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Y4 Obs & Gynae > Early pregnancy complications > Flashcards

Early pregnancy complications Flashcards

1
Q

Common problems in early pregnancy?

A

Miscarriage
Ectopic pregnancy
Gestational trophoblastic disease
Hyperemesis gravidarum

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2
Q

What is a missed miscarriage?

A

Fetus is no longer alive, but no symptoms have occurred

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3
Q

What is a threatened miscarriage?

A

Vaginal bleeding with a closed cervix and a fetus that is alive.

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4
Q

What is an inevitable miscarriage?

A

Vaginal bleeding with an open cervix

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5
Q

What is an incomplete miscarriage?

A

Retained products of conception remain in the uterus after the miscarriage.

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6
Q

What is a complete miscarriage?

A

Full miscarriage has occurred , there are no products of conception left in the uterus

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7
Q

What is an anembryonic pregnancy

A

A gestational sac is present but contains no embryo

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8
Q

Which investigation is used to diagnose a miscarriage?

A

Transvaginal ultrasound scan

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9
Q

How to manage a miscarriage that is less than 6 weeks gestation?

A

Expectant management - awaiting the miscarriage without investigations or treatment.

This is done only when there is no pain and no other complications or risk factors (e.g. previous ectopic).

Repeat urine pregnancy test is performed after 7-10 days - if negative, a miscarriage can be confirmed.

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10
Q

How to manage a miscarriage that is more than 6 weeks gestation?

A

Referral to Early Pregnancy Assessment service (EPAU) for women with positive pregnancy test and bleeding.

US will confirm location and viability of pregnancy.

Three options to manage miscarriage:
1. Expectant miscarriage
2. Medical management
3. Surgical management

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11
Q

What is expectant management?

A

First-line for women without risk factors for heavy bleeding/infection.

1/2 weeks given to allow miscarriage to occur spontaneously. Repeat pregnancy test 3 weeks after bleeding and pain settle to confirm complete miscarriage.

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12
Q

What is medical management?

A

Misopristol (Prostaglandin analogue)

Binds to PG receptors and activates them - PGs soften cervix and stimulate uterine contractions.

Vaginal suppository / Oral dose.

SE: Heavier bleeding, pain, vomit, diarrhoea

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13
Q

What is surgical management?

A

Two options:
1. Manual vacuum aspiration (under LA as an outpatient)
2. Electric vacuum aspiration (under GA)

Prostaglandins (misopristol) given before surgical management to soften the cervix.

Anti-rhesus D prophylaxis is given to rhesus negative women.

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14
Q

What is manual vacuum aspiration?

A

Involves a local anaesthetic applied to the cervix. Manually uses syringe to aspirate contents of the uterus.

Must be below 10 weeks gestation. More appropriate for women that have previously given birth (parous women).

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15
Q

What is electric vacuum aspiration?

A

Performed through the vagina and cervix (no incisions).

Cervix is gradually widened using dilators, conception products removed using an electric-powered vacuum.

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16
Q

How to manage an incomplete miscarriage?

A

Incomplete miscarriage occurs when retained products of conception remain in the uterus.

Retained products create a risk of infection.

Two options to treat:
1. Medical management (misopristol)
2. Surgical management (evacuation of retained products of conception - ERPC)

ERPC involves general anaesthetic. Cervix is gradually widened using dilators and retained products manually removed through cervix using vacuum aspiration and curettage.

Key complication is endometritis (endometrium infx) following the procedure.

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17
Q

Risk factors for miscarriage?

A

Advanced maternal age (women >35 significant more risk)
History of previous miscarriages
Previous large cervical cone biopsy
Smoking
Alcohol
Obesity
Uncontrolled diabetes
Thyroid disorders

18
Q

What is an ectopic pregnancy?

A

Implantation of a fertilised ovum outside the uterus.

19
Q

How does an ectopic pregnancy present?

A

Usually presents around 6-8 weeks gestation.

Missed period
Constant lower abdo pain in L/R iliac fossa
Vaginal bleeding
Lower abdo/pelvic tenderness
Cervical motion tenderness (pain when moving cervix during a bimanual exam)

Also ask about :
Dizziness or syncope (blood loss)
Shoulder tip pain (peritonitis)

20
Q

Risk factors for ectopic pregnancy?

A

Previous ectopic pregnancy
Previous PID
Previous surgery to fallopian tubes
IUD, POP
Older age
Smoking
Endometriosis

21
Q

What is a PUL?

A

Pregnancy of unknown location

When there is a positive pregnancy test and there is no evidence of pregnancy on US scan.

Cannot exclude ectopic pregnancy.

22
Q

What are the management options for an ectopic pregnancy?

A

Expectant management
Medical management (methotrexate)
Surgical management (salpingectomy or salpingotomy)

23
Q

What is the criteria for expectant management?

A
  • Follow up needs to be possible to ensure successful termination
  • Ectopic needs to be unruptured
  • Adnexal mass <35mm
  • No visible heartbeat
  • No significant pain
  • hCG <1500 IU/L
24
Q

What is the criteria for methotrexate?

A
  • hCG <5000 IU/L
  • Confirmed absence of intrauterine pregnancy on US.
25
Q

How is methotrexate given?

A

IM injection to buttock.

Advisable not to get pregnant for 3 months after.

SE: Vaginal bleeding, N+V, abdo pain, stomatitis

26
Q

What is a laparoscopic salpingectomy?

A

First line treatment for ectopic pregnancy.

Under GA, removal of affected fallopian tube, along with the ectopic pregnancy inside the tube.

27
Q

What is a laparoscopic salpingotomy?

A

Cut in Fallopian tube, ectopic pregnancy is removed and tube is closed.

Used in women at increased risk of infertility due to damage to the other tube.

28
Q

Most common location of ectopic pregnancy?

A

Ampulla of fallopian tube

29
Q

Most dangerous location of ectopic pregnancy?

A

Isthmus of fallopian tube

30
Q

What is a molar pregnancy?

A

A hyatidiform mole (type of tumour) that grows inside the uterus like a pregnancy.

31
Q

What is a complete mole?

A

One or two sperm cells fertilise an ovum that contains no genetic material. These sperm then combine genetic material, the cells start to divide and grow into a tumour called a complete mole. No fetal material will form.

Complete moles are diploid (46,XX; 46,XY)

32
Q

What is a partial mole?

A

Two sperm cells fertilise a normal ovum at the same time. The new cell now has 3 sets of chromosomes. The cell divides and multiplies into a tumour called a partial mole.

Some fetal material may form.

Parial moles are triploid (69,XXY; XXX; XYY)

33
Q

How does a molar pregnancy present?

A

Behaves like a normal pregnancy. Periods will stop and the hormonal changes of pregnancy will occur.

  • More severe morning sickness
  • Vaginal bleeding
  • Increased enlargement of the uterus
  • Abnormally high hCG
  • Thyrotoxicosis (hCG can mimic TSH, stimulates thyroid to produce excess T3 and T4)
34
Q

How to diagnose a molar pregnancy?

A

US of the pelvis shows ‘snowstorm appearance’.

Provisional diagnosis made by US, confirmed with histology of the mole after evacuation.

35
Q

How is a molar pregnancy managed?

A

Evacuation of the uterus.

The products of conception need to be sent for histological examination to confirm the molar pregnancy.

Patients referred to the gestational trophoblastic disease centre for management and follow up.

hCG levels monitored until normal again.

Occasionally the mole can metastasis, and the patient may require systemic chemotherapy.

36
Q

What is hyperemesis gravidarum?

A

Refers to persistent and severe vomiting during pregnancy, which leads to weight loss, dehydration and electrolyte imbalances

  • More than 5 % weight loss compared with before pregnancy
  • Dehydration
  • Electrolyte imbalance
37
Q

Normal pattern of nausea during pregnancy?

A

Symptoms usually start from 4-7 weeks, are worst around 10-12 weeks and resolve by 16-20 weeks.

Symptoms can persist throughout pregnancy.

Due to beta-hCG

Worse in molar pregnancies, multiple pregnancies, first pregnancy, overweight.

Smoking is associated with a decreased incidence of hyperemesis.

38
Q

How is the severity of hyperemesis gravidarum assessed?

A

Pregnancy-Unique Quantification of Emesis (PUQE) score.

Out of 15:

  • <7 mild
  • 7-12 moderate
  • > 12 severe
39
Q

How do you treat mild hyperemesis gravidarum?

A

Antiemetics.

  1. Prochlorperazine (stemetil)
  2. Cyclizine
  3. Ondansetron
  4. Metoclopramide

If acid reflux : ranitidine or omeprazole

Complementary therapies: Ginger and acupressure on the wrist at the PC6 point.

40
Q

When should you consider admission with hyperemesis gravidarum?

A
  • Unable to tolerate oral antiemetics or keep down any fluids
  • More than 5% weight loss compared with pre-pregnancy
  • Ketones present in the urine
  • Other medical conditions need treating that required admission.
41
Q

How to treat moderate-severe cases of hyperemesis gravidarum?

A
  • IV or IM antiemetics
  • IV fluids (normal saline with added potassium chloride)
  • Daily monitoring of U&Es whilst having therapy
  • Thiamine supplementation to prevent deficiency (prevents Wernicke-Korsakoff syndrome)
  • Thromboprophylaxis (TED stocking and LMWH) during admission.

Y4 Obs & Gynae (2 decks)

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