Early Pregnancy Concerns Flashcards
Investigations in recurrent T1 pregnancy loss (6)
- pelvic ultrasound
- genetic analysis poc
- hba1c
- tft
- apls screen
- rubella
Risk factors for recurrent miscarriage T1(6)
- PCOS
- Uncontrolled diabetes
- AMA
- balanced reciprocal or robertsonisn translocation
- overt hypothyroidism
- APLS
What is the cervical length associated with increased risk of pregnancy loss
<25mm
Antiphospholipid obstetric factors
- 3 consecutive miscarriages before 10 weeks
- one morphological normally iud after 10 weeks
- one delivery before 34 weeks due to severe pre eclampsia or IUGR
Laboratory investigations for APLS (3)
- anti cardiolipin IgG/IgM
- lupus anticoagulant
- anti b2 flycoprotein 1
Two test
12 weeks apart
What is the success rate of manual vacuum aspiration for T1 miscarriage
95% -98%
Complications if MVA compared to EVA
Incomplete evacuation
1% vs 4%
Cervical laceration
0% vs 3%
Less blood loss in MVA
What is the criteria for expectant management of ectopic pregnancy (6)
- asymptomatic
- clinically stable
- ultraosund diagnosis of ectopic
- decreasing hcg from initial <1000(nice) 1500(gtg)
- <100ml haemoperitoneum
- adnexal mass <30mm
What is the success rate of expectant management for ectopic pregnancy
67%
What is the follow up during expectant management
Twice weekly hcg (<50% initial value over 7 days)
Weekly vaginal ultrasound
Then weekly hcg and tvs until hcg <20iu/l
Criteria for medical management of ectopic pregnancy (6)
- haemodynamically stable
- unruptured ectopic <3.5cm
- no cardiac activity
- hcg <1500iu/l
- ability to comply with follow up
- access to medical care
What is the follow up during medical management
Hcg levels day 1, 4 and 7
Aim 15% fall between day 4 and 7
Then weekly until <20iu/l
Contraindications to MTX therapy (6)
- elevated transaminases -thrombocytopenia <100,000
- leucopenia <2000
- unable to follow up
- corticosteroid therapy
-intraperitoneal haemorrhage
How many patients require a second dose of methotrexate
14%
How many patients require surgical intervention after MTX
<10%
What advice should be given to patients on MTX therapy (8)
- no sex for 2 weeks
- no nsaids due to risk if gastritis
- limit sunlight exposure
- avoid gas forming foods
- avoid 🤰 for 3mnths
- avoid alcohol
- avoid folic acid
- any severe pain ,dizziness, bleeding return to hospital
What are the side effects of MTX (7)
- abdominal pain
- nausea and vomiting
- diarrhea
- stomatitis gastritis, dermatitis
- photo phobia
- bonemarrow suppression
- elevated lft
More common with multi dose regime
Benefit of laparoscopic mx of ectopic (4)
- shorter operating time
- less blood loss
- less analgesia
- shorter hospital admission
Salpingectomy vs salpingotomy
- no difference In future intrauterine pregnancy rates
- higher risk of ectopic in salpingotomy
When to do salpingotomy
- disease or absent contralateral tube
What advice should be given to the patient after salpingotomy
- increased risk of persistent trophoblastic disease
- need fo further therapy such as methotrexate/salpingectomy (1/5 pts)
- increased risk of ectopic pregnancy
Follow up after salpingtomy
Once weekly hcg until negative
What is the risk of recurrence after ectopic pregnancy
1 and 2
1: 8-14%
2 or more : 25%
Overall 18.5
What is the intrauterine pregnancy rate after an ectopic
60%
When can pregnancy be attempted after methotrexate
3-6mnths
The longer the better.
Preconception high dose folic acid if 3 or less months
What is the mechanism of action of methotrexate
Anti- metabolite and anti- folate
How many women are affected by hypermesis gravidarum
0.3- 3.6%
How many patients are affected by nausea and vomiting
80%
What is the course of hyperemesis typically
- start peak resolve
Starts between week 4-7
Peaks around week 9
Resolves by week 20(90% of cases)
What is the triad of hypermesis
- protracted NVP
- 5% prepregnancy weight loss
- dehydration (ketonuria and electrolyte imbalance)
How is the severity of NVP classified
Using the pregnancy unique quantification of emesis (PUQE) score
Mild <6
Moderate 7-12
Severe >13
Used to guide decision on in verses outpatient management
What are common biochemical findings in HG
- hyponatraemia
- hypokalaemia
- low Urea
- elevated hct
- elevated transaminases (40% of women)
Abnormal thyroid function(raised free t4) in 2/3 of cases
What is the differential diagnoses of HG (7)
- peptic ulcer
- cholecystitis
- gastroenteritis
- hepatitis
- pancreatitis
- genitourinary
- hpylori
What is the criteria for inpatient management
- inability to tolerate oral antiemetics
- ketonuria despite oral meds
- confirmed or suspected comorbidty eg uti
What is the criteria for inpatient management
- inability to tolerate oral antiemetics
- ketonuria despite oral meds
- confirmed or suspected comorbidty eg uti
What cautions should be taken with metoclopramide
- do not use in women younger than 25 years : increased risk of extrapyramidal disorders ans tardive dyskinesia
- should only be used for 5 days
Maximum dose 30mg in 24 hours
Incidence of ectopic pregnancy
11:1000
1.1%
2-3% of pts who present to early pregnancy unit
Mortality rate of ectopic in uk
2:1000
What percentage of ectopic are heterotrophic
<0.1%
What is the risk of requiring further surgery or methotrexate following salpingotomy
1:5
20%
What ate the ultrasound features of an ectopic pregnancy
1) inhomegenous or non cystic adnexal mass in 50-60%
2) empty gestational sac in 20-40%
3) extra uterine sav witl a yolk sac or embryonic pole in 15-20%
