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Early Pregnancy Loss Flashcards

Diagnosis and management of early pregnancy loss

1
Q

A 25F G1P0 K10 presents with PV bleeding, RLQ abdominal and shoulder tip pain. She is tachycardic at 120, hypotensive at 80/40. What would be your initial management?

A 
Resuscitation as per DRS ABCD.
Speculum exam to remove POC.
IDC
Urgent bHCG
Gynaecology review.
USS
FBC, G+H
Consider surgery
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2
Q

How do you manage a pregnancy of unknown location?

A

Specialist review
2 x bHCG 48-72hrs apart.
- If you see a rise >/- 66%, likely IUP however ectopic cannot be excluded. If bHCG < 2000 repeat TVS in 1-2 weeks.
- If bHCG >/= 2000 repeat TVS within 1 week OR when MSD estimated to be > 25 mm

  • If you see a fall in bHCG >/= 50%, -> likely non-viable (IUP OR ectopic) pregnancy. Continue serial bHCG and manage as appropriate.
  • If you see a rise of < 66% or a fall of < 50% -> repeat TVS (depending on bHCG levels, described above). If no IUP observed - > likely ectopic. If IUP observed determine viability
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3
Q

What are the steps in determining (ultrasonographically) the viability of an IUP?

A
  1. Fetal heart beat. If yes, then viable.
  2. If fetal HB not visible, assess for fetal pole visible.
    3 If fetal pole visible, is CRL >/=7mm - > (Y) NVP. If CRL NOT >/=7mm, suspicious for NVP.
  3. Fetal pole not visible - > MSD >/= 25mm -> yes -> NVP.
  4. MSD not >/=25mm -&raquo_space; suspicious for NVP.
  5. If suspicious for NVP, undertake serial b-hCG and repeat TVS in 7-10days.
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4
Q

What are the non-viable diagnostic criteria (TVS)?

A

MSD >/= 25mm and NO fetus present.

Fetus with CRL >/=7mm is visible, but no fetal heart movements demonstrated after observation >/=30secs.

Absence of embryo with heartbeat >/= 2weeks after a scan that showed a gestational sac without a yolk sac.

Absence of embryo with heartbeat >/11 days after a scan that showed a gestational sac with a yolk sac.

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5
Q

How do you estimate repeat TVS interval?

A

Estimate repeat TVS interval based on expected normal gestational sac growth rate of 1mm/day. E.g. If MSD = 12mm, repeat TVS in 13 days or more (12mm MSD + 13mm growth over 13 days equals expected MSD of 25mm).

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6
Q

What is the clinical presentation of ectopic pregnancy (may or may not include)?

A 
Absence of menses.
Irregular vaginal bleeding (spotting)
Abdominal/shoulder tip pain.
Cervical motion tenderness.
Tachycardia or hypotension (if in shock)
Palpable adnexal mass (50%) 
Absence of IUP on USS, with a positive bHCG.
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7
Q

What are the treatment options for ectopic pregnancy?

A

Expectant, medical or surgical.

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8
Q

What are the indications for expectant management of ectopic pregnancy? (7)

A

Indicated only if:

  1. Haemodynamically stable
  2. No evidence of rupture
  3. Low and falling serum b-hCG (< 1500 IU/L at initial presentation)
  4. Minimal or no fluid in pelvis on USS
  5. Tubal mass < 3cm
  6. Pain free
  7. Woman understands need for follow-up and can access medical services.

Caution: If potential for non-compliance with follow-up.

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9
Q

A woman is being expectantly managed for an ectopic pregnancy. What is required for ongoing management?

A

Ongoing management:

  1. EPAS or equivalent.
  2. b-hCG every 48hours for 8 days.
  3. If resolution occurring, then weekly b-hCG until negative.
  4. USS if clinically indicated.
  5. Avoid conception until sonographic resolution.
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10
Q

What are the indications for medical management of ectopic pregnancy? (4)

A

Indications:

  1. Haemodynamically stable.
  2. No evidence of rupture.
  3. No signs of active bleeding.
  4. Normal FBC, ELFT.
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11
Q

What are the contraindications to medical management of an ectopic pregnancy? (5)
What are the cautions? (4)

A

Contraindications:

  1. Allergy to MTX
  2. Geographic isolation
  3. Potential non-compliance.
  4. Presence of medical conditions (review on individual basis)
  5. Breastfeeding.

Caution:

  1. Baseline b-hCG > 5000IU/L
  2. Ectopic > 3cm on TVS
  3. Fetal heart motion present
  4. Blood transfusion not an option.
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12
Q

What is the medical treatment for ectopic pregnancy?

A
  • If b-hCG =3000 IU/L, IMI
  • If b-hCG > 3000 IU/L, IVI.

Ongoing management:

  • EPAS or equivalent.
  • Serial b-hCG as per MTX protocol.
  • USS in one week then as clinically indicated. If fetal heart rate present, refer to MFM.
  • Avoid conception for 4 months due to potential teratogenicity.
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13
Q

What other advice would you give to those opting for medical/expectant management of an ectopic pregnancy?

A

Risk of rupture in acute phase from sexual intercourse or pelvic exam.
We made need to consider alternative management if b-HCG is not falling, at woman’s request, tubal rupture or ongoing pain/bleeding.

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14
Q

What are the (other) general considerations in managing ectopic pregnancy? (5)

A
  1. Review histopath of POC
  2. If indicated, recommend RhD-Ig
  3. Analgesia prn
  4. Communicate info to other care providers (e.g. GP)
  5. Early USS (5-6 weeks) in next pregnancy.
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15
Q

What are the indications (2) and absolute indications (4) for surgical management of ectopic pregnancy?

A

Indications:

  1. Woman’s preference
  2. Unsuccessful expectant or medical management.

Absolute indications:

  1. Haemodynamic instability.
  2. Persistent excessive bleeding.
  3. Evidence of infected POC
  4. Suspected GTD.

Cautions:

  • Risk of haemorrhage or effects of haemorrhage (i?Jehova’s witnesses)
  • Previous uterine perforation.
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16
Q

Care provision in surgical management (3)

A

Misoprostol for cervical priming
Routine antibiotics not required.
USS at time of suction curettage (if indicated).

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17
Q

In which locations can an ectopic pregnancy occur?

A

Fallopian tubes.

Cornu, cervix, caesarean section scar, ovary..or other sites.

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18
Q

What is a heterotopic pregnancy?

A

Multiple pregnancy with an intrauterine plus ectopic pregnancy.

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19
Q

Define a miscarriage?

A

Pregnancy loss occurring before 20 completed weeks of gestation or less than 400g birth weight.

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20
Q

Defined a missed miscarriage?

A

US confirmed non-viable pregnancy with no bleeding.

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21
Q

Define recurrent miscarriage?

A

Three or more consecutive miscarriages.

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22
Q

Define threatened miscarriage?

A

Any vaginal bleeding other than spotting before 20 weeks completed gestation with evidence of a progressive, viable pregnancy at US.

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23
Q

What are some physical and psychological complications of early pregnancy loss?

A

Infection, haemorrhage, embolism, damage to uterus and associated structures, anaesthetic complications.

Grief, depression, anxiety.

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24
Q

What advice would you give to a woman regarding return to normal menstrual cycle?

A
  • Resumption of normal menstrual cycle indicates resolution of EPL complications and completion of management.
  • Ongoing, irregular bleeding requires follow-up - consider:
    • b-hCG to exclude GTD
    • Retained productions or infection
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25
Q

What advice would you give to all women following EPL?

i.e. When to seek emergency assistance.

A

If experiencing strong pain unrelieved by paracetamol.
Shoulder tip or diaphragmatic pain.
Soaking of more than one pad within 60 minutes.
Fainting.
Elevated temperature.

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26
Q

A 25F G4P2 at K14 comes in with PV bleeding. Outline your history.

A

Menstrual history and LNMP.
Date of positive pregnancy test.
Previous pregnancies and outcomes, particularly miscarriages.
Other significant gynaecological history.
If assisted contraception, identify method of conception.
Relevant USS and quantitative b-hCG
Symptoms of early pregnancy.
Presence of associated symptoms:
- Vaginal bleeding (timing, extent, severity).
- Pain (lower abdo cramping or backache)
- Postural syncope
- Vomiting
- Shoulder tip/daphragmatic pain
Passage of POC

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27
Q

A negative b-hCG essentially excludes an ectopic pregnancy, true or false?

A

True (except in the case of a chronic ectopic hwere b-hCG has been positive in the recent past).

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28
Q

A 25F G4P2 at K14 comes in with PV bleeding. You have already gained a history. Outline your physical examination.

A

Baseline observations.
Abdominal examination
- Tenderness (rigidity/guarding)
- Distension
PV blood loss (check loss on pad)
Vaginal examination (individualised as clinically indicated):
- Spec exam:
- Source and amount of bleeding.
- Evidence of POC in the cervical os (if present, remove and submit for histology)
- Bimanual examination:
- Cervical motion tenderness
- State of the internal cervical os
- Assess for adnexal masses (ectopic pregnancy or other massess)
Size of uterus relative to menstrual dates.

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29
Q

A 25F G4P2 at K14 comes in with confirmed inevitable miscarriage. What investigations will you order?

A

USS (preferably a TVS)
FBC, blood group, antibody screen.
Midstream specimen or urine for microscopy, culture and sensitivity as clinically indicated.
Scree for STIs as indicated.

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30
Q

Following conception, how many days does it take for serum b-hcG to become positive?
Bonus: at what level b-hCG confirms pregnancy

A
  1. 9
    Bonus: 5 IU/L confirms pregnancy.
    NB: a single b-hCG does not differentiate between a viable and nonviable pregnancy.
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31
Q

What is the basis for undertaking serial b-HCG levels 48-72 hours apart?

A

For a potentially viable IUP up to 6-7 weeks gestation:

  • Mean doubling time for b-hCG is 1.4-2.1 days.
  • 85% show serial b-hCG rise of at least 66% every 48 hours.
  • 15% show serial b-hCG rise between 53-66% every 48 hours.
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32
Q

How do you diagnose a complete miscarriage?

A

A dx of complete miscarriage requires f/u with serum quantitative b-hCG until negative and TVS if clinically indicated, to exclude undiagnosed ectopic.

NB: an IUP can only be confirmed conclusively after identification of a yolk sac. Cannot dx complete miscarriage based on US findings of an ‘empty uterus’.

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33
Q

Describe the use of progesterone in PUL?

A

If PUL, a single progesterone level may assist in identifying women with a low risk of having an ectopic pregnancy or persistent PUL.
In two studies the negative predictive value was 98% and 97% (refer to EPL guidelines, page 12).

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34
Q

b-hCG > 2000 and no IUP with complex adnexal mass and/or free fluid on TVS suggests what diagnosis?

A

High probability of ectopic pregnancy.

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35
Q

Diagnosis of a NVP cannot be made until the MSD is (or has failed to reach) 25mm, true or false.

A

True.

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36
Q

A 25F G4P2 at K14 presents with uncontrolled PV bleeding in context of incomplete miscarriage. Her BP is 84/59. You have begun acute resuscitation protocol. You have excluded ectopic pregnancy. What pharmacological agents could you use to control bleeding in this case?

A
  1. Ergometrine maleate 250mcg IV or IM
  2. Misoprostol 800 - 1000 micg PR
  3. Critical bleeding massive transfusion protocol.
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37
Q

What is the frequency of ectopic pregnancies?

A

1.5 - 2%

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38
Q

What is the most common location of ectopic pregnancy and what is the %?

A

Fallopian tube (95%)

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39
Q

Falling or stationary b-hCG excludes the risk of rupture following medical or expectant management, true or false?

A

False.

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40
Q

Name risk factors for ectopic pregnancy (11)

A

Previous tubal surgery (OR 4.0)
Previous ectopic pregnancy (8.3)
Infertility (risk increases with length of) (2.1-2.7)
Previous genital infection confirmed (3.4)
Previous miscarriage (3.0)
Current smoker (risk increases with amount/day) (1.7-3.9)
Smoking (past or ever) (1.5)
Intrauterine device use more than 2 years (2.9)
Age 40 or older (compared to 25-29yrs) (2.9*)
Sterilisation (9.3)
Documented tubal pathology (3.7)

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41
Q

A woman with a confirmed ectopic pregnancy opts for expectant management. What should you always warn her of?

A

The possibility of tubal rupture despite decreasing b-hCG.

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42
Q

What are the indications for expectant management for ectopic pregnancy? (6)

A

Haemodynamically stable.
Low and falling b-hCG (less than 1500IU/L at initial presentation).
Tubal mass less than 3cm.
No pain
Nil to minimal evidence of blood in the pelvis on USS.
No geographical isolation.

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43
Q

A woman with confirmed ectopic pregnancy opts for expectant management. What is involved in ongoing management of her?

A

Follow-up via EPAS
b-hCG:
- Every 48 hours for 8 days (to confirm levels are falling)
- If satisfactory resolution occurring, may commence weekly levels until negative.
USS not routinely recommended. Consider if b-hCG not falling OR clinically indicated.

Offer surgical or medical mng:

  • At the woman’s request
  • If there is ongoing or increasing pain or bleeding
  • b-hCG is not consistently falling
  • Tubal rupture with haemoperitoneum occurs.
44
Q

What advice would you give to women undergoing expectant mng for an ectopic pregnancy?

A

Pelvic examination and sexual intercourse carry risk of rupture in acute phase of resolution.
Avoid future pregnancy until sonographic resolution of mass, noting that sonographic resolution of mass takes longer than biochemical resolution of b-hCG.
Early USS in next pregnancy (5-6 weeks gestation).

45
Q

What is the MOI of methotrexate?

A

It is a folic acid antagonist which prevents the growth of rapidly dividing cells by interfering with DNA synthesis.

46
Q

What are the indications for medical mng for ectopic pregnancy? (4)

A

Unruptured ectopic pregnancy; haemodynamically stable and no signs of active bleeding.
Unusual sites (e.g. cervical ectopic, interstitial, caesarean scar).
Low initial serum b-hCG.
- Best results achieved if b-hCG less than 5000 IU/L but may be used at any b-hCG level in hte unruptured ectopic.
FBC, electrolytes and LFTs are WNL.

47
Q

What are the C/Is to medical mng of ectopic pregnancy? (13)

A

Haemodynamically unstable.
Allergy to MTX
Evidence of significant haemoperitoneum on TVS
Renal disease/insufficiency (MTX is cleared renally)
Abnormal FBC, ELFT
Acute liver disease, aplastic anaemia, thrombocytopenia
Immunodeficiency
Active pulmonary disease
Active peptic ulcer disease.
Coexistent viable IUP (heterotopic pregnancy)
Breastfeeding.
Potential for non-compiance with prolonged follow-up (35- 109 days)
Geographic isolation

Cautions:
Baseline serum b-hCG greater than 5000IU/L
Ectopic preg > 3-4cm diameter on TVS
Presence of fetal heart motion on TVS
When blood transfusion is not acceptable to the woman
If BMI >/= to 40, and IMI dosage is capped at 2m2 BSA, an additional dose is more likely to be required to achieve complete resolution.

48
Q

With a confirmed ectopic pregnancy, what should you do if a fetal heart is present on USS?

A

Refer urgently to MFM for follow-up - direct injection of KCl may be indicated.

49
Q

What advice would you give for women undergoing medical management for ectopic pregnancy?

A

Provide women information on cytotoxic precautions post treatment with MTX.

Avoid:

  • Sun exposure (to limit skin inflammation)
  • Foods and vitamins containing folate/folic acid

Advise:

  • Pelvic examination and sexual intercourse carry risk of rupture in acute phase of resolution.
  • Common side effects of MTX include: nausea, tiredness, altered bowel habits and mouth ulcers which usually settle without tx w/i a few days.

Advise to delay next pregancy for four months post administration of mtx due to potential teratogenicity of mtx. (ensure sonographic resolution of mass prior ot future pregnancy).

Early USS in next pregnancy (5-6wks gestation).

50
Q

What are the indications for surgical mng of ectopic pregnancy? (3)

A

Women’s preference
Haemodynamic instability.
Persistent excessive bleeding.

51
Q

What follow-up is required following surgical mng of ectopic pregnancy?

A

GP f/u in around 2 weeks post surgery.
USS not routinely required.
If salpingostomy, weekly b-hCG until negative.
If salpingectomy,
- Unusually may see abdominal implantation especially after ruptured ectopic with haemoperitoneum.
Rarely may see ongoing intrauterine gestation if undiagnosed heterotopic pregnancy.
- Urinary b-hCG 3 weeks after surgery.
Advised early USS in next preganncy (5-6 weeks gestation).

52
Q

What is the risk of recurrent ectopic pregnancy after one and two ectopic pregnancies?

A

Risk of recurrent EP is approximately:

  • 15% after one EP
  • 30% after two EP.
53
Q

True or false.
There are no significant differences between expectant, medical and surgical management for rates of infection, psycological outcomes, resumption of normal activities or subsequent fertility.

A

True

54
Q

Name risk factors for non-viable intrauterine pregnancy.

Fetal/placental; maternal; other

A

Fetal/placental:

  • Chromosomal abnormalities
  • Congenital abnormalities.
  • GtD

Maternal:

  • Maternal age: EPL 7% in 25-29 years vs 43% in 40-44 years.
  • Recurrent miscarriage history: risk of EPL 20-70% after three losses.
  • Anatomic factors (e.g. uterine septum)
  • Endocrinopathy (e.g. thyroid disease)
  • Immunologic factors (e.g. SLE)
  • Infection (e.g. CMV)
  • Severe acute illness
  • Thrombophilia (e.g. FVL)
  • Uncontrolled chronic illness (e.g. HTN, diabetes)
  • Very high or very low pre-pregnancy BMI

Other:

  • Drug use/smoking
  • Teratogen exposure
  • Trauma (e.g. physical abuse)
55
Q

Expectant management for non-viable IUP is most suited to which type of miscarriage?

A

Incomplete miscarriage

56
Q

What are the C/Is to expectant management of non-viable IUP? (5)

A 
Suspected GTD
Haemodynamically unstable
IUD (requires removal)
Women at increased risk of haemorrhage (e.g. late in first pregnancy) or effects (e.g. unable to have a blood transfusion or coagulopathies).
Evidence of infection
57
Q

What are some of the risks of expectant mng of non-viable IUP? (Some risks that you would counsel the woman about)

A

Expect bleeding for up to two weeks (or longer in individual cases).

Advise surgical or medical management can be chosen at a later date.

Access to a telephone and 24 hour emergency hospital admission is required plan for access with geographical isolation.

I’m the setting of missed miscarriage, complete resolution may take several weeks and overall efficacy rates are lower.

Timeframe to complete miscarriage is unpredictable.

The proportion of women who subsequently require surgery is unpredictable.

58
Q

Expectant management of non-viable IUP is most suited to which type of miscarriage?

A

Incomplete

59
Q

What are the contraindications to expectant mng of non-viable IUP? (5)

A
  1. Suspected GDM
  2. Haemodynamically unstable
  3. IUD (requires removal)
  4. Women at increased risk of haemorrhage (i.e. late in first trimester) or effects of (e.g. unable to have a blood transfusion or coagulopathies)
  5. Evidence of infection
60
Q

What are some of the risks of expectant mng and what other advice would you give to women opting for expectant mng for non-viable IUP?

A

More days of bleeding and a greater amount of bleeding when compared to surgical treatment.
Some women will go on to require surgery (varies between 2- 44%).
Timeframe to complete miscarriage is unpredictable.
In setting of missed miscarriage, complete resolution may take several weeks and overall efficacy rates are lower.
Access to telephone and 24 hour emergency hospital admission is required or a plan for access where there is geographical/social isolation.
Expect bleeding for up to two weeks (or longer in individual cases).
Surgical or medical mng can be chosen at a later date.

61
Q

A women opts for medical mng of non-viable IUP. What follow-up and ongoing mng would you recommend?

A

Arrange f/u within 7-10 days at GP or EPAS.
!Remain vigilant for GTD and/or ectopic.
Repeat bHCG day 8.
Consider USS if: clinically indicated (symptomatic), to ax for RPOC; if b-hCG level has not fallen more than 90% over 7 days.
Options for medical or surgical mng if woman wishes, ongoing heavy bleeding, pain or persistent intrauterine gestational sac on USS, other clinical conerns.
If infection suspected, recommend early surgical management with antibiotic cover.
Recommend repeat urinary pregnancy test at 3-6 weeks if:
- no POC on histopath
- Failure to return to normal menstruation by 4-6 weeks.
- Ongoing abnormal bleeding.

62
Q

Medical mng of non-viable IUP is most suited to which type of miscarriage?

A

Missed miscarriage

63
Q

What are the contraindications to medical mng for NVIUP? (6)

A
  1. Suspected GDM
  2. Haemodynamically unstable
  3. Increased risk of haemorrhage (e.g. late first trimester) or effects of haemorrhage (eg.. coagulopathy, unable to have blood transfusion)
  4. Evidence of infection
  5. IUD (requires removal)
  6. Medical contraindications (e.g. HTN, allergy to prostaglandins
64
Q

Risks of medical mng for NVIUP?

A

Bleeding is heavier and more prolonged after medical treatment with misoprostal than with curettage.

65
Q

With respect to medical mng for NVIUP, what is the QLD health regimen for misoprostal administration?

A

Day 1: misoprostol 400-800 micrograms PV, PO or S/L
Day 2 or day 3: repeat misoprostol 400-800mcg PV/PO/S/L.
NB: if good history of POC passed, second dose may be omittted.
NB: OPD or day procedure. Offer analgesia and antiemetic.

66
Q

Describe ongoing mng for medical mng of NVIUP?

A

Remain vigilant for GTD and/or ectopic.
bHCG day 1 (of misoprostol) and day 8 (to confirm levels are falling).
Consider USS:
- If clinically indicated (symptomatic)
- To assess for RPOC
- If bHCG level ahs not fallen more than 90% over 7 days.
Surgical mng if woman requests it or other concern, ongoing heavy bleeding.
Recommend repeat urinary preg test in 3-6 weeks if:
- no POC histopath.
- Failure to return to normal menstruation by 4-6 weeks.
- Ongoing abnormal bleeding.

67
Q

What advice would you give to women opting for medical mng of NVIUP?

A
  1. Bleeding heavier than menses is likely.
  2. Cramping may accompany bleeding.
  3. If bleeding has not commenced by 24 hours following treatment, to contact healthcare provider to determine ongoign care.
  4. Potential side effects include pain, diarrhoea and vomiting.
68
Q

What are the absolute clinical indications for surgical mng for NVIUP?

A
  1. Haemodynamic instability
  2. Persistent excessive vaginal bleeding.
  3. Evidence of infected retained tissue
  4. Suspected GTD.
69
Q

What is the recommended surgical method for NVIUP?

A

Suction curettage.

70
Q

What are the risks/benefits of surgical mng for NVIUP?

A

As a primary approach, surgical mng results in a more immediate outcome with less follow-up.
Standard risks a/w procedure and anaesthesia.
?Risk of Ashermann’s syndrome

71
Q

What would make you proceed with caution with surgical mng of NVIUP?

A
  1. increased risk of haemorrhage (e.g. suspected AVM or coagulopathy.
  2. Previous uterine perforation.
72
Q

Describe the process of cervical priming wrt surgical mng of NVIUP?

A
  1. Misoprostol 400mcg PV 3-4 hours prior to surgery OR

2. Misoprostol 400mcg PO, S/L, buccal 2-3 hours prior to surgery

73
Q

Describe follow-up following surgical mng of NVIUP?

A

Advise GP f/u if ongoing clinical concerns
bHCG not usually indicated.
USS not routinely recommended.

74
Q

Describe potential aetiologies of 2nd trimester pregnancy loss.

A

Fetal:

  • Chromosomal abnormalities
  • Congential abnormalities

Maternal

  • Previous 2nd trimester loss
  • Uterine malformations
  • Maternal medical illness (e.g. cardiac disease, autoimmune disease, thrombophilia)
  • PROM
  • Placental complications (e.g. abruption)
  • Cervical insufficiency
  • Infection-estimated to be implicated in 10% to 25% of cases.
75
Q

Describe medical mng of 2nd trimester pregnancy loss where cx is closed and membranes are intact vs membranes ruptured and/or the cx is dilated…

A

If cx is closed and membranes are intact, mifepristone and misoprostol are 1st line agents for IOL. (misoprostol alone may be used).
If membranes are ruptured and/or cx is dilated, consider misoprostol or IV oxytocin.

Active mng is recommended if 3rd stage not complete in 30mins. If not complete within 1 hour consider MROP.
Retain cord, membranes and placenta for histopath

76
Q

When might surgical mng be recommended for 2nd trimester preg loss?

A

persistent excessive bleeding, haemodynamic instability, evidence of RPOC, suspected GTD.

Generally suitable for gestations up to 15 weeks. Beyond 16 weeks, may be suitable where baby has died at an earlier gestation.

77
Q

In a woman who has had a 2nd trimester pregnancy loss, what advice could you give her to help with lactation suppression?

A

Conservative and comfort measures.
Minimal breast stimulation
Cold compresses
Analgesia.

78
Q

What are the contraindications to RhD immunoglobulin?

A
  1. RhD positive women
  2. RhD negative women with preformed anti-D antibodies
  3. Previous sensitivity or allergy to RhD immunoglobulin
  4. Woman declines.
79
Q

Indications for RhD IgG for 1-12+6 weeks gestation? (5)

A
  1. Miscarriage
  2. TOP
  3. Ectopic pregnancy
  4. CVS
  5. Hydatidiform mole.
80
Q

Indications for RhD IgG 13+0 weeks and beyond (5)

A
  1. CVS, amniocentesis, cordocentesis or fetoscopy
  2. Abdominal trauma considered sufficient to cause fetomaternal haemorrhage (even if Kleihauer negative, as 0.001ml fetal blood sensitises an RhD negative mother).
  3. Each occasion of revealed or concealed antepartum haemorrhage.
  4. External cephalic version (performed or attempted)
  5. Miscarriage or TOP
81
Q

When do you quantify FMH and how do you do this?

A

If gestation > 13 weeks, quantifiy FMH.
- Each 100 IU of RhD-Ig protects against 1ml fetal red cells (2mls whole blood)
If the Kleihauer test is negative, nil further dose required.
If Kleihauer test indicates FMH is greater than that covered by RhD-Ig dose administered, give an additional dose within 72 hours.
Most accurate quantitative test for FMH is flow cytometry.
Interpret FMH with caution in women with persistent fetal Hg (i.e. African women, especially if sickle cell traits)

82
Q

What should you tell women before giving them RhD? (1)

A

RhD-Ig is a blood product.

83
Q

How quickly should you give anti-D?

A

Within 72 hours of a sensitising event.

84
Q

What is the dose and routine of anti-D?

A

Deep IMI
Singleton pregnancy of 1-12+6 weeks gestation - > 250IU IMI

625IU IMI for:

  • Multiple pregnancy (any gestation)
  • Gestation uncertain but possibly 13 or more weeks
  • Gestation 13+0 weeks or beyond.

NB: If BMI greater than 30 and FMH > 6mls, IV administration may be considered.

85
Q

Do you give Anti-D in threatened miscarriage?

A

1-12+6:
Insufficient evidence to support routine use of anti-D for bleeding in an ongoing pregnancy.
If there is heavy or repeat bleeding, or bleeding associated with abdo pain, significant abdo traum or a visible subchorionic haematoma, individualise RhD-Ig administration according to clinical circumstances.

13+0 weeks and beyond:
Quantify FMH at 1-2 weekly intervals.
Monitor for new sensitising events..
If Kleihauer positive, give additional RhD-Ig

86
Q

How is GTD classified?

A

Two premalignant diseases:

  1. Complete hydatidiform mole
  2. Partial HM

Four invasive malignant disorders (i.e. gestational trophoblastic neoplasia):

  1. Invasive mole/persistent trophoblast neoplasia
  2. Choriocarcinoma
  3. Placental site trophoblastic tumour (PSTT)
  4. Epithelioid trophoblastic tumour.
87
Q

GTD is more common in which demographic? i.e. Asian, European or North American women

A

More common in Asia (as high as 2 per 1000 pregnancies) compared with Euorpe and North Amergica (less than 1 per 1000 pregnancies).

88
Q

How is definitive dx of GTD made?

A

histological examination of POC

89
Q

How to you treat GTD?

A

suction curettage with concomitant administration of IV uterotonic agents.

90
Q

What features may suggest to you persistent GTD?

A

Increased, stationary or inadequately falling b-hCG trend on 3 consecutive weeks at any time following surgical evacuation.
Continued PV bleeding and detectable b-hCG
Evidence of metastases in the presence of detectable bhCG.

91
Q

Describe the f/u for partial HM vs complete HM?

A

Partial HM:
Weekly serum bhCG levels until negative for three consecutive weeks.
Conception may be attempted immediately after three consecutive negative b-hCG results.
Annual f/u for 5 years with QTC

Complete HM
Weekly serum bhCG until negative for three consecutive weeks. Then monthly for 6 months after the 3rd negative result.
Conception may be attempted immediately after the 6 months of consecutive negative bhCG resutls are finalised.
Annual f/u for 5 years with QTC

92
Q

Describe RFs for EPL? (epidemiological, anatomical, endocrine, genetic, others)

A

Epidemiological:
Advanced maternal age (>40)
Risk of EPL increases after each successive loss .
Anatomical eg. congenital uterine malformations.
Endocrine: e.g. DM, thyroid, PCOS.
Genetic: chromosomal abnormalities of the embryo account for 30-57% of further EPL.
Chromosomal anomaly present in one partner in 2-5% of couples.
Antiphospholipid antibodies: present in 15% of women with recurrent EPL
Infective agents.
Inherited and acquired thrombophilia.

93
Q

What investigations would you arranged for work-up of recurrent EPL?

A 
FBC
ELFT
Thrombophilia screen
Fasting homocysteine and MTHFR (methylenetetrahydrofolate reductase)
APL antibodies
TFTs
Fasting insulin
Fasting blood glucose level 
POC for fetal karyotyping
Parental chromosomes
Pelvic USS to assess anatomy of the uterus and fallopian tubes.
Sperm testing.
94
Q

When is it compulsory to register the birth of a baby born in QLD?

A

Born alive (a baby who’s heart has beaten after delivery of the baby is completed)
20 weeks or more gestation.
400g or more.

NB: If a birth registration is compulsory, a death certificate and burial cremation are also compulsory.

95
Q

When is the embryonic period?

A

From 6-10 weeks

96
Q

When is cardiac activity routinely detected on USS?

A

6-6.5 weeks gestation

97
Q

What is the earliest sonographic finding on USS? (to suggest a pregnancy?)

A

Gestational sac

98
Q

How do you determine gestational age prior to CRL?

A

MSD.

Usually visible from 4 weeks and 3 days after LNMP.

99
Q

What is the first structure usually visible within the gestational sac and at what gestation is this visible?

A

Yolk sac. Visible by 5.5 weeks gestation or MSD of 8-10mm.

No. of yolk sacs usually indicates the no. of amniotic sacs in the case of twin pregnancies

100
Q

When is the fetal pole usually visible on US?

A

5-6 weeks gestation

CRL at 6 weeks and 0 is 4mmm.

101
Q

During which period does the CRL increase by 1mm/day?

A

Embryonic period, week 6-10

102
Q

Describe the key landmarks in embryonic development and how these are used in early first trimester dating?

A

Gestational sac (no yolk sac, embryo or heartbeat) = 5 weeks.
Gestational sac and yolk sac (no embryo, no heart beat) = 5.5 weeks.
Gestational sac and yolk sac (living embryo, CRL < 5mm (too small to measure) = 6 weeks.
When CRL available, usu this to date date.

103
Q

What are the indications for IMI MTX for ectopic pregnancy? (3)

A

Unruptured tubal ectopic pregancy with all of the of the following:

  • b-HCG less than 3000IU
  • fetal sac less than 3.5cm
  • NO fetal cardiac activity.
104
Q

Describe the IMI MTX protocol used for unruptured tubal ectopic pregnancy?

A

Dose calculated based on BSA
Routine bloods + bHCG prior to administration.
Antiemetic 30minsprior.
Give antiemetic for 2/7 following.
D1: bhCG and MTX 50mg/m2 BSA IMI
D4: bhCG
D7: bhCG. If D7 bHCG reduction is less than 15% of day 4 bhCG or less than 25% of D1 bhCG, give 2nd dose of MTX at 50mg/m2 BSA.
D14: bhCG. if bhCG reduction < 15% of D7 bhCG, give 3rd dose.
Monitor bHCG weekly until less than 5IU/L.

105
Q

What are the indications for IV MTX in ectopic pregnancy?

A

Any stable EP at the discretion of the physician, particularly if any of the following:

  • bHCG >3000IU/L
  • Fetal sac > 3000 IU/L
  • Presence of cardiac activity.

Obstetrics (14 decks)

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