Early Pregnancy Flashcards
1
Q
What is an ectopic pregnancy?
A
Pregnancy which is implanted outside the uterus
2
Q
Where is an ectopic pregnancy most likely to implant?
A
Fallopian tubes
3
Q
What are the risk factors of ectopic pregnancy?
A
Previous ectopic pregnancy Previous pelvic inflammatory disease Previous surgery to the Fallopian tubes Intrauterine devices Older age Smoking
4
Q
What are the features of an ectopic pregnancy?
A
Missed period
Constant lower abdominal pain in the right or left iliac fossa
Vaginal bleeding
Lower abdominal or pelvic tenderness
Cervical motion tenderness (pain when moving the cervix during a bimanual examination)
It is also worth asking about…
Any dizziness (indicates blood loss) Shoulder tip pain (peritonitis)
5
Q
What investigations would you carry out for an ectopic pregnancy?
A
Pregnancy test (urine B-HCG)
If positive- pelvic USS should be performed, this determines the presence of absence of an intrauterine ‘normal’ pregnancy. If an intrauterine pregnancy is not seen on trans abdominal USS then transvaginal should be offered
6
Q
What could of happened if pregnancy is not identified on ultrasound scan but the pregnancy test comes back as positive?
A
Very early intrauterine pregnancy
Miscarriage
Ectopic pregnancy
7
Q
How do you distinguish between early intrauterine pregnancy, miscarriage and ectopic pregnancy?
A
In this situation a serum BHCG level should be taken
If the initial B-HCG level is >1500 and there is no intrauterine pregnancy on trans vaginal ultrasound, then this should be considered an ectopic pregnancy until proven otherwise, a diagnostic laparoscopy should be offered.
If the initial B-HCG level is <1500 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 48 hours
. In a miscarriage, HCG level would be expected to halve every 48 hours
8
Q
What is the immediate treatment of an ectopic pregnancy?
A
Admission to hospital
A to E approach if they are unstable
This may include the use of blood products if there are signs of haemodynamic instability.
9
Q
What is the medical management of an ectopic pregnancy?
A
IM methotrexate
10
Q
How does methotrexate work in terms of abortion?
A
An anti folate cytotoxic agent which disrupts the folate dependent cell division of the developing foetus, the pregnancy will then gradually resolve.
11
Q
What are the advantages and disadvantages of IM methotrexate?
A
Advantages: avoids the complications of surgical management and the patient can be at home after the injection.
Disadvantages: potential side effects of methotrexate- abdominal pain, myelosuppression, renal dysfunction, hepatitis, teratogenesis (patient must use contraception for 3-6 months after methotrexate use)
12
Q
What is the surgical management of ectopic pregnancy?
A
Laparoscopic salpingectomy is usually performed- removing the tube that it is implanted in.
Salpingotomy May be needed if collateral tube is also affected.
13
Q
What are the advantages and disadvantages of surgical management of an ectopic pregnancy?
A
Advantages- reassurance about when the definitive treatment can be provided, high success rate
Disadvantages: general anaesthetic risk, risk of damage to neighbouring structures like the bladder, bowel ureters, DVT/PE, haemorrhage, infection.
All rhesus negative women who Recieve surgical management of an ectopic pregnancy, should be offered Anti D prophylaxis.
14
Q
What is the conservative management of an ectopic pregnancy?
A
Watchful waiting of the stable patient while allowing the ectopic pregnancy to resolve naturally. This is suitable for a small number of patients only.
15
Q
What are the complications of an ectopic pregnancy?
A
An untreated ectopic pregnancy can lead to Fallopian tube rupture, the resulting blood loss can result in hypovolaemia shock and result in organ failure and death.
16
Q
What is a miscarriage?
A
Spontaneous termination of a pregnancy
17
Q
What is the difference between early and late miscarriage?
A
Early miscarriage is before 12 weeks gestation
Late miscarriage is between 12 and 24 weeks gestation
18
Q
What is a missed miscarriage?
A
The foetus is no longer alive but no symptoms have occurred
19
Q
What is a threatened miscarriage?
A
Vaginal bleeding with a closed cervix and a foetus which is alive
20
Q
What is an inevitable miscarriage?
A
Vaginal bleeding with an open cervix
21
Q
What is an incomplete miscarriage?
A
This is where retained products of conception remain in the uterus after the miscarriage
22
Q
What is a complete miscarriage?
A
A full miscarriage has occurred, there are no products of conception left in the uterus.
23
Q
What is an anembryonic pregnancy?
A
Gestational sac is present but contains no embryo
24
Q
How do you diagnose a miscarriage?
A
Transvaginal ultrasound scan is the investigation of choice for diagnosing a miscarriage
25
What are the risk factors for miscarriage?
```
Maternal age >30-35
Previous miscarriage
Obesity
Chromosomal abnormalities
Smoking
Uterine anomalies
Previous uterine surgery
Anti phospholipid syndrome
Coagulopathies
```
26
What are the clinical features of miscarriage?
Vaginal bleeding, including passing clots or products of conception however many are found incidentally on ultrasound
27
How would someone present if there is excessive bleeding iniscarriage?
Dizziness, pallor and shortness of breath. The bleeding is also often accompanied by a suprapubic cramping pain
28
What signs would you have on examination of a patient who has suffered from miscarriage?
Haemodynamic instability- pallor, tachycardia, tachypnoea, hypotension
Abdominal examination- abdomen may be distended, with localised areas of tenderness
Speculum examination- assess the diameter of the cervical os, and observe for any products of conception in cervical canal, or local areas of bleeding
Bimanual examination- looking for any uterine tenderness and any adnexal masses or collections (consider ectopic pregnancy)
29
What is differential diagnosis of miscarriage?
Ectopic pregnancy
Hydatidiform mole
Cervical/uterine malignancy
30
How do you diagnose miscarriage in imaging?
Transvaginal ultrasound scan
Most important finding to exclude a miscarriage is fetal cardiac activity, observed transvaginally at 5 1/2-6 weeks gestation
If the crown rump length is <7mm and no foetal heart rate is identified, then a scan is needed again in at least 7 days.
31
What other tests other than a transvaginal ultrasound (ruling out ectopic pregnancy/miscarriage) would you want to do for a woman bleeding during pregnancy?
Blood tests
Serum b-HCG measurements are useful in assessing the possibility of an ectopic pregnancy.
Other investigations indicated in women bleeding are...
. FBC
. Blood group and rhesus status
. Triple swabs and CRP (if pyrexial)
32
What are the advantages and disadvantages of conservative management of miscarriage?
Conservative management allows the products of conception to pass naturally.
Patients should have 24/7 access to gynaecology services during this time
Advantages- can remain at home, there are no side effects of medications, no anaesthetic or surgical risk
Disadvantages- unpredictable timing, HMB, pain during passage of POC, chance of being unsuccessful requiring further intervention and need for transfusion.
33
How can you follow up someone who has had a conservative management of miscarriage?
Scan in 2 weeks or pregnancy test in 3 weeks.
34
What are the contraindications of conservative management of miscarriage?
Infection
| High risk of haemorrhage- coagulopathy, haemodynamic instability
35
What is the medical management of miscarriage?x
Vaginal misoprostol (prostaglandin analogue) this stimulates cervical ripening and myometrial contractions.
36
What are the advantages, disadvantages of medical management of miscarriage and what is the follow up?
Ad.vantages- can be at home if patient desires, with 24/7 access to gynaecology services, avoid anaesthetic and surgical risk
Disadvantages- side effects of medication, vomiting, diarrhoea, heavy bleeding and pain during passage of POC, chance of requiring emergency surgical intervention
Follow up- pregnancy test 3 weeks after
37
What is the surgical management of miscarriage?
Manual vacuum aspiration with local anaesthetic if <12 weeks or evacuation of retained products of conception (ERPC)
'Undergoing a surgical procedure under local or general anaesthetic'
The two main options are vacuum aspiration (suction curettage) or surgical management in theatre
Vacuum aspiration is done under local anaesthetic as an outpatient
- Surgical management is done in theatre under general anaesthetic. This was previously referred to as 'Evacuation of retained products of conception'
38
What are the indications for surgical management of miscarriage?
increased risk of haemorrhage
she is in the late first trimester
if she has coagulopathies or is unable to have a blood transfusion
previous adverse and/or traumatic experience associated with pregnancy (for example, stillbirth, miscarriage or antepartum haemorrhage)
evidence of infection
39
What are the advantages and disadvantages of surgical management of miscarriage?
Advantages- planned procedure, and unaware of procedure (patient is under GA)
Disadvantages- anaesthetic risk, infection (endometritis), uterine perforation, haemorrhage, Ashermann syndrome, bowel or bladder damage, retained products of conception.
40
What is recurrent miscarriage?
The occurrence of three or more consecutive pregnancies that end in miscarriage of the foetus before 24 weeks of gestation.
41
What are the several factors that have been associated with recurrent miscarriage?
Antiphospholipid syndrome refers to the associationbetween antiphodpholipid antibodies and vascular thrombosis or pregnancy failure/complications
Think of 5 main categories
- antiphospholipid
- chromosomal abnormalities
- endocrine
- uterine malformations
- smoking
Genetic factors
Parental Chromosomal rearrangements
Embryonic chromosomal abnormalities
Endocrine factors- PCOS/ diabetes mellitus and thyroid
Uterine malformations
Cervical weakness
Acquired uterine abnormalities
Infective agents
Inherited thrombophilias
42
What are the risk factors of miscarriage?
Advancing maternal age- if there is a decline in both the number and quality of the remaining OOCYTES.
Number of previous miscarriages
Lifestyle- cigarette smoking, moderate to heavy alcohol intake and caffeine consumption have been associated with an increased risk of spontaneous miscarriage in a dose dependent manner
43
What investigations are done for recurrent miscarriage?
Blood tests
Antiphospholipid antibodies
Inherited thrombophilia
Lupus antibodies
```
Genetic tests (karyotyping)
Of foetus and if abnormal then parents
```
TVUS/ abdo US
44
What is gestational trophoblastic disease?
A term used to describe group of pregnancy related tumours, they can be divided into 2 main groups...
Pre malignant conditions- partial molar pregnancy and complete molar pregnancy
Malignant conditions
45
What is antepartum haemorrhage?
Vaginal bleeding from week 24 gestation until delivery
46
What is placental abruption?
Where part or all of the placenta separates from the wall of the uterus prematurely,
47
How does abruption of the placenta occur?
Abruption is thought to occurfollowing a rupture of the maternal vessels within the basal layer of the endometrium, blood accumulates and splits the placental attachment from the basal layer, the detached portion of the placenta is then unable to function which leads to a rapid fetal compromise.
48
What are the two main types of placental abruption?
Revealed- this is where bleeding tracks down from the site of placental separation and drains through the cervix, it results in vaginal bleeding
Concealed- the bleeding remains within the uterus, and forms a clot retroplacentally
The bleeding is not visible but can cause systemic shock
49
What are the risk factors for placental abruption?
```
Previous
Pre eclampsia
Trauma (domestic violence)
Multiple pregnancy
Fetal growth restriction
Multigravida
Increased maternal age
Smoking
Cocaine/amphetamine use
```
50
What are the clinical features of a placental abruption?
Painful vaginal bleeding
If the woman is in labour she may have pain between contractions
On examination the uterus will be tense all the time and painful on palpation
51
What are the differential diagnoses of placental abruption?
Placenta praevia
Marginal placental bleed
Vasa praevia
Uterine rupture
Local genital causes...
benign or malignant lesions (polyps, carcinoma, cervical ectropion (common)
Infections- candidiasis, bacterial vaginosis, chlamydia.
52
What investigations can you do for placental abruption?
If major bleeding is suspected then resuscitate and perform investigations simultaneously
FBC, clotting profile, KLEIHAUER test, group and save, cross match
U and Es, LFTS
CTG (cardiotocograph) in women above 26 weeks gestation
Ultrasound scan
53
How do you manage placental abruption?
Any woman with significant antepartum haemorrhage should be resuscitated with an ABcDE approach, do not delay maternal resuscitation in order to determine fetal viability.
Ongoing management depends on the health of the foetus
Emergency delivery- Caesarean section unless spontaneous delivery is imminent or operative vaginal birth is achievable.
Induction of labour- for haemorrhage at term without maternal or feral compromise
Conservative management- partial or marginal abruption, not associated with maternal or fetal compromise
In all cases give anti D within 72 hours of the onset of bleeding if the woman is rhesus D negative
54
What is placenta praevia?
Where the placenta is fully or partially attached to the lower uterine segment. It is an important cause of antepartum haemorrhage- vaginal bleeding from week 24 of gestation until delivery.
55
What is the difference between a minor and major placenta praevia?
Minor- placenta is low but does not cover the internal cervical os
Major placenta praevia- placenta lies over the internal cervical os
56
What is the risk factor for placenta praevia?
Previous Caesarean section is the main one
Others;
High parity
Maternal age>40
Multiple pregnancy
Previous placenta praevia
History of uterine infection (endometritis)
Curettage to the endometrium after a miscarriage or termination
57
What are the clinical features of placenta praevia?
Clinically presents as painless vaginal bleeding, can vary between spotting to massive haemorrhage. Can be pain if the woman is in labour.
58
What are the bloods for placenta praevia?
```
FBC
Clotting profile
KLEIHAUER test
Group and save
Cross match
```
U and Es
LFTS
Used to exclude hypertensive disorders including pre eclampsia and HELLP syndrome
59
What imaging is done for placenta praevia?
Imaging via ultrasound
60
What is the management of placenta praevia?
A to E approach
If placenta praevia has been identified at their 20 weeks then for a minor it should be repeated at 36 weeks, whereas for a major it should be repeated at 32 weeks and plan for delivery should be made.
Caesarean section is the safest mode of delivery, usually warrants an elective Caesarean section at 38 weeks.
61
What is thought to be responsible for nausea and vomiting during pregnancy?
Human chorionic gonadotropin (produced by the placenta)
62
What is hyperemesis gravidarum?
The severe form of nausea and vomiting in pregnancy, the criteria for diagnosing this is protracted nausea and vomiting, plus...
. More than 5% weight loss compared with before pregnancy
. Dehydration
. Electrolyte imbalance
63
What antiemetics can be used for hyperemesis gravidarum?
1. Prochlorperazine
2. Cyclizine
3. Ondansetron
4. Metaclopramide
Other complimentary therapies may be used by the woman...
. Ginger
. Acupressure on the wrist at the PC6 point (inner wrist) can improve the symptoms
64
What is a molar pregnancy?
This is where there is a hydatiform mole (type of tumour that grows like a pregnancy inside the uterus), can either be partial or complete.
65
Molar pregnancy behaves like a normal pregnancy, periods stop and hormonal changes of pregnancy occur, what things may indicate a molar pregnancy versus a normal pregnancy?
```
More severe morning sickness
Vaginal bleeding
Increased enlargement of the uterus
Abnormally Hugh hCG
Thyrotoxicosis (hCG can mimic TSH and stimulate the thyroid to produce excess T3 and T4)
```
66
How can you diagnose a molar pregnancy?
Ultrasound scan will show ‘ snowstorm appearance’ of the pregnancy
Provisional diagnosis can be made by ultrasound and confirmed with histology of mole after evacuation.
67
How do you manage a molar pregnancy?
Evacuation of the uterus to remove the mole.
The products of conception then 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. HCG levels aren’t monitored until they return to normal
Mole can metastasise and patient may require systemic chemo
68
What is the last gestational age where you can get an abortion?
24 weeks
69
When can an abortion be performed before 24 weeks?
If continuing the pregnancy involves a greater risk to the physical or mental health of...
- the woman
- existing children of the family
The threshold of risk differs from healthcare professionals
70
In what cases can abortion be performed at any time?
- there is a substantial risk that the child would suffer physical or mental abnormalities making it seriously handicapped
Termanating the pregnancy will prevent grave permanent injury to the physicalor mental health of the woman
Continuing the pregnancy is likely to risk the life of a woman
71
What are the legal requirements for abortion
Two registered medical practitioners must sign to agree that abortion is indicated
It must be carried out by a registered medical practitioner in an NHS hospital or approved premise
72
What does pre abortion care involve?
Abortion services can be accessed by self-referral or by GP, GUM or family planning clinic referral. Doctors who object to abortions should pass on to another doctor able to make the referral. Many abortion services are accessed by self-referral, without the involvement of a GP or other doctor to make the referral.
Marie Stopes UK is a charity that provides abortion services. They offer a remote service for women less than 10 weeks gestation, where consultations are held by telephone and medication are issued remotely to be taken at home.
Women should be offered counselling and information to help decision making from a trained practitioner. Informed consent is essential.
73
What are the two treatments involved in a medical abortion?
Mifepristone (anti progestogen)
| Misoprostal (prostanglandin analogue) 1-2 days later
74
What is mifepristone?
An anti progestogen medication which blocks the action of progesterone, halting the pregnancy and relaxing the cervix
75
What is misoprostol
This is a prostaglandin analogue meaning it binds to prostaglandin receptors and activates them
Prostaglandins soften the cervix and stimulate uterine contractions
From 10 weeks gestation, additional misoprostol doses (every 3 hours) are required until expulsion
76
What should you give to women having a medical TOP who are rhesus negative?
Anti D prophylaxis
77
What steps should be taken prior to surgical abortion?
Medications are used for cervical priming, this involves softening and dilating the cervix with misoprostol, mifepristone, osmotic dilators.
Osmotic dilators are devices inserted into the cervix, they gradually expand as they absorb fluid opening the cervical canal
78
What are the 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)
Rhesus negative women having a surgical TOP should have anti-D prophylaxis. The NICE guidelines (2019) say it should be considered in women less than 10 weeks gestation.
79
What does post abortion care involve?
Women may experience vaginal bleeding and abdominal cramps intermittently for up to 2 weeks after the procedure. A urine pregnancy test is performed 3 weeks after the abortion to confirm it is complete. Contraception is discussed and started where appropriate. Support and counselling is offered.
80
What are the complications of abortion?
Bleeding
Pain
Infection
Failure of the abortion (pregnancy continues)
Damage to the cervix, uterus or other structures
81
What is hyperemesis gravidadum?
The severe form of N and V in pregnancy
82
When does N and V occur in pregnancy?
Starts at week 4-7
Worse around 10-12 weeks
Resolves by 16-20
83
What pregnancies are nausea and vomiting worse in?
Molar
Multiple pregnancies
^ due to the higher hCG
First pregnancy
Overweight/obese women
84
What is the criteria for diagnosing hypermesis gravidarum?
More than 5% weight loss compared to before pregnancy
Dehydration
Electrolyte imbalance
85
How can you assess the severity of hyperemesis gravidarum?
The severity can be assessed using Pregnancy Unique Quantification of Emesis (PUQE) this gives a score out of 15
<7 is mild
7-12 is moderate
>12 is severe
86
How do you manage hyperemesis gravidarum?
Antiemetics are used to suppress nausea
The choices are...
1) prochlorperazine
2) cyclizine
3) ondansetron
4) metaclopramide
If reflux is a problem then ranitidine and omeprazole can be used
Complementary therapies include ginger and acupressure
87
When should you admit someone with hyperemesis gravidarum?
- more than 5% weight loss
- can’t tolerate oral antiemetic
- other health conditions
- presence of ketones (2+ is significant)
88
If a patient is admitted with hyperemesis gravidarum, how can you treat them?
IM or IV antiemetics
IV fluids with added potassium chloride
Monitoring of U and Es while having IV therapy
Thiamine supplementation- this prevents deficiency and prevents wernicke korsakoff syndrome
Thromboprophylaxis (TED stocking and LMWH)
89
What is a molar pregnancy?
This is when the patient develops a hydatiform mole (a type of tumour which grows inside the uterus like a pregnancy)
There are 2 types- partial and complete
Partial= where 2 sperm fertilise a normal ovum, the new cell has 3 sets of chromosomes (haploid)
Complete= where 2 sperm fertilise am empty ovum
90
What symptoms would indicate a molar pregnancy?
More severe morning sickness
Vaginal bleeding
An increased enlargement of the uterus
91
What would you find on investigations of a molar pregnancy?
Beta HCG very elevated
Potentially thyrotoxicosis because hCG can mimic TSH and stimulate the thyroid to produce excess T3 and T4
Ultrasound of the uterus which will show a characteristic snowstorm appearance
92
How do you manage molar pregnancy?
Evacuation of the uterus to remove the mole
Products of conception need to be sent for histological diagnosis
Refer to gestational trophoblastic disease centre for management and follow up
HCG levels are monitored until return to normal
Occasionally can metastasise and you will need systemic chemo
