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Obs and Gyne > Early Pregnancy Complications > Flashcards

Early Pregnancy Complications Flashcards

1
Q

What regimen of folic acid should be used pre-pregnancy and for how long?

What patient groups require an alternative regimen? What is the regimen they should be prescribed?

A

0.4mg/day from 1 month pre-conception to 13 weeks gestation.
5mg/day if previous neural tube defects, on antiepileptics, diabetic, obese, HIV+ on co-trimoxazole prophylaxis, sickle cell disease.

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2
Q

What drugs are teratogenic?

Use TERALOWA + ACT to remember.

A 
Thalidomide
Epileptic medications
Retinoid (Vitamin A)
ACEi/ARB
Lithium
Oral contraceptive and hormones.
Warfarin
Alcohol
\+
Aminoglycosides
Chloramphenicol
Tetracyclines
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3
Q

What are 6 main risk factors for ectopic pregnancy?

A 
Damage to tubes
Previous ectopic
Endometriosis
Progesterone-only pill
Intrauterine contraception
IVF
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4
Q

What is the gold-standard investigation for ectopic pregnancy?

A

Trans-vaginal USS

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5
Q

What is expectant management for ectopic pregnancy? When may this approach be used?

A

Monitor over 48 hours, b-hCG should fall. If not, intervention is required.

Only if asymptommatic.

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6
Q

What is the medical management of an ectopic pregnancy?

What follow up tests are required to confirm successful treatment?

A

A single dose of methotrexate. b-hCG at day 4 and 7 to confirm.

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7
Q

What is the surgical management of ectopic pregnancy?

A

Laparoscopic salpingectomy (removal of tube) if contralateral tube is ok.

Salpingostomy to preserve fertility if contralateral tube is damaged/absent.

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8
Q

What are the main indications for surgical management of ectopic pregnancy?

A

> 35mm, has ruptured, heartbeat present, b-hCG > 5000 IU

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9
Q

How is a molar pregnancy managed?

A

Managed at specialist centre.

Gentle suction to remove molar products.

Anti-D if indicated by mother’s Rhesus status.

Pregnancy to be avoided until b-hCG normalises (utilise contraception for up to 12 months if necessary)

Screen for choriocarcinoma - responds well to methotrexate-based chemotherapy.

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10
Q

What is a threatened miscarriage?

A

When the cervical os is closed but there has been some PV bleeding. Often no associated pain.

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11
Q

What is an inevitable miscarriage?

A

When the cervical os is open and there is PV bleeding/clots. Often associated pain.

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12
Q

What is an incomplete miscarriage?

A

When most of the products have been passed, but some remain. There is pain and PV bleeding.

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13
Q

What is a missed miscarriage?

A

When the foetus dies or doesn’t develop, but is still present in utero.

The cervical os is closed. Occurs at < 20 weeks. Light PV bleeding, no associated pain.

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14
Q

When would you utilise expectant, medical and surgical management of a miscarriage?

A

Expectant - most cases will be managed this way initially.

If there is signs of infection or haemorrhage: move straight to surgical.

If expectant management does not work after 14 days, move to medical or surgical.

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15
Q

What does medical and surgical management of miscarriage involve?

A

Medical - vaginal misoprostol + anti-emetics + analgesia.

Surgical - vacuum aspiration (suction curettage) as out patient OR evacuation of uterus under GA.

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16
Q

How may you treat recurrent miscarriage in antiphospholipid syndrome?

A

Low-dose aspirin + daily frogmen (dalteparin)

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17
Q

When is abortion typically permitted up until?

A

24 weeks

18
Q

How is medical abortion performed? At what length in gestation is medical abortion utilised?

A

Utilised up to 23+6 weeks. If < 10 weeks, can be performed at home.

From 10+1 to 23+6, a single dose of oral mifepristone is used.
Misoprostol is then given 36-48 hours later, up to 5 times in a day.

19
Q

How is surgical abortion performed?

A

< 14 weeks - vacuum aspiration
> 14 weeks - dilation and evacuation.

Misoprostol used to dilate and soften cervix.

20
Q

What are the 3 considerations post-abortion?

A

Pain/bleeding? - if not, may be appropriate for same day discharge

Contraception

Anti-D if > 9+6 weeks

21
Q

When does hyperemesis gravidarum normally occur?

A

1st trimester (0-13 weeks). Normally settles by 2nd trimester (14-26 weeks)

22
Q

What are the 1st and 2nd line antiemetics for hyperemesis gravidarum?

A

1st line - cyclizine, prochlorperazine

2nd line - ondansetron, metoclopramide

23
Q

What additional treatments can be used for hyperemesis gravidarum, excluding anti-emetics?

A

Rehydration - 0.9% NaCl + K, or Hartmann’s

H2 receptor antagonist/PPI for associated reflux

Steroids if vomiting is intractable.

24
Q

What supplements/medications are used in multiple pregnancy?

A

Folic acid, iron and low-dose aspirin.

25
Q

When should dichorionic diamniotic twins and monochorionic diamniotic be delivered?

A

DCDA - 37-38 weeks

MCDA - 36 weeks with use of steroids

26
Q

How should triplets and monochorionic monoamniotic be delivered?

A

Triplets - c-section

MCMA - c-section at 34-36 weeks

27
Q

What is Twin-Twin transfusion syndrome? How is it managed?

A

One baby gets less blood supply, the other gets two much. Leads to anaemia/oligohydraminos and polycythaemia/polyhydraminos of twins.

<26 weeks - fetoscopic laser ablation
>26 weeks - amnioreduction/septostomy

28
Q

At what stage in gestation can hypertensive disorders of pregnancy be diagnosed?

A

> 20 weeks

Before is considered pre-existing hypertension.

29
Q

How is pre-eclampsia differentiated from pregnancy-induced hypertension

A

Both have hypertension.

Pre-eclampsia has additional signs (proteinuria, signs of other end-organ involvement - LFTs, creatinine, thrombocytopenia)

30
Q

When is pre-eclampsia considered mild, moderate and severe?

A

Mild - 140-149, 90-99

Moderate - 150-159, 100-110

Severe - >160, >110 or neuro signs or end-organ damage

31
Q

What monitorin is indicated in mild pre-eclampsia? When should delivery occur in these cases?

A

4-hourly BP
2x weekly FBC, LFT, renal function
Growth scans every 2 weeks

Induction at 37-40 weeks

32
Q

What monitoring and management is indicated in moderate pre-eclampsia? When should delivery occur in these cases?

A

4 hourly BP
3x weekly FBC, LFT, renal function
Growth scans every 2 weeks
2x daily CTG

Management:
Admit
Antihypertensives (nifedipine PO, labetalol IV, hydralazine IV)
Induction at 37-40 weeks

33
Q

What is the management for severe pre-eclampsia?

A

Antihypertensives (Nifedipine PO, IV labetalol or hydralazine)
If refractory, prophylactic magnesium sulphate.
Deliver > 34 weeks, steroids for lung maturity.

34
Q

What is eclampsia, how is it treated?

A

Pre-eclampsia + seizures

Magnesium sulfate

Diazepam if refractory

35
Q

What is HELLP syndrome? How is it managed?

A

Haemolysis, elevated liver enzymes, low platelets.

Complication of (pre-)eclampsia.

Managed as per eclampsia, induction also.

36
Q

How is gestational diabetes managed?

A

Clinic, dietician, 30 mins daily exercise.

If ineffective: Metformin 1st line
Glibenclamide 2nd line

If macrosomia, or polyhydraminos - offer insulin therapy.

37
Q

At what gestational period does a miscarriage become a stillbirth?

A

24 weeks

38
Q

How is gestational diabetes diagnosed?

A

Fasting BM > 5.6 or OGTT >7.8.

Perform OGTT if history of diabetes, obesity or family history.

39
Q

How is pre-term rupture of membranes handled?

A

10 days erythromycin

Corticosteroids for foetal development

Deliver after 34 weeks

40
Q

How should cholestasis of pregnancy be managed?

A

Ursodeoxycholic acid and delivery at 36-37 weeks

Obs and Gyne (4 decks)

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