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EOY4 > Gynae - Early Pregnancy Problems > Flashcards

Gynae - Early Pregnancy Problems Flashcards

1
Q

Define an ectopic pregnancy

A

Fertilised egg implants outside of the uterine cavity (essentially where it shouldn’t)

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2
Q

What is the pathophysiology of an ectopic pregnancy?

A

Decidual cells are present in the uterus which tell the zygote to stop implanting

These cells are not present elsewhere e.g. in the fallopian tubes so nothing to stop the implantation leading to rupture and haemorrhage

Most EPs are tubal so in ampulla or isthmus. Isthmus more at risk of rupture

Can also happen elsewhere e.g. abdominal or previous caesarean scar

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3
Q

What are the risk factors for ectopic pregnancy? (4)

A

Non-modifiable - Previous Ectopic

Modifiable - Contraception e.g. IUD/IUS or IVF, Tubal factors e.g. PID

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4
Q

How can tubal factors increase risk of EP?

A

Tubal damage e.g. adhesions due to PID etc

Smoking - damages cilia so don’t waft the egg as much

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5
Q

Which contraception increases risk of EP?

A

IUCD

POP

Tubal ligation

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6
Q

How does IVF increase risk of EP?

A

Heterotropic - multiple ovulation = one fertilised ovum implants normally in the uterus but the other implants abnormally

If they’re needing an assisted pregnancy anyway do they have damaged tubes?

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7
Q

What are the symptoms of an EP? (4)

A

ALWAYS TREAT ABDO/LIF/RIF PAIN AS IF ITS AN ECTOPIC UNTIL PROVEN OTHERWISE SO DO A URINE PREGNANCY TEST AND B-HCG

Pain - unilateral, lower abdominal. can refer to shoulder tip due to diaphragm irritation from haemoperitoneum

PV bleeding > fainting if rupture

Amenorrheoa!

GI symptoms e.g. DNV or dyschezia

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8
Q

What are the gynae signs of an EP? (3)

A

Normal size uterus

Pelvic tenderness

Cervical excitation +/- adnexal tenderness

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9
Q

What are the abdominal and other signs of an EP?

A

pain/tender +/- guarding +/- peritoneum

Signs of haemorrhage - tachycardia/hypotension/shock/collapse

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10
Q

What are the bedside investigations for an EP?

A

Baseline obs - blood loss

Urine pregnancy test!!!!!!!

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11
Q

What are the blood tests to investigate an EP?

A

Group n Save - crossmatch 6 units if unstable

B-hCG - if TVS can’t find the pregnancy

Rhesus status

FBC - baseline

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12
Q

What is the deal with B-hCG in EP?

A

Doubles within 48 hours

Normal pregnancy increases by 63% in 48 hours but EP doesn’t

If 1000 on the day then repeat in 24 hours

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13
Q

What imaging should be done to investigate an EP?

A

TVS - location/foetal pole/heartbeat

TAS - pelvic pathology or enlarged uterus

Do a diagnostic laparoscopy to determine location if PuL

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14
Q

What is the conservative management for EP?

A

Signpost to contact HCP for post-op/emergency help

Ectopic pregnancy trust for info and support

Contraceptive advice if wanted

Expectant management - only offered If low or rapidly falling hCG and clinically symptomatic. Give 24hr access to GAU

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15
Q

When can medical management be offered for EP?

A

Asymptomatic/mild symptoms

hCG <1500 or < 5000

No IUP on USS

Unruptured adnexal mass <35mm and no visible heartbeat

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16
Q

What are the benefits and risks of medical management of EP?

A

Benefits - preserves Fallopian tubes so preserves fertility in the long run

Risks - Can’t get pregnant for 3 months. May fail

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17
Q

What is the medical management of an EP?

A

Methotrexate IM

Do a hCG on day 4 and 7 and use reliable contraception for 3 months after

May need another dose if hCG has fallen by less than 15%

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18
Q

What is the MOA of methotrexate?

A

Antifolate

Competitive inhibitor of DHFR which makes folate

Folate needed for DNA synthesis

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19
Q

What are the ADRs of methotrexate?

A

Myelosuppression - don’t use if renal impairment, older or using another antifolate e.g. trimethoprim

GI toxicity

Hepatotoxicity - discontinue if deranged LFTs

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20
Q

What is the surgical management of EP?

A

Laparoscopic - shorter/better recovery, less blood loss, less analgesia

Salpingectomy - remove tube and ectopic if contralateral tube is healthy

Salpingotomy - open tube and scoop out ectopic if contralateral tube is damaged (failure/persistence)

Have to follow up with serum b-hCG

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21
Q

When should surgical management be offered?

A

Patient wants it

Medical criteria not met

Clinically unwell

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22
Q

What is the definition of a miscarriage?

A

Loss of pregnancy before 24 weeks (no signs of life)

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23
Q

What are the viable types of miscarriage?

A

Threatened

Little bleeding and pain
Signs of life
Os is closed

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24
Q

What are the non-viable types of miscarriage? (4)

A

Complete

Incomplete

Missed

Inevitable

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25
Q

What is a complete miscarriage?

A

All pregnancy tissue has been passed

Pain and bleeding gone

Os is open

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26
Q

What is an incomplete miscarriage?

A

Not all tissue has passed

Os is open

Risk of sepsis due to retained products/intrauterine infection

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27
Q

What is a missed miscarriage?

A

No foetal heartbeat but signs of pregnancy as body has not recognised the pregnancy to be lost

No pv bleeding

Os is closed

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28
Q

what is an inevitable miscarriage?

A

Products will eventually pass

Os is open

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29
Q

What are the risk factors for early miscarriage (<12 weeks)?

A

Chromosomal abnormalities

Implantation problems e.g. uterine abnormalities

30
Q

What are the risk factors for late miscarriage (>12 weeks)?

A

Placental problems e.g. antiphospholipid syndrome or thrombophilias

31
Q

What are general risk factors for miscarriage? (5)

A

Unknown!

Increased age e.g. >30

Substance abuse - cocaine, smoking

Multiple pregnancy

More pregnancy/multips

32
Q

What are the bedside investigations for miscarriage?

A

urine pregnancy test

Baseline observations - signs of haemodynamic instability

33
Q

Which blood tests should be done to manage a miscarriage?

A

Group n Save - don’t have physiological increase in blood volume yet so may lost lots!

B-hCG if ectopic suspected

34
Q

What imaging should be done to investigate miscarriage?

A

TVS or TAS

35
Q

What is the conservative management of a miscarriage? (7)

A

Expectant - let the miscarriage happen naturally. manage pain and bleeding when it does

Analgesia - paracetamol/ibuprofen/hot water bottle

No strenuous exercise

Only go to work if you feel you can

Take urine pregnancy test in 2 weeks

Reduce infection risk by using condoms and not tampons

Signpost for when to seek medical help

36
Q

What is the medical management of miscarriage?

A

Misoprostol PV/PO

Prostaglandin analogue to cause cervical ripening and myometrial contractions

Use if HAEMODYNAMICALLY STABLE

37
Q

What is the surgical management of a miscarriage?

A

Manual vacuum aspiration if <12 weeks

Evacuation under local/GA if >12 weeks

Do if HAEMODYNAMICALLY UNSTABLE

38
Q

When should anti-D be given when treating a miscarriage?

A

All rhesus-negative women who have a surgical procedure to manage an ectopic pregnancy or a miscarriage.

39
Q

Define hyperemesis gravidarum

A

Persistent vomiting in pregnancy leading to weight loses that is more than 5% of pre-pregnancy weight and ketosis

40
Q

What is the pathophysiology of hyperemesis?

A

Mainly unknown but could be:

1) ↑ B-hCG from placenta causes GIT distension (also explains pregnancy induced hyperthyroidism as crosses over with TSH)
2) ↑ oestrogen and progesterone from CL and placenta causes reduced gut motility and LOS pressure and increased LFTs

41
Q

What are the risk factors for hyperemesis?

A

FHx/Hx

Molar pregnancy

Multiple pregnancy

First pregnancy

Hx of eating disorder

42
Q

Why is USS offered at 8-9 weeks if presenting with hyperemesis?

A

Molar pregnancy / multiple pregnancy has increased risk of HG so offered to exclude

43
Q

What are the symptoms of HG?

A

Vomiting - can’t keep food or fluids down

Spitting/unable to swallow saliva

Weight loss

44
Q

What are the signs of HG?

A

Nutritional deficiencies e.g. reduced B vitamins leading to growth restriction

Signs of dehydration: low BP, tachycardia, hypokalaemia and hyponatraemia

Ketosis!

45
Q

What are the bedside investigations for HG?

A

Urinalysis - +++ ketones and UTI exclusion

Baseline obs for dehydration

46
Q

What are the blood tests to investigate HG?

A

U&E - electrolyte disturbance

BM - Exclude DKA if diabetic

TFTs if showing symptoms of hyperthyroidism

47
Q

What imaging should be done to investigate HG?

A

USS @ 8-9 weeks to exclude molar pregnancy or to diagnose multiple pregnancy

48
Q

What is the conservative management of HG?

A

Primary care - eat ginger [biscuits] and psychological support

Admit if:
Can’t keep anything down + ketonuria + co-morbidities

49
Q

What is the conservative management of HG in secondary care?

A

Rehydrate and correct electrolyte imbalances

Don’t give glucose as can precipitate Wernicke’s

TED stockings due to VTE risk

50
Q

What is the medical management of HG? (4)

A

1) Cyclizine PO/ Promethazine PO/ Prochlorperazine PO
2) Metoclopramide PO or Ondansetron PO (not for >5 days)
3) Supplements - Folic Acid 5mg, Thiamine, TPN if v bad
4) Thromboprophylaxis - Enoxaparin

51
Q

What is the surgical management of HG?

A

In very, VERY extreme cases and as a very, VERY last resort, can offer TOP

52
Q

What are the complications of HG?

A

GI - GORD and Mallory-Weiss Tear

Endocrine - Hyperemesis induced hyperthyroidism

Nutritional Deficiencies - Polyneuritis (B12)

VTE - Hypercoaguable in pregnancy + dehydration

53
Q

Describe decidualisation

A

Implantation leads to thickening and structural changes of the endometrium

Leads to formation of the decidua

54
Q

What is the funcitonof the decidua?

A

Nutrition - fat and glycogen storage

Immune privileged via tight junctions

Prepares placental circulation by transforming into a network of anastamosing spiral arteries under the influence of progesterone

55
Q

What are the 3 parts of the decidua?

A

Basalis - maternal portion

Capsularis - grows over blastocyst after implantation

Parietals - lines pregnant uterus everywhere but implantation site

56
Q

What is implantation?

A

Development of the placenta

Embryonic = trophoblast

Maternal = decidua basalis

57
Q

What occurs during early placental development?

A

Pre-lacunar = until day 9

Lacunar = day 9-12. lacunae form in synctiotrophoblast which then fill with maternal blood

early villous = day 12-28

58
Q

Where do primary, secondary and tertiary villi develop from?

A

Primary: inner = cytotrophoblast, outer = syncytiotrophoblast

Secondary = same as primary but with a mesenchymal core

Tertiary = foetal capillaries in mesenchymal core and vascularised

59
Q

When does the placenta fully establish?

A

month 4?

60
Q

What is the function of the placenta?

A

Hormone production

Gas and nutrient exchange

61
Q

What is gestational trophoblastic disease?

A

Abnormal or overgrowth of all or part of the placenta causing a molar pregnancy/hydatidiform mole

62
Q

What is the pathophysiology behind GTD?

A

Overgrowth of trophoblast cells that produce hCG

Pre-malignant - partial and complete molar

Malignant - invasive moles, choriocarcinoma and placental site trophoblastic tumours

63
Q

What is a hydatidiform mole?

A

Commonest trophoblastic disease

Benign overgrowth

64
Q

What is a partial mole?

A

Part of the normal placenta proliferates but part develops normally

Foetus is genetically abnormal and non-viable

2 sperm enter egg but is just wrong rather than twins

65
Q

What is a complete mole?

A

Whole placenta is abnormal and rapidly proliferating

No foetus developing

One sperm in egg but half set of chromosomes

Bigger risk of malignancy

66
Q

What is an invasive mole?

A

Malignant

Molar tissue invades myometrium - uterine mass and raised hCG

May rupture utures

67
Q

What is a choriocarcinoma?

A

V rare and v malignant cancer

Can arise from a molar pregnancy or an otherwise normal pregnancy

68
Q

How does choriocarcinoma present?

A

PV bleeding

Really raised hCG

Mets?

V sensitive to chemo

69
Q

What are the risk factors for molar pregnancy?

A

Complete = age. more common in teenage women and post menopausal

History

Ovulatory disorders

Low in vit a diet

70
Q

Define recurrent miscarriage

A

The loss of 3 or more consecutive pregnancies.

71
Q

What are the causes of recurrent miscarriage?

A

Maternal - uterine structural anomalies (e.g. septate uterus, fibroids), cervical incompetence, PCOS, antiphospholipid/thrombophilia, increased maternal age

Foetal - chromosomal abnormalities

EOY4 (22 decks)

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