Early pregnancy

Question 1

what are the 3 features looked for in assessing viability of pregnancy

Answer 1

Mean gestational sac diameter
Fetal pole and crown-rump length- 7mm
Fetal heartbeat

Question 2

In what circumstance is scan repeared after one week before confirming a non-viable pregnancy

Answer 2

When there is a crown-rump length of 7mm or more, without a fetal heartbeat, the scan is repeated after one week before confirming a non-viable pregnancy.

Question 3

what happens if the crown-rump length is less than 7mm without a fetal heartbeat

Answer 3

scan repeated at least one week after to ensure a heart beat develops

Question 4

In what measurement is a fetal pole (embryo) expected and if there isn’t then how long you wait to repeat the scan again

Answer 4

A fetal pole is expected once the mean gestational sac diameter is 25mm or more. When there is a mean gestational sac diameter of 25mm or more, without a fetal pole, the scan is repeated after one week before confirming an anembryonic pregnancy.

Question 5

what is the management for less than 6 weeks gestation- miscarriage
what are the red flags for immediate referral.

Answer 5

presenting with bleeding can be managed expectantly- with no pain and other complications such as previous ectopic.
-expectant- awaiting miscarriage because ultrasound is unlikely to be helpful this early of pregnancy
repeat test is done 7-10 days. If remains negative then miscarriage confirmed.
- when bleeding continues or pain occur.

Question 6

what is the management for more than 6 weeks with positive pregnancy test and bleeding.

Answer 6

Referral to EPAU. Arrange ultrasound- confirm location and viability. Always exclude ectopic pregnancy

Question 7

when would you confirm expectant management in a miscarriage

Answer 7

• Without risk factors for heavy bleeding or infection.
  1-2 weeks are given to allow the miscarriage to occur spontaneously.
  repeat urine test 3 weeks later

Question 8

When is medical management considered in miscarriage and what is used? Name some side effects

Answer 8

Misoprostol is a prostaglandin analogue and binds to prostaglandin receptors and activates them. prostaglandins soften the cervix and stimulates uterine contractions.
Heavier bleeding
Pain
Vomiting
Diarrhoea

Question 9

When is surgical management considered and how is it performed (two options). what medication is used to soften the cervix

Answer 9

Manual vacuum aspiration under local anaesthetic as an outpatient
Electric vacuum aspiration under general anaesthetic
-misoprostol

Question 10

What is given as a prophylaxis for women having surgical management of miscarriage

Answer 10

Anti-rhesus D prophylaxis is given to rhesus negative women having surgical management of miscarriage.

Question 11

when is investigations initiated in a miscarriage

Answer 11

Three or more first-trimester miscarriages
One or more second-trimester miscarriages

Question 12

what are some of the causes of recurrent miscarriage

Answer 12

-Idiopathic - In older woman
Antiphospholipid syndrome
Hereditary thrombophilias
uterine abnormalities
chronic conditions- SLE

Question 13

why does antiphospolipid syndrome a risk factor for recurrent miscarriage. How can this be managed

Answer 13

blood becomes prone to clotting which is a risk in pregnancy
it can be secondary to SLE
-Low dose of Aspirin
LMWH
consider previous history of DVT

Question 14

What is an ultimate management for recurrent miscarriage

Answer 14

Using vaginal progesterone pessaries.

Question 15

According to Abortion act how many weeks is abortion legal to and what are the criteria

Answer 15

24 weeks.
if continuing the pregnancy is a greater risk to the mum physically or mentally or existing children or family

Question 16

when can an abortion be performed at any time during pregnancy

Answer 16

Continuing the pregnancy is likely to risk the life of the woman
Terminating the pregnancy will prevent “grave permanent injury” to the physical or mental health of the woman
There is “substantial risk” that the child would suffer physical or mental abnormalities making it seriously handicapped

Question 17

what are the two treatment for medical abortion, describe mechanism

Answer 17

Mifepristone- anti progestogen- blocks the action of progesterone, relaxing cervix
Misoprostol- prostaglandin analogue 1-2 day later- soften the cervix and uterine contraction

Question 18

what are the surgical management for TOP

Answer 18

There are two options for surgical abortion:

Cervical dilatation and suction of the contents of the uterus (usually up to 14 weeks)
Cervical dilatation and evacuation using forceps (between 14 and 24 weeks)
Prior to surgical abortion, medications are used for cervical priming. This involves softening and dilating the cervix with misoprostol, mifepristone or osmotic dilators.

Question 19

what is the term used to describe severe form of nausea and vomiting and when does normal N+V start

Answer 19

Hyperemesis gravidarum
-first tremester 8-12 weeks.

Question 20

with Hyperemesis gravidarum which of the weeks do you see symptoms and when does it resolve

Answer 20

Symptoms usually start from 4 – 7 weeks, are worst around 10 – 12 weeks and resolve by 16 – 20 weeks. Symptoms can persist throughout pregnancy.

Question 21

What causes hyperemesis gravidarum

Answer 21

The placenta produces human chorionic gonadotropin (hCG) during pregnancy. This hormone is thought to be responsible for nausea and vomiting. Theoretically, higher levels of hCG result in worse symptoms.

Question 22

What are the symptoms of hyperemesis gravidarum

Answer 22

More than 5 % weight loss compared with before pregnancy
Dehydration
Electrolyte imbalance

Question 23

what tool can be used to assess severity of hyperdemesis gravidarum

Answer 23

< 7: Mild
7 – 12: Moderate
> 12: Severe

Question 24

What is the management for hyperemesis gravidarum

Answer 24

Antiemetics are used to suppress nausea. Vaguely in order of preference and known safety, the choices are:

Prochlorperazine (stemetil)
Cyclizine
Ondansetron
Metoclopramide

Question 25

What is the management for hyperemesis gravidarum for acid reflux

Answer 25

Ranitidine or omeprazole can be used if acid reflux is a problem.

The RCOG also suggest complementary therapies that may be considered by the woman:

Ginger
Acupressure on the wrist at the PC6 point (inner wrist) may improve symptoms

Question 26

management for mild cases of MG, red flags for admission. consider urine findings

Answer 26

Mild cases can be managed with oral antiemetics at home. Admission should be considered when:

Unable to tolerate oral antiemetics or keep down any fluids
More than 5 % weight loss compared with pre-pregnancy
Ketones are present in the urine on a urine dipstick (2 + ketones on the urine dipstick is significant)
Other medical conditions need treating that required admission

Question 27

managment of moderate-severe MG

Answer 27

Moderate-severe cases may require ambulatory care (e.g. early pregnancy assessment unit) or admission for:

IV or IM antiemetics
IV fluids (normal saline with added potassium chloride)
Daily monitoring of U&Es while having IV therapy
Thiamine supplementation to prevent deficiency (prevents Wernicke-Korsakoff syndrome)
Thromboprophylaxis (TED stocking and low molecular weight heparin) during admission

Question 28

What is a molar pregnancy. What are the two types

Answer 28

A hydatidiform mole is a type of tumour that grows like a pregnancy inside the uterus

there are two types of molar pregnancy: two sperm fertilise an ovum that contains no genetic material and you get empty ovum. but cells start to divide and grow into the tumor
- A complete mole and a partial mole. two sperm cells fertilise a normal ovum (contains genetic material) at the same time. Partial mole may have some fetal material

Question 29

what is molar pregnancy and how can you differentiate with normal pregnancy (cosnider hormonal imbalance)

Answer 29

More severe morning sickness
Vaginal bleeding
Increased enlargement of the uterus
Abnormally high hCG
Thyrotoxicosis (hCG can mimic TSH and stimulate the thyroid to produce excess T3 and T4)

Question 30

what is the ultrasound description got molar pregnancy

Answer 30

Ultrasound of the pelvis shows a characteristic “snowstorm appearance” of the pregnancy.

Provisional diagnosis can be made by ultrasound and confirmed with histology of the mole after evacuation.

Question 31

What is the management for molar pregnancy

Answer 31

Management involves evacuation of the uterus to remove the mole. The products of conception need to be sent for histological examination to confirm a molar pregnancy. Patients should be referred to the gestational trophoblastic disease centre for management and follow up. The hCG levels are monitored until they return to normal. Occasionally the mole can metastasise, and the patient may require systemic chemotherapy.