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Obstetrics and Gynaecology > Early pregnancy - done > Flashcards

Early pregnancy - done Flashcards

1
Q

What is an ectopic pregnancy?

A

When a pregnancy is implanted outside of the uterus

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2
Q

Where is the most common site for an ectopic pregnancy?

A
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3
Q

What is the entrance of the fallopian tube called?

A

Cornual region

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4
Q

Where else can an ectopic pregnancy implant?

A
  • Cornual region
  • Ovary
  • Cervix
  • Abdomen
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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
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6
Q

When does an ectopic pregnancy present?

A

6-8 weeks gestation

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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)
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8
Q

When suspecting ectopic pregnancy what are two other useful questions?

A

Dizziness or syncope (blood loss)

Shoulder tip pain (peritonitis)

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9
Q

What is the investigation of choice for diagnosing a miscarriage?

A

Transvaginal ultrasound scan

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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

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11
Q

What is a mass containing an empty gestational sac on vaginal ultrasound referred to as?

A

Blob sign

Bagel sign

Tubal ring

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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

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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”)

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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

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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

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16
Q

Where does hCG come from in pregnancy?

A

developing syncytiotrophoblast

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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)

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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

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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

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20
Q

At what level of hCG should a pregancy be visible on an ultrasound scan?

A

Above 1500

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21
Q

What rise of hCG after 48 hours will indicate an ectopic pregnancy?

A

Less than 63% (patient needs close monitoring and review)

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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)

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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

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24
Q

Is an ectopic pregnancy ever viable?

A

No - always need terminating

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25
Q

What are the three options for terminating an ectopic pregnancy?

A

Expectant management (awaiting natural termination)

Medical managment (methotrexate)

Surgical management (salpingectomy or salpingotomy)

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26
Q

What is the criteria for expectant management?

A
  • 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
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27
Q

What is the criteria for methotrexate termination of ectopic pregnancy?

A
  • HCG level must be <5000 IU/L
  • Confirmed absence of intrauterine pregnancy on ultrasound
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28
Q

How is methotrexate given for termination?

A

Intramuscular injection into a buttock - results in spontaneous termination

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29
Q

What are women advised after methotrexate termination?

A

Not to get pregnant for 3 months

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30
Q

What are the side effects of methotrexate management of ectopic?

A

Vagnial bleeding

Nausea and vomiting

Abdo pain

Stomatitis (inflammation of the mouth)

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31
Q

Who requires surgical mangement for ectopic pregnancy?

A

Those who do not meet the criteria for expectant or medical management

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32
Q

What does the criteria for surgical management include?

A

Those with:

  • Pain
  • Adnexal mass >35mm
  • Visible heartbeat
  • hCG levels > 5000 IU/L
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33
Q

What are the options for surgical managment of ectopic pregnancy?

A
  • Laparoscopic salpingectomy
  • Laparoscopic salpingotomy
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34
Q

What is a laparoscopic salpinectomy?

A

First line treatment for ectopic pregnancy

Using general anaesthesia with removal of the affected fallopian tube along with the ectopic pregnancy inside the tube

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35
Q

What is laparoscopic salpingotomy?

A
  • 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
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36
Q

Why is a salpingectomy first line?

A

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)

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37
Q

What prophylaxis is given to rhesus negative women having surgical managment of an ectopic pregnancy?

A

Anti-rhesus D prophylaxis

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38
Q

What is a miscarriage?

A

Spontaneous termination of a pregnancy

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39
Q

When is a miscarriage early?

A

Before 12 weeks gestation

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40
Q

When is a miscarriage late?

A

Between 12 and 24 weeks

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41
Q

What is a missed misscarriage?

A

Fetus is no longer alive, but no symptoms have occured

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42
Q

What is a threatened miscarriage?

A

Vaginal bleeding with a closed cervix and a fetus thats alive

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43
Q

What is an inveitable miscarriage?

A

Vaginal bleeding with an open cervix

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44
Q

What is an incomplete miscarriage?

A

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

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45
Q

What is a complete miscarriage?

A

A full miscarriage has occured and there are no products of conception left in the uterus

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46
Q

What is anembryonic pregnancy?

A

Gestational sac is present but contains no embryo

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47
Q

What is the investigation of choice for diagnosing a miscarriage?

A

Transvaginal ultrasound scan

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48
Q

What are the three key features which a sonographer looks for in an early pregnancy?

A
  • 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)

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49
Q

When is a pregnancy considered viable?

A

When a fetal heartbeat is visible

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50
Q

At what length of crown-rump is a fetal heartbeat expected?

A

7mm or more

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51
Q

What happens if there is a crown rump length of 7mm or more without a fetal heartbeat?

A

Scan is repeated after one week before confirming a non-viable pregnancy

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52
Q

When is a fetal pole expected?

A

Once the mean gestational sac diameter is 25mm or more

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53
Q

What confirmatory investigation is done when there is a mean gestational sac diameter of 25mm or more without a fetal pole?

A

Scan is repeated after one week before confirming an anembryonic pregnancy

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54
Q

What is the management of women with a pregnancy less than 6 weeks gestation presenting with bleeding?

A

Managed expectantly provided they have no pain and no other complications or risk factors e.g. previous ectopic

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55
Q

What is expectant management of a miscarriage?

A

Awaiting the miscarriage without investigations or treatment

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56
Q

Will an ultrasound be useful in diagnosing a miscarriage less than 6 weeks gestation?

A

No, too small to be seen

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57
Q

How can a miscarriage be confirmed?

A

Repeat urine pregnancy test after 7-10 days

58
Q

How to manage a women with a positive pregnancy test and bleeding?

A

Referral to an early pregnancy assessment unit for women with a positive pregnancy test

59
Q

What are the investigations for a woman presenting after 6 weeks gestation and bleeding?

A

Ultrasound scan to confirm the location and viability of the pregnancy - essential to always consider and exclude an ectopic pregnancy

60
Q

What are the three options for managing a miscarriage?

A

Expectant managment (do nothing and await a spontaneous miscarriage)

Medical managment (misoprostol)

Surgical managment

61
Q

When is expectant management offered for miscarriages in over 6 weeks gestation?

A

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
Q

In an expectant miscarriage, when are further assessments and repeat ultrasounds warranted?

A

Persistent or worsening bleeding - indicates an incomplete miscarriage and require additional management

63
Q

What is misoprostol?

A

Prostaglandin analogue - it binds to prostaglandin receptors and activates them

64
Q

What do prostaglandins do?

A

Soften the cervix

Stimulate uterine contractions

65
Q

How is misoprostol given to expedite the process of miscarriage?

A

Vaginal suppository

Oral dose

66
Q

What are the side effects of misoprostol?

A

Heavier bleeding

Pain

Vomiting

Diarrhoea

67
Q

What are the two options for surgical management of a miscarriage?

A

Manual vacuum aspiration under local anaesthetic as an outpatient

Electric vacuum aspiration under general anaesthetic

68
Q

What is given before surgical management of a miscarriage to soften the cervix?

A

Prostaglandins (misoprostol)

69
Q

How is a manual vacuum aspiration performed?

A

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
Q

How is an electric vacuum aspiration performed?

A

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
Q

What prophylaxis is given to rhesus negative women having surgical management of ectopic pregnancy?

A

Anti-rhesus D prophylaxis

72
Q

What is an incomplete miscarriage?

A

Retained products of conception (fetal or placental tissue) remains in the uterus - risk of infection

73
Q

How are incomplete miscarriages treated?

A
  • Medical management (misoprostol)
  • Surgical management (evacuation of retained products of conception)
74
Q

How is evacuation of retained products of conception (ERPC) performed?

A

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
Q

What is a complication of ERPC?

A

Endometritis (infection of the endometrium) following the procedure

76
Q

What is recurrent miscarriage defined as?

A

Three or more consecutive miscarriages

77
Q

What are the rates of miscarriage?

A

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
Q

When are miscarriage investigations initiated?

A

3 / more first trimester miscarriages

2 / more second trimester miscarriages

79
Q

What are the causes of miscarriage?

A

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
Q

What is antiphospholipid syndrome?

A

Disorder associated with antiphospholipid antibodies where blood becomes prone to clotting - patient is in a hyper-coagulable

81
Q

What are the main associations of antiphopholipid syndrome?

A

Thrombosis and complications in pregnancy, particularly recurrent miscarriages

82
Q

How can antiphospholipid syndrome occur?

A

On its own or secondary to SLE

83
Q

How is the risk of miscarriage in patients with antiphospholipid syndrome reduced?

A
  • Low dose aspirin
  • Low molecular weight heparin
84
Q

How may a history of recurrent miscarriages suggest antiphospholipid syndome?

A

History of DVT - test of antiphospholipid antibodies

85
Q

What are some key hereditary thrombophilias to remember?

A

Factor V Leiden (most common)

Factor II (prothrombin) gene mutation

Protein S deficiency

86
Q

What uterine abnormalities can cause recurrent miscarriages?

A

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
Q

What is chronic histiocytic intervillositis?

A

Rare cause of recurrent miscarriages - particula

88
Q

What is the result of chronic histiocytic intervillositis?

A

Intrauterine growth restriction

Intrauterine death

89
Q

What causes chronic histiocytic intervillositis?

A

Condition is poorly understood

Histiocytes and macrophages build up in the placenta causing inflammation and adverse outcomes

90
Q

How is chronic histiocytic intervillositis diagnosed?

A

Placental histology showing infiltrates of mononuclear cells in the intervillous space

91
Q

What are the investigations for patients with recurrent miscarriages?

A
  • 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
Q

What is the management of recurrent miscarriages?

A

Depends on the underlying cause

93
Q

What may help during early pregnancy for women with recurrent miscarriages and bleeding?

A

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
Q

What is an abortion also known as?

A

Termination of pregnancy (TOP)

95
Q

What are the Acts which govern over abortions?

A

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
Q

When can an abortion be performed before 24 weeks?

A

If continuing the pregnancy involves greater risk to the physical or mental health of:

The woman

Existing children of the family

97
Q

How is the risk of continuing pregnancy weighed up against the risk of terminating the pregnancy?

A

Clinical judgement and opinion of the medical practitioners

98
Q

When can an abortion be performed at any time during the pregnancy?

A
  • 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
Q

What are the legal requirements for an abortion?

A
  • 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
Q

How may abortion services be accessed?

A

Self-referral or by GP, GUM or family planning clinic referral

101
Q

What is a doctor objects to abortions?

A

They should pass the referral on to another doctor to make the referral

102
Q

What is the name of a charity that provides abortion services?

A

Marie Stopes UK

103
Q

Who do Marie Stopes offer a service to?

A

Women less than 10 weeks gestation - consultations are help by telephone and medication are issued remotely to be taken at home

104
Q

When can medical abortion be used?

A

Most appropriate in early pregnancy but can be used at any gestation

105
Q

What medication is given for a medical abortion?

A

Mifepristone (anti-progestogen)

Misoprostol (prostaglanding analogue) 1 - 2 days later

106
Q

How does mifepristone work?

A

Anti-progesterone - halters the pregnancy and relaxes the cervix

107
Q

What is misoprostol?

A

Prostaglandin analogue - binds to prostanglandin receptors and activates then - prostaglandings soften the cervix and stimuate uterine contractions

108
Q

How much misoprostol is needed from 10 weeks gestation?

A

Additional misoprostol doses (e.g. every 3 hours) are required until expulsion

109
Q

What prophylaxis should rhesus negative women going for a TOP at 10 weeks or above gestation be given?

A

Anti-D prophylaxis

110
Q

What pain relief can surgical abortions be performed under?

A

Local anaesthetic

Local anaesthetic plus sedation

General anaesthetic

111
Q

What medications are used for cervical priming before a surgical abortion ?

A

Softening and dilating the cervix with:

Misoprostol

Mifepristone

Osmotic dilators

112
Q

What are osmotic dilators?

A

Devices inserted into the cervix - gradually expand as they absorb fluid - opening the canal

113
Q

What are the options for surgical abortion?

A

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
Q

Should Rhesus negative women having a TOP have anti-D prophylaxis?

A

Considered in women less than 10 weeks gestation

115
Q

What symptoms can a woman expect after an abortion?

A

Vaginal bleeding and abdominal cramps

116
Q

How to confirm a TOP of pregnancy is complete?

A

Urine pregnancy test 3 weeks after the abortion

117
Q

What are some complications of a termination of pregnancy?

A

Bleeding

Pain

Infection

Failure of the abortion (pregnancy continues)

Damage to the cervix, uterus or other structures

118
Q

When is nausea common in pregnancy?

A

Early on (peaking around 8-12 weeks gestation)

119
Q

What is hyperemesis gravidarum?

A

Severe form of nausea and vomiting

120
Q

When do symptoms of nausea and vomiting usually begin and end in pregnancy?

A

Begin in weeks 4-7 and resolve by 16-20 weeks

121
Q

What hormone is thought to be responsible for N&V in pregnancy?

A

Human chorionic gonadotropin (hCG) - theoretically higher levels causes worse symptoms

122
Q

What types of pregnancies are N&V more common in?

A

Molar pregnancies

Multiple pregnancies

First pregnancy

Overweight women

123
Q

How is N&V diagnosed in pregnancy?

A

Typical history

124
Q

How can a diagnosis of N&V in pregnancy be made?

A

Needs to start in first trimester

Other causes excluded

125
Q

Along with long standing N&V, what else is needed to diagnose hyperemesis gravidarum?

A
  • More than 5% weight loss compared with before pregnancy
  • Dehydration
  • Electrolyte imbalance
126
Q

How is the severity of hyperemesis gravidarum assessed?

A

Using the pregnancy-unique quantification of emesis (PUQE) score - giving score out of 15

< 7 = mild

7-12 = moderate

>12 = severe

127
Q

Which antiemetics are used to suppress nausea in pregnancy?

A

Vaguely in order of preference and known safety, the choices are:

Prochlorperazine (stemetil)

Cyclizine

Ondansetron

Metoclopramide

128
Q

What medication can be used if acid reflux is a problem in pregnancy?

A

Ranitidine or omeprazole

129
Q

What alternate therapies may be used for nausea and vomiting in pregnancy?

A

Ginger

Acupressure on the wrist at the PC6 point (inner wrist) may improve symptoms

130
Q

When should admission be considered for N&V during pregnancy?

A

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
Q

How can moderate-severe cases of pregnancy N&V be treated on admission?

A

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
Q

What is a molar pregnancy?

A

Where a hydatiform mole (a type of tumour) grows like a pregnancy inside the uterus

133
Q

What are the two types of molar pregnancies?

A

Complete mole

Partial mole

134
Q

When does a complete mole occur?

A

When two sperm cells fertilise an ovum which contains no genetic material (an “empty ovum”)

135
Q

Will any fetal material form in a complete mole?

A

No

136
Q

How does a partial mole occur?

A

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
Q

What can indicate a molar pregnancy over a normal pregnancy?

A
138
Q

What does ultrasound of a molar pregnancy show?

A

Snowstorm appearance of the pregnancy

139
Q

How is a diagnosis of molar pregnancy made?

A

Ultrasound and confirming with histology of the mole after evacuation

140
Q

How are molar pregnancies managed?

A

Evacuation of the uterus to remove the mole (products of conception need to be sent for histological examination to confirm molar pregnancy)

141
Q

How are molar pregnancies followed up?

A

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

Obstetrics and Gynaecology (10 decks)

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