Gynae - early pregnancy Flashcards
what is a threatened miscarriage?
Symptoms - There is bleeding but
tvus - the fetus is still alive, IUP
abdo exam - the uterus is the size expected from the
dates and
speculum - the cervical os is closed (Fig. 14.3a). Only 25% will go on to miscarry.
what is an inevitable miscarriage ?
Inevitable miscarriage refers to the presence of an open internal os in the presence of bleeding in the first trimester of pregnancy.
speculum - the presence of an open internal os in the presence
sx - of bleeding in the first trimester of pregnancy.
Bleeding is usually heavier. Miscarriage is about to occur.
tvus - the fetus may still be alive, or products non-viable but still in utero
what is a complete miscarriage?
TVUS - All fetal tissue has been passed. epmty uterus
Symptoms - initial Bleeding and passage of fetal products (clots)
eventually - bleeding has diminished,
Abdo palpation- the uterus is no longer enlarged
cervix - the cervical os is closed.
what is a septic miscarriage?
The contents of the uterus are infected, causing endometritis.
Vaginal loss is usually offensive, the uterus is tender, but a fever can be absent.
If pelvic infection occurs there is abdominal pain and
peritonism.
What is a missed miscarriage?
tvus - The fetus has not developed or died
in utero: no heart beat, empty gestational sac
sx - but this is not recognized until bleeding occurs
or ultrasound is done
abdo exam - The uterus is smaller than
expected from the dates and
speculum - the os is closed
what causes miscarriage ?
1 off miscarriage - 60 % due to chromosomal abnormalities - specifically UNBALANCED translocation
Recurrent miscarriage - antiphospholipid syndrome ….etc
in whiich miscarriage may you not get bleeding?
missed miscarriage - usually incidental find
how would you investigate a miscarriage?
History
Examination : for uterine size (abdo palpation?), cerviical os opening (speculum)
Refer to EPAU - ultrasound
Why is the LMP and cyclee regularity important in early pregancy?
on tvus non-viable pregnancies can be confused with
a very early pregnancy, especially where the date of the
last menstrual period is uncertain or periods irregular.
define PUL?
When a woman has a + urine pregnancy test
But on TVUS
the uterine cavity is empty and no abnormal adnexal masses or fluid (blood) can be visualised
in case of PUL how can we predict a VIUP?
hCG levels in the blood normally increase
by >63/66% in 48 hours with a viable intrauterine pregnancy
in case of PUL how can we predict a EP?
In 48 hours if riise of hcg is less than 63/66% this is suggestive of ectopic pregnancy.
hcgs often risee into 1000’s - not technically a criteria
in case of PUL how can we predict a Failed PUL?
In 48 hours if riise of hcg is more than 13% drop in Hcg b
how do you ivx a PUL?
Haemodynamically stable + no pain:
- Expectant management (serial hcg’s at 0&48hrs)
Haemodynamically stable + pain:
- Serum hCG
- Consiider laparoscopy
Haemodynamically unstable + pain:
- laparascopy or laparotomy
when hcg ratios are calculated, what is the follow up based on the risks?
Low risk: Failed PUL
- repeat UPT in 2 weeks
Low risk: Viable IUP
- repeat TVUS 7 days
High risk: Ectopic
- Repeat hCG and/or TVUS in 48hrs
which events in eearly pregnancy can warrant admission?
Suspected ectopic pregnancy - if symptomatic (mortaility is from haemorrhage)
Septic miscarriage
Heavy bleeding in miscarriage
in the management of miscarriage, when is Anti-D given?
Anti-D is given to women who are rhesus negative
if the miscarriage is treated surgically or medically
or if there is bleeding after 12 weeks’ gestation.
how is an ectopic preegnancy confirmed ?
laparoscopy
define recurrent miscarriage?
Recurrent miscarriage is when three or more miscarriages occur in succession;
1% of couples are affected.
If a woman is known to have recurrent miscarriages, how will you manage future pregnancy?
- Need clear management plan for US monitoring
- Managed as high risk; need hiigh risk monitoring
- Treatment for the cause eg aspirin + lmwh if APL antibodies
(obvi hopefully tests have been done to identify cause
after last miscarriage)
what is antiphospholipid syndrome?
what effect does it have on pregnancy?
Is an autoimmune, hypercoagulable state caused by antiphospholipid antibodies.
APS provokes blood clots (thrombosis) in both arteries and veins ->
miscarriage, stillbirth, preterm delivery, and severe preeclampsia.
what is the diagnostic criteria for APL syndrome?
The diagnostic criteria require one clinical event (i.e. thrombosis or pregnancy complication)
and two positive blood test results spaced at least three months apart that detect :
lupus anticoagulant,
anti-apolipoprotein antibodies, or
anti-cardiolipin antibodies.
if some1 has Antiphospholipid antibodies / APLS, how arethey treated?
Managed as high risk; need hiigh risk monitoring
aspirin + low dose lmwh
list the causes of recurrent miscarriage? how are they identiified?
APL antibodies
- early and late
Chromosomal defects
- karyotype fetal miscarriage tissue - UB translocation ->
karyotype parents
- early miscarriage
Uterine abnormalities
- US followed by MRI orr hysterosalpingorgram
- late miscarriage >16 wks
Infection
- early and late
Hormonal:
- thyroid autoantibodies
Others:
Obesity, smoking and excess caffeine intake
have been implicated and should all be addressed.
if parents are found to have chromosomal defects, how do we manage this?
Refer to clinical geneticist for advice and support
Prenatal diagnosis using chorionic villus sampling (CVS) or amniocentesis is offered.
The use of donor oocytes or sperm (all donors are routinely karyotyped) or preimplantation genetic diagnosis (PGD) of IVF embryos
what is a late miscarriage ?
fetal loss after 16weeks gestation
how would we investigate the cause of recurrent miscarriage?
Antiphospholipid antibody screen (repeat at 6 weeks
if positive)
Karyotyping of fetal miscarriage tissue
Thyroid function
Pelvic ultrasound (and MRI or hysterosalpingogram (HSG) if abnormal)
What are the laws on abortion in the uk?
Legal before 24 weeks in these situations :
A The continuance of the pregnancy would involve
risk to the life of the pregnant woman greater than
if the pregnancy were terminated
B The termination is necessary to prevent grave permanent injury to the physical or mental health of
the pregnant woman
C The pregnancy has not exceeded its 24th week
and continuance of the pregnancy would involve
risk, greater than if the pregnancy were terminated,
of injury to the physical or mental health of
the pregnant woman
D The pregnancy has not exceeded its 24th week
“ of injury to the physical or mental health of
any existing child(ren) of the family of the pregnant
woman
E There is a substantial risk that if the child were
born it would suffer from such physical or mental
abnormalities as to be seriously handicapped
under which circumstances is abortion after 24 weeks legal?
if there is grave risk to the life of the woman,
evidence of severe fetal abnormality or
risk of grave physical and mental injury to the woman.
A woman presents to speak to you regarding wanting an abortion at 6 weeks pregnant. What do you discuss/ how do you prepare her?
Make sure her reasons fit under law/regulations for abortion.
Discuss her options; medical/surgical
- since she is 6 weeks: medical is best
Pre-abortion tests:
Blood tests for Hb, haemoglobinopathy, group and Rh
status
Rh –ve women require anti-D within 72h of TOP
Screened for chlamydia & sti risk
Discuss future contraception options she can start using after TOP
How is miscarriage managed?
Singleton pregnancies:
Most effective method at gestations <7 weeks =
Medical
Antiprogesterone: mifepristone
Plus prostaglandins 36-48h later: misoprostol or gemeprost = prostaglandin E1 analogues
Can be used at any gestation
Usual and most effective method for mid trimester abortion also (13-24 weeks)
Surgical
Vacuum aspiration 7-10 weeks
o Before 7 weeks: higher failure rates than with medical abortion
Dilatation and evacuation >13 weeks
o Preceded by cervical preparation (hours or days before) - vaginal misoprostol
Both require abx cover
- tell the woman she is going into theatre
Beyond 22 weeks,
Medical
- feticide is performed to prevent life birth – KCl into umbilical vein or fetal heart
o only performed where fetal abnormality present
A woman is 10 weeks pregnant and opts for surgical miscarriage management. she iis worried about the procedure. what should she know?
She will have vacuum aspiration
A plastic tube is inserted into the womb through into the womb from the vagina, and the pregnancy is removed using suction.
It may be done with:
- local anaesthetic (to numb the cervix)
- conscious sedation (where you’re relaxed but awake)
deep sedation or general anaesthetic (where you’re asleep) - with deep sedation she wont remember anything and wont be aware either during operation. Up to her which she prefers.
Complications:
Infection
Uterine perforation and surgical trauma
Failure -Dependent on experience of the centre
Multiple surgical abortions increase risk subsequent PTD
how and why are terminations conducted n high order pregnancies?
selective termination
Reduce the risk of PTL or where one fetus is abnormal
KCl or occlusive techniques - see mulitiple pregnancy cards
why do ectopics lead to bleeding?
implantation site cannot withstand trophoblastic invasion -> bleeds into lumen or ruptures
what are the risk factors for ectopics?
Idiopathic
Any factor damaging the tubes
o PID
Assisted conception Pelvic surgery Previous ectopic Smoking IUD in situ
how does an ectopic present?
Sx: o Lower abdominal pain o Scanty, dark vaginal bleeding o Pain variable in quality Colicky as tube tries to extrude sac Then constant
o Syncopal episodes and shoulder tip pain = intraperitoneal blood loss
o “Classic” presentation = abdominal pain (actually only occurs in 25%)
o Amenorrhoea of 4-10 weeks is usual
O/E: o Tachycardia = blood loss o Hypotension and collapse = exteme o Usually abdominal + rebound tenderness o Cervical excitation o Uterus smaller than expected for gestation o Cx os is closed
How do you investigate an ectopic?
If symptoms:
Admit
IV access and blood cross matched
Anti D if Rh –ve
Haemodynamically unstable + pain:
- Resuscitation
- Laparoscopy (most senstive) or laparotomy
- this is diagnostic and therapeutic
- likely salpingectomy
Haemodynamically stable + pain:
- Serial hcg 0,48 hrs <66%
- hcg slower rising/plateauing
- TVUS - may not always see EP
which surgical management option best if woman had salpingectomy for previous ectopic?
what should you tell her?
If contralateral tube damage, salpingostomy can allow for future spontaneous conception rather than IVF
Salpingostomy: 10% change repeat surgery for persisting ectopic
10% have subsequent ectopic (after 1)
what is the prognosis of EP?
70% subsequently have another successful pregnancy
10% have subsequent ectopic
when can medical management of EP be considered? what monitoring is required?
Unruptured, no cardiac activity & hCG <3000IU/ml
Systemic single dose methotrexate
o Serial hCG monitored to confirm trophoblastic tissue gone (remember would bee admitted if symptoms)
Serial hCG measurements required until <20IU/ml to confirm resolution
o 15% require second dose
o 10% require surgery
o Equivalent outcomes to laparoscopic salpingostomy
when would conseervative management of EP be considered?
Small and unruptured or location of pregnancy unclear + hCG <1000 and declining, careful
rupture may be appropriate
definie hyperemesis gravidarum?
When nausea and vomiting in pregnancy are so severe to cause severe dehydration, weight loss or electrolyte disturbance
real:
persisteent vomiting in pregnancy with 5% weight loss and ketosis
what are the possible causes of hyperemesis gravidarum?
o UTI
o Multiple pregnancy
o Molar pregnancy - main concern
How is hyperemesis gravdarum managed?
see icsm paces cases
management based on fluid status (physical exam) and urine ketones!
mild sx + no keetones:
community care. oral rehydration
moderate dehydration + 1/2 ketones:
short admission
IV saline 0.9% , thiamine, antiiemetic
outpatint oral rehydration
severe dehydration + 3/4 ketones
admit inpatient. correct other imbalance eg add KCl
as above + lmwh
treat till no ketones and imbalance resolved.
Antiemetics: Metoclopramide, Cyclizine, ondansetron o Thiamine (prevent neurological complications of vitamin depletion e.g. Wernicke’s encephalopathy)
Steroids in severe cases
what is gestational trophoblatic disease?
trophoblastic tissue, which is the part
of the blastocyst that normally invades the endometrium,
proliferates in a more aggressive way than is normal.
Proliferation can be pre-malignant or malignant.
pre-malignant: hydatidiform mole (complete and partial),
malignant: invasive mole, choriocarcinoma,
and PSTT - placental site trophoblastic tumour
what are the features of a complete and partial mole?
A complete mole is entirely paternal in origin,
usually when one sperm fertilizes an empty oocyte and
undergoes mitosis. The result is diploid tissue, usually
46 XX. There is no fetal tissue, merely a proliferation of
swollen chorionic villi.
A partial mole is usually triploid, eg 69XXY
derived from 1 or 2 sperms entering one normal oocyte. There is variable evidence of a fetus. can be tetraploid 92xxxy
what are the features of a malignant moles?
If invasion is only present locally
within the uterus, this is an invasive mole; if metastasis
occurs, it is a choriocarcinoma.
placental site trophoblastic tumour (PSTT) - least common presents an average of 3.4 years after formation.
risk factor for molar pregnancy?
More common at extremes of reproductive age
Twice as common in Asians
what is a typical GTD hx?
Large uterus
Early PET and hyperthyroidism
Hx
o Vaginal bleeding- Heavy
o Hyperemesis
o Can be detected on routine USS
how is GTD diagnosed?
“Snowstorm” appearance of swollen villi with complete moles on TVUS
Diagnosis only confirmed histologically
Serum hCG may be very high
how is GTD managed?
1st line - Trophoblastic tissue removed by Suction curettage/vaccum aspiration - (ERPC - old word)
*except when the size of the foetal parts deters the use of suction curettage and then medical evacuation can
be used
Diagnosis confirmed histologically
Often +++ bleeding
Serial blood/urine hCG levels taken
Management in supra-regional centre - urgent referal to trophoblast screening centre for follow up. will have hcg measured until undetectable. F/U period is 6/12
give contraception after. avoid pregnancy in follow up period
what is Gestational trophoblastic neoplasia?
invasive mole or choriocarcinoma,
- highly malignant
follows 15% of complete moles and 0.5% of partial moles
molar pregnancies can lead to GTN
but so can normal pregnancies and miscarriages
how is Gestational trophoblastic neoplasia diagnosed?
Rx?
persistently elevated or rising
hCG levels, persistent vaginal bleeding or evidence
of blood-borne metastasis, commonly to the lungs
Rx:
Low risk: methotrexate with folic acid
o High risk: combination chemotherapy
What are the optinos for Terminartion of pregnancy?
TOP?
Medical: Mifepristone + Misoprostol (24-48hrs later) Do not use after 9 weeks Most effective option from 13-24wks KCL - post 22wks
urine pregnancy test 2wks afterwards
Surgical:
Manual vacuum aspiration - 9wks+
Dilatation and evacuation
o >13 weeks
o Preceded by cervical preparation - misporostol sublingual
+abx cover for both methods
SEE PACES Sheet for update
what kind of drugs are Mifepristone + Misoprostol
Mifepristone - anti-progesterone
Misoprostol - prostaglandin
- Mifepristone - progesterone antagonist. Prevents the action of progesterone.
- Misoprostol - prostaglandin - starts uterine contraction and expels pregnancy.
why is medical TOP usually not recommended at higher gestations?
heavy bleeding
what are the risks of TOP?
Medical :
heavy bleeding - may then require transfusion
failure to remove pregnancy
infection
Surgical: heavy bleeding failure to remove pregnancy uterine perforation cervical damage
what must you do before TOP?
Investigations:
Blood tests for Hb, haemoglobinopathy, group and Rh status
Rh –ve women require anti-D within 72h of TOP
Screened for chlamydia (extra sti screen after if necessary)
Ultrasound - date pregnancy, inform TOP
VTE risk - we wll be prescribing contraceptives
ahouldnt they need full work up if termination due to eg rubella -> and need surgical so group and save etc?
what are the details for the abx prohylaxis in TOP?
Metronidazole at time of abortion - rectal
doxycyline 7 days before abortion - bd oral
when giving IV saline eg in hyperemesis. what must you not do?
correct too quickly due to;
central pontine myelinolysis
cerebral edema
what are the NATIONAL USS criteria for miscarriage?
very important
national criteria for a miscarriage, which includes
a crown-rump length (CRL) of ⩾7 mm with no evidence of a foetal heartbeat OR
a mean gestation sac diameter of ⩾25 mm in a gestation sac that contains no other structures
if CRL is <7 -> repeat TVUS after 7 days. if still no heartbeat then you can diagnose miscarriage but can only diagnose aftr 2nd scan!
if MSD < 25, repeat TVUS after 7 days. if still no fetal POLE. can confirm diagnosis.
why can mothers with GTD get hyperthyroidism?
extremely high hcg mimics roel of TSH as have an alpha subunit in common
what is the diffeerence between complete vs partial moles?
Complete
Karyotype: C 46,XX (46,XY)
hCG ↑↑↑↑
Uterine Size ↑
Fetal Parts No
Components 2 sperm + empty egg
Partial P 69,XXY hCG ↑ Uterine size unchanged Fetal parts - Yes 2 sperm + 1 egg
what is the malignant potential of complete vs partial moles?
Convert to Choriocarcinoma:
complete - 2%
partial - Rare
Risk of Complications:
complete - 15-20% malignant trophoblastic disease
partial - Low risk of malignancy
a woman presents and her tvus shows an ectopic. her hx & obs are as following:
significant pain,
adnexal mass >35 mm, visible fetal heart activity or a
serum hCG level >5000 IU/mL
what mx option is best for her?
Mx: surgical! lap salpingectomy
This is appropriate if a woman
is unable to return for follow-up or has an ectopic
pregnancy plus any of the following: significant pain,
adnexal mass >35 mm, visible fetal heart activity or a
serum hCG level >5000 IU/mL (medical is usaully hog less than 3000)
