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YEAR 4- OBSTETRICS > Early Pregnancy & Miscarriage > Flashcards

Early Pregnancy & Miscarriage Flashcards

1
Q

What is an ectopic pregnancy?

A

Ectopic pregnancy is when a pregnancy is implanted outside the uterus.

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2
Q

Where is the most common site for a ectopic pregnancy to occur?

A

The fallopian tube

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3
Q

Suggest 3 other locations an ectopic pregnancy can occur.

A

1-Ovaries
2-Cervix
3-Abdomen

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4
Q

Suggets 5 risk factors for ectopic pregnancy.

A
  1. Previous ectopic pregnancy
  2. Previous pelvic inflammatory disease
  3. Intrauterine devices (coils)
  4. Older age
  5. Smoking
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5
Q

At what week gestation do ectopic pregnancies typically present?

A

6-8 weeks gestation

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6
Q

Suggest 3 things you should ask in a history in a women presenting with lower abdominal pain?

A
  1. Missed periods
  2. Any recent unprotected sex
  3. Any possibilty of pregnancy
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7
Q

Suggest 3 signs and 3 symptoms of a ectopic pregnancy?

A

Signs:
1. Constant lower abdominal pain in the LIF or RIF
2. Lower abdominal or pelvic tenderness
3. Cervical motion tenderness
4. Tachycardia

Symptoms:
1. Vaginal bleeding
2. Shoulder tip pain
3. Dizziness/syncope
4. Missed period
5. Palor
6. sweating

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8
Q

Explain why shoulder tip pain may be suggestive of an ectopic pregnancy?

A

-If the ovum has ruptured, get bleeding into the peritoneal cavity.
-This results in inflammation of the perioneum and thus peritonitis.
-The peritoneum is innervated by nerves which are reffered back to the dermatome whihc overlie the shoulder

CHECK THIS

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9
Q

Explain why dizziness or syncope may be suggestive of an ectopic pregnancy.

A

An ectopic pregnancy is a surgical emergency as there is a huge potential for haemorrhaging.

If the patient is experiencing blood loss this may present as dizziness due to the drop in blood volume and thus blood pressure.

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10
Q

What is meant by cervical motion tenderness?

A

Pain when moving the cervix during a bimanual vaginal examination

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11
Q

How would you investigate suspected ectopic pregnancy?

A

Bedside:
-History
-Abdominal examiantion
-Vaginal examination
-Pregnancy test
-STI swab/screen
-Urine dip
-Urine MCS

Bloods:
-FBC
-U&Es
-CRP/ESR
-LFTs
-hCG

Imaging:
-Transvaginal ultrasound scan (Gold standard)

Other:

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12
Q

What features on ultrasound would be suggestive of an ectopic pregnancy?

A
  1. A gestational sac containing a yolk sac or fetal pole may be seen in a fallopian tube.
  2. Non specific mass in fallopian tube
  3. An empty uterus
  4. Fluid in the uterus, which may be mistaken as a gestational sac (“pseudogestational sac”)
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13
Q

What is meant by a ‘Pregnancy of unknown location’ (PUL)?

A

When a woman has a positive pregnancy test but there is no evidence of pregnancy on the ultrasound scan.

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14
Q

Explain how serum human chorionic gonadotropin (hCG) can be tracked over time to help differentiate between a normal pregnancy, ectopic pregnancy and miscarriage?

A

The developing syncytiotrophoblast of the pregnancy produces hCG.

In an intrauterine pregnancy, the hCG will roughly double every 48 hours. A rise of more than 63% after 48 hours is likely to indicate an intrauterine pregnancy.

This will not be the case in a miscarriage or ectopic pregnancy.

A rise of less than 63% after 48 hours may indicate an ectopic pregnancy.

A fall of more than 50% is likely to indicate a miscarriage.

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15
Q

How are ectopic pregnancies managed?

A

All ectopic pregnancies need to be terminated

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16
Q

What are the 3 options for terminating a ectopic pregnancy?

A
  1. Expectant management
  2. Medical management
  3. Surgical management
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17
Q

What is expectant management?

A

Awaiting natural termination

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18
Q

What is the criteria the patient must meet to qualify for expectant management/natural termination of an ectopic?

A
  • Follow up needs to be possible to ensure successful termination
  • The ectopic needs to be unruptured
  • Adnexal mass < 35mm
  • No visible heartbeat
  • No significant pain
  • HCG level < 1500 IU / l
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19
Q

What is the medication of choice for medical termination of an ectopic pregnancy?

A

Methotrexate

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20
Q

What is the criteria the patient must meet to qualify for expectant medical termination of an ectopic?

A
  • Follow up needs to be possible to ensure successful termination
  • The ectopic needs to be unruptured
  • Adnexal mass < 35mm
  • No visible heartbeat
  • No significant pain
  • HCG level must be < 5000 IU / l
  • Confirmed absence of intrauterine pregnancy on ultrasound
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21
Q

Explain how methotrexate works to terminate an ectopic pregnancy.

A

Methotrexate is highly teratogenic
It is given as an intramuscular injection into a buttock. This halts the progress of the pregnancy and results in spontaneous termination.

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22
Q

What is meant by teratogenic?

A

Harmful to pregnancy

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23
Q

How long are women advised NOT to get pregnant for, follwoing treatment with methotrexate?

A

3 months

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24
Q

Suggest 3 side effects of ectopic pregnancy treatment with methotrexate?

A

Vaginal bleeding
Nausea and vomiting
Abdominal pain

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25
Q

Anyone who doesn’t meet the criteria for expectant or medical managment requires surgical intervention.

What are the 2 options for surgical managment of ectopic pregnancy.

A
  1. Laparoscopic salpingectomy (1st line)
  2. Laparoscopic salpingotomy
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26
Q

What is Laparoscopic salpingectomy?

A

This involves a general anaesthetic and key-hole surgery with removal of the affected fallopian tube, along with the ectopic pregnancy inside the tube.

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27
Q

What is a laparoscopic salpingotomy?

A

The aim is to avoid removing the affected fallopian tube. Instead a cut is made in the fallopian tube, the ectopic pregnancy is removed, and the tube is closed.

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28
Q

When might a laparoscopic salpingotomy be used instead of a laparoscopic salpingectomy?

A

Laparoscopic salpingotomy may be used in women who are at increased risk of infertility due to damage to their other fallopian tube.

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29
Q

Which surgery has the biggest risk for failing to successfully remove the ectopig pregnancy?

A

Laparoscopic salpingotomy

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30
Q

Who is anti-rhesus D prophylaxis given to?

A

Anti-rhesus D prophylaxis is given to rhesus negative women having surgical management of ectopic pregnancy.

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31
Q

What is a miscarriage?

A

Miscarriage is the spontaneous termination of a pregnancy.

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32
Q

What gestation is an early miscarriage and what gestation is a late miscarriage?

A

Early miscarriage-Before 12 weeks
Late miscarriage- Between 12-24 weeks

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33
Q

Define this term-
‘Missed miscarriage’

A

The fetus is no longer alive, but no symptoms have occurred

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34
Q

Define this term- ‘Threatened miscarriage’

A

Vaginal bleeding with a closed cervix and a fetus that is alive

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35
Q

Define this term- ‘Inevitable miscarriage’

A

Vaginal bleeding with an open cervix

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36
Q

Define the term- ‘Incomplete miscarriage’

A

Retained products of conception remain in the uterus after the miscarriage

37
Q

Define the term- ‘Complete miscarriage’

A

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

38
Q

Define the term- ‘Anembryonic pregnancy’

A

A gestational sac is present but contains no embryo

39
Q

What is the diagnostic test for a miscarriage?

A

Transvaginal ultrasound scan.

40
Q

When a fetal heartbeat is visible, the pregnancy is considered viable.
A fetal heartbeat is expected once the crown-rump length is what?

A

7mm or more.

41
Q

How is a non-viable pregnancy which is less than 6 weeks gestation managed?

A

Expectant management; awaiting the miscarriage without investigations or treatment.

(Provided they have no pain, no complications or no risk factors)

42
Q

How is a non-viable pregnancy which is more than 6 weeks gestation managed?

A
  1. Expectant management (do nothing and await a spontaneous miscarriage)
  2. Medical management
  3. Surgical management
43
Q

What medical managment is used to manage miscarrigage?

A

Misoprostol
(oral dose or vaginal suppository)

44
Q

Explain how Misoprostol acts to treat miscarriage?

A
  • Misoprostol is a prostaglandin analogue
  • It binds to prostaglandin receptors and activates them.
  • This causes softening of the cervix and stimulates uterine contractions.
  • Ultimately expediting the miscarriage.
45
Q

Suggest 4 side effects of Misoprostol.

A
  1. Heavier bleeding
  2. Pain
  3. Vomiting
  4. Diarrhoea
46
Q

What are the surgical management options for misacarriage?

A
  1. Manual vacuum aspiration under local anaesthetic as an outpatient
  2. Electric vacuum aspiration under general anaesthetic
47
Q

What does manual vacuum aspiration involved?

A
  • It is peformed under local anaesthetic applied to the cervix
  • Misoprostol is given prior to surgery to soften the cervix
  • A tube attached to a specially designed syringe is inserted through the cervix into the uterus.
  • The person performing the procedure then manually uses the syringe to aspirate contents of the uterus
48
Q

Who is manual vacuum aspiration more ideal for?

A
  • Those less than 10 weeks gestation
  • Those who have previously given birth
49
Q

What does electric vacuum aspiration involve?

A
  • Performed under general anaesthetic
  • The operation is performed through the vagina and cervix without any incisions.
  • The cervix is gradually widened using dilators, and the products of conception are removed through the cervix using an electric-powered vacuum.
50
Q

Who is Anti-rhesus D prophylaxis given to after surgical management of miscarriage.

A

Rhesus negative women

51
Q

What is an incomplete miscarriage?

A

An incomplete miscarriage occurs when retained products of conception (fetal or placental tissue) remain in the uterus after the miscarriage.

52
Q

What are the 2 options for treating incomplete miscarraige.

A
  1. Medical management (misoprostol)
  2. Surgical management (evacuation of retained products of conception)
53
Q

What is a key complication of evacuating retained products of conception.

A

A key complication is endometritis (infection of the endometrium) following the procedure.

54
Q

Define this term-‘Recurrent miscarriage’

A

Recurrent miscarriage is the loss of three or more pregnancies before 24 weeks of gestation

55
Q

Suggest 5 causes of reccurent miscarriage?

A
  1. Idiopathic (particularly in older women)
  2. Antiphospholipid syndrome
  3. Hereditary thrombophilias
  4. Uterine abnormalities
  5. Genetic factors in parents (e.g. balanced translocations in parental chromosomes)
56
Q

What is antiphospholipid syndrome?

A
  • Antiphospholipid syndrome is a disorder associated with antiphospholipid antibodies, where blood becomes prone to clotting.
  • The patient is in a hyper-coagulable state.
  • The main associations are with thrombosis and complications in pregnancy, particularly recurrent miscarriage.
57
Q

The risk of miscarriage in patients with antiphospholipid syndrome is reduced by using what 2 medications?

A
  1. Low dose aspirin
  2. Low molecular weight heparin (LMWH) e.g. Dalteparin
58
Q

Name 3 Hereditary Thrombophilias?

A
  1. Factor V Leiden (most common)
  2. Factor II (prothrombin) gene mutation
  3. Protein S deficiency
59
Q

Uterine abnormalities can cause recurrent miscarriages.
Name 4 types of uterine abnormalities.

A
  1. Uterine septum (a partition through the uterus)
  2. Unicornuate uterus (single-horned uterus)
  3. Didelphic uterus (double uterus)
  4. Fibroids
60
Q

How would you investigate recurrent miscarriage?

A

Bloods:
* Antiphospholipid antibodies
* Testing for hereditary thrombophilias

Imaging:
* Pelvic ultrasound

Other:
* Genetic testing of the products of conception from the third or future miscarriages
* Genetic testing on parents

61
Q

How would you manage recurrent miscarriages?

A

It depends on the cause.

62
Q

What is a molar pregnancy?

A

Is an abnormal form of pregnancy in which a non-viable fertilized egg implants in the uterus.

63
Q

What are the 2 types of molar pregnancy?

A

1-Complete mole
2-Partial mole

64
Q

What is a complete mole?

A

A complete mole occurs when two sperm cells fertilise an ovum that contains no genetic material (an “empty ovum”).

These sperm then combine genetic material, and the cells start to divide and grow into a tumour called a complete mole.

No fetal material will form.

65
Q

What is a partial mole?

A

A partial mole occurs when two sperm cells fertilise a normal ovum (containing genetic material) at the same time.

The new cell now has three sets of chromosomes.

The cell divides and multiplies into a tumour called a partial mole.

In a partial mole, some fetal material may form.

66
Q

How can you distinguish between a molar pregnancy and a normal pregnancy?

A

In a molar pregnancy there are these fetaures:

  • More severe morning sickness
  • Vaginal bleeding
  • Increased enlargement of the uterus
  • Abnormally high hCG
  • Thyrotoxicosis (hCG can mimic TSH and stimulate the thyroid to produce excess T3 and T4)
  • Ultrasound of the pelvis shows a characteristic “snowstorm appearance”
67
Q

How is a molar pregnancy managed?

A

Management involves evacuation of the uterus to remove the mole.

The products of conception need to be sent for histological examination to confirm a molar pregnancy.

Patients should be referred to the gestational trophoblastic disease centre for management and follow up.

The hCG levels are monitored until they return to normal.

Occasionally the mole can metastasise, and the patient may require systemic chemotherapy.

68
Q

What is Hyperemesis Gravidarum?

A

Severe form of nausea and vomiting in pregnancy

69
Q

Nausea and vomiting are normal during early pregnancy.

What gestation period do symptoms typically start.

A

Symptoms usually start from 4 – 7 weeks, are worst around 10 – 12 weeks and resolve by 16 – 20 weeks.

70
Q

What hormone in pregnancy is thought to be responsible for nausea and vomiting?

A

Human chorionic gonadotropin (hCG)

The placenta produces human chorionic gonadotropin (hCG) during pregnancy.

Higher levels of hCG result in worse nausea and vomiting.

71
Q

Why is nausea and vomiting more severe in molar pregnancies and multiple pregnancies?

A

Due to the higher hCG levels.

72
Q

How is hyperemesis gravidarum investigated?

A

Nausea and vomiting of pregnancy can be diagnosed based on a typical history.

73
Q

How is Hyperemesis Gravidarum treated?

A

Antiemetics are used to suppress nausea

  1. Prochlorperazine (stemetil)
  2. Cyclizine
  3. Ondansetron
  4. Metoclopramide
74
Q

Suggest 2 complimentary therapies which may also be advised to women experiencing Hyperemesis Gravidarum?

A
  1. Ginger
  2. Acupressure on the wrist at the PC6 point (inner wrist) may improve symptoms
75
Q

Mild cases of Hyperemesis Gravidarum can be managed at home.

When would a woman need to be admitted for Hyperemesis Gravidarum.

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)
  • Other medical conditions need treating that required admission
76
Q

What is a termination of pregnancy (TOP) or abortion?

A

An elective procedure to end a pregnancy.

77
Q

What is the latest gestational age where an abortion is legal?

A

24 weeks

78
Q

An abortion can be performed before 24 weeks if continuing the pregnancy involves greater risk to the physical or mental health of who?

A

1-The woman
2-Existing children of the family

79
Q

What are the 2 legal requirements for an abortion?

A
  1. Two registered medical practitioners must sign to agree abortion is indicated
  2. It must be carried out by a registered medical practitioner in an NHS hospital or approved premise
80
Q

How can abortion services be accessed?

A

-Self-referral
-GP
-GUM
-Family planning clinic referral

81
Q

What are the 2 ways to abort?

A

1-Medical abortion
2-Surgical abortion

82
Q

A medical abortion is most appropriate earlier in pregnancy, but can be used at any gestation.

What does it involve?

A

Two treatments:

  1. Mifepristone -anti-progestogen medication that blocks the action of progesterone, halting the pregnancy and relaxing the cervix.
  2. Misoprostol -prostaglandin analogue given 1 – 2 days later. It binds to prostaglandin receptors and activates them. Prostaglandins soften the cervix and stimulate uterine contractions.
83
Q

When is anti-D prophylaxis indicated in a medical abortion?

A

In Rhesus negative women with a gestational age of 10 weeks or above

84
Q

What are the 2 options for surgical abortion?

A
  1. Cervical dilatation and suction of the contents of the uterus (usually up to 14 weeks)
  2. Cervical dilatation and evacuation using forceps (between 14 and 24 weeks)
85
Q

Prior to surgical abortion, medications are used for cervical priming.
What are the 3 medications used?

A

Misoprostol
Mifepristone
Osmotic dilators.

86
Q

When is anti-D prophylaxis indicated in a surgical abortion?

A

Rhesus negative women having a surgical abortion should have anti-D prophylaxis.

(It should even be considered in women less than 10 weeks gestation.)

87
Q

Suggest 2 features of post abortion care.

A

1-Offering support and counselling

2-A urine pregnancy test is performed 3 weeks after the abortion to confirm it is complete.

88
Q

Suggest 4 complications of abortion?

A
  1. Bleeding
  2. Pain
  3. Infection
  4. Failure of the abortion (pregnancy continues)
  5. Damage to the cervix, uterus or other structures

YEAR 4- OBSTETRICS (5 decks)

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