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repro > early pregnancy complications DONE > Flashcards

early pregnancy complications DONE Flashcards

1
Q

implantation bleeding

A

few days of light bleed at point of implantation happens when they expect to see period

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2
Q

examination in early pregnancy

A

general - collapsed, pain, clammy

per abdomen - abdominal distension, scars

speculum - cervix - neck of womb internal os open, quantify bleeding

bimanual ex - uterus enlarged - fibroids, adenomyosis can also cause it

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3
Q

Ix for early pregnancy

A
  • urine pregnancy test
    USS - Transabdominal fine afteer 8 weeks gestation therefore do transvaginal

US inconclusive - serum BHCG level
above 1500 - nothing in uterus then ectopic more likely

serial measurement fails to rise by 60%

Group and save - collapse need transfusion, anti D

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4
Q

threatened miscarriage

A

Bleeding and or pain up to 20/40
closed cervical os
viable ongoing pregnancy fetal heart seen

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5
Q

incomplete miscarriage

A 
PV bleeding
cervix open
Some POC have been passed
Some tissues and blood clot remain within the uterus
on US youll see POC in uterus
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6
Q

septic miscarriage

A

Septic Miscarriage
If POC infected → septic patient
Rare where Termination of pregnancy (TOP) is legal

IV ABx

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7
Q

complete miscarriage

A
  • All products of conception have been passed
  • Complete sac may be identifiable
  • Bleeding and pain reducing
  • Cervix now closed
- Cannot diagnose with USS – 
this can be helpful but 
no strict cut offs
 Caution required if no previous
USS
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8
Q

US classification of miscarriages

A
  1. Missed miscarriage / Early fetal demise
    - Failed pregnancy with no cardiac pulsations on USS
  2. Blighted ovum / Anembryonic pregnancy
    - Failed pregnancy with empty gestation sac i.e. no fetus present, fetus too small to see
  3. Incomplete miscarriage / Retained products of conception
    - Echogenic mass of blood clot and tissue within the uterine cavity >20mm in Anterior-posterior (AP) diameter
  4. Complete miscarriage
    Empty uterine cavity – Rough guide AP <20mm
    MUST have seen an Intrauterine pregnancy (IUP) on scan before or Pregnancy of unknown location (PUL)
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9
Q

aetiology of miscarriage

A
  • Never established in most cases (no need)
  • Chromosomal abnormalities
  • Congenital abnormalities
  • Maternal disease
  • – Poorly controlled diabetes
  • – Acute illness / infection
  • – Uterine anomalies
  • – Thrombophilia/Antiphospholipid Syndrome
  • age
  • obesity or really low weight
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10
Q

RFs of miscarriage

A

Advanced maternal age (>/= 40)

Previous miscarriage 2 or more higher risk

OBESITY

Smoking

Alcohol (moderate to heavy) and drug use

NSAIDs and Aspirin

Street drugs

Folate deficiency

Consanguinity

Opportunity for health promotion

Certain uterine abnormalities (Mullerian duct anomalies, large cervical cone biopsies)

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11
Q

expectant Mx of miscarriage

when to take pregnancy test

A

Waiting for all POC to pass naturally usually over 2 weeks, but can be longer

take pregnancy test after 3 weeks

Must have 24 hour access to gynae service

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12
Q

advantages of conservative Mx

A

Avoid risks of surgery / medication
Can be at home
if they are <6 weeks gestation

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13
Q

disadva of conservative Mx

A

Pain and bleeding can be unpredictable
Worries re: being at home
Takes longer
May be unsuccessful – still requiring active management

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14
Q

Medical Mx if miscarriage

A
  • Vaginal misoprostol
    Prostaglandin analogue, binds to myometrial cells to cause strong myometrial contractions leading to the expulsion of tissue

+ antiemetics and pain relief

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15
Q

advantages of medical Mx of miscarriage

A

Avoids surgery
High patient satisfaction if successful
Can be done as outpatient in some centres

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16
Q

disadvantages of medical Mx of miscarriage

A

Pain and bleeding may be unpleasant and/or
severe
s/e of drugs
Need for emergency surgical management (SERPC) < 5%

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17
Q

surgical Mx of miscarriage

A

Use of suction curette to empty uterus
5 minute procedure under general anaesthetic (GA)

Vacuum aspiration is done under local anaesthetic as an outpatient

Day case
Return to normal physically 24 hours
Bleeding 1-2 weeks

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18
Q

advantages of surgical Mx

A

planned procedure, closure

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19
Q

Disadvantages of surgical Mx

A

Surgical (perforation, (bowel/bladder damage) damage to cervix, Asherman’s, Cervical weakness) and anaesthetic risk

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20
Q

define recurrent miscarriage

A

The loss of ≥ 3 CONSECUTIVE pregnancies with SAME partner

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21
Q

causes of recurrent miscarriage

A
  • advancing maternal age
  • Balanced (Robertsonian) translocations
  • Uterine anomalies - 2nd trimester more
  • Antiphospholipid syndrome
  • cervical weakness
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22
Q

RFs of ectopic pregnancy

A
  • failed IVF or IVF
  • Anything which could affect tubal function
  • Previous ectopic pregnancy
  • pelvic/Tubal surgery (sterilization or reversal )
  • Tubal pathology
  • Previous pelvic inflammatory disease (PID)/endometriosis
  • Mirena (IUS) or copper coil (IUD) in situ
  • smoking
23
Q

symptoms & signs of ectopic pregnancy

A
  • > Unilateral pain RIF / LIF
  • > Irregular PV spotting/bleeding - prune juice
  • > amenorrhoea or missed period
  • > Shoulder tip pain - heamaperitoneum

-> Fainting, dizziness
-> (N&V)(vomiting usually not prominent - low βhCG )
breast tenderness
gastrointestinal symptoms
dizziness, fainting or syncope
shoulder tip pain
urinary symptoms
passage of tissue
rectal pressure or pain on defecation.

SIGNS
-> pelvic/abdominal/adnexal tenderness or examination
- cervical motion tenderness
pthers
- rebound tenderness or peritoneal signs
- pallor
- abdominal distension
- enlarged uterus
- tachycardia (more than 100 beats per minute) or hypotension (less than 100/60 mmHg)
- shock or collapse
- orthostatic hypotension.
24
Q

when to offer expectant mx for ectopic

A 
- asymptomatic
no evidence of rupture
- less than 35mm w no visible heartbeat on transvaginal US
- hCG is low <1000 and falling 
- increasingly offered
25
Q

when to offer medical Mx of ectopic

what is prescribed

how is it monitored

A
  • no significant pain
  • unruptured ectopic pregnancy w an adnexal mass smaller than 35 mm with no visible heartbeat
  • hCG<1500
  • do not have an intrauterine pregnancy (as confirmed on an US scan)
  • methotrexate
  • may rupture
  • must avoid pregnancy 3 - 6 months

For women with ectopic pregnancy who have had methotrexate, take 2 serum hCG measurements in the first week (days 4 and 7) after treatment and then 1 serum hCG measurement per week until a negative result is obtained

26
Q

surgical Mx of ectopic

A 
2 large bore cannulae
IV fluids
routine bloods
obtain consent
keep NBM

> 5000
pt choice
Laparoscopic / Laparotomy
Salpingectomy / Salpingotomy

an ectopic pregnancy and significant pain
an ectopic pregnancy with an adnexal mass of 35 mm or larger
an ectopic pregnancy with a fetal heartbeat visible on an ultrasound scan
an ectopic pregnancy and a serum hCG level of 5000 IU/litre or more.

27
Q

trophoblastic disease

A

A spectrum of disorders of trophoblastic development arising from abnormal fertilisation

Potentially pre-malignant
Hydatidiform Mole / Molar pregnancy
Complete Mole (empty egg, 1sperm)
Partial Mole (egg and 2 sperm) – more common

Malignant
Invasive mole
Choriocarcinoma

28
Q

presentation of trophoblastic disease

A
  • Asymptomatic – USS diagnosis
  • Bleeding / haemorrhage
  • Severe nausea and vomiting
  • severe very early pre-eclampsia 2nd trimester -> similar to TSH
  • Uterus large for dates
29
Q

how to confirm trophoblastic disease

A

histology

on US snowstorm appearnace

30
Q

Mx of trophoblastic disease

A

Surgical mx (SERPC)

Register with one of 3 national GTD centre
Sheffield
Charing Cross
Dundee

Postal follow-up of serum and urine Serial ßhCG – as directed by the centre

follow up for 3 months they cant get pregnant

31
Q

hyperemesis gravidarum

A

excessive nausea and vomiting in pregnancy

32
Q

true hyperemesis gravidarum

A 
Severe dehydration
Deranged bloods
Marked ketosis
Weight loss
Nutritional deficiency
Complications of all of above
33
Q

possible pathology for hyperemesis gravidarum

A

Elevated hCG
More common in twin / molar pregnancies
Same α subunit thyroid stimulating hormone (TSH) → Thyrotoxicosis

Elevated oestrogen/progesterone
↓ Gut motility
↑ Liver enzymes
↓ Cardiac sphincter pressure

Helicobacter pylori
Sub-clinical infection activated by altered immunity in pregnancy

Psychological
Difference in incidence in different populations and cultures

34
Q

diagnosis of exclusion for hyperemesis

A

History of hyperemesis in previous pregnancies

Usually no abdominal pain

Infections
UTI, gastroenteritis, appendicitis, pancreatitis etc

Metabolic
Biochemical thyrotoxicosis
Graves disease - HCG activating thyroid
Addisons, DKA

Drugs
Antibiotics, iron preparations

Tumours
hydatidiform mole formation, Choriocarcinoma, teratoma with elements of choriocarcinoma
germ cell tumors
islet cell tumor
negative pregnancy test
35
Q

Ix of hyperemesis gravidarum

A 
Urine: PT / ketonuria / urinary tract infection (UTI)
Full blood count (FBC): Haematocrit
U&E (esp K) hypokalaemia 
LFT and Amylase
TFT – can be difficult to interprete
USS: exclude GTD/Multiple pregnancy
36
Q

Mx of hyperemesis gravidarum

A
  • Rehydration: NOT with glucose (precipitates Wernicke’s), replace K
  • Thiamine replacement and folic acid - psychosis, wernicke maybe irreversible
  • Antiemetics: parenteral route initially
  • Ranitidine - evidence of mallory weiss tear
  • Consider thromboprophylaxis - dehydrated
Rarely
- Steroids – stimulate appetite
- TPN/JEG
- Termination
stomach cancer mistaken for hyperemesis gravidarum
37
Q

when is expectant Mx contraindicated

A

increased risk of haemorrhage

  • late in the first trimester
  • coagulopathies or is unable to have a blood transfusion
  • previous adverse and/or traumatic experience ass w pregnancy
  • evidence of infection
38
Q

when to do BHCG in ectopic pregnancy woman

A

day 2, 4, 7

39
Q

Ix for ectopic pregnancy

A

pregnancy test

transvaginal US to identify the location of the pregnancy
- fetal pole and heartbeat

Consider a transabdominal ultrasound scan for women with an enlarged uterus or other pelvic pathology, such as fibroids or an ovarian cyst.

40
Q

how to diagnose tubal ectopic pregnancy

A
  • > an adnexal mass, moving separate to the ovary (sometimes called the ‘sliding sign’), comprising a gestational sac containing a yolk sac, or
  • > an adnexal mass, moving separately to the ovary (sometimes called the ‘sliding sign’), comprising a gestational sac and fetal pole (with or without fetal heartbeat).
  • > empty uterus
  • > collection of fluid within the uterine cavity
41
Q

when to measure serum hCG level in ectopic pregnancy

A

they have had methotrexate
- take 2 serum hCG measurement between days 4 and 7 after treatment

  • 1 serum hCG measurement per week until a negative result is obtained
42
Q

when do we offer surgery as first line Mx in ectopic pregnancy

A
  • unable to return for follow-up after methotrexate
  • ectopic pregnancy and significant pain
  • ectopic pregnancy with a fetal heartbeat visible fetal heartbeat visible on an US scan
  • an ectopic pregnancy and serum hCG >5000

laparoscopy
offer salpingectomy if they have nor other RFs for infertility
salpigotomy to those who are infertile

43
Q

when do u offer women anti D prophylaxis in ectopic pregnancy

A

Offer anti-D rhesus prophylaxis at a dose of 250 IU (50 micrograms) to all rhesus negative women who have a surgical procedure to manage an ectopic pregnancy or a miscarriage.

44
Q

what is the abortion act 1967

A
  • That the pregnancy has not exceeded its 24th week and that the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman or any existing children of her family; or
  • That the termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman; or
  • That the continuance of the pregnancy would involve risk to the life of the pregnant woman, greater than if the pregnancy were terminated; or
  • That there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped.
45
Q

Mx of ectopic pregnancy

A

offer methotrexate

  • have no significant pain and
  • have an unruptured ectopic pregnancy with an adnexal mass smaller than 35 mm with no visible heartbeat and
  • have a serum hCG level less than 1500 IU/litre and
  • do not have an intrauterine pregnancy (as confirmed on an ultrasound scan) and
  • are able to return for follow-up.
46
Q

hCG monitoring in pts who used methotrexate

A

take 2 serum hCG measurements in the first week (days 4 and 7) after treatment and then 1 serum hCG measurement per week until a negative result is obtained. If hCG levels plateau or rise, reassess the woman’s condition for further treatment.

47
Q

Ix for pregnancy unknown location

A

Take 2 serum hCG measurements as near as possible to 48 hours apart (but no earlier) to determine subsequent management of a pregnancy of unknown location

48
Q

decrease in HCG of more than 50% after 48hrs

A

inform her that the pregnancy is unlikely to continue but that this is not confirmed and
provide her with oral and written information

ask her to take a urine pregnancy test 14 days after the second serum hCG test, and explain that:

  • if the test is negative, no further action is necessary
  • if the test is positive, she should return
49
Q

increase in hCG of more than 63%

A

Inform her that she is likely to have a developing intrauterine pregnancy (although the possibility of an ectopic pregnancy cannot be excluded).

Offer her a transvaginal ultrasound scan to determine the location of the pregnancy between 7 and 14 days later. - Consider an earlier scan for women with a serum hCG level greater than or equal to 1500 IU/litre.

50
Q

Ix for recurrent miscarriage

A

antiphospholipid antibodies
karyotyping
- Cytogenetic analysis should be performed on products of conception of the third and
subsequent consecutive miscarriage(s).
- Parental peripheral blood karyotyping of both partners should be performed in
couples with recurrent miscarriage where testing of products of conception reports
an unbalanced structural chromosomal abnormality

  • All women with recurrent first-trimester miscarriage and all women with one or
    more second-trimester miscarriages should have a pelvic ultrasound to assess uterine
    anatomy.
  • Suspected uterine anomalies may require further investigations to confirm the
    diagnosis, using hysteroscopy, laparoscopy or three-dimensional pelvic ultrasound.
  • screened for thrombophilias factor V lieden, factory II genen mutation, protein S
51
Q

Mx for recurrent miscarriage

A

specialist clinic

antiphospholipis -> low-dose aspirin plus heparin

geneticist

IVF

52
Q

TOP Mx

comp

follow up

A

medical mx
1. mifepristone - anti-progestorone - vaginal buccal or sublingual

  1. followed by misoprostol - PG analogue
    >10 weeks on misoprostol

> 14 weeks

manual vacuum aspiration before 14 weeks -> increased risk of failure before 7 weeks can be done under local

vacuum aspiration using large bore cannulae
dilation and surgical evacuation after 14 weeks

cervical preparations to reduce trauma

we should not use sharp curettage use suction cannula

comp

  • failure to end the pregnancy
  • need for further intervention
  • haemorrhage requiring transfusion
  • uterine rupture

surgical comp
cervical trauma
uterien perforation

follow up
• how much bleeding to expect in the next few days and weeks
• how to recognise potential complications, including signs of ongoing pregnancy
• when they can resume normal activities (including sexual intercourse)
• how and where to seek help if required

Women who want to try again to conceive should be advised to wait until after having at least one normal menstrual period, longer if chronic health problems (e.g. anaemia) require treatment
AND CONTRACEPTION

53
Q

what is pregnancy if uncertain viability

A

transvaginal ultrasound demonstrating a crown-rump length <7mm with no cardiac activity

54
Q

inevitable miscarriage

A

open cervical os
PV bleeding
pain

repro (28 decks)

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