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Obs & Gyn > Early pregnancy problems > Flashcards

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)

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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

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3
Q

hormones released in pregnancy 3

A

porgresterone

estrogens

Human chorionic gonadotropin
(HCG is total, beta-HCG is free form of HCG)

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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

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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

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6
Q

define a miscarriage

A

any pregnancy loss before 24 weeks gestation

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7
Q

define a stillbirth

A

any fetus born dead at or after 24 weeks gestation

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8
Q

define a livebirth

A

a fetus which shows signs of life after delivery at any gestation

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9
Q

Miscarriage definitions
-Threatened

A

bleeding with continuuing intrauterine pregnancy

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10
Q

Miscarriage definitions
-Inevitable

A

bleeding with non-continuing intrauterine pregnancy
-cervic may be open

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11
Q

Miscarriage definitions
-Incomplete

A

Incomplete passage of pregnancy tissue

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12
Q

Miscarriage definitions
-Complete

A

All pregnancy tissue expelled and uterus now empty

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13
Q

Miscarriage definitions
-Delayed/missed (silent) or early embyronic demise

A

Fetus has died in-uetero prior to 24 weeks gestation

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14
Q

Miscarriage definitions
-Septic

A

complicated by intrauterine infection

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15
Q

Miscarriage definitions
-Recurrent

A

3 or more consecutive miscarriages

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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
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17
Q

main risk factor for increasing incidence of miscarriage

A

increase in maternal age

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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)

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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

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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

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21
Q

Aspects of the clinical exam when investigating someone with a miscarriage 3

A

haemodynamically stable?

assess pain & bleeding

removal of POC (speculum)

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22
Q

types of USS used when assessing for miscarriage in a newborn 2

A

Transabdominal

transvaginal

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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)

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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

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25
Q

if abnormlaities seen on an USS in pregnancy what is needed 1

A

confirmatory scan

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26
Q

how can the different Management options of miscarriage be classified 3

A

expectant

medical

surgical

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27
Q

success of expectant misscarriage management 1

A

60%

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28
Q

management of expectant miscarriage management

A

intensive follow up

-review every 7-14 days

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29
Q

management of medical miscarriage 1

A

Misoprostol
-oral or vaginal
-dose dependent on gestation

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30
Q

success of medical miscarriage management

A

80-90% success

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31
Q

options for surgical management of miscarriage 2

A

cervical priming (usualy misoprostol)
-then electrical vacuum aspiration under GA as day case
or
Manual vacuum aspiration under local anaesthetic as outpatient

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32
Q

Success of surgical miscarriage management 1

A

both 97% success

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33
Q

When is anti-D required in resus negative women in miscarriage 2

A

surgical managemnt of miscarraige <12wks

any potentially sensitizing event >12wks

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34
Q

when is anti-D not required in Rh negative women 2

A

threatened or complete miscarriage

medical management of miscarriage

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35
Q

When is a pregnancy considered viable

A

when a fetal heart beat is visible

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36
Q

three key features to look for on USS for early pregnancy 3

A

mean gestational sac diameter

fetal pole and crown-rump length

fetal heart beat

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37
Q

symptoms of normal early pregnancy 6

A

tender swollen breasts
-cravings
-N+V
-constipation
increased urinary frequency
-headaches

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38
Q

define miscarriage

A

spontaneous termination of pregnancy

-early miscarriage- before 12 weeks gestatoin

-late miscarriage- between 12-24 weeks gestation

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39
Q

when is a fetal heart beat expected in terms of one of the other ultrasound findings

A

when the crown-rump length is 7mm or more

40
Q

what is the importance of the crown-rump length

A

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
Q

define a fetal pole and when it is expected in terms of one of the ultraosund findings

A

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
Q

When is expectant managemnt of miscarraiges used

A

less than 6 weeks gestation

43
Q

when is expectant miscarriage management contraindicated at less than 6 weeks gestation

A

if bleeding present thats fine

if pain or other complications or risk factors (like previous ecotopic)- not suitable

44
Q

how is expectant miscarriage confirmed

A

urine pregnancy test afteer 7-10 days
-if negative - miscarriage is confirmed

if bleeding continues or pain occurs- refer and further investigations needed

45
Q

if a women has a positive pergnancy test, bleeding and is passed 6 weeks gestations what should happen initially 1

A

referral to early rpegnnacy assessment service

46
Q

what is the role of the early pregnancy assessment service/unit

A

arragne USS

confirm location adn viabiltiy of pregnancy
-*always consider and exclude an ectopic

47
Q

how does misoprostol work

A

prostaglandin analouge
-binds to prostglandin receptors and activates them
-prostaglandins soften the cervix and stimuate uterine contractions

48
Q

side effects of misoprostol 4

A

heavier bleeding

pain

vomiting

diarrhoea

49
Q

how can causes of miscarriage be classified 9

A

unexplained -50% of cases

maternal age

fetal chromone abnormality

immunological

endocrine

uterine anomalies

infection

environment

cervical weakness

50
Q

regarding causes of miscarriage
-how does maternal age affect risk

A

age 30-35 15% risk

age 40-45 51% risk

51
Q

regarding causes of miscarriage
-how does fetal chromonsoen abrnomalties differ in each trimester in terms of risk of miscarriage

A

50% 1st trimester loss
20% 2nd trimester loss

52
Q

regarding causes of miscarriage
-types of immunological 2

A

autoimmune -lupus anticoagulant and antiphospholipid antibodies

alloimmune- uncertina role of NK cells

53
Q

regarding causes of miscarriage
-encodrine causes 3

A

PCOS

poorly ocntrolled DM

poorly controlled thyroid disease

54
Q

regarding causes of miscarriage
infection 2

A

pyrexia and loss

specific infections
-CMV, rubella, listeria monocytogenes, syphillis

55
Q

regarding causes of miscarriage
enviroment 2

A

cigarettes

alcohol

56
Q

how is recurrent miscarrage defined

A

3 consecutive miscarriages
-appox 1 in 100 couples

investigate probable cause

57
Q

how are antiphosphlipid anitobodies managed if causing recurrent miscarriages 2

A

aspirin and LMWH

58
Q

types of ectopic pregnancy by location 8

A

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
Q

risk factors for ectopic pregnancy 7

A

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
Q

incidence of ectopic pregnancy

A

~1 in 100

aprox 12000/year in UK

major cause of maternal mortality

61
Q

clinical presenation of ectopic pregnancy with a positive pregnancy test 6

A

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
Q

investigations for ectopic pregnancy 5

A

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
Q

what is the benefit of HCG tracking
-how often should it be done

A

helpful if pregnancy fo unknown location (PUL) and patient stable

-measure 48hrs apart

64
Q

when HCG tracking what changes in levels indicate different outcomes in pregnancy 3

A

48hrs apart:

increased >66% - intrauterine

<66% increase or <50% decrease - ectopic

> 50% decrease - failing Pregnancy of unknown locaiton

65
Q

emergency mangemtn of ecotpic pregnnacy

A

if haemodynamically unstble

ABC resus

early involement of seniors
-gynae
-anaesthetics
-haematology +blood

prepare for theatre

66
Q

non emergency manegmnt of ecotpic pregnnancy options 3

A

conservative

medical

surgical

67
Q

how does hCG change in an interuterine pregnancy

A

roughly doubles every 48 hrs

68
Q

criteria for expectant manaegmtn of an ecotpic pregnancy 6

A

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
Q

what is the medical managemnt of ectopic pregnancy

A

methotrexate

70
Q

criteria for medical manegmnt of ectopic pregncy 2

A

same as ecpectant except:
-HCG level must be <5000
confirmed absence of intrauterine pregnancy on USS

71
Q

how is methotrexate used to terminate ectopic pregnancy 3

A

highly teratogenic

givem as IM injection into buttock

halts progression of pregnancy and results in spontaneous termination

72
Q

what are women treated with methotrexate for ectopic pregnancy advised against

A

not to get pregnant for 3 months following treatment

73
Q

side effects of methotrexate when used to terminate ecoptic pregnancy 4

A

vaginal bleed
N+V

abdo pain

stomatitis (inflam of mouth)

74
Q

most common management type of ectopic pregnancy

A

surgical

75
Q

criteria for surgical ectopic management 4

A

pain

adnexal mass >35mm

visible heartbeat

HCG levels >5000

76
Q

options for surgical ectopic management 2

A

laparosocpic salpingectomy

laparaocscopic salpingotomy

77
Q

describe Laparoscopic salpingectomy

A

first line treatment for ectopic preganncy
GA and key hole surgery
-removal of affected fallopian tube along with the ectopic pregnancy

78
Q

describe laparoscopic salpingotomy
-when is it used

A

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
Q

for ectopic pregnancy manngemtn why is a salpingectomy better than a salpingotomy

A

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
Q

when is anti-D required in manaegmtn of ectopic pregnancy

A

if mother is Rh negative after surgical management

not required if ectopic is conservatively or medically managed

81
Q

define Gestational Trophoblastic Disease
-prevalence
types 2

A

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
Q

how can premalignant causes of Gestational Trophoblastic Disease be split

A

partial hydatidiform mole

complete hydatidiform mole

83
Q

describe partial hydatidiform mole Gestational Trophoblastic Disease

A

triploid
-69 chromosomes (23 mother + 46 father)
-2 sperm, 1 egg

may be embryo present
-most present as failed pregnancy

84
Q

describe complete hydatidiform mole Gestational Trophoblastic Disease

A

diploid
=46 all father - empty ovum
1-2% malginagy risk

85
Q

types of malignant Gestational Trophoblastic Disease 3

*-treatment

A

choriocarcinoma

placental site trophoblastic tumour

invasive mole

*- very sensitive to chemo

86
Q

Gestational Trophoblastic Disease risk factors

A

extremes of materal age
- <20 yr x3
- >40yr x10

previous molar pergnnacy

ethnicity

87
Q

clinical features of Gestational Trophoblastic Disease 5

A

PV bleeding

enlarged uterus

hyperemesis gravidarium (severe N+V during pregnancy)

hyperthyroidism

early onset pre-eclampsia

88
Q

investgations for Gestational Trophoblastic Disease 3

A

USS

histology

BHG tracking
-registed at sepcalist centres (dundee in Scotland) for followup and co-oridnation of care

89
Q

USS appearance ofGestational Trophoblastic Disease 1

A

snowstorm appearance

90
Q

managemtn of Gestational Trophoblastic Disease 5

A

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
Q

management of hyperemesis gravidarum

A

small freuwnet meals

IV fluids

TPN

antiemdits
-promethazine, meclizine and droperidol

92
Q

emotional support after pregnancy loss 5

A

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
Q

cause of hyperemeis gravidarum

A

unknown
may be associated with hCG levels

severe cases are associated with high hCG
-muotiple pregnancy
-molar pregnancy

94
Q

what can severe cases of hyperemesis gravidarum result in 3

A

Wernicke’s encephalopathy (thiamine deficiency)
central pontine myelinolysis (rapid correction of hyponatraemia)
maternal death (rare)

95
Q

affect of hyperemeis gravidarum on infant

A

Higher incidence of intrauterine growth restriction
significantly smaller at birth

96
Q

investigations for hyperemeis gravidarum 6

A

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
Q

managemnt of hypermeiss gravidarum 10

A

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

Obs & Gyn (23 decks)

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