Early pregnancy - done Flashcards
1
Q
What is an ectopic pregnancy?
A
When a pregnancy is implanted outside of the uterus
2
Q
Where is the most common site for an ectopic pregnancy?
A
3
Q
What is the entrance of the fallopian tube called?
A
Cornual region
4
Q
Where else can an ectopic pregnancy implant?
A
- Cornual region
- Ovary
- Cervix
- Abdomen
5
Q
What are the risk factors for an ectopic pregnancy?
A
- Previous ectopic pregnancy
- Previous PID
- Previous surgery to the fallopian tubes
- Intrauterine devices (coils)
- Older age
- Smoking
6
Q
When does an ectopic pregnancy present?
A
6-8 weeks gestation
7
Q
What are the classic features of an ectopic pregnancy?
A
- Missed period
- Constant lower abdo pain in the right or left iliac fossa
- Vaginal bleeding
- Lower abdo or pelvic tenderness
- Cervical motion tenderness (pain when moving the cervix during a bimanual examination)
8
Q
When suspecting ectopic pregnancy what are two other useful questions?
A
Dizziness or syncope (blood loss)
Shoulder tip pain (peritonitis)
9
Q
What is the investigation of choice for diagnosing a miscarriage?
A
Transvaginal ultrasound scan
10
Q
What may be seen on a transvaginal ultrasound for a misscarriage?
A
Gestational sac containing a yolk sac or fetal pole may be seen in a fallopian tube
11
Q
What is a mass containing an empty gestational sac on vaginal ultrasound referred to as?
A
Blob sign
Bagel sign
Tubal ring
12
Q
How is a tubal ectopic pregnancy differentiated from a corpus luteum?
A
Tubal ectopic pregnancy moves separately to the ovary where as a corpus luteum will move with the ovary
13
Q
What other scan features may there be for an ectopic pregnancy?
A
An empty uterus
Fluid in the uterus (may be mistaken as a gestational sac - “pseudogestational sac”)
14
Q
What is a pregnancy of unknown location?
A
Woman has a positive pregnancy test but there is no evidence of pregnancy on the ultrasound scan
15
Q
What can be measured to help monitor a pregnancy of unknown origin?
A
Human chorionic gonadotrophin (hCG) - repeated after 48 hours to measure the change from baseline
16
Q
Where does hCG come from in pregnancy?
A
developing syncytiotrophoblast
17
Q
How do hCG levels change during an interuterine pregnancy?
A
hCG will double every 48 hours (not the case in miscarriage or ectopic pregnancy)
18
Q
What rise in hCG after 48 hours will indicate an interuterine pregnancy?
A
Rise of more than 63% is likely to indicate an intrauterine pregnancy
19
Q
After a suitable rise in hCG what else is required to confirm an interuterine pregnancy?
A
Repeat ultrasound scan after 1-2 weeks to confirm an intrauterine pregnancy
20
Q
At what level of hCG should a pregancy be visible on an ultrasound scan?
A
Above 1500
21
Q
What rise of hCG after 48 hours will indicate an ectopic pregnancy?
A
Less than 63% (patient needs close monitoring and review)
22
Q
What fall of hCG after 48 hours is likely to indicate a miscarriage?
A
More than 50% (urine pregnancy test should be performed after 2 weeks to confirm the miscarriage is complete)
23
Q
Where are women with pelvic pain or tenderness and a positive pregnancy test referred to?
A
Early pregnancy assessment unit or gynaecology service
24
Q
Is an ectopic pregnancy ever viable?
A
No - always need terminating
25
What are the three options for terminating an ectopic pregnancy?
**Expectant management** (awaiting natural termination)
**Medical managment** (methotrexate)
**Surgical management** (salpingectomy or salpingotomy)
26
What is the criteria for expectant management?
- **Followup** needs to be **possible** to ensure successful termination
- Ectopic needs to be **unruptured**
- Adnexal mass \<35mm
- No visible heartbeat
- No significant pain
- HCG level \<1500 IU/L
27
What is the criteria for **methotrexate** termination of ectopic pregnancy?
- HCG level must be \<5000 IU/L
- Confirmed **absence of intrauterine pregnancy on ultrasound**
28
How is methotrexate given for termination?
**Intramuscular injection** into a buttock - results in spontaneous termination
29
What are women advised after methotrexate termination?
**Not** to get **pregnant** for **3 months**
30
What are the **side effects** of **methotrexate management of ectopic?**
Vagnial bleeding
Nausea and vomiting
Abdo pain
**Stomatitis** (inflammation of the mouth)
31
Who requires surgical mangement for ectopic pregnancy?
Those who do not meet the criteria for expectant or medical management
32
What does the criteria for surgical management include?
**Those with:**
- Pain
- Adnexal mass \>35mm
- Visible heartbeat
- hCG levels \> 5000 IU/L
33
What are the options for surgical managment of ectopic pregnancy?
- **Laparoscopic salpingectomy**
- **Laparoscopic salpingotomy**
34
What is a **laparoscopic salpinectomy**?
**First line** treatment for ectopic pregnancy
Using general anaesthesia with **removal of the affected fallopian tube** along with the **ectopic pregnancy inside the tube**
35
What is **laparoscopic salpingotomy**?
- Used in women at increased risk of infertility due to damage to the other tube (**avoid removing the affected fallopian tube**)
- Cut is made in the fallopian tube - ectopic pregnancy is removed - tube is closed
36
Why is a salpingectomy first line?
There is a increased risk of **failure** with a **salpingotomy** (1 in every 5 women having a salpingotomy may need **further treatment** with **methotrexate** or salpingectomy)
37
What prophylaxis is given to **rhesus negative** women having surgical managment of an ectopic pregnancy?
**Anti-rhesus D prophylaxis**
38
What is a miscarriage?
Spontaneous termination of a pregnancy
39
When is a miscarriage **early**?
Before 12 weeks gestation
40
When is a miscarriage late?
Between 12 and 24 weeks
41
What is a **missed misscarriage**?
Fetus is no longer alive, but no symptoms have occured
42
What is a **threatened miscarriage?**
Vaginal bleeding with a closed cervix and a fetus thats alive
43
What is an **inveitable miscarriage**?
Vaginal bleeding with an open cervix
44
What is an **incomplete miscarriage**?
**Retained products of conception** which remain in the uterus after the miscarriage
45
What is a **complete miscarriage**?
A full miscarriage has occured and there are no products of conception left in the uterus
46
What is **anembryonic pregnancy?**
Gestational sac is present but **contains no embryo**
47
What is the investigation of choice for diagnosing a miscarriage?
**Transvaginal ultrasound scan**
48
What are the three key features which a sonographer looks for in an early pregnancy?
- Mean gestational sac diameter
- Fetal pole and crown rump length
- Fetal heartbeat
(appear sequentially as pregnancy develops, as each appear the previosu feature becomes less relevant in assessing viability of the pregnancy)
49
When is a pregnancy considered viable?
When a **fetal heartbeat** is visible
50
At what length of crown-rump is a **fetal heartbeat** expected?
7mm or more
51
What happens if there is a crown rump length of 7mm or more without a fetal heartbeat?
Scan is **repeated** after one week before confirming a non-viable pregnancy
52
When is a **fetal pole** expected?
Once the **mean gestational sac diameter** is **25mm** or more
53
What confirmatory investigation is done when there is a **mean gestational sac diameter** of 25mm or more **without a fetal pole**?
Scan is repeated after one week before confirming an **anembryonic pregnancy**
54
What is the management of women with a pregnancy less than 6 weeks gestation presenting with bleeding?
Managed **expectantly** provided they have **no pain** and no other complications or risk factors e.g. previous ectopic
55
What is **expectant** management of a miscarriage?
Awaiting the miscarriage without investigations or treatment
56
Will an ultrasound be useful in diagnosing a miscarriage less than 6 weeks gestation?
No, too small to be seen
57
How can a miscarriage be confirmed?
Repeat urine pregnancy test after 7-10 days
58
How to manage a women with a positive pregnancy test and bleeding?
Referral to an **early pregnancy assessment unit** for women with a positive pregnancy test
59
What are the investigations for a woman presenting after 6 weeks gestation and bleeding?
**Ultrasound scan** to confirm the **location** and **viability** of the pregnancy - essential to always consider and exclude an **ectopic pregnancy**
60
What are the three options for managing a miscarriage?
**Expectant managment** (do nothing and await a spontaneous miscarriage)
**Medical managment** (misoprostol)
**Surgical managment**
61
When is expectant management offered for **miscarriages** in over **6 weeks gestation**?
First-line for women without risk factos for heavy bleeding or infection
**1-2 weeks are given** to allow the miscarriage to occur spontaneously (repeat urine pregnancy test should be performed three weeks after bleeding and pain settle to confirm miscarriage is complete)
62
In an expectant miscarriage, when are further assessments and repeat ultrasounds warranted?
**Persistent** or **worsening bleeding** - indicates an incomplete miscarriage and require additional management
63
What is **misoprostol**?
**Prostaglandin analogue** - it binds to prostaglandin receptors and activates them
64
What do prostaglandins do?
**Soften** the **cervix**
**Stimulate** uterine **contractions**
65
How is misoprostol given to expedite the process of miscarriage?
**Vaginal suppository**
**Oral dose**
66
What are the **side effects** of **misoprostol**?
Heavier bleeding
Pain
Vomiting
Diarrhoea
67
What are the two options for surgical management of a miscarriage?
**Manual vacuum aspiration** under local anaesthetic as an outpatient
**Electric vacuum aspiration** under general anaesthetic
68
What is given before surgical management of a miscarriage to soften the cervix?
**Prostaglandins** (misoprostol)
69
How is a **manual vacuum aspiration** performed?
Apply **local anaesthetic** to the cervix
Tube attached to a syringe is inserted through cervix into uterus
Syringe aspirates contents of the uterus
**Must be below 10 weeks gestation** (more appropriate for women who have previously given birth - **parous** women)
70
How is an **electric vacuum aspiration** performed?
Traditional surgical management of a miscarriage using **general anaesthetic**
Performed through the vagina and cervix without incisions.
Cervix is **widened** with dilators - product of conception are removed through cervix using an **electric powered vacuum**
71
What prophylaxis is given to **rhesus negative** women having surgical management of ectopic pregnancy?
**Anti-rhesus D prophylaxis**
72
What is an incomplete miscarriage?
**Retained products of conception** (fetal or placental tissue) remains in the uterus - **risk of infection**
73
How are incomplete miscarriages treated?
- Medical management (**misoprostol**)
- Surgical management (**evacuation of retained products of conception**)
74
How is **evacuation of retained products of conception** (ERPC) performed?
Surgical procedure with **general anaesthetic** - cervix is widened with dilatos and the retained products are **manually removed** through the cervix using **manual aspiration** and **curettage** (scraping)
75
What is a complication of ERPC?
**Endometritis** (infection of the endometrium) following the procedure
76
What is recurrent miscarriage defined as?
**Three or more consecutive** miscarriages
77
What are the rates of miscarriage?
**10%** in women aged 20 – 30 years
**15%** in women aged 30 – 35 years
**25%** in women aged 35 – 45 years
**50%** in women aged 40 – 45 years
78
When are miscarriage investigations initiated?
**3 / more** first trimester miscarriages
**2 / more** second trimester miscarriages
79
What are the **causes of miscarriage**?
**Idiopathic** (particularly in older women)
**Antiphospholipid syndrome**
**Hereditary thrombophilias**
**Uterine abnormalities**
**Genetic factors** in parents (e.g. **balanced translocations** in parental chromosomes)
**Chronic histocytic intervillositis**
Other chronic diseases e.g. **diabetes**, **untreated thyroid disease** and **SLE**
80
What is **antiphospholipid syndrome**?
Disorder associated with **antiphospholipid antibodies** where blood becomes prone to clotting - patient is in a **hyper-coagulable**
81
What are the main associations of antiphopholipid syndrome?
**Thrombosis** and complications in pregnancy, particularly **recurrent miscarriages**
82
How can antiphospholipid syndrome occur?
On its own or secondary to **SLE**
83
How is the risk of **miscarriage** in patients with **antiphospholipid** syndrome **reduced**?
- Low dose **aspirin**
- Low molecular weight **heparin**
84
How may a history of recurrent miscarriages suggest antiphospholipid syndome?
History of DVT - test of **antiphospholipid antibodies**
85
What are some key hereditary thrombophilias to remember?
**Factor V Leiden** (most common)
**Factor II** (prothrombin) gene mutation
**Protein S deficiency**
86
What uterine abnormalities can cause recurrent miscarriages?
**Uterine septum** (a partition through the uterus)
**Unicornuate uterus** (single-horned uterus)
**Bicornuate uterus** (heart-shaped uterus)
**Didelphic uterus** (double uterus)
**Cervical insufficiency**
**Fibroids**
87
What is **chronic histiocytic intervillositis**?
Rare cause of **recurrent miscarriages** - particula
88
What is the result of chronic histiocytic intervillositis?
Intrauterine growth restriction
Intrauterine death
89
What causes chronic histiocytic intervillositis?
Condition is poorly understood
**Histiocytes** and **macrophages** build up in the placenta causing inflammation and adverse outcomes
90
How is chronic histiocytic intervillositis diagnosed?
Placental histology showing **infiltrates** of **mononuclear cells** in the **intervillous space**
91
What are the investigations for patients with recurrent miscarriages?
- Antiphospholipid antibodies
- Testing for hereditary thrombophilias
- Pelvic ultrasound
- Genetic testing of the **products of conception** from the third or future miscarriages
- Genetic testing on **parents**
92
What is the management of recurrent miscarriages?
Depends on the underlying cause
93
What may help during early pregnancy for women with recurrent miscarriages and bleeding?
**Vaginal progesterone pessaries** (evidence from PRISM trial) - may become guidelines in future but current guidelines state that there is insufficient evidence for progesterone supplementation
94
What is an abortion also known as?
Termination of pregnancy (TOP)
95
What are the Acts which govern over abortions?
**1967 Abortion Act**
**1990** **Human Fertilisation and Embryology Act** (altered and expanded act and reduced the latest gestational age where an abortion is legal from 28 to 24 weeks)
96
When can an abortion be performed before 24 weeks?
If continuing the pregnancy involves greater **risk** to the **physical or mental health** of:
## Footnote
**The woman**
**Existing children of the family**
97
How is the risk of continuing pregnancy weighed up against the risk of terminating the pregnancy?
**Clinical judgement** and opinion of the medical practitioners
98
When can an abortion be performed at **any time** during the pregnancy?
- Continuing pregnancy is likely to **risk the life of the woman**
- Terminating the pregnancy will **prevent "grave permanent injury"** to the **physical or mental health** of the woman
- There is **substantial risk** that the **child would suffer** physical or mental abnormalities making it severely handicapped
99
What are the legal requirements for an abortion?
- Two registered medical practioners **must sign to agree abortion** is indicated
- Must be carried out by **regustered medical practioner** in an NHS hospital or approved premise
100
How may abortion services be accessed?
**Self-referral** or by **GP, GUM or family planning clinic** referral
101
What is a doctor objects to abortions?
They should **pass the referral** on to another doctor to **make the referral**
102
What is the name of a charity that provides abortion services?
Marie Stopes UK
103
Who do Marie Stopes offer a service to?
Women **less than 10 weeks gestation** - consultations are help by telephone and medication are issued remotely to be taken at home
104
When can medical abortion be used?
Most appropriate in early pregnancy but can be used at **any gestation**
105
What medication is given for a medical abortion?
**Mifepristone** (anti-progestogen)
**Misoprostol** (prostaglanding analogue) 1 - 2 days later
106
How does mifepristone work?
**Anti-progesterone** - halters the pregnancy and relaxes the cervix
107
What is **misoprostol**?
**Prostaglandin analogue** - binds to **prostanglandin receptors** and activates then - prostaglandings soften the cervix and stimuate uterine contractions
108
How much misoprostol is needed from 10 weeks gestation?
Additional misoprostol doses (e.g. every 3 hours) are required until expulsion
109
What prophylaxis should **rhesus negative** women going for a **TOP** at **10 weeks or above gestation** be given?
Anti-D prophylaxis
110
What pain relief can surgical abortions be performed under?
**Local anaesthetic**
**Local anaesthetic plus sedation**
**General anaesthetic**
111
What medications are used for **cervical priming** before a surgical abortion ?
Softening and dilating the cervix with:
## Footnote
**Misoprostol**
**Mifepristone**
**Osmotic dilators**
112
What are osmotic dilators?
Devices inserted into the cervix - gradually expand as they absorb fluid - opening the canal
113
What are the options for surgical abortion?
**Cervical dilatation and suction** of the contents of the uterus (usually up to 14 weeks)
**Cervical dilatation and evacuation using forceps** (between 14 and 24 weeks)
114
Should **Rhesus negative** women having a **TOP** have anti-D prophylaxis?
**Considered** in women less than 10 weeks gestation
115
What symptoms can a woman expect after an abortion?
Vaginal bleeding and abdominal cramps
116
How to confirm a TOP of pregnancy is complete?
Urine pregnancy test 3 weeks after the abortion
117
What are some complications of a termination of pregnancy?
**Bleeding**
**Pain**
**Infection**
**Failure** of the abortion (pregnancy continues)
**Damage** to the cervix, uterus or other structures
118
When is nausea common in pregnancy?
Early on (peaking around **8-12 weeks gestation**)
119
What is **hyperemesis gravidarum**?
**Severe** form of **nausea** and **vomiting**
120
When do symptoms of nausea and vomiting usually begin and end in pregnancy?
Begin in weeks 4-7 and resolve by 16-20 weeks
121
What hormone is thought to be responsible for N&V in pregnancy?
**Human chorionic gonadotropin** (hCG) - theoretically higher levels causes worse symptoms
122
What types of pregnancies are N&V more common in?
**Molar pregnancies**
**Multiple pregnancies**
**First pregnancy**
**Overweight women**
123
How is N&V diagnosed in pregnancy?
Typical history
124
How can a diagnosis of N&V in pregnancy be made?
Needs to **start in first trimester**
## Footnote
**Other causes excluded**
125
Along with long standing N&V, what else is needed to diagnose **hyperemesis gravidarum**?
- **More than 5% weight loss** compared with before pregnancy
- **Dehydration**
- **Electrolyte imbalance**
126
How is the severity of hyperemesis gravidarum assessed?
Using the **pregnancy-unique quantification of emesis** (**PUQE**) score - giving score out of 15
\< 7 = mild
7-12 = moderate
\>12 = severe
127
Which antiemetics are used to suppress nausea in pregnancy?
Vaguely in order of preference and known safety, the choices are:
## Footnote
**Prochlorperazine (stemetil)**
**Cyclizine**
**Ondansetron**
**Metoclopramide**
128
What medication can be used if acid reflux is a problem in pregnancy?
**Ranitidine** or **omeprazole**
129
What alternate therapies may be used for nausea and vomiting in pregnancy?
**Ginger**
**Acupressure** on the wrist at the PC6 point **(inner wrist**) may improve symptoms
130
When should **admission** be considered for **N&V during pregnancy**?
**Unable** to **tolerate** **oral** **antiemetics** or keep down any fluids
**More than 5 % weight loss** compared with pre-pregnancy
**Ketones** are present in the **urine** on a **urine dipstick** (2 + ketones on the urine dipstick is significant)
131
How can **moderate-severe** cases of pregnancy N&V be treated on admission?
**IV or IM antiemetics**
**IV fluids** (normal saline with added potassium chloride)
Daily monitoring of U&Es while having IV therapy
**Thiamine supplementation** to prevent deficiency (prevents **Wernicke-Korsakoff syndrome**)
**Thromboprophylaxis** (TED stockings and LMWH) during admission
132
What is a **molar pregnancy**?
Where a **hydatiform mole** (a type of tumour) grows like a pregnancy inside the uterus
133
What are the two types of molar pregnancies?
**Complete mole**
## Footnote
**Partial mole**
134
When does a complete mole occur?
When **two sperm cells** **fertilise** an ovum which **contains no genetic material** (an "empty ovum")
135
Will any fetal material form in a **complete mole**?
No
136
How does a **partial mole** occur?
Two sperm fertilise a normal ovum (containing genetic material) at the same time - the new cell now has **three sets of chromosomes** (it is a **haploid cell**) - cell divides and multiples into a tumour with some fetal materal
137
What can indicate a molar pregnancy over a normal pregnancy?
138
What does ultrasound of a molar pregnancy show?
**Snowstorm appearance** of the pregnancy
139
How is a **diagnosis** of **molar pregnancy** made?
**Ultrasound** and confirming with **histology** of the mole after evacuation
140
How are molar pregnancies managed?
**Evacuation of the uterus** to remove the mole (products of conception need to be sent for **histological examination to confirm** molar pregnancy)
141
How are **molar pregnancies** followed up?
Referred to the **gestational trophoblastic disease centre**
hCG levels are monitored until they return to normal
Occasionally the **mole can metastasise** and the patient may **require systemic chemotherapy**
