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JCU Obstetrics & Gynaecology > Early pregnancy problems > Flashcards

Early pregnancy problems Flashcards

1
Q

The single most important question in gynaecology is….

A

When was your LNMP (Last NORMAL menstrual period)

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2
Q

Gynaecological causes of pelvic pain include…

A
  • Ovarian cyst
  • PID
  • Hydro/pyo salpinx
  • Pregnancy related: ectopic/miscarriage
  • Endometriosis
  • Fibroids
  • Cervical cancer
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3
Q

Non-gynaecological causes of pelvic pain include…

A
  • Constipation (bad diets everywhere!!)
  • UTI
  • IBS
  • Ureteric calculi
  • Appendicitis
  • Diverticulitis
  • Adhesions
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4
Q

What features of pain are important to help you differentiate between the various causes of pelvic pain?

A

Severity

Speed of onset (natural history of condition)

Associated features (e.g. constipation, other symptoms, pregnancy, missed pill)

Laterality: is the organ central (e.g. pain of miscarriage) vs lateral (ectopic, ovarian cyst)

Character of pain: e.g. miscarriage = exaggerated menstrual pain vs intermittent torsion of an ovary vs gradual worsening of growing ectopic vs severe pain of a ruptured ectopic or totally torted ovary

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5
Q

What are the 3 main parts to carrying out a pelvic examination?

A

External inspection

Speculum exam findings

Digital (bimanual exam)

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6
Q

What findings must be described when you document bimanual exam?

A

Uterus:

  1. ante/retro-verted
  2. size (=weeks of pregnancy)
  3. additional masses (e.g. fibroids)
  4. mobility (mobile = normal, fixed = POD adhesions)
  5. tenderness (general, local, cervical motion)
  6. uterosacral thickening (=endometriosis)

Adnexa (singular = adnexum)

  1. presence of masses
  2. palpable normal ovaries
  3. tenderness
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7
Q

What is the discriminatory zone for intrauterine pregnancies and β-hCG?

A

The discriminatory zone is the serum β-hCG level above which a gestational sac should be visible on TVS or TAS if an IUP is present

IUP is usually visible on TVS when gestational sac greater than or equal to 3 mm. This corresponds to a discriminatory zone for β-hCG of:

  • 1500-2000 IU/L on TVS (may occasionally be seen at greater than or equal to 1000 IU/L)

Cautions:

  • Multiple gestations: There is no proven discriminatory zone for β-hCG
  • Presence of fibroids: USS may be less reliable
  • Other causes of high β-hCG - you know what they are
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8
Q

What is a normal β-hCG rise in pregnancy?

A

For a potentially viable intrauterine pregnancy (IUP) up to 6-7 weeks gestation the following applies:

  1. Mean doubling time for β-hCG is 1.4-2.1 days
  2. 85% show serial β-hCG rise of at least 66% every 48 hours
  3. 15% show serial β-hCG rise between 53-66% every 48 hours
  4. The slowest recorded rise over 48 hours is 53%

Remember the flourishing ectopics and flailing intrauterines

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9
Q

What does a declining β-hCG indicate and what do you do?

A

Indicates a non-viable pregnancy (intrauterine or ectopic)

Ensure appropriate follow-up to ensure adequate resolution of either diagnosis

It cannot differentiate between the two

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10
Q

What is the CRL cut-off for diagnosing a miscarriage with no fetal heart beat?

A

If the CRL is more than 7mm on TVS, a fetal heartbeat should be seen. Repeat ultrasound 1 week later may be advisable.

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11
Q

What is the cut-off for expecting to see a fetal pole inside a gestation sac?

A

If the mean sac diameter (MSD) is more than 30mm, a fetal pole should be visualised. Repeat ultrasound 1 week later may be advisable.

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12
Q

Apart from β-hCG, which other blood tests are important in the management of early pregnancy complications?

A

FBC - Hb - ?anaemia due to ectopic rupture or significant vaginal bleeding associated with miscarriage, WCC - septic miscarriage or PID in differential

Group & Hold - in case of need for transfusion AND Anti-D required for Rh negative women

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13
Q

What are the 3 most common symptoms of ectopic pregnancy

A
  1. abdominal or pelvic pain
  2. amenorrhoea or missed period
  3. vaginal bleeding with or without clots

Most ectopics in developed countries present sub-acutely

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14
Q

Reported symptoms of ectopic pregnancy other than pain, vaginal bleeding or amenorrhoea include…

A
  • breast tenderness
  • gastrointestinal symptoms
  • dizziness, fainting or syncope
  • shoulder tip pain
  • urinary symptoms
  • passage of tissue
  • rectal pressure or pain on defecation
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15
Q

Who should have surgical management of ectopic pregnancy?

A

Offer surgery as a first-line treatment to women who are unable to return for follow-up after methotrexate treatment or who have any of the following:

  • an ectopic pregnancy and significant pain
  • an ectopic pregnancy with an adnexal mass of 35 mm or larger
  • an ectopic pregnancy with a fetal heartbeat visible on an ultrasound scan
  • an ectopic pregnancy and a serum hCG level of 5000 IU/litre or more
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16
Q

Who might benefit from medical (methotrexate) management of ectopic pregnancy?

A

Offer the choice of either methotrexate or surgical management to women with an ectopic pregnancy who have a serum hCG level of at least 1500 IU/litre and less than 5000 IU/litre, who are able to return for follow-up and who meet all of the following criteria:

  1. no significant pain
  2. an unruptured ectopic pregnancy with an adnexal mass smaller than 35 mm with no visible heartbeat
  3. no intrauterine pregnancy (as confirmed on an ultrasound scan)

Advise women who choose methotrexate that their chance of needing further intervention is increased and they may need to be urgently admitted if their condition deteriorates.

17
Q

At laparoscopy for ectopic, who should have a salpingectomy and who salpingotomy?

A

Offer a salpingectomy to women undergoing surgery for an ectopic pregnancy unless they have other risk factors for infertility.

Consider salpingotomy as an alternative to salpingectomy for women with risk factors for infertility such as contralateral tube damage.

Repeat ectopic rate is 50% higher with salpingotomy as comapred to salpingectomy

18
Q

What must you tell women undergoing salpingotomy for ectopic management - something that you don’t usually need to tell women who have their tube removed?

A

Inform women having a salpingotomy that up to 1 in 5 women may need further treatment - i.e. they may have persistent trophoblast because some was left behind adherent to the tube.

This could include methotrexate and/or a salpingectomy

19
Q

What early follow up testing should women have after surgical management of ectopic pregnancy?

A

For women who have had a salpingotomy, take 1 serum hCG measurement at 7 days after surgery, then 1 serum hCG measurement per week until a negative result is obtained.

Advise women who have had a salpingectomy that they should take a urine pregnancy test after 3 weeks. Advise women to return for further assessment if the test is positive.

20
Q

What is the diagnosis here?

How can it be managed and what are the future implications?

A

This is a cornual ectopic pregnancy. The pregnancy has implanted in the intrauterine portion of the fallopian tube.

The treatment is excision of the ectopic via cornual resection.

Implications for the future include:

  1. Increased risk of ectopic pregnancy again
  2. Risk of uterine rupture during a future pregnancy/labour. Patient will need elective caesarean section

JCU Obstetrics & Gynaecology (14 decks)

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