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MFSRH Part 2 (2023) > Early Pregnancy, Unplanned Pregnancy, and Abortion Care > Flashcards

Early Pregnancy, Unplanned Pregnancy, and Abortion Care Flashcards

1
Q

How is someone with positive lupus anticoagulant / antiphospholipid antibodies treated in pregnancy?

A
  • Low dose aspirin and prophylactic LMWH throughout pregnancy
  • Not synonymous with SLE
  • If untreated, subsequent fetal loss is 90%
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2
Q

What CRL measurements are used to detect FH and absence of FH?

A
  • 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
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3
Q

What gestation sac measurements are used to diagnose miscarriage?

A
  • 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
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4
Q

What’s a pseudosac seen on USS?

A
  • Fluid secreted under hCG stimulation of an ectopic pregnancy
  • Lacks the double decidual ring outline seen with a true gestation sac
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5
Q

What are ultrasound findings of a tubal ectopic pregnancy?

A
  • 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
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6
Q

Who is not appropriate for expectant / conservative management of miscarriage?

A
  • 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
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7
Q

When managing a tubal ectopic pregnancy expectantly, what is the follow-up plan?

A
  • 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
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8
Q

Who can be offered expectant management of tubal ectopic pregnancy?

A
  • 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
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9
Q

Who can be offered methotrexate for management of tubal ectopic pregnancy?

A
  • 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
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10
Q

What is the follow-up for someone receiving methotrexate for management of ectopic pregnancy?

A
  • Serial bhCGs day 4 and day 7, then 1 per week until negative result is obtained
  • Avoid conception for 3 months
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11
Q

Who is offered surgical management of tubal ectopic pregnancy?

A
  • If unable to return to follow-up
  • Significant pain
  • Adnexal mass 35mm or larger
  • Ectopic with FH
  • Serum bhCG >5000
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12
Q

Why might someone be offered salpingectomy vs salpingotomy for tubal ectopic pregnancy?

A
  • Salpingectomy first line unless other risk factors for infertility (these women can have salpingotomy)
  • 1/5 of women may need further treatment with salpingotomy
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13
Q

What is the follow-up for someone who has had surgical management of ectopic pregnancy?

A
  • If salpingotomy, bhCG in 7 days and then weekly until negative result
  • If salpingectomy, PT in 3 weeks
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14
Q

What investigations are performed for someone with recurrent miscarriage?

A
  • 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
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15
Q

Describe the role of progesterone following a miscarriage

A
  • 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
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16
Q

What is the chance of a successful pregnancy after 3+ consecutive miscarriages?

A

60-75%

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17
Q

What are NICE recommended maximum waiting times for accessing abortion?

A
  • Provide the assessment within 1 week of the request
  • Provide the abortion within 1 week of the assessment
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18
Q

What does NICE guidance say about antibiotic prophylaxis for TOP?

A
  • 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
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19
Q

What does the abortion act clarify re. upper gestation limit if feticide has been given?

A

If feticide has been given at or before 23+6 gestation, the abortion itself can be performed shortly afterwards

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20
Q

What is the upper limit for at home medical TOP?

A
  • 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
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21
Q

What advice do you give someone who wants to take mifepristone and misoprostol at the same time?

A
  • Risk of ongoing pregnancy may be higher, and may increase with gestation
  • It may take longer for the bleeding and pain to start
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22
Q

For TOP up to and including 10+0 weeks, what regime is approved by UK marketing authorisation when using 200mg mifepristone?

A
  • 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
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23
Q

What regime is NICE recommended for MTOP between 10+1 and 23+6 weeks, who have taken 200mg mifepristone?

A
  • 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
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24
Q

What misoprostol doses are NICE recommended for abortion after 23+6 weeks (after taking 200mg mifepristone)?

A

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

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25
Q

Why do we give lower doses of misoprostol in later gestations?

A

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

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26
Q

What is NICE recommended for cervical priming for STOP up to and including 13+6 weeks?

A
  • 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
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27
Q

Why use cervical priming before STOP?

A
  • 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

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28
Q

What cervical priming is NICE recommended for STOP between 14+0 and 16+0 weeks?

A
  • Osmotic dilators
    Or
  • Buccal, vaginal or sublingual misoprostol
    OR
  • 200mg oral mife, given the day before
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29
Q

What cervical priming is NICE recommended for women who are having a STOP between 16+1 and 19+0 weeks gestation?

A
  • Osmotic dilators
    Or
  • Buccal, vaginal or sublingual misoprostol
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30
Q

What cervical priming is NICE recommended for women having STOP between 19+1 and 23+6 weeks gestation?

A
  • 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

31
Q

What anaesthetic options are there for STOP?

A
  • 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

32
Q

How does maternal age affect miscarriage risk?

A

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%

33
Q

Name some other risk factors (other than maternal age) for miscarriage

A
  • 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
34
Q

When is cervical cerclage offered?

A
  • Women with a previous second trimester loss with suspected cervical involvement who have a cervix length off <25mm before 24 weeks
35
Q

Name some risk factors for ectopic pregnancy

A
  • 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
36
Q

How do contraceptive methods affect the risk of ectopic pregnancy?

A

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

37
Q

How do complete molar pregnancies (diploid) form?

A
  • Empty ovum plus sperm that duplicates (75%)
    Or
  • Empty ovum plus 2 sperm (25%)
38
Q

How do partial molar pregnancies (triploid) form?

A
  • Normal ovum and dispermic fertilisation
39
Q

How is a molar pregnancy managed surgically?

A
  • Surgical suction procedure
  • Anti-D if required
  • Prolonged cervical preparation not recommended
  • Use of oxytocin not recommended (risk of embolisation and dissemination)
  • Routine histology
40
Q

Who should be referred to the GTD screening centres?

A
  • Complete hydatiform mole
  • Partial hydatiform mole
  • Twin pregnancy with complete or partial hydatiform mole
  • Choriocarcinoma
  • Placental-site trophoblastic tumour
  • Atypical placental site nodules
41
Q

What are the risks of failure to end the pregnancy EMA vs vacuum aspiration?

A
  • EMA 1/100
  • Vacuum aspiration 1/1000
42
Q

What are the risks of retained tissue in EMA vs vacuum aspiration?

A
  • EMA 3-5/100
  • Vacuum aspiration 1/100
43
Q

What are the risks of infection in EMA vs vacuum aspiration?

A
  • EMA <1/100
  • Vacuum aspiration <1/100
44
Q

What are the risks of haemorrhage in EMA vs vacuum aspiration?

A
  • EMA 1/1000
  • Vacuum aspiration 1/1000
45
Q

What are the risks of cervical tear and uterine perforation in vacuum aspiration?

A
  • Cervical tear 1/100
  • Uterine perforation 1/1000
46
Q

How can a cervical laceration be managed in a STOP?

A
  • Direct pressure with gauze or forceps
  • Application of silver nitrate or ferric subsulfate solution
  • Absorbable sutures
47
Q

What rapid response should the clinician do in the case of uterine atony causing bleeding post STOP?

A
  • Uterine massage
  • Uterotonics
  • Re-aspiration
  • Uterine tamponade
  • Surgical measures
48
Q

What uterotonic medications are available for haemorrhage post TOP?

A
  • Misoprostol 800 micograms sublingually or rectally
  • Oxytocin 10-40 units per 500-1000ml IV
  • Oxytocin 10 units IM
49
Q

How can intrauterine tamponade be performed for haemorrhage post TOP?

A
  • Sterile gauze
  • 30-75ml Foley catheter balloon
  • Obstetric balloon
50
Q

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?

A
  • Perforation
  • Coagulopathy (including DIC)
  • Placenta accreta

4 Ts of PPH are
- Trauma
- Thrombin
- Tone
- Tissue

51
Q

What surgical measures are there to stop haemorrhaging post TOP when all else has failed?

A
  • Hysterectomy
  • Uterine compression sutures
  • Uterine artery ligation
  • Uterine artery embolisation
52
Q

What does the Cremation Regulations 2008 guidance in England and Wales state re. fetal remains under 24 weeks?

A
  • 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
53
Q

Who commissions and provides abortion care services in England?

A
  • 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
54
Q

Name 4 contraindications to MTOP (not including ectopic or gestational limits)

A
  • 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)
55
Q

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?

A
  • Hysterotomy
  • Gravid hysterectomy
56
Q

RCOG Best Practice Abortion Care - MVA or EVA (electrical vacuum aspiration) can be performed up until what gestation?

A
  • 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)
57
Q

RCOG Best Practice Abortion Care - D+E should be performed between which gestations?

A
  • Between 14 and 24 weeks
  • Long forceps and suction cannula
  • D+C should not be used anymore, is obsolete
58
Q

Can you use cervical preparation (i.e. misoprostol) prior to an evac for molar/partial molar pregnancy?

A

Yes (just not use uterotonics such as syntocinon)

59
Q

Who has a higher chance of GTD?

A
  • Extremes of age
60
Q

How may a partial hydatiform mole present on ultrasound scan?

A
  • 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
61
Q

What will histology show in a partial hydatiform mole?

A
  • Focal hyperplasia and swelling of villi
  • May have fetal parts
62
Q

What is the risk of malignant change in partial hydatiform mole?

A
  • <1%
  • Very few patients will need chemo
63
Q

What would histology show for a complete hydatiform mole?

A
  • Never any fetal material
  • Placental tissue has marked hyperplasia and gross vesicular swelling of villi
  • Macroscopic ‘bunch of grapes’ appears in second trimester
64
Q

How might a complete hydatiform mole present?

A
  • ‘snowstorm appearance’ on USS - hydropic villi and intrauterine haemorrhage
  • May present as large for dates (bulk of tumour), HG, or thyrotoxicosis
65
Q

What is the risk of malignant change for complete molar pregnancies?

A
  • 10-15% will become malignant requiring chemotherapy
66
Q

What does histology of choriocarcinoma look like?

A
  • Haemorrhage, necrosis and intravascular growth
  • Lacks the villous structure of normal trophoblastic tissue in a molar pregnancy
67
Q

How does choriocarcimona usually present?

A
  • 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
68
Q

What is a placental site trophoblastic tumour?

A
  • 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
69
Q

What is the bhCG follow up for a complete mole?

A
  • 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
70
Q

A patient has had a molar pregnancy, what is her risk of another in a subsequent pregnancy?

A

10% higher risk

71
Q

What is the most common chemo agent used for choriocarcinoma?

A

Methotrexate

If need more toxic chemo combo, usually ‘EMA-CO’ (etoposide, methotrexate, actinomycin D, cyclophosphamide, vincristine)

72
Q

What are some indications to using chemotherapy for malignant GTD?

A
  • 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
73
Q

Someone has had management of malignant GTD, does she need any extra follow-up after subsequent pregnancies?

A
  • 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

MFSRH Part 2 (2023) (22 decks)

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