    -97% success with surgical management
    No difference in haemorrhage, infection, ED visits between groups
    -Increased blood loss in miso group (SS)
    -Medical management found to be acceptable
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15
Q

What is the criteria for missed miscarriage (3)

A

Initial scan
-MSD >25mm and no visible yolk sac
-CRL >7mm and no FH seen
-No Sac or fetal growth over a time period no less than 7 days

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16
Q

Discuss ectopic pregnancy
-Definition
-Incidence
-Classification and incidence of each
-Risk factors

A
  1. implantation and development of pregnancy at a site other than endometrial cavity
  2. 1% of pregnancies
  3. Classification
    -Tubal - 95%
    -Ampullary - 55%
    -Isthmic 25%
    -Fimbrial 17%
    -Interstitial - 2%
    -Other
    - CS Scar 6% of ectopic in women with >=1 previous CS
    - Cervical 1%
    Intramural, ovarian, abdominal
  4. Risk factors
    -Tubal damage - PID, Surgery, endometriosis
    -Chromosomally abnormal pregnancies
    -Progesterone containing contraception
    -POP 4-6%, Jadelle - 10-20%
    -IUD - Mirena 50%, CuIUD 30%
    -DES, ART, Smoking, Douching
    -30% no risk factors
    -Previous ectopic
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17
Q

What are the USS signs of ectopic pregnancy
-Sensitivity, specificity
-% inconclusive on USS
-Feature - 5

A
  1. If ectopic identified Sens - 87-99%, Spec 94-99%
  2. 10-50% scans inconclusive
  3. Features:
    -Empty extrauterine GS moving separately to ovary - 12-20%
    -Complex inhomogenous adnexal mass moving sep from ovary 20-40% (Most common finding)
    -Empty uterus
    -Pseudo sac in the uterus 20%
    -FF in POD
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18
Q

Discuss expectant management of ectopic
1. Criteria
2. Monitoring
3. Prognosis

A
  1. Criteria
    -Clinically stable and pain free
    -HCG <1000 (Can consider <1500)
    -Tubal ectopic <35mm with no visible FHB
    -Can be followed up
  2. Monitoring
    -HCG 2,4,7 then weekly until negative
    -If not falling by >15% then clinical review +/- USS
  3. Prognosis
    -Up to 90% success if HCG <1000
    -Up to 66% success if HCG <1500
    -No difference between medical and expectant management in terms of tubal rupture, additional treatment, fertility outcomes, time to be able to conceive again
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19
Q

How should a PUL be managed (6)

A

If haemodynamically stable can:
-HCG 48hrs apart
-If rise >63% then likely IUP but some ectopics can double appropriately (HCG doesn’t tell location of pregnancy)
-Repeat USS once HCG >1500. If IUP not seen then likely ectopic
-If HCG decreases by >50% likely miscarriage. Suggest PT at 14/7 and if neg has miscarried
-Don’t use progesterone to work out if IUP or viable or ectopic
-Anything in between 50% decline and 63% rise refer to EPAU

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20
Q

Discuss medical management of ectopic pregnancy
-Criteria
-Meds
-Follow-up
-Prognosis
-Side effects (6)

A
  1. Criteria
    -No significant pain
    -Ectopic <35mm
    -HCG <5000. Ideally <1500
    -No Fetal heart
    -No evidence of rupture
    -No IUP
    -Able to be followed up
  2. Medication = methotrexate - destroys proliferating trophoblasts. Dose50mg/M2
  3. Follow up
    -HCG 1,4,7 Continue weekly till negative
    -If drop of <15% between D4-D7 = repeat treatment
    - Needs USS before second dose to R/O Rupture and FHR
    -Avoid pregnancy 3 month
    -Avoid Alcohol and folic acid until HCG <5
  4. Prognosis
    -90% success, 14% need repeat dose, 10% need surgery
    -Better success with lower initial HCG <1000 or slow rising HCG before Rx
  5. Side effects of methotrexate
    -Bone marrow suppression
    -Pulmonary fibrosis or pneumonitis
    -Liver cirrhosis
    -Renal failure
    -GIT sx - flatulence and bloating
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21
Q

Discuss surgical management of ectopic pregnancy
-Methods (2)
-Follow-up

A
  1. Methods
    -Aim Laparoscopic approach
    -Salpingectomy
    - If contralateral tube normal, active bleeding, no risk factors for infertility
    -No difference in fertility outcomes or repeat ectopic
    -Salpingotomy
    -If contralateral tube damage and fertility desired
    -Up to 1:5 women will need further treatment MTX or surgery
    -Higher rates of pregnancy if fertility issues
  2. Follow-up
    -Salpingectomy - UTP in 3 weeks
    -Salpingotomy - Follow HCG until negative. 20% require further Rx
  3. If RH neg give Anti D (not required for medical or expectant management)
22
Q

Discuss the prognosis of ectopic pregnancy

A

-70% of women will go on to have an IUP following ectopic
-Risk of recurrence
- 1 x previous with normal tube 6-12%
- 1 x previous with abnormal tube 25-50%
- 2 x previous 25-40%
-If no infertility issues then outcomes the same for all methods
-If subfertility then MTX or expectant better

23
Q

Discuss cervical ectopic pregnancy
-Incidence
-USS findings (5)
-Management

A
  1. 1% of all ectopic pregnancies
  2. USS findings
    -Barrel shaped cervix
    -Empty uterus
    -GS below level of internal os
    -Absence of sliding sign / miscarriages in the cervix slide (Distinguishes between the two)
    -Blood flow around GS with colour doppler
  3. Management
  4. Medical. First line- MXT - systemic or intra sac. Best if HCG <10,000
  5. Surgical. Second line- Hysteroscopy + resection, D&C, Hysterectomy. Only in significant bleeding
24
Q

Discuss caesarian scar ectopic pregnancy
-Incidence
-Types
-USS features (4)
-Management (4)
-FU

A
  1. Epidemiology
    -1:2500 pregnancies
    - 6% of ectopic pregnancies in women who have had a CS
    - 3-5% risk of recurrence
  2. Types:
    -Endogenic - grows into uterine cavity. Can reach term, increased risk of placenta accreta spectrum)
    -Exogenic - grows outwards into serosal surface, increased risk of first trimester rupture and haemorrhage
  3. USS findings (first line for dx)
    -Empty uterine cavity
    -GS or mass embedded in previous lower segment scar
    -Thin (1-3mm) or absent myometrium between GS and bladder
    -Prominent vascular pattern on doppler
  4. Management - no RCTs to base advise on
  5. Expectant - not recommended as first line
    -Consider if: aSx, non viable CSP and HCG dropping or viable clearly endogenic in woman declining TOP.
  6. Medical - if woman stable and CSP unruptured
    -Systemic MXT
  7. Interventional radiology
    -Intragestational sac MXT/Sac aspiration/KCl
  8. Surgical - recommended first line but not much in the literature.
    -Dilation & suction curettage
    -Laparoscopic / open resection
    -Hysteroscopic resection
    -Hysterectomy
    -Combined lap and hysteroscopic
  9. Follow-up
    -Until HCG -ve
    -If HCG plateaus consider MXT
    -Consider CS scar defect repair
    -Recommend CS in next delivery
    -Early USS in future pregnancies
25
Q

Describe interstitial ectopic pregnancy
-Location (2)
-USS features (3)
-Management

A

-Located at the proximal tubal part of the uterus where it enters the uterus.
-Ectopic able to grow larger as myometrium stronger and distendable
-Different from cornual as these occur in a uterus with a structural abnormality - i.e. rudementary horn.
2. USS features
-GS sac located laterally in the interstitial part of the tube
-Less than 5mm of myometrium in all imaging planes
-Presence of interstitial line sign (80% sens, 98% spec)
3. Management
-Expectant - if asx and HCG dropping or low
-Medical - systemic MXT, USS guided intrasac MTX +/- KCl, lap guided intrasac MXT +/- KCl
-Surgical
-Laparoscopic/open wedge resection of cornual +/- Salpingostomy
-Hysterectomy
-Hysteroscopic resection with USS or lap guidance

26
Q

Describe ovarian ectopic pregnancy
-USS features (4)
-Management

A
  1. USS features:
    -No agreed criteria
    -Empty uterus
    -Echogenic ring with internal anechoic area on ovary
    -Unable to separate cystic mass from ovary - negative sliding sign
    -CL seen separately
  2. Management:
    -Laparoscopic first line as required to make Dx
    -Wedge resection
    -Enucleation
    -Oophorectomy if bleeding ++
    Can use systemic MXT if surgical risk is high
27
Q

Discuss heterotropic pregnancy
-Incidence
-Flags for heterotropic pregnancy
-Management
-FU

A
  1. Epidemiology:
    -1:4000 (used to think 1:40,000)
    -1:1000 in ART pregnancies
  2. Red flags for heterotropic pregnancy
    -Rising HCG despite miscarriage
    -IUP with persistent pelvic pain
    -Post ART
  3. Management
    If unstable - surgical management
    -Laparoscopic removal of non-IUP
    -Avoid manipulation of uterus
    If stable
    -Wants IUP - KCl to ectopic + sac aspiration or surgical resection of ectopic
    -Doesn’t want IUP - Systemic MXT or intra-sac MXT or surgical resection + D&C
    -If IUP not viable and stable can consider expectant
  4. Follow-up
    -USS FU to check resolution of ectopic
28
Q

Discuss HCG
-Timing to be positive after ovulation
-Normal rise
-Peak concentration
-False positives (4)

A
  1. Timing
    -Usually positive in UPT at time of missed period
    -Earliest detectable = 6 days post ovulation on serum HCG
    -Earliest detectable = 8 days post ovulation on UTP
    -UPT positive when serum HCG 25-50
  2. HCG rise
    -Normal rise = doubles every 48hrs.
    -Normal low rise = 63% increase every 48hrs
    -15% of pregnancies have an abnormal rise
    ->63% rise in 48hrs has a PPV of 96.5% for IUP
  3. Peak concentration = 100,000 IU/L (most women)
  4. False positives
    -IVF - exogenous HCG
    -Chemical pregnancy
    -HCG secreting tumour
    -HCG secretion from pituitary
29
Q

What are the earliest signs of IUP on USS

A
  1. Decidual reaction - echogenic ring with thickened decidua
  2. Double decidual sign - 2 concentric echogenic rings
  3. IUP can only be dx when YS or FP seen
    -Pseudo sac can be mistaken for IUP but most likely is early IUP (99.98%) not ectopic (0.02%) if no adnexal mass seen
30
Q

Discuss CRL
-How to measure
-Expected growth
-Dating with CRL

A
  1. Method of measurement
    -If <7 weeks do length
    -If >7 weeks do sagittal plan
  2. Expected growth = 1mm / day
  3. GA in days = CRL mm + 42
31
Q

Discuss dating in early pregnancy
-What to use
-Approximate dates by apparent structures (4)

A
  1. How to date
    -Use LMP if sure and regular periods
    -Use Scan if - unsure LM, irregular periods, >7 day discrepancy between EDD with LMP and scan
  2. Approximate dates by structures
    -GS but nothing else - 5/40 (4+3)
    -GS + YS but nothing else -5.5/40 (>5)
    -GS + YS + FH but can’t measure embryo - 6/40
    -Fetal pole -7-8 weeks
32
Q

What are the possible outcomes of a PUL? (4)

A
  1. Failing PUL - 50%
  2. IUP 30%
  3. Ectopic 20%
  4. Persisting PUL 2%
33
Q

Describe the management of PUL

A
  1. Cannot r/o ectopic - give safety netting advice (written)
  2. Clinical symptoms are more important the HCG levels
  3. Don’t use serum progesterone to determine location.
  4. Don’t use HCG measures to determine location
  5. Take HCG measures 48hrs apart
    -If >63% rise = likely IUP but can’t rule out ectopic
    -Repat in 48hrs
    -USS once HCG >1500 or after 7-14 days
    -If level drop >50% - likely failing PUL
    -Repeat HCG in 2 weeks then weekly until <5
    -If level decreased <50% or rise <63% then specialist review
    -Repeat USS in 7-10 days
34
Q

Describe the management of RPOC
-When to investigate
-Investigations
-When to treat
-Treatment

A
  1. Bleeding after 3 weeks from miscarriage, Heavy PVB, fevers pain
  2. HCG - if neg then dx very unlikely, if + is suggestive
  3. USS - poorly specific for RPOC - mimics clot
  4. Treat if sx. Don’t treat asx women
  5. Treatment:
    -Expectant if stable and RPOC <1cm
    -Medical miso 400 PO
    -Surgical - if septic, unstable, or requested.
    -Hysteroscopic approach favoured
35
Q

Discuss recurrent miscarriage
-Definition
-Incidence
-Causes (7)

A
  1. Definition
    Loss of three or more consecutive pregnancies before 24 weeks (some societies say 2)
  2. Incidence
    -3 consecutive losses - 1%
    -2 consecutive losses - 5%
  3. Causes
    -Unknown - 50%
    -Age
    -Chromosomal abnormalities 30-57%
    -Parental chromosomal abnormalities - 3-5%
    -60% balanced reciprocal translocation
    -40% Robertsonian transloaction
    -Antiphopholipid syndrome - 10-20%
    -Inherited thrombophillia - FV Lieden, Prothrombin gene mutation
    -Uterine anomalies
    -congenital 6% -septate, arcuate, bicournuate
    -Acquired - fibroids - submucosa/intramural, adhesions
    -Endocrine factors - hypothyroidism, diabetes, PCOS, TPO antibodies, prolactin imbalances
    -Previous miscarriage
    -Smoking, caffeine, alcohol
    -Extremes of BMI
    -Infection
    -Sperm DNA fragmentation
36
Q

What are the investigations for recurrent miscarriage?

A
  1. Karyotyping both parents if fetal material shows abnormality
  2. Early follicular phase FSH and estradiol - assess diminished egg reserve
  3. THS T4 TPO
  4. Pelvic USS +/- saline infused sonohysterography
  5. Antiphospholid screen
    -Anticardiolipin antibodies, lupus anticoagulent, anti B2- glycoprotien. 6/52 post miscarriage and 2 positive results 12 weeks apart.
  6. Thrombophillia screen if loss in second trimester - Protein C and S def, factor V leiden, prothrombin gene mutation. 6/52 postnatal and without hormones
  7. Thrombophillia screen otherwise not recommended
  8. Test the pregnancy tissue for cytogenetics. If unbalanced translocation test the parents for balanced translocations.
37
Q

What is the management for recurrent miscarriage

A

-Depends on cause
1. Parental chromosomal abnormality
- ref to genetics
- Can consider prenatal or preimplantation genetic screening - not routinely suggested
2. Antiphospholipid antibody syndrome
-Aspirin from pre-pregnancy until 34/40
-UFH/LMWH 40mg from positive pregnancy test till at least 34/40
-Can improve birth rate from 10-70%
3. Inherited thrombophillias - no evidence for LMWH but could consider for FVL, prothrombin Gene, protein S def +/- Hx of second trimester loss +/- risk factors doe thrombosis
4. Uterine abnormalities
-Septum hysteroscopic resection - observational data only
-Fibroids and polyps - no data but seems reasonable
5. Unexplained
-Reassurance - life birth rate following 3 miscarriages 70%
-Consider PV progesterone if PVB 400mg micronised PV BD until 16/40 in threatened miscarriage
6. Treat hypothyroidism and hyperprolactinemia.
-If euthyroid and TPO+ don’t treat.
-Can treat moderate Subclinical hypothyroid with TPO + but not mild cases
7. Maintain a weight between 19-25 BMI, stop smoking, limit caffeine and alcohol

38
Q

Describe the epidemiology of abortion
-Life time risk
-Number of pregnancies ending in termination
-Number of deaths / yr where termination is illegal

A
  1. Life time risk = 33%
  2. Number of pregnancies terminated = 1:4
  3. Number of maternal deaths 50,000/yr
39
Q

What are the longer term risks of abortion (5)

A
  1. Psychological trauma - studies not causative
  2. Small increase in subfertility
  3. Small increase in subsequent miscarriage
  4. Small increase in PTB with recurrent STOP
  5. Increase in PID if current infection

No increase in breast cancer, no increase in placenta praevia, no increase in ectopic pregnancy

40
Q

Describe early TOP
-Definition
-Success rates
-Methods
-Regimen

A
  1. TOP before 8+6/40
  2. 95% success in medical TOP
  3. Methods
  4. Medical - mife 200mg then miso 36-48hrs later 800mcg
    Sx onset 6-8hrs. 95% Complete within 24hrs
  5. Surgical - MVA or suction curretage
    -Not recommended <7/40 - increased failure rate
    -recommend surgical priming with miso 2 x 400mcg 30 and 60 mins prior to procedure
41
Q

Discuss late TOP
-Definition
-Methods
-Complications
-When should feticide be offered

A
  1. TOP after 8+6/40
  2. Methods
    Surgical evacuation 14-24 weeks
    -medical priming of cervix from 12/16 weeks
    -medical and manual priming of cervix 16-24 weeks
    Medical IOL >14 weeks
    -Should be hospitalised
    -Mife 200mg then miso 400mcg Q3H after 24-36hrs
    -Offer feticide if risk of live birth 1-5% of births 18-24 weeks
  3. Complications:
    Surgical: RPOC, Infx, Cx lacceration, Uterine perforation, Bleeding
    Medical: Retained placenta 10-20%, bleeding requiring transfusion 1-2%, RPOC, Live fetus born 1-5%, failed procedure if not delivered in 72hrs
42
Q

What are the RANZCOG recommendations for use of mife in MTOP (4)

A
  1. Mife + miso is best available regimen for MTOP.
  2. Termination should be conducted in accordance with local legal requirements
  3. Where TOP is offered emergency services should be available
  4. For gestations >9 weeks treatment should be in a treatment facility
43
Q

Discuss threatened miscarriage
-Management

A

-If PVB in viable IUP offer 400mg micronised progesterone PV BD
-Continue to 16/40 pregnancy

44
Q

Discuss pregnancy outcomes post ectopic management
-Differences between management options in fertile women (3)
-Differences in management options in sub-fertile women (2)

A
  1. Differences in management options in fertile women
    -No difference in fertility rates in all management options
    -No difference in repeat tubal ectopic in all management options
    -No difference in tubal patency rates
  2. Difference in management options in sub-fertile women
    -Fertility higher in expectant and medical management
    -MXT doesn’t impact ovarian reserve
45
Q

What are the main causes of second trimester miscarriage (3)

A

-Infection
-Uterine abnormalities
-Cervical insufficiency

46
Q

Discuss the SPIN trial
-Aim (1)
-Study design (4)
-Primary outcomes (1)

A
  1. Aim
    -To assess whether LMWH and LDA + intensive pregnancy surveillance reduces rate of pregnancy loss cf intensive pregnancy surveillance alone in women with 2 or more consecutive pregnancy losses
  2. Study design
    -Multicentre RCT
    -Included if >= 2 consecutive pregnancy losses before 24/40 and <7/40 in current pregnancy
    -Randomised to 75mg LDA + 40mg SC clexane or surveillance only
    -FU till 36/60
  3. Primary outcomes
    -Pregnancy loss rate
    -Tolerance and safety of LMWH
47
Q

Discuss the SPIN trial
-Number included (1)
-Outcomes (2)

A
  1. Number included
    -n= 300 ~ 150 in each arm
  2. Outcomes
    -No difference in pregnancy losses between the two groups 22 in intervention arm vs 20% in control (NS)
    -No difference in serious adverse events between groups
48
Q

Discuss the trial investigating aspirin + heparin vs aspirin alone for recurrent miscarriage
-Aim (1)
-Study design (5)
-Primary outcomes (1)
-Secondary outcomes (3)

A
  1. Aim
    -To determine the impact LMWH +/- aspirin on outcomes for women with recurrent miscarriage
  2. Study design
    -RCT. Blinded for aspirin but not heparin
    -Three arms: heparin + aspirin, aspirin only, Placebo
    -Included women with at least 2 pregnancy losses <20/40
    -Women were enrolled at gest <6/40
    -Aspirin continued to 36/40. Heparin continued until labour
  3. Primary outcome
    -Live birth rate
  4. Secondary outcome
    -Miscarriage rate
    -Obstetric complications
    -Adverse fetal and maternal events
49
Q

Discuss the trial investigating aspirin + heparin vs aspirin alone for recurrent miscarriage
-Number included in study
-Results

A
  1. Number included in the study
    n = 360 approx 120 in each arm
  2. Results
    -No difference in live birth rates between the three groups
    -No difference were seen in secondary outcomes
50
Q

Discuss the findings of 2021 Meta analysis on management of first trimester loss (5)

A
  1. Expectant management least effective to achieve complete evaluation of products
  2. There was similar effectiveness mife + miso or miso only and surgical management
  3. No evidence to suport miso + evac combo
  4. Mife and miso better than miso but lack of good data and more research required
  5. Satisfaction same across all modalities

RANZCOG -Gynaecology 2024 Edward (11 decks)

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