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O&G > Early Pregnancy > Flashcards

Early Pregnancy Flashcards

1
Q

Definition of miscarriage and early miscarriage

A
  • Loss of n intrauterine pregnancy before 24 weeks of gestation OR expulsion of a fetus or embryo weighing less the 500g, less than 22 weeks gestation
  • Early<12 weeks gestation
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2
Q

Definition of threatened versus inevitable miscarriage

A

Threatened: bleeding, closed cervix, viable intrauterine pregnancy

Inevitable: heavy bleeding, crampy pain, cervix open

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3
Q

Definition of complete versus incomplete miscarriage

A

Complete: empty uterus, closed cervix, minimal bleeding

Incomplete: Bleeding, pain, open, contents of pregnancy still in uterus

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4
Q

Definition of missed miscarriage

A

No pain, no bleeding, closed cervix, no fetus/no heartbeat

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5
Q

Examinations done in ?miscarriage

A

Pulse, BP, temp (ABC)
Abdo (guarding, mass/uterus, tenderness)
Speculum (amount of bleeding, products of conception, os of cervix open?)
Internal examination (adnexal masses)
USS (transvaginal up to 8 weeks, then trans-abdominal)

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6
Q

What is conservative management of a miscarriage?

A

Repeat scan in 10-14 days, wait for passage of products of conception

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7
Q

What is medical management of a miscarriage?

A

mifepristone and misoprostol, anti progesterone reverses pregnancy signal and prostaglandin to help induce passing of tissue

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8
Q

What is the surgical management of a miscarriage?

A

ERPC= evacuation of retained products of conception), also called SMM= surgical management of miscarriage, under GA, vaginal misoprostol and dilate cervix

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9
Q

When is surgical management of a miscarriage indicated?

A

Surgical if retained products have caused endometritis.

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10
Q

Definition of recurrent miscarriage

A

3 or more consecutive, spontaneous miscarriages occurring in the first trimester with the same biological father. They may or may not follow a successful birth.

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11
Q

Causes of recurrent miscarriage

A

Antiphospholipid syndrome (15%, most important treatable cause, presence of anticardiolipin antibodies or lupus anticoagulant antibodies with any of:

  • 3 or more consecutive fetal losses before 10th week
  • 1 fetus at 10 weeks gestation or older
  • 1 or more preterm births of a morphologically normal fetus at less than 34 weeks associated with severe PET or placental insufficiency

Genetics (unbalanced reciprocal/Robertsonian translocations)
Fetal chromosomal abnormalities
Anatomical abnormalities (uterine septa/bicornuate uterus)
Fibroids?
Thrombophilic disorders (Factor V Leiden and factor II prothrombin G20210A)
Infection?
Endocrine disorders
Cervical weakness

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12
Q

Investigations for recurrent miscarriage

A
  • Parental blood for karyotyping
  • Cytogenic analysis of products of conception
  • Pelvic USS
  • Thrombophilia screen
  • Lupus anticoagulant
  • Anticardiolipin antibodies
  • Bacterial vaginosis screening
  • Cervical weakness from Hx
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13
Q

Management of recurrent miscarriage

A
  • 35% unexplained-> 75% chance of success next time
  • Surgery for uterine septum/fibroids
  • Mini aspirin and heparin for antiphospholipid syndrome
  • Cervical cerclage
  • Genetics referral
  • Vaginal swabs and Abx for BV
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14
Q

Define ectopic pregnancy

A

A pregnancy in which the fetus develops outside the uterus, typically in a fallopian tube.

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15
Q

What is the main risk of ectopic pregnancy

A

Rupture
Risk of massive intraperitoneal bleeding
Will suddenly collapse after more than 2 litres is in the retroperitoneal pouch

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16
Q

Risk factors for ectopic pregnancy

A
  • Previous ectopic (10% risk of recurrence)
  • Previous tubal surgery (sterilisation)
  • PID/pelvic adhesions
  • Intrauterine contraceptive device in situ
  • Subfertility
  • IVF
  • Smoking
  • Progesterone only pill when they conceive
17
Q

Signs and symptoms of ectopic pregnancy

A
  • Pain (shoulder pain if ruptured, rectal, period, iliac fossa)
  • Amenorrhoea
  • Bleeding (spotting, brown)
  • Bladder/urinary symptoms
  • Diarrhoea, vomiting
  • Dizziness
  • Tenderness +/- rebound
  • Pallor, tachycardia, hypotension, shock, collapse (rupture)
  • Tender in iliac fossa, cervical tenderness
  • PREGNANCY TEST (catheter if too unwell)
18
Q

What is a PUL?

A

Pregnancy of unknown location

ßHCG raised but no embryo seen on USS

19
Q

Management of PUL?

A

Serum beta-hCG, doubles every 48hrs in a normal pregnancy
If over 1000 then should be able to see the sac. (bagel sign on USS)
Repeat in 48hrs, has it doubled? Repeat scan.

20
Q

What does an ectopic/failing pregnancy look like?

A
  • Sub optimal rise in beta-hCG levels

* Low progesterone

21
Q

Management of ectopic pregnancy

A
  • Rupture/live ectopic-> straight to theatre for laparoscopic salpingectomy
  • Salpingostomy if tube is needed for future fertility
  • Stable with small ectopic can be measured conservatively, 50% will be absorbed by body. Monitor until pregnancy test is negative
  • Medical: methotrexate, may still rupture
22
Q

Are abortions common?

A

Yes

More than 40% of women will end a pregnancy by abortion at some point in their reproductive lives.

23
Q

When can a termination of pregnancy occur legally?

A

If 2 registered medical practitioners agree that:
Up to 24 weeks:
• The continuance of the pregnancy would involve risk, greater than if the pregnancy was terminated, of injury to the physical or mental health of the pregnant woman or any existing children of her family.
• The woman’s actual or reasonably foreseeable future environment may be taken into account.

With no time limits:
• The termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman
• There is a risk to the life of the pregnant woman, greater than if the pregnancy were terminated
• There is substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped.

24
Q

What if a 16yr old wants a TOP?

A

Patients under 16 should be encouraged to involve their parents in the decision but provided they are considered to be competent, they can give their own consent.

25
Q

Define viability

A

Viability: the fetus’ ability to survive extrauterine life with or without life support. Generally >26 weeks, >500g.

26
Q

What maternal conditions carry a significant risk in pregnancy?

A 
Severe diabetes with retinopathy
Cardiac/renal complications
Advanced cardiac or respiratory disease
Renal failure
Sickle cell disease
Autoimmune diseases
Psychiatric disease
Especially severe mitral stenosis, coarctation of the aorta, aortic stenosis, MI, artificial valves
27
Q

What fetal indications for TOP are there?

A 
Anencephaly
Trisomy 13, trisomy 18
Renal agenesis
Severe hydrocephalus
Thanatophoric dysplasia (limb defects)
Neural tube defects
Trisomy 21
Cleft limb or face abnormalities
Intracranial calcifications of viral disease
28
Q

4 methods of surgical TOP

A

Manual vacuum aspiration (menstrual extraction) (7-15 weeks gestation, 99.2% effective)
Suction curettage (6-14 weeks gestation)
Dilation and extraction (15-24weeks) (Dilation with GEMEPROST)
Hysterectomy (12-24 weeks if all other methods contraindicated, eg placenta accreta)

29
Q

When is a medical TOP contraindicated?

A

Contraindicated in clotting disorders, severe liver disease, renal disease, cardiac disease and chronic steroid use.
Also contraindicated in patients with no access to emergency services or no partner/family to be with the patient during the heaviest bleeding times.

30
Q

Describe a medical TOP

A

MIFEPRISTONE and MISOPROSTOL
(progesterone receptor blocker and prostaglandin)
Mifepristone allows progesterone withdrawal to occur, with placental necrosis and detachment, uterine contraction.
Misoprostol is a PGE2 analogue.
Prostaglandin then contracts uterus and products of conception are expulsed.

31
Q

What is done following a TOP?

A 
METRONIDAZOLE 1g PR plus DOXYCYCLINE PO BD for 7 days. 
•	Anti-D for all rhesus negative women
•	Provide written patient information
•	Follow up within 2 weeks
•	Refer to further counselling if needed
•	Discuss/provide contraception
32
Q

6 causes of miscarriage

A 
Fetal abnormality
Infection
Maternal age
Abnormal uterine cavity
Intervention (amniocentesis/CVS)
33
Q

What drugs are given after surgical management of miscarriage (after 12 weeks gestation)

A

Syntocin (minimise blood loss)

Anti-D if rhesus -ve

O&G (12 decks)

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