Early pregnancy problems Flashcards
1
Q
state the exepcted length of pregnancy and how it is measured
A
expected date of delivery
-280 days (40 weeks)
-from 1st day of last menstrual period (LMP)
2
Q
basic steps of fetilisation and implanatation
A
1- feritlisation occurs in tube
2-transportation of embryo along tube
3-Implantation into endometrium approximately 6 days post feritlisation
3
Q
hormones released in pregnancy 3
A
porgresterone
estrogens
Human chorionic gonadotropin
(HCG is total, beta-HCG is free form of HCG)
4
Q
how do levels of HCG progress throughout pregnancy
A
begins release at week 4
-sharp increase
-peaks at week 10/12
-decreases slowly then plateaus around week 24
5
Q
how do levels of estrogen and progersteron progress throughout pregnancy
A
slowly rise
-more progresterone up until week 24
-then more estorgen
-progresterone begins to dip towards the end of pregnancy
6
Q
define a miscarriage
A
any pregnancy loss before 24 weeks gestation
7
Q
define a stillbirth
A
any fetus born dead at or after 24 weeks gestation
8
Q
define a livebirth
A
a fetus which shows signs of life after delivery at any gestation
9
Q
Miscarriage definitions
-Threatened
A
bleeding with continuuing intrauterine pregnancy
10
Q
Miscarriage definitions
-Inevitable
A
bleeding with non-continuing intrauterine pregnancy
-cervic may be open
11
Q
Miscarriage definitions
-Incomplete
A
Incomplete passage of pregnancy tissue
12
Q
Miscarriage definitions
-Complete
A
All pregnancy tissue expelled and uterus now empty
13
Q
Miscarriage definitions
-Delayed/missed (silent) or early embyronic demise
A
Fetus has died in-uetero prior to 24 weeks gestation
14
Q
Miscarriage definitions
-Septic
A
complicated by intrauterine infection
15
Q
Miscarriage definitions
-Recurrent
A
3 or more consecutive miscarriages
16
Q
Overall Miscarriage prevalence
-after 1st trimester
- after Fetal heart seen on US
A
Approx 20% of pregnancies
-1 in 100
- <5 in 100
17
Q
main risk factor for increasing incidence of miscarriage
A
increase in maternal age
18
Q
True or False
-Will a mother have increased recurrence of another miscarriage after having one
A
False
(No increased risk after 1 miscarriage)
19
Q
Clinical presenation of a miscarriage in the presence of a positive pregnancy test 3
A
vaginal bleeding - brown spotting -> heavy ± tissue
pelvic discomfort or pain
Asymptomatic
20
Q
Investigations in a women presenting with a miscarriage 5
A
Clinical exam
Ultrasound scan
Examination of POC (products of conception)
Serum HCG tracking
Assess FBC and blood group
21
Q
Aspects of the clinical exam when investigating someone with a miscarriage 3
A
haemodynamically stable?
assess pain & bleeding
removal of POC (speculum)
22
Q
types of USS used when assessing for miscarriage in a newborn 2
A
Transabdominal
transvaginal
23
Q
Ultrasound defintinos of miscarriage 3
A
no fetal heart activity >7mm crown-rump length (CRL)
empty sac when mean gestional sac diameter >25mm
retained tissue (in incomplete miscarriage)
24
Q
what could an empty uterus on USS mean 3
A
complete passage of tissue (complete miscarriage)
pregnancy too early to visualise on scan
ectopic pregnancy
25
if abnormlaities seen on an USS in pregnancy what is needed 1
confirmatory scan
26
how can the different Management options of miscarriage be classified 3
expectant
medical
surgical
27
success of expectant misscarriage management 1
60%
28
management of expectant miscarriage management
intensive follow up
-review every 7-14 days
29
management of medical miscarriage 1
Misoprostol
-oral or vaginal
-dose dependent on gestation
30
success of medical miscarriage management
80-90% success
31
options for surgical management of miscarriage 2
cervical priming (usualy misoprostol)
-then electrical vacuum aspiration under GA as day case
or
Manual vacuum aspiration under local anaesthetic as outpatient
32
Success of surgical miscarriage management 1
both 97% success
33
When is anti-D required in resus negative women in miscarriage 2
surgical managemnt of miscarraige <12wks
any potentially sensitizing event >12wks
34
when is anti-D not required in Rh negative women 2
threatened or complete miscarriage
medical management of miscarriage
35
When is a pregnancy considered viable
when a fetal heart beat is visible
36
three key features to look for on USS for early pregnancy 3
mean gestational sac diameter
fetal pole and crown-rump length
fetal heart beat
37
symptoms of normal early pregnancy 6
tender swollen breasts
-cravings
-N+V
-constipation
increased urinary frequency
-headaches
38
define miscarriage
spontaneous termination of pregnancy
-early miscarriage- before 12 weeks gestatoin
-late miscarriage- between 12-24 weeks gestation
39
when is a fetal heart beat expected in terms of one of the other ultrasound findings
when the crown-rump length is 7mm or more
40
what is the importance of the crown-rump length
if <7mm and fetal heartbeat-> viable pregancy
if<7mm and NO heartbeat-> repeat scan 1wk to ensure heartbeat develops
if >7mm and NO heartbeat-> scan repeated 1wk and then non-viable pregnancy confirmed
41
define a fetal pole and when it is expected in terms of one of the ultraosund findings
it is the thickening of the margin of the yolk sac in early pregnancy
-shoudl be seen when the mean gestational sac diameter is 25mm or more
if sac diameter is >25mm and NO fetal pole-> repeated after one week before confirming an anembryonic pregnancy
42
When is expectant managemnt of miscarraiges used
less than 6 weeks gestation
43
when is expectant miscarriage management contraindicated at less than 6 weeks gestation
if bleeding present thats fine
if pain or other complications or risk factors (like previous ecotopic)- not suitable
44
how is expectant miscarriage confirmed
urine pregnancy test afteer 7-10 days
-if negative - miscarriage is confirmed
if bleeding continues or pain occurs- refer and further investigations needed
45
if a women has a positive pergnancy test, bleeding and is passed 6 weeks gestations what should happen initially 1
referral to early rpegnnacy assessment service
46
what is the role of the early pregnancy assessment service/unit
arragne USS
confirm location adn viabiltiy of pregnancy
-*always consider and exclude an ectopic
47
how does misoprostol work
prostaglandin analouge
-binds to prostglandin receptors and activates them
-prostaglandins soften the cervix and stimuate uterine contractions
48
side effects of misoprostol 4
heavier bleeding
pain
vomiting
diarrhoea
49
how can causes of miscarriage be classified 9
unexplained -50% of cases
maternal age
fetal chromone abnormality
immunological
endocrine
uterine anomalies
infection
environment
cervical weakness
50
regarding causes of miscarriage
-how does maternal age affect risk
age 30-35 15% risk
age 40-45 51% risk
51
regarding causes of miscarriage
-how does fetal chromonsoen abrnomalties differ in each trimester in terms of risk of miscarriage
50% 1st trimester loss
20% 2nd trimester loss
52
regarding causes of miscarriage
-types of immunological 2
autoimmune -lupus anticoagulant and antiphospholipid antibodies
alloimmune- uncertina role of NK cells
53
regarding causes of miscarriage
-encodrine causes 3
PCOS
poorly ocntrolled DM
poorly controlled thyroid disease
54
regarding causes of miscarriage
infection 2
pyrexia and loss
specific infections
-CMV, rubella, listeria monocytogenes, syphillis
55
regarding causes of miscarriage
enviroment 2
cigarettes
alcohol
56
how is recurrent miscarrage defined
3 consecutive miscarriages
-appox 1 in 100 couples
investigate probable cause
57
how are antiphosphlipid anitobodies managed if causing recurrent miscarriages 2
aspirin and LMWH
58
types of ectopic pregnancy by location 8
intersitial
tubal (isthmus)-MOST DANGEROUS
tubal (ampullar)-MOST COMMON
interstitial
abdominal
infundibular (ostial)
ovarian
peritoneal
cerivcal
*more than 95% of ectopic pregnancies are tubal
59
risk factors for ectopic pregnancy 7
previous ectopic pergnancy
endometriosis
pelvic infection
-partiularly chlamydia
perlvic surgery
-C sections
-sterilisation procedures
-appendicetomy
contraception
-progesterone only pill, IUD/IUS
assisted conception techniques
cigarette smoking
60
incidence of ectopic pregnancy
~1 in 100
aprox 12000/year in UK
major cause of maternal mortality
61
clinical presenation of ectopic pregnancy with a positive pregnancy test 6
asymptomamtic
vaginal bleeding- borwn spotting to heavay loss
pelvic discomfort or pain
-typically localised to one side ± shoulder tip pain
pain with opening bowels
maternal collapse/hypovolaemic shock
62
investigations for ectopic pregnancy 5
Clinical examination – Are they haemodynamically stable?
Assess pain & bleeding – evidence of peritonism
Bimanual – assess cervical excitation, adenexal masses
*NICE advise NOT to examine for an adnexal mass due to an increased risk of rupturing the pregnancy. A pelvic examination to check for cervical excitation is however recommended
Consider vaginal swabs
Ultrasound scan
Transabdominal
Transvaginal
Serum HCG tracking
Assess FBC and blood group (x-match if needed)
63
what is the benefit of HCG tracking
-how often should it be done
helpful if pregnancy fo unknown location (PUL) and patient stable
-measure 48hrs apart
64
when HCG tracking what changes in levels indicate different outcomes in pregnancy 3
48hrs apart:
increased >66% - intrauterine
<66% increase or <50% decrease - ectopic
>50% decrease - failing Pregnancy of unknown locaiton
65
emergency mangemtn of ecotpic pregnnacy
if haemodynamically unstble
ABC resus
early involement of seniors
-gynae
-anaesthetics
-haematology +blood
prepare for theatre
66
non emergency manegmnt of ecotpic pregnnancy options 3
conservative
medical
surgical
67
how does hCG change in an interuterine pregnancy
roughly doubles every 48 hrs
68
criteria for expectant manaegmtn of an ecotpic pregnancy 6
follow up neeeds to be possible to ensure successful termination
ectopic needs to be unruptured
adnexal mass <35mm
no visible heart beat
no significant pain
HCG levels <1500 IU/l
69
what is the medical managemnt of ectopic pregnancy
methotrexate
70
criteria for medical manegmnt of ectopic pregncy 2
same as ecpectant except:
-HCG level must be <5000
confirmed absence of intrauterine pregnancy on USS
71
how is methotrexate used to terminate ectopic pregnancy 3
highly teratogenic
givem as IM injection into buttock
halts progression of pregnancy and results in spontaneous termination
72
what are women treated with methotrexate for ectopic pregnancy advised against
not to get pregnant for 3 months following treatment
73
side effects of methotrexate when used to terminate ecoptic pregnancy 4
vaginal bleed
N+V
abdo pain
stomatitis (inflam of mouth)
74
most common management type of ectopic pregnancy
surgical
75
criteria for surgical ectopic management 4
pain
adnexal mass >35mm
visible heartbeat
HCG levels >5000
76
options for surgical ectopic management 2
laparosocpic salpingectomy
laparaocscopic salpingotomy
77
describe Laparoscopic salpingectomy
first line treatment for ectopic preganncy
GA and key hole surgery
-removal of affected fallopian tube along with the ectopic pregnancy
78
describe laparoscopic salpingotomy
-when is it used
avoids remoing the affected fallopina tube
a cut is made in the fallopian tube, the ecoptic pregnancy is removed and the tube is closed
-used in women with increased risk of infertility due to damage to the other tube
79
for ectopic pregnancy manngemtn why is a salpingectomy better than a salpingotomy
increased risk of failure to reomve the ecoptic pregnancy with salpingotmoy compared to salpingectomyy
1 in 5 women with a salpingotomy may need further treatment with emthotrexate or salpingectomy
80
when is anti-D required in manaegmtn of ectopic pregnancy
if mother is Rh negative after surgical management
not required if ectopic is conservatively or medically managed
81
define Gestational Trophoblastic Disease
-prevalence
types 2
group of condiitons characterised by abnormal proliferation of trophoblastic tissue with production of HCG
-molar pregnancy
1 in 714 livebirths in UK
premalignant and malignant forms
82
how can premalignant causes of Gestational Trophoblastic Disease be split
partial hydatidiform mole
complete hydatidiform mole
83
describe partial hydatidiform mole Gestational Trophoblastic Disease
triploid
-69 chromosomes (23 mother + 46 father)
-2 sperm, 1 egg
may be embryo present
-most present as failed pregnancy
84
describe complete hydatidiform mole Gestational Trophoblastic Disease
diploid
=46 all father - empty ovum
1-2% malginagy risk
85
types of malignant Gestational Trophoblastic Disease 3
*-treatment
choriocarcinoma
placental site trophoblastic tumour
invasive mole
*- very sensitive to chemo
86
Gestational Trophoblastic Disease risk factors
extremes of materal age
- <20 yr x3
- >40yr x10
previous molar pergnnacy
ethnicity
87
clinical features of Gestational Trophoblastic Disease 5
PV bleeding
enlarged uterus
hyperemesis gravidarium (severe N+V during pregnancy)
hyperthyroidism
early onset pre-eclampsia
88
investgations for Gestational Trophoblastic Disease 3
USS
histology
BHG tracking
-registed at sepcalist centres (dundee in Scotland) for followup and co-oridnation of care
89
USS appearance ofGestational Trophoblastic Disease 1
snowstorm appearance
90
managemtn of Gestational Trophoblastic Disease 5
evacuation of uterus to remove mole
products of conception sent for hisotlogical examination to confirm
referred to gestatinal tropblastic disease centre for management and follow up
hCG levels monitored until they return to normal
can occasionally metastasis - ptx may require systemic chemo
91
management of hyperemesis gravidarum
small freuwnet meals
IV fluids
TPN
antiemdits
-promethazine, meclizine and droperidol
92
emotional support after pregnancy loss 5
Experienced as a bereavement
Emotional impact will vary between individuals and couples
Support groups e.g. Miscarriage Association UK
Sensitive disposal of pregnancy tissue
Local book of remembrance
93
cause of hyperemeis gravidarum
unknown
may be associated with hCG levels
severe cases are associated with high hCG
-muotiple pregnancy
-molar pregnancy
94
what can severe cases of hyperemesis gravidarum result in 3
Wernicke’s encephalopathy (thiamine deficiency)
central pontine myelinolysis (rapid correction of hyponatraemia)
maternal death (rare)
95
affect of hyperemeis gravidarum on infant
Higher incidence of intrauterine growth restriction
significantly smaller at birth
96
investigations for hyperemeis gravidarum 6
Urine
Ketones
Other cause of vomiting e.g. UTI
Serum
Renal function
Liver function
(Thyroid function – only if clinical signs)
Ultrasound scan
Multiple pregnancy, molar pregnancy
97
managemnt of hypermeiss gravidarum 10
Oral intake advice/ dietician
IV fluids (avoid dextrose) tailor to correct electrolyte imbalance
Regular antiemetics
Omeprazole
Thromboprophylaxsis
Vitamin replacement
Oral steroids
Total parenteral nutrition (extreme)
Psychological support
Assessment of fetal growth
