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Obstetrics & Gynaecology > Early pregnancy problems > Flashcards

Early pregnancy problems Flashcards

1
Q

On which day does the oocyte enter the uterus to become a multicellular morula?

A

Day 4

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2
Q

On which day does the trophoblast invade the enodmetrium (ie implantation)?

A

Day 6-12

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3
Q

What secretes hCG and when does this peak by?

A

Trophoblast

Peaks on 12th week

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4
Q

When is placental morphology complete by?

A

Week 12

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5
Q

When is fetal heart beat present

When is it visible on TVUS?

A

Weeks 4-5

Visible on TVUS from 6th week onwards

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6
Q

When is the gestational sac visible on ultrasound?

A

On the 5th week

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7
Q

Definition of early pregnancy miscarriage? When do most occur?

A

Death of fetus before 24 weeks

<12 weeks

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8
Q

What is the aetiology of miscarriage?

A
  1. Implantation- defective trophoblast
  2. Ovofetal factors- structural chromosomal abnormality
  3. Maternal factors- Smoking >10 a day, maternal disease eg SLE, and infection (TORCH, parvovirus B19 and Listeria)
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9
Q

Is cervical os open or closed in threatened miscarriage, and what amount of bleeding?

A

Closed
Mild
Uterus same size as expected

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10
Q

How do you differentiate between completed miscarriage and missed miscarriage?

A

Both have closed cervical os
Completed will have passage of products of conception, and evidence of prior pregnancy
Missed- no passage of contents and ultrasound will show blighted ovum, and uterus will be smaller for dates than expected

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11
Q

How does septic miscarriage present?

A

Offensive vaginal discharge
Boggy tender uterus
No fever

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12
Q

What are the investigations for miscarriage?

A
  1. Transvaginal ultrasound- fetal pole, heart beat, crown-rump length
  2. Urinary hcg diagnose pregnancy
  3. Serum hCG- >50% decrease or slow doubling times then miscarriage
  4. FBC, coagulation, cross match blood, Rhesus D prophylaxis to rhesus negative women
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13
Q

If a fetal heart beat not present and CRL length >7mm and <7mm what do you do?

A

Repeat transvaginal ultrasound in 7-14 days, if >7mm then repeat but also get second opinion

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14
Q

When would you expectant management for a miscarriage be suitable?

If bleeding stops with expectant when do you conduct urinary pregnancy tests?

A

If no pain, minimal blood loss and <6 weeks gestation
>6 weeks gestation, minimal blood loss and no pain

In 3 weeks

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15
Q

What is used in the medical management of incomplete or missed miscarriage? Mifepristone or misoprostol

A

Mifepristone not indicated anymore- anti-progesterone

Vaginal misoprostol is indicated- is E1 synthetic prostaglandin analogue

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16
Q

When is surgical management indicated for miscarriages?

A

Excessive bleeding
retained tissue >50mm
suspected gestational trophoblastic disease
infected retained tissue

17
Q

What is the surgical management of a miscarriage?

A

Manual vaccum aspiration
Surgical curettage
All tissue sent to histopathology to exclude choriocarcinoma

18
Q

What is the management of RPOC?

A

Vaginal examination- speculum-polyp forceps remove products
FBC, coagulation, cross match blood and Anti-D prophylaxis if rhesus negative
ABC and vital signs- give IM Ergometrine (stops bleeding via uterine contraction and vasoconstriction)
If fever- swabs for culture and broad spectrum antibiotics

19
Q

What are recurrent miscarriages?

A

> 3 or more consecutive miscarriages

20
Q

Investigations for recurrent miscarriages?

A
  1. Antiphospholipid antibody screen
  2. Fetal karytoyping
  3. TFT’s
  4. Pelvic ultrasound- hysterosalpinogram
21
Q

Where are the places an ectopic pregnancy can implant?

A
  • fallopian tubes 97%
  • Ovaries
  • Fimbriae
  • Insterstium
  • Cervix
  • C-section scars
  • Abdomen and peritoneum
22
Q

Aetiology of ectopic?

A 
PID, pelvic infection 
Endometriosis (adhesions) 
Pelvic, tubal surgery 
Assistive reproductive techniques 
IUS, ICD
23
Q

Features of ectopic?

A

Abdo pain first- colicky- then constant- unilateral
Vaginal bleeding- scanty dark
Syncope, light-headedness
Nausea and vomiting
diarrhoea
Shoulder tip pain, collapse, shock- indicate peritoneal blood loss due to rupture. May have absence of vaginal bleeding if this is the case

24
Q

Examination findings for ectopic?

how does uterus and cervical os appear?

A
  • bimanual pelvic exam: adnexal tenderness pelvic tenderness
  • vaginal exam: cervical motion tenderness, cervical os is closed
  • Uterus is small for dates
  • Adbo exam: rebound tenderness
25
Q

How is a tubal pregnancy identified and what do you look out for?

A

Transvaginal ultrasound- look for fetal pole or heart beat
Will show adnexal mass below the level of the internal cervical os
Intrauterine pregnancy may not be able to see if <5 weeks

26
Q

With serum hCG when diagnosing ectopic how many samples do you take, and what indiciates ectopic pregnancy?

What woud indicate GTD?

A

2 samples 48 hours apart

If rise of hCG between between >63% increase and >50% decrease

Massively elevated or persistent elevation above >63% increase

27
Q

How would you stabilise an ectopic patient ie symptomatic?

A

Hypotensive- IV fluids
FBC, crossmatch blood, coagulation screen
Anti-D prophylaxis to rhesus negative

28
Q

Which patients should receive conservative management?

A

Clinically well
Falling hCG levels with initial level <1500 IU
Unruptured ectopic
Location not known

29
Q

What is medical management of ectopic and when do you use it?

A

Methotrexate- do LFTS (adequate renal and liver function for this)

No pain
hCG levels <1500 IU
No intrauterine pregnancy on ultrasound
Unruptured ectopic with adnexal mass <35mm

30
Q

When is surgical management indicated for ectopic and what is surgical?

A

hCG levels >5000 IU
Adnexal mass >35mm
Fetal heart beat on ultrasound
Significant pain

  1. Hysterosalpingogram- check condition of other tube
    Laproscopic salpingectomy
    Laproscopic salpingostomy (if infertility risk factors)

Send all tissue to histopathology to exclude choriocarcinoma

31
Q

What are complications of ectopic, ie recurrance rate?

A

Recurrence rate- 10/20%

Rupture- massive haemorrhage- vasovagal shock- DIC-death

Obstetrics & Gynaecology (16 decks)

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