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*Medicine: Obstetrics + Gynaecology > Early Pregnancy > Flashcards

Early Pregnancy Flashcards

1*

1
Q

What is the general outline of an obstetric history?

A
  • basics - intro, details, consent etc
  • key preg details - gestation, gravidity, parity
  • presenting complaint
  • history of presenting complaint
  • specific obstetric symptoms
  • current pregnancy
  • previous obstetric history
  • gynaecological history
  • past medical history
  • surgical history
  • drug history
  • family history
  • social history
  • systems enquiry
  • ICE, signposting, summarising
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2
Q

Which specific obstetric symptoms might you want to enquire about?

A

The following symptoms are important to enquire about with some examples of what might have caused them

  • nausea + vomiting -> hyperemesis gravidarum?
  • reduced foetal movements -> stillbirth, IUGR, congenital?
  • vaginal bleeding -> APH, placental, cervical?
  • abdominal pain -> UTI, placental abruption?
  • urinary symptoms -> UTI?
  • vaginal discharge -> placenta praevia, infection, BV?
  • headache/vis disturbance/epigastric pain -> pre-eclampsia?
  • pruritis -> obstetric choleostasis?
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3
Q

What is important to ask about in regards to the current pregnancy?

A
  • gestation + EDD
  • scan results - foetal growth, placental position, anomalies
  • screening - down’s, rhesus, hep B/HIV/syphillis
  • other details - single/multiple, folic acid, delivery, illness
  • immunisation hx - flu jab, whooping cough, hep B
  • mental health hx - self-harm, suicide
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4
Q

What do you need to ask about in the previous obstetric history?

A
  • gravidity + parity
  • term pregnancy (>24wks):
    • gestation at delivery
    • birth weight
    • mode of delivery
    • complications
    • assisted reproduction
    • stillbirth
  • other pregnancies (<24wks):
    • miscarriage - gestation, management, cause
    • ToP - gestation + management
    • ectopic - site + management
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5
Q

What pre-existing medical conditions is it important to be aware of during pregnancy, in the PMHx?

A
  • diabetes (T1 or 2)
  • hypothyroidism
  • epilepsy
  • VTE
  • blood-borne viruses
  • genetic disease
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6
Q

Clarify the medications the patient has been taking since falling pregnant, noting which they are still taking and which they have now stopped.

What are some teratogenic drugs?

A
  • ACE inhibitors
  • sodium valporate
  • methotrexate
  • retinoids
  • trimethoprim

*in medication hx also ask about contraception, supplements, OTCs + allergies

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7
Q

What is important to ask about in family history?

A
  • inherited genetic conditions (eg. CF, sickle-cell dx)
  • type 2 diabetes (1o degree relative) - inc risk of developing GD
  • pre-eclampsia (maternal mother or sister) - inc risk of developing pre-eclampsia
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8
Q

What would you like to ask about in the social history?

A
  • smoking -> quantify + counsel
  • alcohol -> quantify + counsel
  • rec drugs
  • diet + weight
  • home situation - who, support, children, adls
  • occupation
  • domestic abuse
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9
Q

Preconceptual care is distinct from antenatal care. What should it include?

A
  • informed choice, helps women + men understand health issues that may affect conception + pregnancy
  • women + their partners being encouraged to prepare actively for pregnancy, and be healthy as possible
  • optimising management of chronic health problems
  • identifying couples who are at inc risk of having babies w/ a genetic malformation + provide them w/ sufficient knowledge to make informed decisions
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10
Q

What information should be provided in pre-pregnancy health education and promotion?

A
  • timing of planned pregnancy
  • hx of miscarriage
  • routine smear tests
  • genetic -> give folic acid (400mcg routine, 1mg diabetes), carrier screening in high risk (eg. sickle-cell, CF)
  • screen for infection -> HIV, syphillis, hep B + immunisations?
  • environment -> assess occupational exposure + use of household chemicals
  • lifestyle -> smoking cessation, avoiding alcohol + rec drugs, weight, exercise, diet
  • medical conditions + medications:
    • strict diabetic control
    • HTN -> avoid ACEi, ARBS + thiazides
    • epilepsy -> switch to lamotrigine if on valporate
    • DVT -> switch warfarin to heparin

*for more and detailed info go here

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11
Q

Describe the sperm’s journey to the egg

A
  • passage through uterus not well understood
  • currents set up by uterine/tubal cilia
  • chemo-attractants released from oocyte cumulus complex
  • sperm become hyperactivated
  • forceful tail beats w/ inc freq + amplitude mediated by ca2+ influx
  • via CatSper channels (on sperm tail)
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12
Q

What happens to the oocyte at ovulation?

A
  • LH spike causes resumption of meiosis + ovulation
  • converts primary oocyte -> secondary oocyte + 1st polar body
  • basement membrane breaks -> blood pours into middle
  • oocyte cumulus complex extruded out + caught by fimbrae of uterine tube
  • theca + granulosa become mixed
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13
Q

Where is the site of fertilisation?

A

Ampulla of fallopian tube

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14
Q

The second week of human development is concerned with the process of implantation and the differentiation of the blastocyst into early embryonic + placental forming structures.

When does implantation take place (day) and what is the pathophysiology of this?

A
  • implantation commences about day 6-7
  • adplantation - begins w/ initial adhesion to uterine epithelium
    • blastocyst then slows in motility, “rolls” on surface, aligns with the inner cell mass closest to the epithelium and stops
  • implantation - migration of the blastocyst into the uterine epithelium, process complete by about day 9
  • coagulation plug - left where the blastocyst has entered the uterine wall day 12
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15
Q

Where is the commonest site of implantation?

A
  • uterine wall - superior, posterior, lateral
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16
Q

An ectopic pregnancy is any pregnancy which is implanted at a site outside of the uterine cavity. In the UK, 1 in 80-90 pregnancies are ectopic.

What are common sites for ectopic pregnancy?

A

Most common sites include the ampulla and isthmus of the fallopian tube.

Less commonly, the ovaries, cervix or peritoneal cavity can be involved.

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17
Q

How do you diagnose intrauterine pregnancy?

A
  • history -> amenorrhoea (beware emotional strain or other 2o causes of amenorrhoea, or IUDs), morning sickness (6-12th wk) and urinary symptoms (irritability, freq, nocturia). Later there may be breast pain, constipation + weight gain
  • examination -> bluish discolouration of cervix and vagina (pelvic congestion), abdominal enlargement from 12th week onwards + breast enlargement
  • investigations -> urine HCG, USS (showing enlarged uterus, gestational sac or foetus)
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18
Q

How soon can you do a pregnancy test?

A
  • most pregnancy tests can be carried out from the first day of a missed period
  • if you don’t know when your next period is due, do the test at least 21 days after last unprotected sex
  • some very sensitive pregnancy tests can be used even before you miss a period, from as early as 8 days after conception
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19
Q

How do you calculate gestational age from LMP?

A

Naegele’s formula works out EDD - to the first day of the LMP (eg. 22nd June 2008):

  • add seven days* (ie. 29th)
  • subtract 3 months (ie. march)
  • add one year (ie 2009)

Then for exact gestational age, work out the difference of weeks between the current date and the EDD

*based on a 28day cycle, if longer than 28 add on number of days in addition to 7 already added

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20
Q

How do you work out gestational age from USS and SFH?

A
  • USS -> measure crown-rump length, performed at 11-13wks, accurate to within 5 days
  • symphysis-fundal height (SFH) -> accurate from 24 weeks, distance from pubic symphysis -> uterine fundus in cm approximates gestational age to +/- 2cm
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21
Q

What are 6 events that occur to cope with the changes during pregnancy?

A
  • increase in size of uterus
  • increased metabolic requirements of uterus
  • structural + metabolic requirements of fetus
  • removal of fetal waste products
  • provision of amniotic fluid
  • preparation for delivery + puerperium (first 6 weeks)
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22
Q

Which hormones cause most of the changes?

A
  • maternal steroids - placenta takes over ovarian (CL) production around week 7
  • placental peptides - hCG, hPL, GH
  • placental + foetal steroids - progesterone, oestradiol, oestriol
  • maternal + fetal pituitary hormones - GH, thyroid hormones, prolactin, CRF
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23
Q

What physiological changes occur in the endocrine system during pregnancy?

A
  • progesterone + oestrogen increase
  • oestrogen produced by placenta, progesterone produced by CL + later by placenta
  • oestrogen increase -> increase hepatic prod of thyroid binding globulin (TBG) -> more T3 + T4 bind to TBG -> TSH increases -> therefore free T3 + T4 remain unchanged, but total T3 + T4 levels rise
  • thyroxin essential for foetus’ neural development
  • anti-insulin hormones increase (HPL, prolactin, cortisol) -> inc insulin resistance in mother + reduce peripheral uptake of glucose -> ensures continuous supply of glucose to foetus
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24
Q

What is the total weight gain during pregnancy?

A
  • 12.5-13kg
    • fetus + placenta = 5kg
    • fat + protein = 4.5kg
    • body water = 1.5kg
    • breasts = 1kg
    • uterus = 0.5-1kg
  • ideally keep to less than 13kg
  • failure to gain or sudden change needs monitoring
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25
Q

What happens to the basal metabolic rate?

A

rises by:

  • 350 kcal/day mid gestation
  • 250 kcal/day late gestation
  • usage: 75% fetus and uterus, 25% respiration (H&L)
  • 9 calories = 1g fat, therefore 40g fat for 350kcal ie 1 large mars bar
26
Q

What happens to the maternal blood content?

A
  • Hb concentration will measure slightly lower due to higher intravascular fluid (haemodilution)
  • red cell mass should rise (18%)
  • placenta in fetuses are also iron-hungry
  • increaseded efficiency of iron absorption from gut
  • white cells increase
  • blood becomes hypercoagulable = inc fibrinogen for placental separation, but inc risk of thrombosis
27
Q

What happens to the foetal blood?

A
  • increased Hb and altered in type
  • increased O2 binding
  • oxygen given up by maternal Hb
28
Q

What changes occur in the respiratory system, physiologically in pregnancy?

A
  • upward displacement of diaphragm, doesn’t reduce total lung capacity significantly as increase in transverse + AP diameters of thorax also
  • increase in metabolic rate -> inc demand for oxygen -> tidal volume + minute ventilation rate increases
  • inc prog -> increased CO2 production + inc resp drive -> hyperventilation -> resp alkalosis
29
Q

What physiological changes take place in the cardiovascular system, during pregnancy?

A
  • progesterone reduces systemic vascular resistance -> reduced diastolic BP during 1st and 2nd trimester
  • in response: (40%) increased cardiac output
  • begins as early as 3 weeks to max at 40% at 28 weeks
  • for maternal muscle and fetal supply
  • RAAS also activated -> inc sodium + water retention -> total blood volume increases
  • neoangiogenesis - including extra capillaries in skin (spider naevi) to assist in heat loss
30
Q

What physiological changes take place in the GI tract during pregnancy?

A
  • upward displacement of stomach -> inc intra-gastric pressure -> reflux, n+v
  • appendix may move to RUQ
  • inc prog -> sm muscle relaxation -> reduced GIT motility -> constipation
  • inc prog -> relaxation of gallbladder so biliary tract stasis may occur
31
Q

What happens to the urinary tract, physiologically in pregnancy?

A
  • increase in renal plasma flow -> inc GFR (50-60%) -> increased renal excretion -> urea + creatinine lower
  • progesterone -> relaxation of ureter -> hydroureter
  • bladder relaxation

The above 2 changes of relaxation result in urinary stasis which predisposes a woman to UTIs, commonly pyelonephritis

32
Q

What changes occur in uterine size?

A
  • huge increase in muscle mass (x20)
  • huge increase in blood flow
  • placenta + uterus = 1/6 of total
33
Q

What changes occur to the cervix?

A
  • primary function to retain pregnancy
  • inc in vascularity
  • tissue softens + turns bluer from 8 weeks
    • changes in connective tissue
    • begins gradual preparation for expansion
  • proliferation of glands
    • mucosal layer becomes half of mass
    • great increase in mucus production
    • protective.. ie anti-infective
34
Q

What is hyperemesis gravidarum and its clinical features?

A
  • nausea + vomiting (NVP) common in preg women (75%)
  • N+V begins between 4th + 7th week after LMP, resolving in the second trimester (14wks)
  • hyperemesis gravidarum is the most severe form of NVP and is characterised by triad of: 5% pre-preg weight loss, dehydration and electrolyte imbalance
  • common between 8-12wks, should resolve by 20wks
  • other signs include tachycardia, postural hypotension, hypokalaemia and hyponatraemic shock, polyneuritis and behaviour disorders
35
Q

What is the aetiology of hyperemesis gravidarum?

A

Aetiology remains largely unknown, 3 main theories:

  • psychological predisposition - psychological response may be conditioned?
  • evolutionary adaptation - to protect both mother + foetus from harmful substances?
  • hormone response - progesterone reduces gastric motility + causes nausea + vomiting in non-pregnant women
  • associated w/ elevated hCG
  • more common in women w/ high oestrogen
  • association tied with presence of H. Pylori
36
Q

What are risk factors for hyperemesis gravidarum?

A
  • positive family history
  • history of previous nausea + vomiting in pregnancy
  • multiple gestation
  • gestational trophoblastic disease
  • other causes of increased placental mass
    • eg. triploidy, trisomy 21 or 18, hydrops fetalis
  • female fetus
37
Q

What investigations can be done for hyperemesis gravidarum?

A
  • FBC to exclude alternative aetiologies
  • metabolic panel might show hypokalaemia or hyponatraemia
  • LFTs to exclude pancreatitis, hep, biliary causes
  • U+Es may be elevated in hyperemesis
  • TFTs often abnormal (reduced TSH)
    • order free T4 to exclude hyperthyroid
  • urinanalysis -> ketonuria in hyperemesis, rule out UTI
  • fetal USS -> multiple gestation? trophoblastic disease? exclude mole
  • H.Pylori breath test
38
Q

What is the conservative treatment for hyperemesis gravidarum?

A
  • dietary modifications
    • smaller, frequent meals
    • sour + tart liquids > water
    • bland food, high in carbs, low in fat
    • salty foods in morning
  • acupressure or acupuncture
  • ginger 250mg qds
39
Q

What are pharmacological treatments for hyperemesis gravidarum?

A
  • 1st Line → antihistamines (promethazine then cyclizine)
  • 2nd Line → ondansetron and metocloperamide
  • Administer thiamine (Vit B1)
  • Extreme cases → steroids (after first trimester), total parenteral nutrition
40
Q

What is the treatment in hyperemesis gravidarum patients with volume depletion?

A
  • IV fluid replacement of either:
    • Ringer’s lactate
    • 0.9% NaCl + K
    • 5% dextrose-saline
    • Hartmann’s
  • maintenance fluids - 2/3L / day
41
Q

Epidemiology of miscarriages:

  • What is a miscarriage?
  • When do they most commonly occur?
  • How common are they?
A
  • miscarriage = loss of pregnancy at less than 24 weeks gestation
  • early miscarriages occur in the first trimester (<12-13 wks)
  • early miscarriages more common than late miscarriages (13-24wks)
  • relatively common - occur in 20-25% of pregnancies
42
Q

The majority of spontaneous miscarriages occur in the first trimester, with <3% occurring in the second trimester.

What are the causes of miscarriage?

A

Can be divided into embryonic and/or maternal factors, although likely to be multi-factorial.

  • Embryonic factors:
    • majority of first-trimester miscarriages are due to primary embryonic disease/damage
    • 80% chromosomally abnormal + positive FHx (x2 likely if 1o female relative exp spontaneous miscarriage)
    • embryonic malformations (esp of CNS)
  • Maternal factors:
    • many second-trimester miscarriages due to maternal genital tract dysfunction or infection or systemic ilness
    • maternal exposure to high dose toxic agents
    • asymptomatic BV
    • large sub-mucosal fibroids
    • cervical incompetence
    • rehsus iso-immunisation

In the first trimester the most common cause of miscarriage is chromosomal abnormality (50-60%) - trisomy 16, 45x karyotype. In the second trimester miscarriage is commonly due to an incompetent cervix.

43
Q

What are the risk factors for miscarriage?

A
  • maternal age >30-35
  • prev recurrent miscarriages
  • obesity
  • chromosomal abnormalities (maternal or paternal)
  • smoking
  • uterine abnormalities
  • prev uterine surgery
  • anti-phospholipid syndrome
  • coagulopathies
  • bacterial vaginosis
44
Q

What are the diagnostic factors in a history for miscarriage?

A
  • presence of risk factors
  • vaginal bleeding +/- clots
  • suprapubic cramping pain
  • low back pain
  • recent post-coital bleed
45
Q

What signs are seen on examination for miscarriage?

A
  • haemodynamic instability - pallor, tachycardia, tachypnoea, hypotension
  • abdominal examination - distended w/ localised areas of tenderness
  • speculum examination - assess diameter of cervical os, observe for any products of conception in cervical canal or local areas of bleeding
  • bimanual examination - assess any uterine tenderness and any adnexal masses or collections (consider ectopic pregnancy)
46
Q

What are the main 3 differential diagnoses that should be excluded, not including miscarriage?

A
  • ectopic pregnancy
  • hydatidiform mole
  • cervical/uterine malignancy
47
Q

What are the 6 different types of miscarriages and what are each of their clinical features?

A
  • threatened - mild bleeding +/- pain, cervix closed, viable pregnancy, 25% miscarry
  • inevitable - heavy bleeding, clots, pain, internal cervical os open, fetus can be viable or non-viable
  • missed - asymptomatic or Hx of threatened miscarriage, on-going discharge, small for dates uterus, no foetal heart pulsation in foetus where crown rump >7mm
  • incomplete - prods of conception partially expelled - sx of missed miscarriage or bleeding/clots, A/P endometrial diameter >15mm + proof that there was IU pregnancy present previously
  • complete - hx of bleeding, passing clots + PoC + pain, sx settling, no PoC seen in uterus, w/ endometrium that is <15mm diameter + prev proof of IU pregnancy
  • septic - infected PoC: fever, rigors, uterine tenderness, bleeding/discharge, pain, leucocytosis, raised CRP + can be features of complete or incomplete
48
Q

In the UK, patients with a suspected miscarriage (positive urine pregnancy test + vaginal bleeding +/- pain) should be investigated in an Early Pregnancy Assessment Unit with access to scanning equipment and expertise in managing early pregnancy problems.

How do you make a definitive diagnosis of miscarriage?

A
  • transvaginal ultrasound scan
  • most important finding to exclude miscarriage is fetal cardiac activity
  • observed transvaginally at 5.5-6wks of gestation
  • gestation can be estimated by the foetal crown rump length
    • but if <7.0mm + no foetal heart is identified, a conclusive diagnosis of miscarriage cannot be made - a repeat scan in at least 7 days is required
  • if foetal pole not visible, but intrauterine pregnancy is confirmed w/ gestational sac + yolk sac, management depends on the mean sac diameter (MSD) - obtained by measuring gestational sac in 3 dimensions:
    • if ≥25mm, a diagnosis of failed pregnancy can be made
    • if <25mm, a repeat scan needs to be arranged in 10-14 days

Can use transabdominal scanning for those w/ enlarged uterus or other pelvic pathology - not as sensitive and specific as TV USS.

49
Q

If ultrasound is not immediately available, what blood tests can be done to diagnose miscarriage?

A
  • serum b-HCG titres - falling
    • drop of >50% in 48hrs -> failing pregnncy
  • FBC -> low Hb
  • urine pregnancy test -> positive
  • rhesus blood group -> identifies Rh-negative blood group + need for anti-D immunoglobulin administration
50
Q

There are three options for the definitive management of miscarriage, which all carry a similar risk of infection.

Regardless of treatment type, if the patient is Rhesus negative and is greater than 12 weeks gestation, they require anti-D prophylaxis. If they are managed surgically, regardless of the gestation, they require anti-D (if RhD-ve).

Describe the conservative management of miscarriage

A

if expectant, allows products of conception to pass naturally

pts should have 24/7 access to gynae services during this time

  • advantages: can remain at home, no side-effects, no anaesthetic or surgical risk
  • disadvantages: unpredictable timing, heavy bleeding + pain during passage of PoC, chance of being unsuccessful requiring further intervention + transfusion
    • follow-up: some units arrange repeat scan in 2 weeks, others arrange preg test 3 weeks later
  • contraindications: infection, high risk of haemorrhage ie. coagulopathy, haem instability
51
Q

What is the medical management of miscarriage?

A
  • use of vaginal misoprostol (prostaglandin analogue)
  • stimulates cervical ripening + myometrial contractions
  • can be preceded by mifepristone 24-48hrs prior to administration
  • advantages: at home, avoid anaesthetic + surgical risk
  • disadvantages: SEs - vom/diarrhoea, heavy bleeding + pain during passage of PoC, chance of requiring emergency surgical intervention
  • follow-up: preg test 3 weeks later
52
Q

What is the surgical management of miscarriage?

A
  • manual vacuum aspiration w/ local anaesthetic if <12 wks
  • OR evacuaton of retained products of conception (ERPC)
    • under GA
    • speculum passed to visualise cervix
    • dilated + suction tube passed to remove PoC
    • discharged same day

Surgical options are indicated if haemodynamically unstable, infected tissue or gestational trophoblastic disease. Advantages of this are that it is a planned procedure (may help pt to cope) and that pt is unaware during process. Disadvantages include anaesthetic risk, infection, uterine perforation, haemorrhage, Asherman’s syndrome, bowel or bladder damage and retained PoC

53
Q

What is the tailored management for the following different types of miscarriage?

  • threatened
  • inevitable
  • missed
  • incomplete
  • complete
  • septic
A
  • threatened - if heavy bleeding admit/observe, if not reassure + back to GP/midwife. If >12wks + Rh -ve -> Anti-D
  • inevitable - if heavy bleeding admit/observe, offer conserv/med/surg options. Likely to proceed to incomplete/complete miscarriage. If >12wks + Rh -ve -> Anti:D
  • missed - may want to rescan + 2nd person to confirm, manage conserv/med/surgically. If >12wks + Rh-ve -> Anti-D
  • incomplete - expectant, med or surg mgmt. If >12wks + Rh -ve -> Anti-D
  • complete - discharge to GP, if >12wks + Rh -ve -> Anti-D
  • septic - med or surg mgmt, IV Abx + fluids, if >12 wks + Rh -ve -> Anti-D
54
Q

What are the key points of counselling a woman who has suffered recent foetal loss?

A
  • miscarriage is a common occurrence, pt is not alone - 1/5 pregnancies end in miscarriage
  • patient couldn’t have done anything to prevent the miscarriage
  • not necessarily an underlying cause for miscarriage
  • the risk of miscarriage in the next pregnancy is not any higher
  • patient has a chance to have successful pregnancy in future
  • no investigations needed unless 3 miscarriages occur in a row
  • inform about support groups - leaflets + tel numbers
  • offer time off work if required
  • display empathy + establish social, family or spiritual support networks
  • suggest pt tries again when emotionally ready
55
Q

Recurrent miscarriage is defined by the Royal College of Obstetricians and Gynaecologists as ‘the occurrence of three or more consecutive pregnancies that end in miscarriage of the fetus before 24 weeks of gestation‘.

What are the causes of recurrent miscarriage?

A
  • idiopathic recurrent miscarriage (50%)
  • genetic - embryonic chromosomal abnormalities + paretnal chromosomal abnormalities
  • anatomical - cervical incompetence
  • immune - antiphospholipid syndrome
  • thrombophilic - factor V leiden, protein C/S deficiency
  • endocrine - PCOS, hyperprolactinaemia, thyroid, DM
  • infective - BV
  • environmental - chemicals, alcohol, smoking, caffeine, xrays
56
Q

An ectopic pregnancy is a fertilised ovum implanting and maturing outside of the uterine endometrial cavity, with the most common site being the fallopian tube (97%), followed by the ovary (3.2%) and the abdomen (1.3%).

What are the risk factors for an ectopic pregnancy?

A

PIPPA:

  • P - prev ectopic
  • I - intrauterine contraceptive device
  • P - pelvic inflammatory disease
  • P - pelvic or tubal surgery
  • A - assisted reproduction

NB. A third of women with an ectopic have no risk factors

57
Q

What is the clinical presentation of an ectopic pregnancy?

A
  • abdominal pain
    • typically uniliteral + lower
      • vomiting -> tubal rupture
    • shoulder tip pain
  • abdominal tenderness - guarding
  • amenorrhoea - LMP typically 6-8 wks before presentation
  • vaginal bleeding + discharge
  • adnexal tenderness or mass
  • haemodynamically unstable if rupture

*vaginal bleeding in ectopic pregnancy is the result of decidual breakdown in the uterine cavity due to suboptimal β-HCG levels. Bleeding from a ruptured ectopic pregnancy is usually intra-abdominal, not vaginal.

58
Q

What are the relevant investigations for a suspected ectopic pregnancy?

A
  • pregnancy test (B-hCG) -> positive - “suboptimal rise in hCG”
  • once confirmed, TVUS to determine location of pregnancy
    • ectopic pregnancy is visualised on TVUS (either by ‘doughnut sign’ - presence of a heterogenous adnexal mass separate from two clearly identified ovaries, or ‘ring of fire’ - increased blood flow to the ectopic gestation seen on colour Doppler)
    • an intrauterine pregnancy should be seen by 5 weeks after the last menstrual period
  • alternative: consider transabdominal USS for women w/ enlarged uterus or other pelvic pathology
  • group + save / cross match 4 units + FBC
59
Q

What is meant by ‘pregnancy of unknown location’?

A

If a pregnancy cannot be identified on ultrasound scan (but β-HCG is positive), this is termed a pregnancy of unknown location. It has three main differential diagnoses; (i) very early intrauterine pregnancy; (ii) miscarriage; and (iii) ectopic pregnancy. In this situation, a serum β-HCG should be taken:

  • if initial β-HCG level is >1500 iU (discriminatory level) + there’s no intrauterine pregnancy on TVUS, then this should be considered an ectopic pregnancy until proven otherwise + diagnostic laparoscopy should be offered
  • If the initial β-HCG level is <1500 iU and the patient is stable, a further blood test can be taken 48 hours later:
    • in a viable pregnancy, HCG level would be expected to double every 48hrs
    • in a miscarriage, HCG levels would be expected to halve every 48hrs
    • where the inc or drop in the rate of change is outside these limits, an ectopic pregnancy cannot be excluded + pt should be managed accordingly
60
Q

What are the treatment options for an ectopic?

A
  • Expectant
  • Medical → methotrexate
  • Surgical:
    • laparoscopy is preferred approach wherever possible
    • salpingectomy is preferred to salpingostomy if no other risk factors for subfertility

Remember: need follow-up in next pregnancy. All should be seen in Early Pregnancy Unit at 6 weeks for assessment and ultrasound.

61
Q

What is a hydatidiform mole?

A

Hydatidiform moles are chromosomally abnormal pregnancies that have the potential to become malignant (gestational trophoblastic neoplasia).

Gestational trophoblastic disease includes tumours of fetal tissues, including hydatidiform moles, arising from placental trophoblasts. Syncytiotrophoblasts secrete human chorionic gonadotrophin and, therefore, this hormonal product is used as a tumour marker for the disease.

62
Q

What is choriocarcinoma?

A

Choriocarcinoma is a rare cancer that occurs as an abnormal pregnancy. A baby may or may not develop in this type of pregnancy.

The cancer may also occur after a normal pregnancy. But it most often occurs with a complete hydatidiform mole. This is a growth that forms inside the womb at the beginning of a pregnancy. The abnormal tissue from the mole can continue to grow even after attempted removal, and can become cancerous.

About one half of all women with a choriocarcinoma had a hydatidiform mole, or molar pregnancy. Choriocarcinomas may also occur after an early pregnancy that does not continue (miscarriage). They may also occur after an ectopic pregnancy or genital tumor.

*Medicine: Obstetrics + Gynaecology (12 decks)

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