EARLY PREGNANCY PROBLEMS Flashcards
1
Q
When does nausea and vomiting typically occur in pregnancy
A
Usually starts 4-7th week, peaks at 9-16 weeks and is resolved by 16-20 weeks
2
Q
What does onset of nausea and vomiting in pregnancy after 11 weeks usually suggest?
A
An alternative cause unrelated to pregnancy
3
Q
Prevalence of nausea and vomiting in pregnancy?
A
70-80% of all pregnancies
4
Q
Cause of nausea and vomiting in preganncy?
A
Raised hCG levels - e.g. multiple pregnancies, molar pregnancies
Oestrogen levels increased
May be an evolutionary adaptation to prevent women eating potentially harmful foods
Delayed gastric emptying occurs in pregnancies due to smooth muscle relaxation by progesterone; this causes oesophageal, gastric and small bowel motility to be impaired which can also contribute to n+v
5
Q
Risk factors for developing nausea and vomiting in preganncy?
A
Increased placental mass e.g. advanced molar gestation or multiple pregnancy
First preganncy
History of HG in previous pregnancy
History of motion sickness
History of migraines
FHx
History of nausea with oestrogen-containing oral contraceptives
Obesity
6
Q
Complications of nausea and vomiting in pregnancy?
A
Weight loss
Dehydration
Electrolyte imbalance
AKI
Abnormal liver tests
Nutritional and vitamin deficiencies - particularly B6 and B12
GORD, oesophagitis or gastritis
Retinal haemorrhage
Splenic avulsion
Mallory-Weiss tears or oesophageal rupture
Pneumothorax
VTE
If woman has HG and low preganncy weight gain - at risk of preterm delivery, LBW, SGA babies
7
Q
What questionnaire can be used to assess the severity of nausea and vomiting in pregnancy?
A
Pregnancy-Unique Quantification of Emesis score (PUQE)
8
Q
Investigtaions for nausea and vomiting in preganncy
A
Dipstick urine for ketones - if symptms are severe and affecting oral intake
Arrange MSU sample if UTI as underlying cause suspected
Consider arranging a pelvic USS to identify predisposing factors e.g. multiple pregnancy or molar pregnancy
9
Q
Outline the PUQE score
A
In the last 24 hours for how long have you felt nauseated or sick to your stomach?
(Not at all = 1, 1 hr or less = 2, 2-3 hrs = 3, 4-6 hrs = 4, >6hrs = 5)
In three last 24 hours have you vomited or thrown up?
(Did not = 1, 1-2 = 2, 3-4 = 3, 5-6 = 4, 7 or more = 5)
In the last 24 hours, how many times have you had retching without bringing anything up?
(None = 1, 1-2 times = 2, 3-4 times = 3, 5-6 times = 4, 7 or more = 5)
Total score: mild <6, moderate 7-12, severe 13-15
10
Q
How common is hyperemesis gravidarum?
A
1% of pregnancies
11
Q
What can decrease the incidence of hyperemesis gravidarum?
A
Smoking
12
Q
Which women with nausea and vomiting should you consider admitting?
A
Continued N&V and is unable to keep down liquids or oral antiemetics
Continued N&V with ketonuria or weight loss >5% body weight, despite treatment with oral antiemetics
A confirmed or suspected comorbidities e.g. unable to tolerate oral antibiotics for UTI
13
Q
Triad for diagnosis of hyperemesis gravidarum?
A
5% pre-pregnancy weight loss
dehydration
electrolyte imbalance
14
Q
Management for nausea and vomiting in preganncy
A
Self care measures: rest, avoid sensory stimuli that may trigger symptoms e.g. odours, try eating plain biscuits or crackers in the morning, try eating bland small frequent protein-rich meals low in carbs and fat, cold meals, drinking little and often, ginger, acupressure (e.g. over P6 point on the ventral aspect of the wrist)
Advise avoiding meds that may contribute to symptoms such as iron-containing preparations
If the symptoms persist…
Antiemetics
Specialist advice or admission for IV hydration
15
Q
First line anti-emetics for nausea and vomiting in pregnancy?
A
Antihistamines - cyclizine or promethazine
Phenothiazines - prochlorperazine or chlorpromazine
Xonvea which is a combination drug of doxylamine and pyridoxine
16
Q
What fluids should be used for IV hydration in women with nausea and vomiting?
A
Normal saline with added K+
17
Q
A
18
Q
Size of foetus at 4 weeks through to 12 weeks?
A
4 weeks - 2mm - poppy seed
6 weeks - 6mm - pea
7 weeks - 10mm - blueberry
8 weeks - 16mm - raspberry
9 weeks - 22mm - olive
10 weeks - 3cm - strawberry
11 weeks - 4.1 cm - lime/fig
12 weeks - 5.4cm - plum
19
Q
Signs + symptoms of pregnancy
A
Amenorrhoea
Tender breasts
Mood swings
Fatigue and tiredness
N&v
Food cravings or you may lose interest in certain foods/drinks
You may lose interest in smoking
May have heightened sense of smell
Polyuria
Dizziness
20
Q
What produced hCG?
Main role?
How do levels change in pregnancy?
When do levels peak?
When do levels start to fall?
A
Embryo and then later the placental trophoblast
To prevent degeneration of the corpus luteum - this produces progesterone to support the uterine lining
Double every 48 hours in the first few weeks
Peak at 8-10 weeks
Should start to fall around 12 weeks after conception. This is because by now the placenta should take over production of progesterone so hCG levels can decline
21
Q
What is the “foetal pole”?
A
The first direct imaging manifestation of the foetus - a thickening on the margin of the yolk sac during early pregnancy
Can be identified from 6.5 weeks with abdominal USS but may not be visible til 9 weeks
22
Q
What is the yolk sac?
A
The first anatomical structure identified within the gestational sac
Has a critical role in embryonal development by providing nutrients, serving as the site of initial haematopoiesis, providing endocrine/metabolic/immunological functions, and contributing to the development of foetal GI/reprodyctive systems
As pregnancy advances it progressively increases from the 5th-10th week of pregnancy and then will gradually disappear. It will be sonographically undetectable after 14-20 weeks
Will appear as a circular thickness walled echogenic structure with an anechoic centre within the gestational sac, but outside the amniotic membrane
23
Q
Causes of bleeding in early pregnancy?
A
Cervical changes caused by progesterone - sexual intercourse
Implantation bleed
Miscarriage
Ectopic pregnancy
Gestational trophoblastic diseases
Others: STIs, cervical ectropion, vaginitis, trauma, polyps
24
Q
What is ectopic pregnancy?
A
Implantation of a fertilised ovum outside the uterus
25
Where can an ectopic pregnancy implant?
Fallopian tube - 97% (mostly ampulla but some isthmus, fimbria, interstitium and cornua)
Non-tubal - ovary, abdomen, cervix, c-section scar
26
What is a heterotopic pregnancy?
Coexistence of both intrauterine pregnancy and an ectopic pregnancy
27
What does it mean when an ectopic pregnancy is in the interstitium?
At the junction of the uterus and proximal part of the fallopian tube
Associated with higher risk of rupture and haemorrhage compared to tubal ectopic pregnancies
28
Risk factors of ectopic pregnancy?
Tubal epithelial damage which impairs ability to transport gametes or embryos and predisposes women to faulty implantation:
- previous ectopic pregnancy
- history of PID
- previous pelvic surgery
- black ethnicity
- history of infertility
- assisted reproduction techniques, esp IVF - 3% are ectopic
- smoking
- salpingitis
- maternal age >35
- maternal in-utero exposure to diethylstilbesterol
- multiple sexual partners
- intrauterine contraception
- progesterone only pill
- sterilisation
Note 1/3rd of cases will occur in the absence of any risk factors!!
29
Incidence of ectopic pregnancy?
11 in 1000 pregnancies
Incidence in ectopic pregnancy in women attending EPAU is 3%
30
Rate of recurrence following Tx for ectopic pregnancy?
18.5%
31
Prognosis of ectopic pregnancy?
If undiagnosed and untreated, spontaneous tubal abortion occurs in about 50% of ectopic pregnancies and women may have no sympotms - usually self-limiting
If it persists and remains undiagnosed and untreated, the tube may rupture causing intra-abdominal bleeding, haemodynamic instability and maternal death
32
Complications of ectopic pregnancy:
Maternal death - leading cause in early pregnancy. 0.2 per 1000 result in maternal death. Non-tubal ectopics (particuarly interstitial and cornual) are associated with significantly higher mortality and morbidity as difficult to diagnose and tend to present late with sudden rupture
Recurrent ectopic pregnancy
Tx adverse effects. Surgery may damage surrounding organs. Adverse effects of methotrexate
Psychological effects
33
What is tubal abortion?
In ectopic pregnancy… When the embryo is expelled by the fallopian tube before rupture occurs
May cause severe bleeding requiring surgery or just minimal bleeding that does not require Tx
34
What is tubal absorption?
Ectopic pregnancy; if the tube doesnt rupture then the blood and embryo may be shed or converted into a tubal mole and absorbed
35
What is tubal rupture?
an ectopic pregnancy can grow large enough to split open the fallopian tube
Very serious and surgery to repair fallopian tube needs to be carried out asap
36
Common sympotms of ectopic pregnancy
6-8 weeks after LMP. Have a low threshold for suspecting it as often atypical presentation!
Abdominal or pelvic pain - constant and may be unilateral
Amenorrhoea
Vaginal bleeding - usually less than normal period and may be dark brown in colour
Less common:
Symptoms of pregnancy e.g. Breast tenderness
GI - d+v
Dizziness, fainting, syncope - from blood loss
Shoulder tip pain
Urinary symptms
Passage of tissue
Rectal pressure or pain on defecation
37
Signs of ectopic pregnancy
Abdominal tenderness
Pelvic tenderness
Adnexal tenderness - note NICE recommend not to examine for this due to increased risk of rupturing the pregnancy!
Cervical motion tenderness
Peritoneal signs e.g. rebound tenderness
Pallor
Abdominal distension
Enlarged uterus
Tachycardia or hypotension
Pallor
Collapse/shock
Orthostatic hypotension
38
Symptoms and signs of tubal rupture and intra-abdominal bleeding?
Vomiting and diarrhoea
Shoulder tip pain caused by irritation of diaphragm due to leakage of blood from implantation site
Pallor, tachycardia, hypotension, shock, collapse
39
What causes lower abdominal pain in an ectopic pregnancy?
Tubal spasm/growth and stretching
40
If symptoms of ectopic pregnancy, from what week in pregnancy, is this unlikely and so you should you think of another cause?
10 weeks
It typically occurs at 6-8 weeks from start of last period!
41
Assessment of a woman with ?ectopic pregnancy?
Confirm pregnancy with a urine pregnancy test
Medical X- symptoms and signs, date of LMP, date when symptoms started, date of positive preganncy test, risk factors
Abdominal examination
Gently pelvic examination - do not palpate for Adnexal or pelvic mass!
42
Where should you send women with ?ectopic pregnancy?
Haemodynamincally unstable? - A&E
Symptoms/signs + positive preganncy test - EPAU
43
Investigations of ectopic pregnancy?
Pregnancy test
Transvaginal USS - gestational sac containing a yolk sac or foetal pole may be seen in the fallopian tube, empty uterus, may be fluid in the uterus (pseudo gestational sac)
In pregnancy of unknown location - serum bhCG >1500 is indicative of ectopic pregnancy but note that clinical symptoms are thought to be of more significance than HCG levels
44
Which women with ectopic pregnancy can you use expectant management?
<6 weeks gestation
<35mm in size
Asymptomatic
Unruptured
No foetal heart beat
HCG <1000IU/L
Have no risk factors
Must be prepared for follow up to ensure successful termination
45
How can you tell the difference between an ectopic preganncy mass and the corpus luteium on USS?
The corpus luteum will move with the ovary
46
Expectant management of ectopic pregnancy?
This is awaiting for natural termination of the pregnancy
Initial hCG-> repeat in 48 hours
As long as the hCG level drops you will be monitored in a further 48 hours and then a further 72 hours. Providing your levels continue to fall, you will be monitored weekly until the hCG hormone is < 20mIU/
Advise these women:
To return if bleeding continues or pain develops - may need to move to active intervention
To repeat a urine pregnancy test after 7-10 days and to return if it is positive.
That a negative pregnancy test means that the pregnancy has miscarried.
47
Criteria for medical management of ectopic preganncy?
Adnexal mass size <35mm
Unruptured
No significant pain
No foetal heartbeat
hCG <1500IU/L
Not suitable if there is an intrauterine pregnancy
48
What is medical management of an ectopic preganncy?
Giving methotrexate IM - this is highly teratogenic so it halts the progression on preganncy and results in spontaneous termination
49
After having methotrexate for termination of an ectopic pregnancy, how long should a woman wait to get pregnant again?
3 months following treatment
50
Common side effects of methotrexate?
Vaginal bleeding
Nausea and vomiting
Abdominal pain
Skin rashes
Indigestion
Tiredness
Light headedness or dizziness
Less commonly… some women may experience sensitivity to sunlight, temporary hair loss, sore throat or stomatitis
51
Criteria for surgical management of ectopic preganncy
Adnexal mass size >35mm
Ruptured or unruptured
Pain/symptomatic
Visible foetal heartbeat
HCG >5000
Comparable with another intrauterine pregnancy
52
Surgical options for ectopic pregnancy?
Salpingectomy (removal of tube in keyhole surgery) - first line for women with no other risk factors for infertility
Salpingotomy (remove ectopic pregnancy by making a cut in the tube and then closing it) - consider for women with risk factors for infertility e.g. contralateral tube damage
53
Why is salpingotomy usually second line for ectopic pregnancy treatment (unless woman at increased risk of infertility due to damage on other tube)?
As there is an increased risk of failure to remove the ectopic preganncy
1 in 5 women having salpingotomy may need further Tx with methotrexate or salpingectomy
54
Rhesus-negative women who have surgical removal of ectopic pregnancy need what?
Anti-D immunoglobulin
55
Follow up on a woman after Tx for ectopic pregnancy?
Ensure arrangements for routine antenatal care are cancelled
Give woman opportunity to discuss any Qs she may have about the ectopic pregnancy
Assess woman’s psychological wellbeing and offer counselling if appropriate
Advise women medically treated to wait at least 3 months before trying to conceive again
Give appropriate contraception advice
Ensure all rhesus-negative women who had surgical management receive anti-D immunoglobulin
Advise the woman she should inform her GP ASAP about any future pregnancy so an USS can be arranged 6-7 weeks to establish location and viability of the pregnancy
56
What is the Ectopic Pregnancy Trust?
The leading charity focusing on early pregnancy loss through ectopic pregnancy
They provide extensive general information and peer support for anyone experiencing this. They advance education and promote awareness of ectopic pregnancies, as well as supporting research into ectopic pregnancies
57
What is the “Think Ectopic” project pilot?
This is a campaign set up by the Ectopic Pregnancy Trust
MBRRACE-UK 2022 report identified that ectopic preganncy remains the most frequent cause of maternal death in early pregnancy
They created biocards as an easy to use reference tool for primary and urgent care settings to aim to help HCP recognise signs of ectopic pregnancy and the time critical next steps
58
Early vs late miscarriage?
Miscarriage is the spontaneous loss of pregnancy before 24/40
Early <13 weeks gestation
Late 13-24 weeks gestation
59
Missed miscarriage?
Aka delayed or silent miscarriage
Gestational sac which contains a dead foetus - non-viable pregnancy identified on USS
No symptoms of expulsion
May have light vaginal bleeding and discharge and the symptoms of pregnancy will disappear but no pain
Cervical os is closed
60
Threatened miscarriage
Typically occurs at 6-9 weeks
Painless vaginal bleeding that is often less than menstruation
Cervical os closed
fetus that is alive - viable pregnancy
Complicates up to 25% of pregnancies
61
Inevitable miscarriage
Heavy vaginal bleeding with clots and pain
Non-viable pregnancy
Cervical os is open but pregnanc tissue remains in uterus
Pregnancy will proceed to incomplete or complete miscarriage
62
Incomplete miscarriage
Non-viable pregnancy where preganncy tissue remains in the uterus
Pain and vaginal bleeding
Cervical os is open
63
Complete miscarriage?
a full miscarriage has occurred, and all the products of conception have been expelled from the uterus and bleeding has stopped
64
Anembryonic pregnancy?
a gestational sac is present but contains no embryo
65
Investigation of choice for diagnosing miscarriage
Transvaginal USS - note that if viability cannot be established because foetus is of insufficient size for a heartbeat to be visualised, repeat the scan after at least 7 days
66
Findings on transvaginal USS for miscarriage?
Mean gestational sac diameter
Fetal pole and crown-rump length
Fetal heartbeat (should be present once crown-rump length is 7mm or more)
(These appear sequentially as the pregnancy develops. As each appears, the previous feature becomes less relevant in assessing the viability of the pregnancy.)
67
When is a pregnancy considered viable?
When a foetal heartbeat is visible
68
At what crown-rump length is a foetal heartbeat expected?
7mm
69
What does it mean if crown-rump length is 7mm or more but there is no foetal heartbeat?
Non-visible pregnancy
70
At what mean gestational sac diameter is a foetal pole expected?
25mm or more
71
What does it mean if there is a mean gestational sac diameter of 25mm or more, without a fetal pole?
Repeat scan 1 week later before confirming an anembryonic preganncy
72
Management of miscarriage <6 weeks gestation?
Expectant management - awaiting miscarriage without investigations or Tx (USS is unlikely to be helpful as too early)
Repeat preganncy test after 7-10 days. If negative then miscarriage confirmed. If bleeding continues or pain occurs -> refer and further investigation
73
Management of miscarriage >6 weeks gestation?
Refer to EPAU for all women with positive pregnancy test >6 weeks gestation and bleeding
USS - confirms location and viability (important to exclude ectopic pregnancy)
3 options:
Expectant management
Medical management
Surgical management
74
Expectant management of miscarriage?
Expectant management is offered first-line for women without risk factors for heavy bleeding or infection. 1 – 2 weeks are given to allow the miscarriage to occur spontaneously. A repeat urine pregnancy test should be performed three weeks after bleeding and pain settle to confirm the miscarriage is complete.
Persistent or worsening bleeding requires further assessment and repeat ultrasound, as this may indicate an incomplete miscarriage and require additional management.
75
Medical management of miscarriage?
Misoprostol - a prostaglandin analogue - softens cervix and stimulates uterine contractions
This can be a vaginal suppository or an oral dose
76
Key SE of misoprostol?
Heavier bleeding
Pain
Vomiting
Diarrhoea
77
Surgical management of miscarriage?
Manual vacuum aspiration under local anaesthetic as an outpatient
Electric vacuum aspiration under general anaesthetic
Note: misoprostol given before to soften cervix
78
What is manual vacuum aspiration?
involves a local anaesthetic applied to 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.
To consider manual vacuum aspiration, women must find the process acceptable and be below 10 weeks gestation.
It is more appropriate for parous women
79
What is electric vacuum aspiration?
the traditional surgical management of miscarriage.
It involves a 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.
80
What must be given to rhesus negative women having surgical management of miscarriage?
Anti-rhesus D prophylaxis
81
What is the problem with an incomplete miscarriage?
High risk of infection
82
Tx of incomplete management?
Medical management (misoprostol)
Surgical management (evacuation of retained products of conception)
83
What is evacuation of retained products of conception?
a surgical procedure involving a general anaesthetic.
The cervix is gradually widened using dilators, and the retained products are manually removed through the cervix using vacuum aspiration and curettage (scraping products away from endometrium).
A key complication is endometritis following the procedure.
84
Epidemiology of miscarriage
15-24% of clinically recognised pregnancies end in miscarriage
Most miscarriages occur in first trimester
Recurrent miscarriage affect 1% of women trying to conceive
85
What is a recurrent miscarriage?
defined as the loss of three or more consecutive pregnancies before 24 weeks of gestation
86
Causes of spontaneous miscarriage?
Chromosomal abnormalities - most common cause of first trimester miscarriage
Genetic abnormalities
Defects in development of placenta or embryo
Increases risk:
Increased maternal + paternal age
Number of previous miscarriages
Obesity
Smoke
Stress
Long term health conditions e.g. poorly controlled diabetes, hypertension, lupus, kidney disease, thyroid disease, APS, PCOS
Infections e.g. rubella, CMV, BV, HIV, STDs, malaria
Food poisoning - listeriosis, toxoplasmosis, salmonella
Med use - misoprostol, retinoids, methotrexate, NSAIDs
Womb structure e.g. fibroids or cervical incompetence
87
Symptoms of miscarriage
Symptoms of pregnancy and vaginal bleeding in the first 24 weeks of preganncy
Bleeding is typically scanty, varying from a brownish discharge to bright red bleeding and may recur over several days
Lower abdominal cramping pain or lower backache usually after onset of bleeding
May just be resolving symptoms of preganncy if a missed miscarriage has occurred!
88
How should you follow up a woman after a miscarriage?
Ensure arrangements for routine antenatal care are cancelled
Discuss any questions she has about her miscarriage - explain that menstruation can be expected to resume within 4-8 weeks and ovulation will occur before this so if they wish to become pregnant again they can try to as soon as they feel physically and psychologically ready.
Advise on contraception if they do not wish to become pregnant
Assess the woman’s psychological well-being and offer counselling if appropriate
Ensure all rhesus-negative women who have had surgical management receive anti-D immunoglobulin
Provide patient information on miscarriage
89
Outline how risk of miscarriage increases with age?
10% in women aged 20 – 30 years
15% in women aged 30 – 35 years
25% in women aged 35 – 40 years
50% in women aged 40 – 45 years
90
When should you offer referral to investigate the cause of recurrent miscarriage?
3 or more miscarriages before 10/40
1 or more morphologically normal foetal losses occurring after 10/40
91
Causes of recurrent miscarriage?
Idiopathic - particuarly in older women
antiphospholipid syndrome
Hereditary thrombophilias e.g. factor V leiden
endocrine disorders: poorly controlled diabetes mellitus/thyroid disorders. Polycystic ovarian syndrome
uterine abnormality: e.g. uterine septum
parental chromosomal abnormalities
smoking
92
Investigtaions for women with recurrent miscarriages?
Antiphospholipid antibodies
Genetic testing on parents
Genetic testing of the products of conception from the third or future miscarriages
Pelvic ultrasound scan to detect uterine abnormalities
93
What are gestational trophoblastic disorders?
A spectrum of disorders originating from the placental trophoblast
It includes:
A complete hydatidiform mole
Partial hydatidiform mole
Choriocarcinoma
94
What is a complete hydatidiform mole?
A benign tumour of trophoblastic material
An empty egg is fertilised by a single sperm that then duplicates its own DNA, hence all 46 chromosomes are of paternal origin (sometimes 2 sperm combine with an empty egg but this is rare) - no foetal material will form!
95
Features of a complete hydatidiform mole?
bleeding in first or early second trimester
exaggerated symptoms of pregnancy e.g. hyperemesis
uterus large for dates
very high serum levels of hCG
hypertension and hyperthyroidism may be seen (because hCG can mimic TSH)
96
What % of complete hydatidiform moles go on to develop choriocarcinoma?
2-3%
97
Management of molar pregnancies?
urgent referral to specialist centre - evacuation of the uterus is performed via suction curettage (or if fertility preservation is not a concern a hysterectomy)
Bimonthly HCG testing until levels are normal
effective contraception is recommended to avoid pregnancy in the next 12 months
98
What is a partial hydatidiform mole?
A normal haploid egg may be fertilized by two sperms, or by one sperm with duplication of the paternal chromosomes.
Therefore the DNA is both maternal and paternal in origin but there are 3 sets of chromosomes.
Usually triploid - e.g. 69 XXX or 69 XXY.
The cell divides and multiplies into a tumour called a partial mole where some material may form so foetal parts may be seen
99
Diagnosis of molar pregnancies?
Signs of normal pregnancy e.g. amenorrhoea
More severe morning sickness
Vaginal bleeding
Increased enlargement of uterus
Abnormally high hCG
Thyrotoxicosis as hCG can mimic TSH!
Transvaginal USS shows “snowstorm appearance” of the pregnancy and absence of foetus in complete molar pregnancy
Provisional diagnosis can be made by USS and confirmed with histology of the mole after evacuation!
100
Risk factors for molar pregnancies?
Extreme ends of fertility age range - <16 or >45
101
What is choriocarcinoma?
A very rare type of trophoblastic disease
Its an aggressive cancer that can develop if cells left behind after a preganncy are cancerous
It can happen after any pregnancy but its more likely after molar pregnancies
102
Current law surrounding abortion
Current law is based on 1967 Abortion Act. This was amended in 1990 under the Human Fertilisation and Embryology Act, reducing the upper limit from 28 weeks to 24 weeks gestation.
An abortion can be carried out before 24 weeks if continuing the pregnancy involves greater risk to the physical or mental health of the woman OR existing children of the family.
It can only be carried out after 24 weeks under specialist circumstances -continuing the pregnancy is likely to risk the life of the woman, terminating the pregnancy will prevent grave permenant injury to physical or mental health of the woman, or there is substantial risk that the child would suffer physical or mental abnormalities making it seriously handicapped
2 registered medical practitioners must sign a legal document (1 if emegrency!)
Only a registered medical practitioner can perform an abortion, which must be in a NHS hospital or licensed premises
103
How to get an abortion on the NHS?
Self refer by contacting an abortion provider directly e.g. British pregnancy Advisory Service
Speak to a GP and ask for a referral to an abortion service
Contact a sexual health clinic and ask for a referral to an abortion service
You should not ahve to wait more than 2 weeks from when you first contact an abortion provider to having an abortion
104
Charity in the Uk that provides remote abortion services for women <10 weeks gestation?
Marie Stopes UK
105
Which women having abortions should be given anti-D prophylaxis?
Women that are rhesus D negative and having an abortion after 10+0 weeks gestation
106
Medical abortion options
Mifepristone followed 48 hours later by prostaglandins to stimulate uterine contractions
“Mimics a miscarriage”
Takes hours-days to complete and timing is not predictable
Pregnancy test to detect level of hCG required 2 weeks later to confirm pregnancy has ended “multi level preganncy test”
107
Moa of mifepristone and prostaglandins for abortion?
Mifepristone is an anti-progestogen -blocks action of progesterone, halting pregnancy and relaxing the cervix
Misoprostol is a prostaglandin analogue that softens the cervix and stimulates uterine contractions which helps with expulsion
108
Surgical options for abortion?
Vacuum aspiration
Electric vacuum aspiration
Dilatation and evacuation - usually for later e.g. 14-24 weeks
Cervical priming with misoprostol +/- mifepristone before procedures - softens and dilates the cervix
Women are usually offered local anaesthesia, local anaesthetic+ sedation or general anaesthesia
109
Post-abortion
Women may experience vaginal bleeding and abdominal cramps intermittently for up to 2 weeks after the procedure.
A urine pregnancy test is performed 2 weeks after the abortion to confirm it is complete.
Contraception is discussed and started where appropriate.
Support and counselling is offered.
110
Risks of abortion?
Failure of abortion: you may need another procedure to remove parts of pregnancy that remains in the womb - 7 in 100 women in medical or 3.5 in 100 in surgical
Infection of uterus -> PID
Pregnancy tissue retained in womb
Excessive bleeding
Damage to womb or cervix
111
Support for bereavement e.g. miscarriage?
The Miscarriage Assocation
Cruse Bereavement Care
Child bereavement UK
Saying Goodbye
The Ectopic Pregnancy Trust
112
What is polymorphic eruption of pregnancy?
Aka Pruritic and urticarial papules and plaques of pregnancy
An itchy rash that starts in the 3rd trimester and usually begins on the abdomen, often in abdominal striae
Periumbilical area is often spared
113
Management of polymorphic eruption of pregnancy?
Typically gets better towards the end of pregnancy and after delivery
Control symptoms with topical emollients, steroids, oral antihistamines
114
What is the commonest skin dsorder found in pregnancy?
Atopic eruption of pregnancy
115
What is atopic eruption of pregnancy?
An eczematous, itchy red rash in the first and second trimester
Essentially it’s eczema that flares up!
116
Management of atopic eruption of pregnancy?
No Tx needed as it will improve after delivery but you can use topical emollients, steroids or even phototherapy with UVB
117
What is melasma?
Increased pigmentation to patches of skin on the face - usually symmetrical and flat, affecting sun-exposed areas
Thought to be related to female sex hormones as can also occur with COCP and HRT
118
Management of melasma?
Avoiding sun exposure and using suncream
Makeup (camouflage)
Skin lightening cream (e.g. hydroquinone or retinoid creams), although not in pregnancy and only under specialist care
Procedures such as chemical peels or laser treatment (not usually on the NHS)
119
What is pyogenic granuloma?
AKA lobular capillary haemangioma - a benign rapidly growing tumour of capillaries - will grow over days to 1-2cm
Can present as a discrete lump with a red/dark appearance. Often occur on fingers, upper chest, back, neck or head. If injured may cause profuse bleeding and ulceration
Occur more often in pregnancy and with hormonal contraceptives
Typically resolve after delivery!
120
What is pemphigoid gestationis?
A rare autoimmune condition that can occur in the 2nd or 3rd trimester
Causes pruritic blistering lesions that often develop in the peri-umbilical region, later spreading to the trunk, back, buttocks and arms. Itchy red papular rash -> large fluid-filled blisters
121
Management of Pemphigoid gestationis? why?
Oral corticosteroids
Risks of FGR, preterm, blistering rash to baby after delivery as maternal antibodies pass to baby
122
What is a subchorionic haematoma?
Symptoms?
Prognosis?
Blood collecting under the chorion membrane (between amniotic sac and uterus) during pregnancy
May cause some vaginal bleeding during pregnancy - most commonly <20 weeks
Most don’t experience any symptoms and it is discovered on routine USS
Usually resolve on their own without intervention and dont cause any complications
Rarely can cause miscarriage, preterm delivery or placental abruption
123
What is round ligament pain?
A common pregnancy symptom that is harmless
Most common in second trimester
Sharp pain triggered by movement located within 1 or both sides of lower abdomen/groin
It occurs when round ligaments stretch as uterus grows
124
If a woman comes in with bleeding in the first trimester, what is the most important investigation?
TVUS - determines whether pregnancy is intrauterine or ectopic
125
Problem with using ondansetron during pregnancy?
Small increase in risk of cleft lip or cleft palate
