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O&G > Early pregnancy > Flashcards

Early pregnancy Flashcards

1
Q

Risk factors for Miscarriage

A
  • advancing age
  • 2 or more consecutive miscarriages
  • Uncontrolled DM/thyroid
  • Uterine abnormalaities e.g. cone biopsy
  • smoking/alcohol
  • weight - over or under
  • invasive prenatal testing/chromosomal anomalies
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2
Q

what % of pregnancies end in early miscarraige

A

15-20%

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3
Q

Risk factors for ectopic pregnancy

A 
Previous PID
Smoking
prior tubal surgery
Hx of infertility
Assisted conception
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4
Q

What investigations should be carried out if suspecting an ectopic pregnancy

A
  • FBC, G&S
  • Serum progesterone and HCG
  • US
  • 2 large bore cannulas
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5
Q

What may you seen on USS in ectopic pregnancy

A

Extra uterine pregnancy
intra peritoneal haemorrage
NB. No signs of ectopic does not rule it out

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6
Q

What progesterone and bHCG would you expect to see in a viable pregnancy

A
  • bHCG increasing >53% every 48 hours

- Progesterone >60

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7
Q

Who can have medical management of an ectopic pregnancy

A
  • HCG <3000
  • <3cm if seen on scan
  • No fetal activity
  • Aysmptomatic/mild
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8
Q

What is the medical management of an ectopic pregnancy

A
  • methotrexate - folate antagonist
  • Repeat HCG in 4-7 days
  • repeat dose if bHCG <15%
  • reliable contraception for 3 months after
  • Low threshold for representing
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9
Q

Who should have surgical management of an ectopic pregnancy

A
  • unstable

- symptomatic

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10
Q

What is a threatened miscarriage

A

Confirmed pregnancy
Vaginal bleeding
Os closed
75% settle

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11
Q

What is an inevitable miscarriage

A

bleeding

cervical os is open

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12
Q

What is an incomplete miscarriage

A

Some pregnancy tissue remains in the womb

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13
Q

What is a delayed miscarriage

A

Pregnancy stopped growing or no fetal heart beat
no bleeding or sx
Cervical Os is closed

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14
Q

What should you ALWAYS as when seeing a patient who’s bleeding in early pregnancy

A
  • LMP
  • date of first pregnancy test
  • severity of bleeding
  • pain: referred, shoulder tip, rectal
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15
Q

At what point would you begin to see finding on USS in early pregnancy

A
  • sac begins to be seen 4.5-5 weeks

- no findings prior to this

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16
Q

How do you diagnose a miscarriage on USS

A
  • Crown-rump length <7mm
  • No fetal heart detection
  • Mean gestational sac diameter of 25mm with no yolk sac or embryo
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17
Q

What are the risks/disadvantages of expectant management of miscarriage

A
  • infection 1%
  • haemorrhage 2%
  • Risk of retained tissue (>6w)
  • Uncertainty
  • bleeding at home
  • passing concepti
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18
Q

What is expectant management

A
  • watch and wait -> effective 50%
  • Usually takes around 3 weeks
  • Pregnancy test after 1 week
  • Rescan if still bleeding days 10-14
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19
Q

Who can have expectant management

A

not bleeding heavily

not missed/delayed miscarriage

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20
Q

What is used in medical management

A
  • Misoprostol - vaginal pessary or 2 tablets
  • effective 80-90%
  • takes up to 3 weeks
  • Can be done as an inpatient or outpatient
  • pregnancy test at 3 weeks
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21
Q

What are the risks/disadvantages of medical management of miscarriage

A

Painful
Very heavy bleeding
Infection 1%
Haemorrhage 1%

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22
Q

What does misoprostol do?

A

Causes uterine contractions

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23
Q

Safety net for a woman who is miscarrying

A
  • heavy or prolonged vaginal bleeding
  • smelly vaginal discharge
  • fever/flu symptoms
  • increasing abdominal pains
  • loss of appetite
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24
Q

What is surgical management of a miscarriage

A

operation to remove tissue under general or local anaesthetic - 95% effective

  • Given a tablet/pessary to soften cervix then tissue is removed
  • done within a few days
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25
Q

What are the risks of surgical management of miscarriage

A 
Infection 1%
Heavy bleeding
damage to the womb
1/30 000 require hysterectomy
uterine adhesions
risks of GA
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26
Q

What happens to tissue in surgical removal

A
  • remains can be tested to ensure it was a pregnancy and no abnormal cells were there
  • chose to bury or cremate the remains
  • discuss further with a nurse
27
Q

What advise should you give RE vaginal bleeding following a miscarriage

A
  • Heavy for a few days then lessen to brown
  • Sanitary towels over tampon - reduce ifnection
  • bleed 1-2 weeks
  • regular period in 4-6 NB. NOW FERTILE!!!
28
Q

When can you return to work after a miscarriage

A
  • rest for a few days before starting routine activities

- most return in a week but variable

29
Q

When can you have sex after a miscarriage

A

whenever you both feel ready

30
Q

What is triple testing

A
  • optional maternal blood test weeks 14-20
  • detects down syndrome and spina bifida
  • 3-7 days for results to come back
  • if results low, no further action
31
Q

what does triple testing assess

A

AFP
hCG
Oestradiol

32
Q

What may you see in triple testing if down syndrome is present

A

HCG raised

AFP and oestradiol reduced

33
Q

Explain spina bifida

A
  • incomplete closure of spinal cored
  • may lead to disability
  • hydrocephalus
  • incontinence
34
Q

What is hydrocephalus

A

increased pressure in fluid in the brain which can gradually damage the brain function esp. if untreated

35
Q

What is the management of chicken pox exposure in pregnant women

A
  • urgently check mother of VZIG if any doubt whether she has had chicken pox
  • If not immune, VZIG immunoglobulin immediately (up to 10 days post exposure)
36
Q

What is the management of pregnant women with chicken pox

A

Oral aciclovir within 24 hours of onset of rash

37
Q

Features of fetal varicella syndrome

A
  • skin scarring
  • eye defects (microphthalmia)
  • limb hypoplasia
  • microcephaly
  • learning disabilities
38
Q

What are the risk of fetal varicella syndrome in infants of mothesr exposed to chicken pox

A
  • 1% <20 weeks
  • few 20-28
  • 0 <28 weeks
39
Q

What is the risk to the mother if exposed to chickenpox during pregnancy

A

5 times greater risk of pneumonitis

40
Q

What the causes of recurrent miscarriage

A
  • Idiopathic (particularly in older women)
  • Antiphospholipid syndrome
  • Other thrombophilias (usually second trimester)
  • Uterine abnormalities unsupportive of pregnancy (usually second trimester)
  • Genetic factors in parents (e.g. balanced translocations in parental chromosomes)
  • Chronic histiocytic intervillositis
  • Other chronic disease (e.g. diabetes or SLE)
41
Q

What investigations should you conduct for recurrent miscarriages

A

Antiphospholipid antibodies
Pelvic ultrasound
Genetic testing on parents (microarray test)

42
Q

What is Chronic histiocytic intervillositis

A
  • A rare cause of recurrent miscarriages, particularly in the second trimester.
  • This can also lead to IUGR and intra uterine death.
  • Diagnosed by placental histology showing inflammatory infiltrates by mononuclear cells in the intervillous spaces of the placenta.
43
Q

What are the legal requirements for a termination of pregnancy

A
  • 2 medical practitioners must sign to agree that the abortion is indicated.
  • It must be carried out by a medical practitioner in an NHS or licensed premise
44
Q

What is a medical termination of pregnancy

A
  • Mifepristone (anti-progestogen) to followed 1-2 days later with misoprostol (prostaglandin)
  • Up to 9 weeks gestation
45
Q

What is a surgical termination of pregnancy

A
  • Cervical dilatation and suction of the contents of the uterus (usually up to 15 weeks)
  • Cervical dilatation and evacuation using forceps (between 15 and 24 weeks)
46
Q

What must you tell a patient Post termination of pregnancy

A
  • Often left with temporary vaginal bleeding and abdominal cramps.
  • Use contraception (fertility usually returns immediately)
47
Q

What are the complications of termination of pregnancy

A
  • Infection (common and if untreated could lead to pelvic inflammatory disease)
  • Bleeding (common)
  • Pain (common)
  • Failure of abortion (pregnancy continues)
  • Damage to local structures such as the cervix or uterus
48
Q

What is the criteria hyperemesis gravidarum

A
  • > 5 % weight loss (compared with pre-pregnancy)
  • Dehydration
  • Electrolyte imbalance
49
Q

what causes severe nausea and vomiting in early pregnancy

A
  • high beta hcg: molar pregnancies and multiple pregnancies
  • worse in first pregnancy
  • worse in obese/overweight women
50
Q

How do you assess the severity of nausea and vomiting in pregnancy

A

Pregnancy-Unique Quantification of Emesis Score (PUQE).

This gives a score out of 15:

Mild <7
Moderate 7-12
Severe >12

51
Q

Which anti-emetics can be prsecribed for nausea and vomting

A
  1. Prochlorperazine (stemetil)
  2. Cyclizine
  3. Ondansetron
  4. Metoclopramide (short term use only – theoretical risk of oculogyric crisis)
52
Q

What complementary therapies do the RCOG recomemned for morning sickness

A
  • Ginger
  • Acupressure on the wrist at the P6 point (inner wrist)
  • Acupuncture
53
Q

When should admission be considered for women with severe morning sickness

A
  • Unable to tolerate oral antiemetics / keep down any fluids
  • Ketones on urinalysis
  • electrolyte imbalances (e.g. hypernatraemia)
  • co-morbidities
54
Q

Management of severe hyperemesis gravidarum

A
  • IV antiemetics
  • IV fluids
  • Thiamine supplementation to prevent deficiency (prevents Wernicke-Korsakoff syndrome)
  • Thromboprophylaxis
55
Q

What is a hyaditiform mole

A

Tumour that grows in the uterus - molar pregnancy

2 types: complete and partial

56
Q

What is a complete mole

A

two sperm cells fertilise an ovum that contains no genetic material (an “empty ovum”). These sperm then combine genetic material and the cells start to divide and grow into a tumour called a complete mole. No fetal material will form.

57
Q

What is a partial mole

A

two sperm cells fertilise a normal ovum (containing genetic material) at the same time. The new cell now has three sets of chromosomes (it is a haploid cell) and this starts to divide and two into a tumour called a partial mole. In a partial mole, some fetal material may form.

58
Q

What signs may indicate a molar pregnancy over a normal pregnancy

A
  • More severe morning sickness.
  • Vaginal bleeding
  • Increased enlargement of the uterus
  • Abnormally high bHCG
  • Thyrotoxicosis (bHCG can mimimic TSH and stimulate the thyroid to produce excess T3 and T4)
59
Q

What will you see on pelvic USS if there is a molar pregnancy

A
  • snowstorm appearance

- must be confirmed with histology after evacution

60
Q

What is the management of a molar pregnancy

A
  • Evacuation of the uterus
  • Send the products of conception for histology
  • Refer to the gestational trophoblastic disease centre
  • Measurements of bHCG to ensure they return to normal
  • Occasionally the mole can metastasise and the patient may require chemotherapy
61
Q

What are the risks of smoking in pregnancy

A
  • Intrauterine growth restriction
  • Miscarriage
  • Stillbirth
  • Pre-term labour
  • Placental abruption
  • Pre-eclampsia
  • Cleft lip / palate
62
Q

What medications and supplements should you take pre-conception

A
  • Take folic acid 400mcg from before pregnancy to 12 weeks (reduces neural tube defects)
  • Take vitamin D supplement
63
Q

What should you avoid during pregnancy

A
  • Alcohol
  • Liver and pate- Vitamin A
  • Avoid unpasturised dairy or blue cheese (listeriosis)
  • Avoid undercooked or raw poultry (salmonella)

O&G (13 decks)

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