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Y4 GOSH gynae > Early pregnancy problems > Flashcards

Early pregnancy problems Flashcards

1
Q

What are the main causes of miscarriage?

A

-Sporadic chromosomal abnormalities (most common)
–1/3 of Downs Syndrome pregnancies miscarry
-Acute pyrexial illness
-Antiphospholipid antibody syndrome
-Uterine malformations eg bicornuate uterus

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2
Q

How do miscarriages present?

A

-Vaginal bleeding (amount and type varies)
-Abdo pain
-Regression of pregnancy symptoms
-Incidental finding

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3
Q

How should miscarriages be investigated?

A

-Pregnancy test (urine or blood)
-USS - possible findings:
–Empty uterus (ectopic, complete miscarriage, very early pregnancy)
–Viable pregnancy
–Non-viable pregnancy
–Too early to confirm

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4
Q

What is a threatened miscarriage?

A

-Painless vaginal bleeding <24w (typically 6-9 weeks)
-Symptoms suggestive of miscarriage but pregnancy continues
-No long-term harm to baby but complicates up to 25% of pregnancies

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5
Q

What is an inevitable miscarriage?

A

-Woman presents in the process of a miscarriage and nothing can be done to save the pregnancy
-Heavy vaginal bleeding with clots, pain, open cervical os

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6
Q

What is a complete miscarriage?

A

-Process has completed without intervention
-Presents with bleeding which has now lessened, closed cervical os
-Still must exclude ectopic pregnancy

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7
Q

What is an incomplete miscarriage?

A

-Products of conception still remain within the uterus
-Pain and vaginal bleeding
-Open cervical os and mixed debris in uterus seen on USS
-Medical or surgical treatment may be offered

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8
Q

What is a missed or delayed miscarriage?

A

-Entire gestational sac remains within the uterus containing dead foetus (<20 weeks)
-May have light vaginal bleeding, cervical os is closed
-Uterus and foetus are SGA
-Treat with vaginal misoprostol

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9
Q

When is expectant management offered for miscarriage?

A

-If not bleeding heavily
-Allows the body to complete miscarriage itself
-Unpredictable and can take weeks to complete
-Repeat TVS to ensure completion at 2 weeks, offer surgical management if unsuccessful
-Offer simple analgesia for pain

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10
Q

What surgical management is offered for miscarriage?

A

-Evacuation of uterus (under GA, minor)
-Manual vacuum aspiration (under LA, offered to those with excessive bleeding or on patient request)
-Complications = infection, cervical trauma, haemorrhage, uterine perforation

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11
Q

What medical management is offered for miscarriage?

A

-Prostaglandins / antiprogesterones (induce contractions)
–Mifepristone then misoprostol 2 days later (PO or PV)
-Can cause moderate bleeding and abdo pain
-Good completion rate

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12
Q

What is gestational trophoblastic disease?

A

-Spectrum of diseases originating from the placenta
-Types:
–Partial and complete hydatidiform mole
–Choriocarcinoma
–Trophoblastic tumour

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13
Q

What risk factors are there for molar pregnancies?

A

-Maternal age >35
-Prior molar pregnancy
-Asian women
-Long term use of oral contraception
-Dietary deficiency

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14
Q

What is a hydatidiform mole?

A

-Tumour forms within the uterus at the start of pregnancy
-Consist of proliferating chorionic villi
-Makes lots of hCG –> exaggerated pregnancy symptoms

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15
Q

What is a partial vs complete hydatidiform mole?

A

PARTIAL
-Dispermy + normal egg
-Triploid karyotype with paternal chromosomes
COMPLETE
-Sperm + empty egg
-Diploid karyotype of paternal origin

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16
Q

How do molar pregnancies present?

A

-Early pregnancy failure, heavy bleeding
-LGA
-Snowstorm effect seen on US
-May see increased T3/4 and decreased TSH + symptoms of thyrotoxicosis as bHCG can act on thyroid

17
Q

How do complete and partial molar pregnancies present on US?

A

PARTIAL = focal cystic spaces in placenta
-Non-viable foetus
COMPLETE = snow-storm appearance without foetus
-No foetus

18
Q

How are molar pregnancies managed?

A

-Electric vacuum aspiration (+histology)
-Give anti-D if Rh-
-Monitor bhCG until they are undetectable
-Avoid pregnancy until bhCG at normal levels, hysterectomy if no desire to conceive

19
Q

What is a choriocarcinoma?

A

-Complication of molar pregnancy - may present years later with vague symptoms and raised hCG
-Metastases common

20
Q

What are the most common sites for ectopic pregnancies?

A
  1. Ampulla
  2. Isthmus
  3. Cornua
    More rare = cervix, ovary, peritoneal cavity
    >90% are tubal
21
Q

How are ectopic pregnancies defined?

A

Any gestation in which implantation occurs at a location other than the endometrial lining
-Leads to 10% of pregnancy-related deaths

22
Q

What risk factors are there for ectopic pregnancy?

A

-PID (especially if related to chlamydia)
-Previous ectopic pregnancy
-Tubal damage (surgery, salpingitis)
-Endometriosis
-IVF
-Sterilisation or reversal of sterilisation
-Use of IUD/IUS/POP

23
Q

How do ectopic pregnancies present?

A

-Often asymptomatic
-Lower abdo pain usually around 6-7 weeks - constant, unilateral, can be severe
-PV bleeding (dark brown) with Hx of amenorrhoea
-D+V
-Shoulder tip pain and pain on defecation / urination
-Collapse (rupture)
-Cervical motion tenderness and unilateral adnexal tenderness

24
Q

How should you investigate a ?ectopic pregnancy?

A

-PREGNANCY TEST (a negative result confidently excludes)
-TV/USS to confirm an intrauterine pregnancy / establish adnexal mass
-If highly suspicious of ectopic:
–Serum progesterone (<20nmol indicates failing pregnancy)
–Serum hCG
-Laparoscopy (if doubtful of diagnosis)

25
Q

How do serum hCG levels change in pregnancy vs ectopic and miscarriage?

A

NORMAL
-0-8 weeks = doubles every 48h
-8-10 weeks = doubles every 5 days
ECTOPIC
-Slow rise and/or plateau
MISCARRIAGE
-Rapid fall

26
Q

When should ectopic pregnancies undergo expectant management?

A

-If <30mm, unruptured, asymptomatic, no foetal heartbeat
-If hCG <1500IU/L
-Closely monitor for 48h and intervene if hCG levels rise or symptoms present
-Safety net to contact EPAU if severe pain, heavy bleeding, dizziness (rupture)

27
Q

What medical management is offered for ectopic pregnancies?

A

-If <30mm, unruptured, asymptomatic, no foetal heartbeat
-If hCG <1500IU/L
-Give methotrexate IM - induces spontaneous termination
–Must not get pregnant for at least 3 months after due to highly teratogenic properties of methotrexate
-Can cause N+V, PV bleeding, abdo pain, and take 4-6 weeks to completely resolve

28
Q

What surgical management is offered for ectopic pregnancies?

A

-If >35mm, ruptured, in severe pain, visible foetal heartbeat
-If hCG >1500 or another intrauterine pregnancy is in situ
-Laparoscopic salpingectomy / salpingotomy

Y4 GOSH gynae (12 decks)

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