early pregnancy, miscarriage, abortion and ectopic Flashcards
what are the rules regarding anti-D in management of miscarriage?
all rhesus negative patients should be given anti D regardless of gestation if having surgical management of miscarriage
- if having medical management of miscarriage wait until >12 weeks gestation to offer.
what are the anti-D rules surrounding management of TOP
all rhesus D negative patients - surgical TOPs offered anti D
If rhesus D negative and having medical TOP only need it once > 10 weeks
If managing a patient who is rhesus D negative and been diagnosed with an ectopic pregnancy when should they be offered anti-D
all rhesus negative patients with ectopic pregnancies managed surgically should receive anti D (250IU) as soon as possible but must be within 72 hours.
what % of pregnancies in the UK are unplanned
50%
How many women will have accessed an abortion before the age of 45 in the UK
1 in 3 i.e. abortion is common
what year was the abortion act introduced
1967
which countries does the 1967 abortion act cover
England, wales and Scotland
what country within the UK does the abortion act not include
northern Ireland
what changes did the human fertilisation and embryology act 1990 make to the 1967 abortion act
it reduced the general gestational limit to 24 weeks and introduced no time limit if performing an abortion where continuing the pregnancy would cause death or serious permanent injury to mum or fetal anomaly
what is the name in England of the legal form that 2 doctors must sign prior to an abortion and indicate the clause under which the abortion is legalised?
HSA form 1 (cert A in scotland)
what are the 5 clauses listed on the HSA 1 form
a) no gestational limit - cont pregnancy would result in risk of life to the pregnant woman
b) no gestational limit - cont pregnancy would result in permanent physical or mental injury to pregnant woman
c) pregnancy does not exceed 24 weeks, cont pregnancy would result in severe physical or mental harm to pregnant woman
d) pregnancy does not exceed 24 weeks, cont pregnancy would result in severe physical or mental harm to existing children in the family
e) no gestational limit, cont pregnancy would result in severe physical or mental abnormalities to the born child (fetal anomaly)
how many doctors must sign the HSA form 1 to make the abortion legal and when must it be signed
must be signed by 2 doctors, prior to abortion
what clauses on a HSA form can be used in case of emergency when an abortion must be performed to safe mums life or prevent permanent injury to mum?
f (safe life) or g (prevent permanent injury) clauses
this is on HSA form 2
can be signed by just ONE doctor, ideally before the abortion but if time does not allow then within 24 hours post abortion.
how long should a HSA form 1 be kept for
2 years
how long should a HSA form 2 be kept for
3 years
does the pregnant woman’s partner have any rights to veto an abortion or be consulted regarding an abortion?
no
in 2022 the government approved ‘home’ as a place for abortion. (EMA)
a) what is the legal gestational limit for EMA at home in England and wales?
b) in scotland?
a) < 10 weeks
b) < 12 weeks
what year did abortion become decriminalised in northern Ireland
Oct 2019
what is NI law regarding abortion
can access abortion in NI up to 24 weeks if continuing pregnancy would cause physical or mental issues
no time limit to access if continuing pregnancy presents:-
- fatal injury to mum
- permanent injury to mum’s physical or mental wellbeing
- fetal anomaly
- involves greater risk than termination
(very similar to England, wales and Scotland)
what is the law regarding abortion in republic of Ireland
Abortion is legal up to 12 weeks gestation.
can only access abortion beyond 12 weeks if fetal anomaly or serious risk of harm/life to mum
however very difficult to access.
can you list some of the contra-indications to abortion
- known or suspected ectopic pregnancy
- allergy to mife or misoprostol
- inherited porphyria
- severe asthma on steroids or adrenal insufficiency/ chronic adrenal failure on steroids (as mifepristone is a glucocorticoid antagonist so can exacerbate pre existing condition)
when should you consider antibiotic prophylaxis in patients accessing a TOP and what would you recommend
routine antibiotic prophylaxis if having surgical TOP
recommendation is doxycycline 100mg BD 3 days (no need to combine with metronidazole, 3 day course just as effective as 7 days)
what is the timescale that RCOG best practice abortion care suggest patients requesting TOP should be assessed within and TOP completed?
should be assessed within 7 days of requesting TOP
TOP should be completed within 7 days of being assessed.
what is the mode of action of misoprostol
misoprostol is a prostaglandin analogue = increased prostaglandins = increase smooth muscle contraction and cervical ripening (softens and dilates the cervix)
what is the mode of action of mifepristone? what is the usual dose of mifepristone?
mifepristone is a glucocorticoid receptor antagonist (i.e. blocks glucocorticoid receptors) = anti progesterone = progesterone antagonist.
this blocks the action of progesterone on the endometrium ==> necrosis and shedding of the endometrium ==> less favourable for implantation.
It also sensitises the uterus to prostaglandins. Unopposed prostaglandin synthesis –> increased uterine contractions of the uterine smooth muscles
What does the abortion act clarify re. upper gestation limit if feticide has been given?
if feticide has been given at or before 23+6, the actual abortion can be performed shortly after
What is the upper limit for at home medical TOP?
9+6 weeks
What advice do you give someone who wants to take mifepristone and misoprostol at the same time?
can increase chance of TOP failure esp as gestation increases.
taking together can mean the process takes longer to complete the TOP (takes longer for bleeding and pain to start)
For TOP up to and including 10+0 weeks, what regime is approved by UK marketing authorisation when using 200mg mifepristone?
200mg mifepristone first then 24 -48 hours later 800mcg misoprostol (PV, sublingual or buccal). if no bleeding/ not passed anything after 3 hours then repeat dose of 400mcg misoprostol.
For STOP < 10 weeks: mifepristone 200mg 24-48 hours pre STOP for cervical priming
What regime is NICE recommended for MTOP between 10+1 and 23+6 weeks, who have taken 200mg mifepristone?
-Misoprostol 800mcg PV or 400mcg Sublingually or bucal
further 400mcg every 3 hours (max four doses) until pregnancy passed
What misoprostol doses are NICE recommended for abortion after 23+6 weeks (after taking 200mg mifepristone)?
Need to reduce dose and time interval between misoprostol doses as gestation increases esp when beyond 24 weeks due to risk of uterine rupture (uterus becomes VERY sensitive) to misoprostol as gestation increases
Between 24+0 and 25+0 weeks
- 400 micrograms misoprostol every 3 hours until delivery
Between 25+1 and 28+0 weeks
- 200 micrograms misoprostol every 4 hours until delivery
After 28 weeks
- 100 micrograms misoprostol every 6 hours until delivery
what are the risk factors for uterine rupture during TOP
multi-parity, previous c-section, increasing gestation age, previous uterine surgery
Why use cervical priming before STOP?
makes cervical dilation easier, less likely to cause trauma to the cervix and more likely to succeed with abortion (decreased risk of incomplete abortion)
At what gestation is medical abortion usually done as an inpatient
12-24 weeks
what are the surgical abortion method options and for what gestations
EMA or MVA up to 14 weeks (could be done up to 16 weeks if cannula up to 16mls)
D&E : 14-24 weeks (dilation and evacuation)
n/b D &C = dilatation and curettage no longer recommended
why is it recommended to combine mife and miso as an abortion regime?
higher rates of failure at 48 hours if just using misoprostol (48 hours approximately 10% failure rate)
whereas < 1% failure rate if combined mifepristone and misoprostol at 36 hours
what is the usual time to expel the pregnancy if using mife and miso?
6-9 hours
what is the usual time to expel the pregnancy if using miso on its own
12-18 hours
what is the risk of major adverse events if using mife and miso or just miso on its own
< 1%
what is the typical risk of failing to end the pregnancy following
a) medical TOP versus b) surgical TOP
medical 1 in 100 = 0.01%
surgical 1 in 1000 = 0.001%
what is the typical risk of RPOC
a) medical TOP versus b) surgical TOP
medical = 3-5 in 100 = 0.03%
surgical = 1 in 100
what is the typical risk of infection
a) medical TOP versus b) surgical TOP
both same 1 in 100 = 0.01%
what is the typical risk of haemorrhage
a) medical TOP versus b) surgical TOP
medical and surgical < 20 weeks = 1 in 1000
medical and surgical > 20 weeks = 4 in 1000
risk of cervical injury from manipulation and dilatation in surgical management
1 in 100
risk of uterine rupture during medical management
< 1 in 1000 ( in second and third trimester)
what happens to the risk of requiring further intervention following a TOP as gestational age increases
risk of further intervention decreases as gestational age increases
if using osmotic dilators for cervical priming when should you consider inserting them pre surgical TOP procedure
the day before (esp if > 19/40)
if a patient is having a surgical TOP <=13+6/40 what cervical priming could she be offered
a) mifepristone 200mg 24-48 hours prior (if miso can’t be used)
OR
b) misoprostol 400mcg sublingual 1-2 hours before
OR
c) misoprostol 400mcg buccal or vaginally 2-3 hours before
if using osmotic dilators to dilate in cervical priming regimes what drug should you not combine it with
misoprostol
What cervical priming is NICE recommended for STOP between 14+0 and 16+0 weeks?
osmotic dilators
OR
Misoprostol sublingingual/ buccal or PV
or
mifepristone 200mg day before
What cervical priming is NICE recommended for women who are having a STOP between 16+1 and 19+0 weeks gestation?
osmotic dilators
OR
misoprostol
(don’t give mife)
What cervical priming is NICE recommended for women having STOP between 19+1 and 23+6 weeks gestation?
osmotic dilators AND
mifepristone at same time (the day before)
what is feticide?
Feticide is the injection of digoxin or potassium chloride into the fetus, or an injection of digoxin into the amniotic cavity, to stop the fetal heart before an abortion.
who shouldn’t receive anti D
do not routinely offer patients having:-
1. medical management of miscarriage or ectopic pregnancy
2. threatened miscarriage
3. PUL
4. complete miscarriage
do not use a Kleihauer test for quantifying feto-maternal haemorrhage
what is the name of the legal form that must be filled out by the abortion practitioner to inform the chief medical officer?
HSA 1
HSA 2
HSA 4
HSA 4 (now electronic)
what is the WHO definition of infertility (SBA)
a) unable to conceive after 6 months of trying
b) unable to conceive after at least 12 months of trying, having regular UPSI every 2-3 days
c) unable to conceive, despite regular UPSI every 2-3 days
d) unable to conceive after at least 12 months of trying, having regular UPSI every 4-5 days
b) unable to conceive after at least 12 months of trying, having regular UPSI every 2-3 days
out of the following list what is the most common cause of infertility
a) male problems
b) ovulatory causes
c) fallopian tubes
d) uterine/peritoneal causes
a) male problems (30%)
ovulatory - 25%, fallopian tubes - 20% and uterine/peritoneal causes 10%
what % of infertility is no cause found i.e. unexplained infertility
a) 10%
b) 20%
c) 25%
d) 35%
c) 25%
according to NICE CKS at what stage should a couple be referred to infertility clinic following initial assessment with GP if they have been unable to conceive despite regular UPSI every 2-3 days with no other known RF or conditions to cause infertility and women <36 years old.
a) 6 months
b) 12 months
c) 18 months
d) 24 months
b) 12 months
note refer earlier if women is age >36 years or pre-existing condition that would be a RF for infertility e.g PCOS
when would you consider referring a couple earlier than 12 months to infertility specialists
if woman is age >36 years or known pre-existing condition or RF that could cause infertility (proactive management e.g. PCOS)
what is the difference between primary and secondary infertility
primary - no previous pregnancies
secondary - couples who have previously conceived at least once before
what % of couples will conceive within 1 year of trying?
a) 40%
b) 50%
c) 70%
d) 80%
d) 80%
of the couples who fail to conceive within the first year of trying what % will conceive within the second year?
half will conceive within the second year
cumulative pregnancy rate increases to 90%
what proportion of couples have difficulty conceiving?
a) 1 in 3
b) 1 in 4
c) 1 in 5
d) 1 in 7
d) 1 in 7
what are the initial investigations a GP should do for a female when presenting with infertility?
- Serum progesterone day 21 (mid luteal) as this confirms ovulation
- Serum gonadotrophins - LH and FSH
- TFTs - rule out thyroid
- prolactin (prolactinomas - can suppress HPO axis, often have visual changes, headaches, galactorrhea)
- STI screen - CT/GC specifically CT on NICE CKS
also check BMI, modifiable RF - smoking. alcohol, drugs, OTC drugs and prescribed meds that can affect fertility
what are the initial investigations a GP should do for a male when presenting with infertility?
- semen sample
- STI screen - check for CT in particular but NAAT does ct/gc
what are some of the RF for infertility
- age - women and men (however men >55years)
- BMI - >30 and also low BMI < 19 a/s infertility
- excess alcohol, smoking, recreational drugs
- stress
- medications - prescribed and OTC (sulfasalazine in men decreased sperm production, NSAIDs decrease ovulation, chemotherapy POI, anti-psychotics can cause raised prolactin switches of HPO axis)
- occupational risks - pesticides, NO, metals, formaldehyde
at what stage should GP start to do initial investigations
at 1 year (12 months of regular UPSI) - do tests in couple simultaneously
what time frame should sperm sample be repeated if abnormal
after 3 months (to allow for new spermatozoa) unless grossly abnormal repeat in 2-4 weeks (ASAP really)
if 2 abnormal sperm samples refer to secondary care.
what is recommended alcohol intake for
a) women
b) men
A) women - 1-2 units per week
b) men 3-4 units per week
