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cOGTEXT > Early Pregnancy Care > Flashcards

Early Pregnancy Care Flashcards

1
Q

what happens at ovulation?

A

ovum released into fallopian tube where it is fertilized

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2
Q

what happens after ovum is fertilized?

A

cells divide and the fertilized ovum becomes a morula then a blastocyst
blastocyst travels along fallopian tube to the uterus where it implants into uterine lining at day 5-8

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3
Q

what happens after the blastocyst implants into uterine wall at day 5-8?

A

inner cells develop into the embryo

outer cells invade the endometrium and become the placenta

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4
Q

what are the possible outcomes of fertilization?

A
  1. embryo in normal location and normal development = live birth
  2. normal/abnormal embryo in a normal location but ending in miscarriage
  3. normal embryo in abnormal location (ectopic pregnancy)
  4. abnormal embryo (molar pregnancy)
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5
Q

most common site for ectopic pregnancy?

A 
fallopian tube (interstitial, isthmic, ampullary or fimbrial)
can also implant in ovary, peritoneum, cervix, scar tissue etc
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6
Q

what is a molar pregnancy?

A

gestational trophoblastic disease in which there is a non-viable fertilized egg with an overgrowth of placental tissue swollen with fluid

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7
Q

2 classifications of molar pregnancy?

A

partial and complete

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8
Q

what is a partial mole?

A

one set of DNA from the egg and 2 set from the sperm (3 sets overall)

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9
Q

what is a complete mole?

A

no DNA in the egg

2 sets in the sperm (either 2 sperm fertilizing the egg or 1 diploid sperm cell)

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10
Q

which type of mole has a foetus?

A

only a partial mole

complete mole is just an overgrowth of placental tissue

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11
Q

at what point is HCG detectable?

A

some sensitive tests can pick it up a levels as low as 20 IU

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12
Q

how should HCG increase in a normal pregnancy?

A

should double every 48 hrs

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13
Q

when does nausea and vomiting usually resolve by?

A

around 16 weeks (when HCG levels peak)

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14
Q

when do placenta and foetal heart develop and begin to function?

A

week 5

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15
Q

what hormone is produced from developing placenta?

A

human placental lactogen (HPL)

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16
Q

what does HPL do?

A

has growth hormone like effects and decreases insulin resistance in the mother
also involved in breast development (alongside oestrogen)

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17
Q

what physiological changes happen in early pregnancy (non-hormonal)?

A 
increases in CO
increased plasma volume
raised HR
ECG changes
functional murmurs
reduced Hb (due to dilution in larger blood volume)
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18
Q

what usually causes minimal bleeding in early pregnancy?

A

implantation bleeding
occurs in 20% of pregnancy
happens just before when womans period would have been due (usually about 10 days after ovulation)

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19
Q

describe implantation bleeding

A

light brown
small volume
(earlier and lighter than would be expected from a period)
usually resolves as the pregnancy continues

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20
Q

what is a subchorionic haematoma?

A

collection of blood between the chorion and the uterine wall

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21
Q

symptoms of subchorionic haematoma?

A

symptoms vary based on size of haematoma and how long it carries on for
symptoms include bleeding, cramping and threatened miscarriage

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22
Q

risks of subchorionic haematoma?

A

usually self resolve

large haematomas may lead to miscarriage or be a source of infection or irritability

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23
Q

describe types of epithelium in the cervix?

A 
ectocervix = tough, squamous epithelium
endocervix = columnar epithelium
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24
Q

what is the transitional zone?

A

squamo-columnar junction between ectocervix and endocervix

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25
Q

how does position of transitional zone change?

A

position changes as a physiological response to menarche, pregnancy and menopause?

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26
Q

what can happen as a result of transitional zone changing position in pregnancy?

A

can lead to exposure of the delicate endocervical epithelium to the acidic environment of the vagina
this leads to a cervical erosion (aka ectropion) which can bleed

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27
Q

what are cervical polyps?

A

benign localised inflammatory outgrowth

can be asymptomatic or can bleed if ulcerated

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28
Q

management of cervical polyps?

A

can be removed if needed

can just be left alone

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29
Q

definition of miscarriage?

A

spontaneous loss of pregnancy between conception and 23+6 weeks

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30
Q

symptoms of miscarriage?

A

usually have bleeding, crampy abdominal pain

some women describe or bring in passed products

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31
Q

classifications of miscarriage

A 
threatened
inevitable 
incomplete
septic
recurrent
missed
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32
Q

threatened miscarriage?

A

when there is risk to pregnancy
bleeding but no cramping
cervical os is closed
US will show intra-uterine pregnancy

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33
Q

when should a foetal heart be present?

A

if foetal pole is present and measuring >7mm

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34
Q

what is an inevitable miscarriage?

A

symptoms consistent with miscarriage and the pregnancy cannot be saved
US scan may show a viable pregnancy or products that are in the process of expulsion
cervical os is open
may see products of conception sitting in cervical os

35
Q

what is an incomplete miscarriage?

A

where some of the products have already passed but there are some products remaining in the uterus
speculum may or may not reveal products in the cervix
os may be closing if all products of conception have passed

36
Q

what is a complete miscarriage?

A

where all products have passed

37
Q

what is a septic miscarriage?

A

where there is an infection alongside an incomplete or a complete miscarriage
woman may experience typical sepsis features

38
Q

what is a recurrent miscarriage?

A

3 or more consecutive pregnancy losses

39
Q

what should be done if a woman has recurrent miscarriage?

A

referral to clinic to be assessed for antiphospholipid syndrome, thrombophilia, balanced translocations and/or uterine abnormalities

40
Q

what is a missed miscarriage?

A

no symptoms of miscarriage or a history of threatened miscarriage
but US shows no viable pregnancy

41
Q

what can cause missed miscarriage?

A 
anembryonic pregnancy (where there is no foetus, just an empty sac)
early foetal demise
42
Q

embryo causes of miscarriage?

A

chromosomal abnormalities

43
Q

maternal causes of miscarriage?

A 
PCOS
diabetes
increasing age
heavy smoking
alcohol
drugs
severe hypertension
obesity
44
Q

uterine causes of miscarriage?

A

septate uteri
bicornate uteri
unicornate uteri

45
Q

immunologic causes of miscarriage?

A

APS

46
Q

infectious causes of miscarriage?

A

CMV
rubella
toxoplasmosis
listeria

47
Q

iatrogenic causes of miscarriage?

A

after chorionic villous sampling or amniocentesis

48
Q

what can increase risk of recurrent miscarriage?

A

increasing maternal/paternal age
previous miscarriages
obesity
APS
structural abnormality in one of the parents (usually a balanced translocation)
cervical weakness can cause second trimester miscarriage (not really proven)
acquired thrombophilia

49
Q

how do previous miscarriages impact risk of further miscarriages

A

risk of miscarriage increases with each subsequent miscarriage, reaching approximately 40% risk after 3 miscarriages

50
Q

main hypothesis of miscarriage pathophysiology?

A

bleeding from chorion or placental bed causes villous/placental dysfunction which starves the foetus of oxygen causing foetal demise

51
Q

when does cervical shock occur?

A

occurs during incomplete miscarriage where the products are sitting in the cervix

52
Q

symptoms of cervical shock?

A 
cramps
severe abdominal pain
nausea
vomiting
sweating
fainting
bradycardia
hypotension
53
Q

management of cervical shock?

A

may need fluid resuscitation
may need uterotonics
only real treatment is to remove the products from the cervix (can be done using speculum and sponge forceps)

54
Q

predominant symptom of miscarriage?

A

bleeding
often have pain of varying amounts
can be haemodynamically unstable if losing a lot of blood

55
Q

how does ectopic usually present?

A

localised pelvic pain
light PV bleeding
may have discharge, shoulder tip pain, shortness of breath, dizziness, collapse, breast tenderness, GI symptoms, urinary symptoms, passage of tissue, rectal pressure or pain on defecation

56
Q

examination signs of ectopic?

A 
pallor
haemodynamic instability (tachycardia, hypotension etc)
signs of peritonism
guarding
general abdo/pelvic pain
adnexal tenderness
cervical motion tenderness
abdo distension
enlarged uterus 
orthostatic hypotension
57
Q

how does molar pregnancy usually present?

A

hyperemesis
other symptoms include large for dates fundus, can have bleeding
some woman describe passing a “grape like” tissue
can have shortness of breath

58
Q

how is molar pregnancy diagnosed?

A 
US scan
HCG levels (very high)
59
Q

how much of a drop in HCG is suspicious of miscarriage?

A

drop of 50% every 48 hrs

60
Q

investigations in ectopic?

A

bloods (FBC, G&S, HCG)
transvaginal US
HCG will not rise as much as its meant to (doesnt double every 48 hrs)

61
Q

US features of molar pregnancy?

A

snowstorm appearence

with or without foetus present

62
Q

management of molar preganncy?

A

surgical evacuation of uterus

monitor HCG for 6 months afterwards

63
Q

how is a threatened miscarriage managed?

A

mostly just watchful waiting with emotional support and realistic discussions about what to expect

64
Q

how is a missed or incomplete miscarriage managed where the woman is haemodynamically stable?

A

should be offered conservative, medical or surgical management
alongside emotional support etc

65
Q

conservative miscarriage management?

A

pregnancy passes with time

offered for up to 2 weeks but can be extended of patient wishes

66
Q

medical management of miscarriage?

A

similar to termination of pregnancy
involves administration of misoprostol
can be done at home or in hospital

67
Q

surgical management of miscarriage?

A

surgical evacuation of uterus under general anaesthetic
or
manual vacuum aspiration under local anaesthetic

68
Q

how is an inevitable or incomplete miscarriage managed if haemodynamically unstable?

A

ABCDE
resuscitation
further management depends on how unwell they are but surgical may be the only option

69
Q

management of septic miscarriage?

A

ABCDE
resuscitation
active management of the miscarriage (medical/surgical)
start sepsis 6

70
Q

management of recurrent miscarriage due to thrombosis (APS, thrombophilia etc)?

A

low dose aspirin and daily fragmin injections to reduce further miscarriage risk
aspirin can be started before or when patient takes +ve pregnancy test
LMWH should be started when IU pregnancy is confirmed

71
Q

when is conservative management of ectopic appropriate?

A 
well patient
compliant with regular follow up
haemodynamically stable
small, unruptured ectopic
low HCG levels
72
Q

what does conservative management of ectopic involve?

A

similar to miscarriage
allows nature to run course
patient asked to return for repeat HCG levels on days 2, 4 and 7 after their initial test
if HCG falls by at least 15% from previous value then they can be repeated weekly until a negative test (<20IU/L) is obtained

73
Q

when is surgical management of ectopic needed?

A 
large ectopic
acutely unwell
rupturing/ruptured ectopic
significant pain
adnexal mass >35mm
ectopic with a visible heartbeat on US
HCG >5000
74
Q

what is involved in surgical management of ectopic?

A

laparoscopy and removal of ectopic pregnancy, usually via salpingectomy
laparotomy may be required if laparoscopy not possible

75
Q

how is molar pregnancy managed?

A

surgical
tissue is collected and sent for histology to determine whether partial or complete mole
once diagnosis made the woman will be followed up at one of the molar pregnancy services

76
Q

who is given anti D in early pregnancy?

A

all rhesus negative women that are undergoing a surgical procedure
require a dose of 500 IU anti-D

77
Q

risks of hyperemesis gravidarum?

A 
dehydration 
ketosis
electrolyte imbalance 
weight loss
altered liver function
mental health problems
anxiety and depression
increased thrombosis risk (dehydration causes hypercoagulable state)
78
Q

management of hyperemesis gravidarum?

A

IV rehydration
electrolyte replacement
anti-emetic (try oral first then other route if not tolerated)
may give PPI/ranitidine to help reflux
prednisolone may be used in protracted, severe cases

79
Q

first line anti-emetics in hyperemesis gravidarum?

A

cyclizine (50mg oral/IM/IV 8 hourly)

prochlorperazine (12.5mg IM/IV 8 hourly)

80
Q

second line anti-emetics in hyperemesis gravidarum?

A

ondansetron (4-8mg IM 8 hourly for max 5 days)

metoclopramide (5-10mg IM 8 hourly)

81
Q

risk of ondansetron?

A

cleft palate

82
Q

risk of metoclopramide?

A

oculogyric crisis which is treatable with procyclidine

83
Q

what nutritional supplements are given in hyperemesis gravidarum?

A

thiamine (50mg tds)
or pabrinex IV
may need NG feeding for TPN in severe enough

cOGTEXT (17 decks)

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