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OBSTETRICS > Early pregnancy problems > Flashcards

Early pregnancy problems Flashcards

1
Q

Name 4 conditions that can cause bleeding in early pregnancy

A
  1. Miscarriage
  2. Ectopic pregnancy
  3. Gestational trophoblastic disease
  4. Gynae infection
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2
Q

What is miscarriage?

A

Loss of an intrauterine pregnancy <24 weeks.

Early: <12 weeks.

Expulsion of foetus <500g <22 weeks

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3
Q

When does the majority of miscarriage occur? and what is the most common cause?

A

Early miscarriage

Genetic/chromosomal abnormalities

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4
Q

What advice would you give to women with threatened miscarriage?

A

If bleeding doesn’t stop for 14 days - seek help

If bleeding stops, continue antenatal care.

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5
Q

When is US/TVS used for diagnosis?

A
  1. If the gestational sac >/= 25mm without a cold sac present.
  2. Foetal pole with crown rump length >/=7 without evidence of heart activity
    - seek second opinion on viability of pregnancy
    - perform scan in 7 days
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6
Q

What would you do if gestational sac <25 on US?

A

Wait 7 days then re-measure before making a diagnosis

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7
Q

when is expectant management used to treat miscarriage?

A

First line for 7-14 days in women with a confirmed diagnosis

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8
Q

When do you not consider expectant management?

A
  1. high risk of bleeding (late miscarriage)
  2. infection
  3. previous traumatic pregnancy experience
  4. increased risk from the effects of haemorrhage
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9
Q

How long is conservative management continued for?

A
  1. as long as the women is willing
  2. As long as there are no signs of infection

usually takes 6-8 weeks

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10
Q

What is the medical management of miscarriage?

A
  1. Pain relief and anti-emetic
  2. inform about treatment + SE associated (diahroeaa, pain, N+V)
  3. return to doctor if experiencing worsening symptoms
  4. Take a pregnancy test 3 weeks after treatment commenced - if positive, return to Dr for review - potential ectopic/molar
  5. Mifepristone
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11
Q

When is mifepristone contraindicated? what do you offer instead.

A

Missed or incomplete miscarriage.

Offer oral/reftam misoprostol

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12
Q

How do you treat a missed/ incomplete miscarriage?

A

800 mg misoprostol + tell them to contact EPAU if bleeding doesn’t start in 24 hours

Offer antiemetic/Pain relief

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13
Q

What is the surgical management of miscarriage?

A
  1. Manual vacuum aspiration - local/GA
  2. SMOM - day case, FBC, G+S, anti-D, chlamydia screening
    give prophylactic doxycycline 100 mg for 10 days + PR metronidazole1g
    send products to histology to exclude molar pregnancy +
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14
Q

What are the complications of SMOM?

A 
Infection
haemorrhage
uterine perforation
intrauterine adhesions
cervical tears
intra-abdominal trauma
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15
Q

What minimises cervical + uterine trauma?

A

Administering prostaglandins

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16
Q

When would you give Anti-D in confirmed miscarriage?

A
  1. Any Rhesus -ve women that is not sensitised + miscarries after 12 weeks
  2. Any women who miscarries <12 weeks when the uterus is medically/surgically evacuated
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17
Q

What dose of anti-D do you give?

A

<12 weeks = 250iU

after 12 weeks = 500 iU

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18
Q

When would you give Anti-D in threatened miscarriage?

A

All non-sensitised women >12 weeks

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19
Q

When would you give Anti-D in confirmed ectopic?

A

ALL pregnant women with ectopic

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20
Q

Are hCG + TVS useful diagnostic tools in early pregnancy problems?

A

NO

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21
Q

What is threatened miscarriage?

A

Features: vaginal bleed, abdominal pain, foetus alive + heartbeat present. uterus size is normal.

only 1/4 miscarry

Cervical OS: Closed

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22
Q

What is inevitable miscarriage?

A

Features: vaginal bleeding and abdominal pain. No foetal heart beat.

all miscarry

Cervical OS: open

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23
Q

What is incomplete miscarriage?

A

Features: some foetal parts have passed, retains some products of conception, vaginal bleed and abdominal pain.

Cervical OS: open.

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24
Q

What is complete miscarriage?

A

Features: all foetal tissue passed, bleeding and pain resolved. uterus no longer enlarged. Serum hCG to exclude ectopic.

Cervical OS: closed

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25
Q

What is septic miscarriage?

A

Features: infected content –> endomemetritis. vaginal loss is offensive, uterus tender, +/- fever, pelvic infection.

Cervical OS: open/closed

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26
Q

What is missed miscarriage?

A

Features: Foetus not developed/died in utero. Asymptomatic, not recognised until bleeding occurs.

Cervical OS: closed

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27
Q

What is Recurrent miscarriage?

A

When miscarriage happens >3 x

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28
Q

What are the 10 causes of recurrent miscarriage?

A
  1. Age: Maternal age mainly >40, paternal age also.
  2. Anti-phospholipid syndrome: causes adverse pregnancy outcomes.
  3. Thrombophilia
  4. Genetic factors
  5. Cervical incompetence
  6. Infection
  7. Diabetes + thyroid
  8. Immune factors
  9. Uterine anomalies
  10. No cause found
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29
Q

What are the adverse pregnancy outcomes associated with APS?

A
  1. 3+ miscarriages before 10 weeks of gestation
  2. 1+ morphologically normal foetal losses after 10 weeks of gestation
  3. 1+ preterm birth before 34 weeks due to placental abnormality
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30
Q

Name 3 APS antibodies

A
  1. lupus anticoagulant
  2. anticardioplin antibodies
  3. B2 glycoprotein 1 antibodies
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31
Q

Name Types of thrombophilia:

A
  1. protein C+S deficiency
  2. Factor 5 leiden
  3. PT gene mutation
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32
Q

How are Genetic factors diagnosed?

A

Cytogenetics + blood karyotyping

33
Q

How is cervical incompetence diagnosed?

A
  1. History of second trimester miscarriage proceeded by ruptured membranes/painless cervical dilation

cervical sonographic surveillance for 24 hours

34
Q

What infection increases the risk of miscarriage and how is it treated?

A

Bacterial vaginosis in first trimester.

Treat with clindamycin.

35
Q

What secretes bHCG? and what is its function?

Which hormone is it identical to?

A

Trophoblasts - to maintain corpus luteum

identical to LH

36
Q

When is bhCG mainly used? and what does a very increased number indicate?

A

4-8 weeks

Molar pregnancy

37
Q

How much does bhCG rise by every 48 hours?

A

66%

38
Q

What is an ectopic pregnancy?

A

Implantation of a pregnancy outside the endometrial cavity

39
Q

Where is the commonest place of an ectopic?

A
  1. Tubal - ampulla
  2. ovarian
  3. interstitial
  4. CS scar
  5. abdominal
40
Q

What features are associated with tubal miscarriage?

A
  1. Haematosalpinx
  2. tubal miscarriage
  3. Rupture
  4. Pain
41
Q

How do you diagnose ectopic?

A
  1. history + examination
  2. TVS: to establish the location of pregnancy + presence of adnexal masses
  3. Serum progesterone to distinguish if the pregnancy is failing <20 nmol
  4. serial bhCG measurements
  5. Laparoscopy: used if diagnosis is unclear.
42
Q

What can give a false TVS diagnosis of ectopic?

A
  1. pseudosac

2. heterotrophic

43
Q

At what level of hCG can TVS identify an intrauterine pregnancy?

A

1000 iU

44
Q

What constitutes a confirmed gestation sac?

A
  1. yolk sac
  2. foetal pole
  3. foetal HR
45
Q

When are ectopic pregnancies at a higher risk of rupture?

A

Associated high hCG

46
Q

How do you approach a haemodynamically stable patient?

A
  1. History + examination
    - abdominal tenderness, rebound tenderness, cervical excitation
  2. Look for signs of miscarriage - open cervical OS
  3. Look for the passage of products of conception
47
Q

What are the signs of a harm-dynamically unstable patient

A

-raised HR, low BP, LOC

48
Q

How do you approach a haemodynamically unstable patient?

A
  1. Urgent resuscitation
  2. 2 large bore canulas + IV fluids
  3. Crossmatch 6U blood
  4. call senior help
49
Q

What are the symptoms of an ectopic pregnancy? (8)

A
  1. Assymptomatic
  2. Amenorrhea 6-8w
  3. Lower abdominal pain - unilateral + vague
  4. vaginal bleed - bwon
  5. diarrhoea + vomiting
  6. Dizziness
  7. Shoulder tip pain - haematoperitoneum
  8. collapse
50
Q

What are the signs of ectopic pregnancy?

A
  1. Non-specific
  2. Normal uterus size
  3. cervical excitation + adnexal tenderness
  4. adnexal mass
  5. Peritonism
51
Q

What are the risk factors of an ectopic pregnancy? (7)

A
  1. History of infertility/ assisted conception
  2. PID/ endometriosis
  3. pelvic/tubal surgery
  4. previous ectopic
  5. IUCD
  6. IVF
  7. smoking
52
Q

What information do you need to give women with ectopic pregnancy?

A
  1. How to contact emergency department
  2. Post-operative advice
  3. When to seek help
53
Q

When would you go for expectant management for ectopic pregnancies? (5)

A
  1. Clinically stable women
  2. Assymptomatic women
  3. US diagnosis
  4. decreasing b/hcg <1500 iU
  5. Women is willing to attend follow up appointments
54
Q

When would you go for medical management for ectopic pregnancies? (6)

A
  1. Able to return for follow up
  2. No pain
  3. Unruptured ectopic with adnexal mass <35 mm
  4. no visible heart beat
  5. Serum h/cg <1500 iU
  6. no intrauterine pregnancy confirmed on US
55
Q

What drug do you use in the medical management of ectopic pregnancy?

A

Systemic Methotrexate

56
Q

When would you go for surgical management for ectopic pregnancies? (5)

A
  1. Methotrexate is contraindicated/not accepted
  2. Visible foetal heart beat
  3. Significant pain
  4. Adnexal mass >35mm
  5. serum hCG > 5000 iU
57
Q

Is the chance of needing further intervention with methotrexate high or low?

A

High

58
Q

What two surgical approaches are used to treat an ectopic pregnancy?

A
  1. Laparotomy

2. Laparoscopy: GS. Stable patient and competent doctor.

59
Q

When is salpingectomy offered to women with an ectopic pregnancy?

A

When she has no other risk factors for infertility

60
Q

What Information do you give patients post operatively (ectopic)?

A
  1. You will take a serum hCG weekly until it is negative

2. Advice patient to take a urine pregnancy test and to return if it is still positive

61
Q

When would you conifer salpingotomy instead of salpingectomy?

A

When the patient has other risk factors for infertility

62
Q

What is the MOA of methotrexate and how can it be administered?

A
  1. It is a folcic acid antagonist (acts by blocking the di-hyra-folate enzyme) blocking DNA synthesis.
  2. Can be administered systemically (PO/IV/IM) or locally via hysteroscopy/laparoscopy
63
Q

What are the pros of using methotrexate over surgery?

A
  1. Preserves uterine tube

2. No surgical risks

64
Q

Name 4 side effects of methotrexate?

A
  1. leucopenia
  2. Conjunctivits
  3. GI disturbances
  4. Mucocytis
65
Q

How do you know if methotrexate is failing to treat miscarriage?

A
  1. Significant pain
  2. haematoperitoneum
  3. increased bhCG day 7
  4. hCG decrease <15% after day 7
  5. Rise in bHCG levels
66
Q

Name 3 risk factors for developing a Molar pregnancy?

A
  1. Extremes of age
  2. Asian
  3. Previous molar
67
Q

What is molar pregnancy?

A

Gestational trophoblastic disease caused by the overgrowth of placents

68
Q

Name 3 types of molar pregnancies

A
  1. Choriocarcinoma - local invasion
  2. Invasive mole
  3. Hydatiform Mole
69
Q

What is the MOA for developing a complete hydatiform molar pregnancy

A

Sperm fertilises empty ovum+ undergoes mitosis duplicating its own chromosomes

70
Q

What are the two types of hydatiform molar pregnancies?

A
  1. Complete

2. Partial

71
Q

What are the characteristics of complete hydatiform moles?

A
  1. 46 XX
  2. hydronic villi
  3. trophoblastic hyperplasia
72
Q

What is the MOA for developing a Partial hydatiform molar pregnancy?

A

2 sperms fertilize one oocyte –> triploid.

A foetus is present

73
Q

What are the clinical features of a molar pregnancy? (4)

A
  1. Vaginal bleed
  2. uterus large for dates
  3. Pain - ovarian hyperstimulation
  4. N+V
74
Q

What Investigations do you do for a patient with a Molar pregnancy?

A
  1. Bloods: FBC, group and save, Rhesus antibody
  2. bHCG
  3. US
  4. Histopathological analysis to look for products of conception
75
Q

What is the classical US appearance of a molar pregnancy called?

A

Snowstorm vesicular pattern

76
Q

How do you treat patients with a Molar pregnancy who want to preserve their fertility?

A

Surgical evacuation - suction curretage

77
Q

Why should medical management be avoided in Molar pregnancy?

A

Risk of increased trophoblastic embolisation by inducing uterine contractions

78
Q

What medical options are available to treat a Molar pregnancy and when do you use them?

A
  1. Oxytocin: After complete evacuation.

2. Anti-D: All Rhesus -ve women

OBSTETRICS (11 decks)

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