Early Pregnancy, Unplanned Pregnancy, and Abortion Care Flashcards
How is someone with positive lupus anticoagulant / antiphospholipid antibodies treated in pregnancy?
- Low dose aspirin and prophylactic LMWH throughout pregnancy
- Not synonymous with SLE
- If untreated, subsequent fetal loss is 90%
What CRL measurements are used to detect FH and absence of FH?
- TV USS: If CRL >7mm and no FH, either seek second opinion or perform second scan minimum 7 days after the first
- TA USS: If no visible FH, record CRL and perform second scan minimum 14 days after the first
- FH is usually seen at CRL 2-3mm, but should definitely be seen by 7mm
What gestation sac measurements are used to diagnose miscarriage?
- If <25mm with TVUSS and no fetal pole, perform second scan 7 days after the first
- If >25mm with TVUSS and no fetal pole, seek second opinion or perform second scan 7 days after the first. Pregnancy unlikely to be viable
- It’s worth asking the patient when she first had a positive pregnancy test - if >3 weeks previously, gestation is likely to be at least 6 weeks and so fetal pole should be seen now
What’s a pseudosac seen on USS?
- Fluid secreted under hCG stimulation of an ectopic pregnancy
- Lacks the double decidual ring outline seen with a true gestation sac
What are ultrasound findings of a tubal ectopic pregnancy?
- Adnexal mass moving separate to the ovary (may contain a gestation sac, yolk sac, fetal pole, FH)
- Adnexal mass with empty gestation sac (tubal ring / donut sign)
- Complex homogenous adnexal mass
- Pseudo sac
- Free fluid in POD
Who is not appropriate for expectant / conservative management of miscarriage?
- If it’s been longer than 14 days since confirmed diagnosis
- Women at increased risk of bleeding (i.e. late first trimester)
- Previous traumatic experience with pregnancy
- Increased risk from haemorrhage effects
- Evidence of infection
When managing a tubal ectopic pregnancy expectantly, what is the follow-up plan?
- Repeat bhCG levels day 2, day 4, day 7
- If bhCG levels drop by >15% then repeat weekly until negative (<20)
- If bhCG levels do not fall by 15%, stay the same, or rise - needs another clinical review
Who can be offered expectant management of tubal ectopic pregnancy?
- Clinically stable and pain-free
- Tubal ectopic measuring <35mm with no visible FH on TV USS AND bhCG levels <1000 AND able to return for follow-up
Who can be offered methotrexate for management of tubal ectopic pregnancy?
- No significant pain
- Unruptured tubal ectopic pregnancy with adnexal mass <35mm with no FH
- AND bhCG <1500
- AND do not have an intrauterine pregnancy
- AND are able to return for follow-up
- Can offer a choice of surgical or medical if bhCG 1500-5000 but well otherwise and meets the other criteria
What is the follow-up for someone receiving methotrexate for management of ectopic pregnancy?
- Serial bhCGs day 4 and day 7, then 1 per week until negative result is obtained
- Avoid conception for 3 months
Who is offered surgical management of tubal ectopic pregnancy?
- If unable to return to follow-up
- Significant pain
- Adnexal mass 35mm or larger
- Ectopic with FH
- Serum bhCG >5000
Why might someone be offered salpingectomy vs salpingotomy for tubal ectopic pregnancy?
- Salpingectomy first line unless other risk factors for infertility (these women can have salpingotomy)
- 1/5 of women may need further treatment with salpingotomy
What is the follow-up for someone who has had surgical management of ectopic pregnancy?
- If salpingotomy, bhCG in 7 days and then weekly until negative result
- If salpingectomy, PT in 3 weeks
What investigations are performed for someone with recurrent miscarriage?
- Karyotype from both parents
- Maternal sampling for lupus anticoagulant and anticardiolipin antibodies
- APS can be diagnosed if positive assay on >1 occasion at least 6 weeks apart
- Aspirin and LMWH throughout their next pregnancy will give 70% success for APS
- Thrombophilia screen (activated protein C resistance, antithrombin III deficiency, protein C deficiency, protein S deficiency)
- Pelvic USS to check for uterine abnormalities
- Rule out PCOS
- Rule out uncontrolled diabetes or thyroid disorder
Describe the role of progesterone following a miscarriage
- NICE updated guidance 2021 to recommend progesterone pessaries to lower the risk of miscarriage if someone presents with PV bleeding in early pregnancy and has already experienced a miscarriage before
- Viable pregnancy must be confirmed by USS
- 400mg progesterone BD until 16 weeks
What is the chance of a successful pregnancy after 3+ consecutive miscarriages?
60-75%
What are NICE recommended maximum waiting times for accessing abortion?
- Provide the assessment within 1 week of the request
- Provide the abortion within 1 week of the assessment
What does NICE guidance say about antibiotic prophylaxis for TOP?
- Do not routinely offer to women having an MTOP
- Offer oral doxycycline 100mg BD for 3 days for women having a STOP
- If using metronidazole, do not routinely offer in combination with another broad-spectrum antibiotic such as doxycycline
What does the abortion act clarify re. upper gestation limit if feticide has been given?
If feticide has been given at or before 23+6 gestation, the abortion itself can be performed shortly afterwards
What is the upper limit for at home medical TOP?
- For women having MTOP and taking mifepristone up to and including 9+6, offer the option of expulsion at home
- If 10+0 and having the mifepristone, they can still have the option of taking the misoprostol at home
What advice do you give someone who wants to take mifepristone and misoprostol at the same time?
- Risk of ongoing pregnancy may be higher, and may increase with gestation
- It may take longer for the bleeding and pain to start
For TOP up to and including 10+0 weeks, what regime is approved by UK marketing authorisation when using 200mg mifepristone?
- 200mg mife followed by 800 micrograms PV miso 36-48 hours later (up to and including 63 days of amenorrhoea i.e. 9 weeks) [this regime is also part of the UK authorisation for misoprostol]
or - 200mg mife for cervical priming, 36 to 48 hours before first trimester STOP
What regime is NICE recommended for MTOP between 10+1 and 23+6 weeks, who have taken 200mg mifepristone?
- 800 micrograms miso vaginally, or
- 400 micrograms miso sublingually
- Follow the initial dose with 400 micrograms doses of miso (vaginal, sublingual, buccal), given every 3 hours until expulsion
What misoprostol doses are NICE recommended for abortion after 23+6 weeks (after taking 200mg mifepristone)?
Between 24+0 and 25+0 weeks
- 400 micrograms misoprostol every 3 hours until delivery
Between 25+1 and 28+0 weeks
- 200 micrograms misoprostol every 4 hours until delivery
After 28 weeks
- 100 micrograms misoprostol every 6 hours until delivery
Why do we give lower doses of misoprostol in later gestations?
Uterus is more sensitive to miso as pregnancy advances
Be aware of risk factors for uterine rupture, including c-section scar, increased gestational age, and multiparity
What is NICE recommended for cervical priming for STOP up to and including 13+6 weeks?
- 400 micrograms sublingual miso, 1 hour before
OR - 400 micrograms vaginal miso, 3 hours before
OR, if miso cannot be used - 200mg mife 24 to 48 hours before
Why use cervical priming before STOP?
- Reduces risk of incomplete abortion for women who are parous
- Makes dilation easier for women who are parous or nulliparous
Explain it may cause bleeding or pain before the procedure
What cervical priming is NICE recommended for STOP between 14+0 and 16+0 weeks?
- Osmotic dilators
Or - Buccal, vaginal or sublingual misoprostol
OR - 200mg oral mife, given the day before
What cervical priming is NICE recommended for women who are having a STOP between 16+1 and 19+0 weeks gestation?
- Osmotic dilators
Or - Buccal, vaginal or sublingual misoprostol
What cervical priming is NICE recommended for women having STOP between 19+1 and 23+6 weeks gestation?
- 200mg oral mifepristone the day before the abortion
AND - Osmotic dilators at the same time as the mifepristone
Do not offer misoprostol if the woman has had an osmotic dilator
What anaesthetic options are there for STOP?
- Local anaesthetic (less time in the hospital)
- IV sedation plus LA (conscious sedation)
- Deep sedation or GA
If using conscious sedation, use IV rather than oral
If using general, consider IV propofol and a short-acting opioid (fentanyl) rather than inhalation anaesthesia
How does maternal age affect miscarriage risk?
Age 12-19: 13%
Age 20-24: 11%
Age 25-29: 12%
Age 30-34: 15%
Age 35-39: 25%
Age 40-44: 51%
Age >45: 93%
Name some other risk factors (other than maternal age) for miscarriage
- Paternal age (generally over 40)
- Antiphospholipid syndrome
- Inherited thrombophilia
- Chromosomal abnormalities (2-5% of couples with recurrent miscarriage will have balanced translocation)
- Uterine anomalies
- Poorly controlled diabetes
- Bacteraemia / viraemia
- BV in first trimester
When is cervical cerclage offered?
- Women with a previous second trimester loss with suspected cervical involvement who have a cervix length off <25mm before 24 weeks
Name some risk factors for ectopic pregnancy
- 1/3 have no risk factors
- Previous ectopic pregnancy (risk of recurrence is 18.5%)
- Previous PID
- Previous pelvic surgery (including sterilisation)
- History of infertility
- Assisted reproductive techniques
- Cigarette smoking
- Maternal age over 35 years
How do contraceptive methods affect the risk of ectopic pregnancy?
Overall lower the risk due to prevention of unplanned pregnancies, but
- IUC - if a woman becomes pregnant with IUC in-situ, risk of 1/20
- POP - 1/10 pregnancies that occur may be ectopic due to cilia disruption
- Sterilisation
How do complete molar pregnancies (diploid) form?
- Empty ovum plus sperm that duplicates (75%)
Or - Empty ovum plus 2 sperm (25%)
How do partial molar pregnancies (triploid) form?
- Normal ovum and dispermic fertilisation
How is a molar pregnancy managed surgically?
- Surgical suction procedure
- Anti-D if required
- Prolonged cervical preparation not recommended
- Use of oxytocin not recommended (risk of embolisation and dissemination)
- Routine histology
Who should be referred to the GTD screening centres?
- Complete hydatiform mole
- Partial hydatiform mole
- Twin pregnancy with complete or partial hydatiform mole
- Choriocarcinoma
- Placental-site trophoblastic tumour
- Atypical placental site nodules
What are the risks of failure to end the pregnancy EMA vs vacuum aspiration?
- EMA 1/100
- Vacuum aspiration 1/1000
What are the risks of retained tissue in EMA vs vacuum aspiration?
- EMA 3-5/100
- Vacuum aspiration 1/100
What are the risks of infection in EMA vs vacuum aspiration?
- EMA <1/100
- Vacuum aspiration <1/100
What are the risks of haemorrhage in EMA vs vacuum aspiration?
- EMA 1/1000
- Vacuum aspiration 1/1000
What are the risks of cervical tear and uterine perforation in vacuum aspiration?
- Cervical tear 1/100
- Uterine perforation 1/1000
How can a cervical laceration be managed in a STOP?
- Direct pressure with gauze or forceps
- Application of silver nitrate or ferric subsulfate solution
- Absorbable sutures
What rapid response should the clinician do in the case of uterine atony causing bleeding post STOP?
- Uterine massage
- Uterotonics
- Re-aspiration
- Uterine tamponade
- Surgical measures
What uterotonic medications are available for haemorrhage post TOP?
- Misoprostol 800 micograms sublingually or rectally
- Oxytocin 10-40 units per 500-1000ml IV
- Oxytocin 10 units IM
How can intrauterine tamponade be performed for haemorrhage post TOP?
- Sterile gauze
- 30-75ml Foley catheter balloon
- Obstetric balloon
If a patient is still haemorrhaging post STOP, and complete evacuation has been assured and no obvious visible lacerations are seen, what other complications could be considered?
- Perforation
- Coagulopathy (including DIC)
- Placenta accreta
4 Ts of PPH are
- Trauma
- Thrombin
- Tone
- Tissue
What surgical measures are there to stop haemorrhaging post TOP when all else has failed?
- Hysterectomy
- Uterine compression sutures
- Uterine artery ligation
- Uterine artery embolisation
What does the Cremation Regulations 2008 guidance in England and Wales state re. fetal remains under 24 weeks?
- Not subjected to the provisions of the Cremation Act or regulations
- Crematoriums cremate these remains at their own discretion
- Cremation Form 10 (‘crem form’) need not be completed
Who commissions and provides abortion care services in England?
- Integrated care boards (ICBs) within Integrated Care Systems (ICS) from 1st July 2022
- 77% of all TOPs in NHS England and Wales are provided by independent service providers
- 33% are provided through NHS trusts
Name 4 contraindications to MTOP (not including ectopic or gestational limits)
- Previous allergy to misoprostol or mifepristone
- Severe uncontrolled asthma (mife may exacerbate, but misoprostol alone could be considered)
- Chronic adrenal failure (again, miso alone could be considered)
- Inherited porphyria (miso alone could be considered)
A patient has a large obstructing tumour at the cervix, and is 9/40 gestation, but STOP and MTOP are deemed unsuitable. What are the methods of TOP in these very rare circumstances, as outlined in RCOG Best Practice Abortion Care?
- Hysterotomy
- Gravid hysterectomy
RCOG Best Practice Abortion Care - MVA or EVA (electrical vacuum aspiration) can be performed up until what gestation?
- 14 weeks
- EVA: electric vacuum pump
- MVA: Hand-activated 60ml plastic aspirator
- Vacuum aspiration COULD be used at 15-16 weeks if a large bore cannula is available (16mm)
RCOG Best Practice Abortion Care - D+E should be performed between which gestations?
- Between 14 and 24 weeks
- Long forceps and suction cannula
- D+C should not be used anymore, is obsolete
Can you use cervical preparation (i.e. misoprostol) prior to an evac for molar/partial molar pregnancy?
Yes (just not use uterotonics such as syntocinon)
Who has a higher chance of GTD?
- Extremes of age
How may a partial hydatiform mole present on ultrasound scan?
- Usually a very early embryo may be detected on USS
- Early USS done because of PV bleeding, pain or HG
- May not be US features and diagnosis may only occur from histology of failed pregnancy
What will histology show in a partial hydatiform mole?
- Focal hyperplasia and swelling of villi
- May have fetal parts
What is the risk of malignant change in partial hydatiform mole?
- <1%
- Very few patients will need chemo
What would histology show for a complete hydatiform mole?
- Never any fetal material
- Placental tissue has marked hyperplasia and gross vesicular swelling of villi
- Macroscopic ‘bunch of grapes’ appears in second trimester
How might a complete hydatiform mole present?
- ‘snowstorm appearance’ on USS - hydropic villi and intrauterine haemorrhage
- May present as large for dates (bulk of tumour), HG, or thyrotoxicosis
What is the risk of malignant change for complete molar pregnancies?
- 10-15% will become malignant requiring chemotherapy
What does histology of choriocarcinoma look like?
- Haemorrhage, necrosis and intravascular growth
- Lacks the villous structure of normal trophoblastic tissue in a molar pregnancy
How does choriocarcimona usually present?
- Usually persistent vaginal bleeding and markedly raised bhCG (which should fall within 3 weeks postpartum)
- Diagnosis can also be made after metastasis to lung, brain, GI tract, liver and kidney
- Can present shortly after pregnancy but also up to 20 years later
What is a placental site trophoblastic tumour?
- Arises from intermediate trophoblastic cells, which have a lower capacity to invade and make less bhCG
- Similar presentation to choriocarcinoma
- Only occurs after delivery of a female infant
- More likely to be associated with hCG-induced amenorrhoea
What is the bhCG follow up for a complete mole?
- In majority, bhCGs fall to normal within 2 months
- Follow-up is needed for 6 months after evac, or 6 months after the first normal bhCG
- Serum bhCGs every fortnight until levels are <4
- Urine bhCG every 4 weeks until 1 year after evac, then every 3 months until follow-up for 2 years
- If bhCG normalises within 8 weeks, follow-up is limited to 6 months
A patient has had a molar pregnancy, what is her risk of another in a subsequent pregnancy?
10% higher risk
What is the most common chemo agent used for choriocarcinoma?
Methotrexate
If need more toxic chemo combo, usually ‘EMA-CO’ (etoposide, methotrexate, actinomycin D, cyclophosphamide, vincristine)
What are some indications to using chemotherapy for malignant GTD?
- Serum bhCG >20,000 at 4 weeks after evac
- Static or rising bhCG levels after evac, in the absence of a new pregnancy
- Persistent symptoms
- Evidence of metastasis
Someone has had management of malignant GTD, does she need any extra follow-up after subsequent pregnancies?
- hCG levels should be checked at 6 weeks and 10 weeks after each subsequent pregnancy
- no need for routine follow-up in subsequent pregnancies after previous complete/partial molar pregnancy
