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early pregnancy complications Flashcards

1
Q

how is a miscarriage defined? (include early and late miscarriage

A

loss of pregnancy <24 weeks gestation

early: <13 weeks gestation
late >13 weeks gestation

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2
Q

what are the causes of a miscarriage?

A

chromosomal abnormalities,
congenital abnormalities
uncontrolled maternal disease - e.g. infection, diabetes, uterine anomalies, thrombophilia

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3
Q

what increases the risk of having a miscarriage?

A

maternal age >35 - chromosomal abnormalities
paternal age >45
chromosomal abnormalities in mother or father

uterine abnormalities - adhesions, fibroids
low BMI/ obese
folate deficiency
antiphospholipid syndrome / coagulopathy
smoking, alcohol, drugs (NSAIDs, aspirin)

previous miscarriage
consanguinity

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4
Q

if a pregnancy test is positive does this rule out a miscarriage?

A

a pregnancy test can be positive for several days post miscarriage

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5
Q

what are the clinical features of a miscarriage?

A

vaginal bleeding - passing clots/ products of conception
- if excessive can lead to dizziness, pallor, SoB

subrapubic cramping pain

significant number are found incidentally

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6
Q

what should you look for on examination if you suspect a miscarriage?

A

speculum examination - cervical os diameter, any products of conception or areas of bleeding

bimanual examination - assess for uterine tenderness or adnexal masses

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7
Q

what are the differentials to a miscarriage

A

implantation bleeding
ectopic pregnancy
hydatidiform mole
cervical/uterine malignancy

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8
Q

how does a threatened miscarriage present?

A

mild bleeding +/- pain, cervical os is closed

transvaginal USS - viable pregnnacy

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9
Q

what is meant by an inevitable miscarriage?

A

heavy bleeding, clots, pain
cervix os is open
TVUS - open os, viable/nonviable preg

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10
Q

what is meant by a missed miscarriage?

A

asymptomatic

TVUS - no fetal HR found, crown rump length >7mm

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11
Q

what is meant by an incomplete miscarriage

A

bleeding clots/ products of conception.
partially expelled
TVUS shows retained products of conception, AP endometrial diameter >15mm, proof there was a previous intrauterine pregnancy

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12
Q

what is meant by a complete miscarriage

A

bleeding, clots, POC , cervix now closed

TVUS - closed os, AP endometrial diameter <15mm, proof of previous intrauterine pregnancy (otherwise could be ectopic)

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13
Q

what is a septic miscarriage?

A

POC infection
fever, rigors, intrauterine tenderness
bleeding, discharge
raised WCC and CRP

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14
Q

how is a miscarriage investigated?

A

assessment in early pregnancy unit
use Transvaginal USS for definitive diagnosis:
1. look for fetal HR (usually first picked up around 6 weeks) - if present, no miscarriage
2. if fetal HR absent, look for fetal pole and measure crown rump length
- if >7mm = confirm miscarriage, with second opinion
- if < 7mm = wait 7 days and re-assess for fetal HR
3. if no fetal pole, measure gestational sac
- if >25mm = confirm miscarriage with second opinion
- if <25 mm = repeat scan in 7 days.

bloods:
- serial bHCG - for ectopic
- FBC, blood group and rhesus antigen
- triple swab and CRP is pyrexic

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15
Q

why is crown rump length and gestational sac measured In process of confirming miscarriage?

A

if crown rump is <7mm or gestational sac is <25 mm then measurement of fetal HR is inaccurate and cannot confirm a miscarriage based on the absence of fetal HR (may just not be visible at this point)

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16
Q

what are the 3 management options for miscarriage?

A

expectant/ conservative
medical
surgical

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17
Q

what is the expectant/conservative way to manage a miscarriage?

A

conservative - wait and see
allow products of conception to pass naturally over 2-3 weeks
must have 24 hour access to gynae services
repeat scan in 2 weeks or pregnancy test in 3 weeks.

indicated when <6 weeks and no pain

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18
Q

what is the medical way to manage a miscarriage?

A

Vaginal misoprostol (prostaglandin analogue) is given - cervical ripening and myometrial contractions are stimulated. (oral version also available)
Do not give misopristone
pregnancy test 3 weeks later

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19
Q

what is the surgical way to manage a miscarriage?

A

manual vacuum aspiration with local anaesthetic if <12 weeks - quicker, safer and less painful
if >12 weeks then evacuation of POCs under general anaesthetic - speculum inserted and suction of POC

need to screen for chlamydia before undergoing surgery

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20
Q

what are the advantages and disadvantages of conservative management of miscarriage?

A

no side effects of surgery/ medicine. can be managed at home

but takes longer and thus at increased risk of heavy bleeding. also unpredictable timing and more pain. higher chance of being unsuccessful

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21
Q

what are the contraindications of using a conservative method for managing miscarriage?

A

at risk of haemorrhage e.g. coagulopathy

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22
Q

what are the advantages and disadvantages of medical management of miscarriage?

A

advantage - quicker than conservative, at home, surgery avoided

disadvantage - side effects from medication (N+V, diarrhoea)

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23
Q

what are the indications for surgical management of miscarriage?

A

infection
gestational trophoblastic disease
haemodynamically unstable

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24
Q

what are the advantages and disadvantages of surgical management of miscarriage?

A

advantages - quick, planned time

disadvantage - damage to bowel, bladder, nerves, uterine rupture, ashermans (adhesions), infection (endometritis), anaesthetic risk

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25
when is Anti-D prophylaxis recommended in miscarriage?
``` any surgical removal of miscarriage or ectopic DO NOT NEED if: - complete miscarriage - threatened miscarriage - medically managed miscarriage - pregnancy of unknown location ```
26
how is a septic miscarriage managed?
Abx, anti pyretics, IV fluids, surgical evacuation
27
define recurrent miscarriage
3 or more consecutive miscarriage (loss of fetus <24 weeks) with the same partner
28
what is the aetiology behind recurrent miscarriages?
systemic disease - antiphospholipid, inherited thrombophilias (factor V leiden, protein S, C or ATIII deficiency) - risk of uteroplacental thrombosis - infection - especially if pyrexia e.g. bacterial vaginosis in T1 can lead to miscarriage in T2 - endocrine factors: PCOS, diabetes, thyroid anatomical defects - uterine malformations - bicornate or septate uterus - cervical weakness - dilates before pregnancy reaches erm - adhesions and fibroids chromosomal abnormalities - balanced translocations or robertsonian translocation I leads to increased risk of unbalanced chromosomal rearrangements.
29
what are the risk factors for recurrent miscarriage?
same as risk factors for miscarriage | the number of previous miscarriages is an independent risk factor for future miscarriage
30
what investigations can be done in someone presenting with recurrent miscarriages?
anti phospholipid syndrome - ab screening: lupus anticoagulant testing, anti cardiolipin Ab, anti B2 glycoprotein Ab (need 2 positive tests, 12 weeks apart) inherited Thrombophillia screen pelvic USS to assess uterine anatomy if abnormality found can do laparoscopy or hysteroscopy karyotyping: - cytogenetic analysis of products of conception for any chromosomal abnormalities - if chromosomal abnormalities are found then can karyotype parental peripheral blood
31
how is recurrent miscarriages managed if a genetic abnormality is identified?
refer to clinical specialist to discuss gamete donation, adoption or just trying again offer IVF and pre-implantation testing genetic counselling support and counselling for psychological distress.
32
how is recurrent miscarriage managed if cervical weakness was found to be cause of previous miscarriage?
cervical weakness - offer cervical cerclage = sutures used to close and hold cervix. If the patient decides to not have this then instead can offer cervical surveillance by USS.
33
what are the complications of cervical cerclage?
bleeding membrane rupture stimulation of uterine contractions
34
when is cervical cerclage indicated?
cervix shortening on USS history of cervical weakness symptomatic women with premature cervical dilation and exposed fetal membranes in vagina
35
how are recurrent miscarriages managed if thrombophilia/ antiphospholipid syndrome is identified as the cause?
low dose aspirin and LMWH counselling and support for any psychological distress
36
How is infertility defined? (include primary and secondary)
inability to conceive after 12 months of regular unprotected intercourse. this may be primary - never previously conceived or secondary - previous children.
37
what are the causes of infertility ?
age - maternal age (as mum gets older, reduced number of oocytes) ovulation defections: - ovarian failure/ PCOS - hyperprolactinaemia - high / low BMI genetic : turners, CF male factors chromosomal problems ``` uterine adhesions (ashermans ) / previous PID endometriosis ``` unexplained
38
what questions should you ask in history both men and women presenting with infertility?
age previous successful pregnancies regularity of intercourse and any problems when did they stop contraception and what method PMH / systemic disease drug history social history - stress, excessive exercise , weight loss, drugs/alcohol/smoking?
39
what questions should you ask in history just women presenting with infertility?
menstrual history - regularity, menorrhagia/oligomenorrhea etc, any previous STIs - particularly PID / chlamydia last cervical smear previous tubal surgery specific: galactorrhoea - hyperprolactinaemia any PCOS? (ask about acne and hirsituism) any endometriosis - (ask about dysmenorrhoea)
40
what questions should you ask in history just men presenting with infertility?
ejaculation difficulties? history of Mumps, torsion, trauma or STIs? history of undescended testes? previous surgery e.g. hernial repair
41
how can you examine a women presenting with infertility ?
BMI - high or low look for features of turners or PCOS or galactorrhoea feel for any mass - ovarian cysts tenderness - PID, endometriosis
42
how would you examine a women presenting with infertility?
feel testis for softness and size (hypogonadism) or absence (undescended) look for features of gynacomastia , absence of axillary hair etc - indicating hypogonadism check penis for structural abnormalities
43
how would you investigate a woman presenting with infertility?
LH, FSH on day 2 of cycle progesterone on day 21 of cycle TFTs and prolactin SHBG and testosterone levels test for chlamydia and rubella USS of uterus and ovaries hysteroscopy test tubal patency - hysterosalpingogram or laparoscopy and dye
44
how would you investigate a man presenting with infertility?
LH, FSH and progesterone levels. USS of prostate and seminal vesicles semen analysis x2 - constituent and sperm count - if sperm count low can do chlamydia test - sampled 2 days post but <7days since last ejaculation
45
how is infertility managed?
give general advice: gain/loose weight, healthy diet, stop smoking, alcohol, drugs. start taking folic acid, regular intercourse (every 2-3 days), reduce stres depends on the cause: e. g. tubal disease - may require surgery to unblock tubes e. g. endometriosis - surgery e. g. hyperprolactinaemia - dopamine agonists otherwise can help with ovulation by giving certain medications - clomifene citrate: inhibits oestrogen receptors at hypothalmus to reduce negative feedback and thus more LH to stimulate ovulation - gonadotrophins if resistant to clomifene citrate
46
what are the methods of assisted conception?
``` Intrauterine insemination Intracytoplasmic sperm injections - if sperm count is very low IVF donor insemination donor oocyte ```
47
what are the complications of assisted conception?
ovarian hyperstimulation syndrome (OHSS) - bloating, oedema, tense ascites, N+V, oliguria, VTE and respiratory distress ectopic pregnancy multiple pregnancy increased cancer risk increased infection risk. IVF increases risk of pre-eclampsia
48
Define an ectopic pregnancy?
An implantation of pregnancy outside of the uterine cavity. This may be in fallopian tubes, cervix, interstitium or peritoneal cavity
49
where is the most common site for an ectopic pregnancy? where are the less common sites?
most commonly in isthmus or ampulla of fallopian tube less commonly in cervix or peritoneal cavity
50
what are the past medical risk factors for ectopic pregnancy?
PID - resulting in adhesions and destruction of cilia previous ectopic pregnancy endometriosis motility disorders of cilia
51
what are the contraception risk factors for ectopic pregnancy?
Intrauterine device or intraunterine system progesterone only pill - reduces ciliary motility tubal ligation or occlusion remember contraception reduces chance of getting pregnant - so still less of a risk than no contraception
52
what are the iatrogenic risk factors for ectopic pregnancy ?
tubal surgery | embryo transfer in IVF
53
what are the clinical features of an ectopic pregnancy?
pain - lower abdominal/ pelvic pain bleeding - usually intraperitoneal - results in shoulder tip pain because blood irritates diaphragm (innervated by C3,4,5) and referred to shoulder - can result in vaginal bleeding due to decidua (endometrium) breaking down because of insufficient BhCG - can lead to dizziness, collapse brown vaginal discharge - break down of decidua
54
what are the clinical features of an ectopic pregnancy?
pain - lower abdominal/ pelvic pain bleeding - usually intraperitoneal - results in shoulder tip pain because blood irritates diaphragm (innervated by C3,4,5) and referred to shoulder - can result in vaginal bleeding due to decidua (endometrium) breaking down because of insufficient BhCG - can lead to dizziness, collapse brown vaginal discharge - break down of decidua history of amenorrhea = pregnancy
55
what do you expect to find on examination in someone with an ectopic pregnancy?
pelvic/ abdominal tenderness cervical excitation or adnexal tenderness if ruptured ectopic pregnancy: - haemodynamic instability - pallor, low BP, prolonged cap refil, tachycardia - signs of peritonism - fullness in pouch of douglas on vaginal examination
56
how can an ectopic pregnancy be investigated?
1. pregnancy test - if positive … 2. transabdominal/ pelvic USS to look for intrauterine pregnancy … if this cant be found... 3. offer a transvaginal USS if no intrauterine pregnancy can be identified but pregnancy test is positive = pregnancy of unknown location 4. measure BHCG - if >1500iU then confirmed ectopic and offer diagnostic laparoscopy - if <1500 iU and stable then repeat in 48 hours - in normal pregnancy it should double - in miscarriage it should half - anything inbetween treat as ectopic
57
what are the differentials for pregnancy of unknown location (i.e. positive pregnancy test but cant be identified on USS)?
ectopic miscarriage early intrauterine pregnancy
58
how is an ectopic pregnancy managed? (in broad terms)
ABCDE | definitive treatment: choose between medical and surgical management
59
what is the medical management of an ectopic pregnancy?
IM methotrexate - inhibits folate dependant cell division and thus stops developing fetus and pregnancy will gradually resolve re-check BHCG to ensure level is declining and if not repeat methotrexate dose. give 24 hour access to gynae services and inform symptoms of rupture and when to seek help.
60
what is the surgical management of an ectopic pregnancy ?
surgical removal of ectopic pregnancy e.g. removal of ectopic and tube its implanted in. however in some women this may be the only viable tube and thus try to salvage the tube whilst removing ectopic follow up BhCG - measure after 7 days and then weekly until <5iU give anti D prophylaxis (250IU) to any rhesus negative mother.
61
when is medical management offered over surgical management?
medical management: no fetal HR, stable, no pain, adnexal mass <35mm , bHCG < 1500, not ruptured surgical management: pain, fetal HR, bHCG >5000, adnexal mass >35mm if bHCG is between 1500 and 500 and no pain, HR or adnexal mass is <35mm then offer surgical OR medical
62
what are the advantages and disadvantages of medical management of an ectopic pregnancy ?
no surgical complications, can occur at home however methotrexate has side effects - abdo pain, myelosuppression, renal toxicity, hepatitis, teratogenesis (advised not to get pregnant for 3-6 months after use)
63
what are the advantages and disadvantages of surgical management of ectopic pregnancy?
advantages: high success rate disadvantage - damage to bowel, bladder, anaesthetic risk, DVT, P.E, haemorrhage , infection
64
what is the conservative management of an ectopic pregnancy?
watchful waiting of stable patient while allowing ectopic to naturally resolved. monitor bHCG every 48 hours to ensure it is falling >/= 50% used when BhCG is rapidly falling
65
when is the conservative management of ectopic pregnancy preferred?
when rupture is unlikely , pain is well controlled, B-hCG basaline is low and small unruptured ectopic on USS
66
what are the advantages and disadvantages of the conservative management of ectopic pregnancy?
advantages - avoids risk of medical/ surgery, can be done at home disadvantages - risk of failure or complications (rupture)
67
what is gestational trophoblastic diseases? how are they categorised?
group of pregnancy related tumours. divided into 2 groups - pre-malignant conditions (more common) - parital molar pregnancy and complete molar pregnancy - malignant conditions - invasive molar pregnancy, placental trophoblastic site tumours, choriocarcinoma, and epithelioid trophoblastic tumour
68
what is the pathophysiology behind molar pregnancies?
occurs when abnormal contribution of chromosomes in pregnancy e. g. partial molar - 2 sperm and 1 egg - results in 69 chromosomes. both placenta and fetus may be triploidy or may have mosaism where placenta is but fetus isn't e. g. complete molar pregnancy - oocyte has no chromosomes and is fertilised by one sperm which duplicates chromosomes or 2 sperms. thus chromosomes are both paternal but 46 all together. usually benign but can become malignant (invasive molar pregnancy) and invade uterine myometrium and disseminate around the body
69
what is the pathophysiology behind choriocarcinoma?
a malignancy of the trophoblastic cells of the placenta commonly co-exists with molar pregnancy commonly metastasises to the lung
70
what is the pathophysiology of a placental site trophoblastic tumour?
malignancy of intermediate trophoblasts which are normally responsible for anchoring the placenta to the uterus these can occur after a normal pregnancy (more common), molar pregnancy or miscarriage
71
what is the pathophysiology behind an epitheloid trophoblastic tumour?
malignancy of trophoblastic placental cells difficult to distinguish from a choriocarcinoma similar features to squamous cell carcinoma
72
what are the risk factors for gestational trophoblastic disease?
previous gestational trophoblastic disease age <20 or >35 yrs previous miscarriage oral contraceptive pill
73
what are the clinical features of gestational trophoblastic disease?
pain and vaginal bleeding in early pregnancy hyperemesis hyperthyroidism anaemia
74
how will the uterus appear on examination of someone with gestational trophoblastic disease ?
larger uterus, boggy and soft.
75
why may.. a) hyperemesis b) hyperthyroidism develop in gestational trophoblastic disease?
hyperemesis due to high BhCG hyperthyroid because BhCG mimics TSH
76
what investigations could be done if gestational trophoblastic disease is suspected?
urine and blood BhCG (elevated at diagnosis and used to monitor) USS - complete molar pregnancy has a characteristic appearance but not all of them do histological examination of products of conception - performed post treatment to confirm diagnosis for follow up if metastatic - need MRI or staging CT CAP or Pelvic USS
77
how are gestational trophoblastic diseases managed?
any women diagnosed is referred to GTD centre for follow up and monitoring in future pregnancies. molar pregnancies: - suction curettage - complete and non-viable partial moles - however if partial mole is greater gestation then medical evacuation should be performed - monitoring BhCG 3 weeks post treatment - anti D prophylaxis if rhesus negative some require chemotherapy
78
what is hyperemesis gravidarum?
excessive/ prolonged nausea and vomiting in early pregnancy
79
what is the normal pattern of nausea and vomiting in pregnancy?
normal pregnancy N+V starts around weeks 4-7 and peaks at weak 9 and then usually settles by week 20. affects 80% of pregnancy
80
what are the features of hyperemesis gravidarum?
dehydration nutritional deficiency excessive vomiting and nausea
81
what are the complications of hyperemesis gravidarum
dehydration / malnutrition / weight loss - B12 defieicney - periepheral neuropathy and anaemia - B1 deficiency - wernickes ketosis / acidosis deranged electrolytes - hypo NA, hypoK - lethargy, seizures, arrhtyhmias - hypoNa can lead to central pontine myelinosis without treatment can lead to nervous system complications: - wernickes encephalopathy - central pontine myelinosis ``` AKI liver failure oesophageal rupture / Mallory Weiss tear pneumothorax retinal haemorrhage splenic avulsion ```
82
what is the pathophysiology behind hyperemesis gravidarum?
BhCG can bind receptors in chemoreceptor trigger zone in brain BHCG can also induce T4 release - thyrotoxicosis leads to hyperemesis high progesterone and oestrogen - reduce gut motility and increase liver enzymes and oesophageal sphincter pressure. psychological
83
who is N+V more common in pregnancy in?
younger and obese women
84
what are the first factors for hyperemesis gravidarum?
``` first pregnancy HG present in previous pregnancy multiple pregnancy raised BMI hydatidiform mole ```
85
what is a hydatidiform mole?
same name for molar pregnancy
86
how is hyperemesis gravidarum diagnosed?
objective scoring: scoring system can be used to classify severity = pregnancy unique quantification of emesis (PUQE) score. history of hyperemesis in previous pregnancy exclude other causes - infection, graves, Addison's, tumours (hydatidiform mole)
87
what scoring system is used to grade hyperemesis gravidarum and how is it used?
pregnancy unique quantification emesis score (PUQE) 6 = mild 7-12 = moderate 13-15 - severe
88
what investigations can be carried out for suspected hyperemesis gravidarum ?
weight and urine dipstick (ketouria) blood tests: UES, LFTs, blood glucose, FBC (infection, anaemia, haemocrit) , amylase (pancreatitis excluded) , TFT USS - exclude GTD/ multiple pregnancy midstream urine
89
how is hyperemesis gravidarum managed?
small frequent meals, low in fat referred for fluid, vitamin replacement and nutritional support rehydrate - not with glucose (could precipitate wernickes), replace K give thiamine and folic acid antiemetics: - first line: cyclizine, prochlorperazine, promethazine - second line: metoclopramide, domperidone, ondansetron - third line: hydrocortisone IV ranitidine for reflux consider thromboprophylaxis level of care depends on how severe
90
when does hyperemesis gravidarum usually resolve?
16 to 20 weeks
91
what are the differentials for hyperemesis gravidarum?
``` UTI gastroenteritis pancreatitis drug induced raised ICP metabolic disturbance pre-eclampsia ```

Obstetrics (8 decks)

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