Gynae - Early Pregnancy Problems Flashcards
Define an ectopic pregnancy
Fertilised egg implants outside of the uterine cavity (essentially where it shouldn’t)
What is the pathophysiology of an ectopic pregnancy?
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
What are the risk factors for ectopic pregnancy? (4)
Non-modifiable - Previous Ectopic
Modifiable - Contraception e.g. IUD/IUS or IVF, Tubal factors e.g. PID
How can tubal factors increase risk of EP?
Tubal damage e.g. adhesions due to PID etc
Smoking - damages cilia so don’t waft the egg as much
Which contraception increases risk of EP?
IUCD
POP
Tubal ligation
How does IVF increase risk of EP?
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?
What are the symptoms of an EP? (4)
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
What are the gynae signs of an EP? (3)
Normal size uterus
Pelvic tenderness
Cervical excitation +/- adnexal tenderness
What are the abdominal and other signs of an EP?
pain/tender +/- guarding +/- peritoneum
Signs of haemorrhage - tachycardia/hypotension/shock/collapse
What are the bedside investigations for an EP?
Baseline obs - blood loss
Urine pregnancy test!!!!!!!
What are the blood tests to investigate an EP?
Group n Save - crossmatch 6 units if unstable
B-hCG - if TVS can’t find the pregnancy
Rhesus status
FBC - baseline
What is the deal with B-hCG in EP?
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
What imaging should be done to investigate an EP?
TVS - location/foetal pole/heartbeat
TAS - pelvic pathology or enlarged uterus
Do a diagnostic laparoscopy to determine location if PuL
What is the conservative management for EP?
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
When can medical management be offered for EP?
Asymptomatic/mild symptoms
hCG <1500 or < 5000
No IUP on USS
Unruptured adnexal mass <35mm and no visible heartbeat
What are the benefits and risks of medical management of EP?
Benefits - preserves Fallopian tubes so preserves fertility in the long run
Risks - Can’t get pregnant for 3 months. May fail
What is the medical management of an EP?
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%
What is the MOA of methotrexate?
Antifolate
Competitive inhibitor of DHFR which makes folate
Folate needed for DNA synthesis
What are the ADRs of methotrexate?
Myelosuppression - don’t use if renal impairment, older or using another antifolate e.g. trimethoprim
GI toxicity
Hepatotoxicity - discontinue if deranged LFTs
What is the surgical management of EP?
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
When should surgical management be offered?
Patient wants it
Medical criteria not met
Clinically unwell
What is the definition of a miscarriage?
Loss of pregnancy before 24 weeks (no signs of life)
What are the viable types of miscarriage?
Threatened
Little bleeding and pain
Signs of life
Os is closed
What are the non-viable types of miscarriage? (4)
Complete
Incomplete
Missed
Inevitable
What is a complete miscarriage?
All pregnancy tissue has been passed
Pain and bleeding gone
Os is open
What is an incomplete miscarriage?
Not all tissue has passed
Os is open
Risk of sepsis due to retained products/intrauterine infection
What is a missed miscarriage?
No foetal heartbeat but signs of pregnancy as body has not recognised the pregnancy to be lost
No pv bleeding
Os is closed
what is an inevitable miscarriage?
Products will eventually pass
Os is open
What are the risk factors for early miscarriage (<12 weeks)?
Chromosomal abnormalities
Implantation problems e.g. uterine abnormalities
What are the risk factors for late miscarriage (>12 weeks)?
Placental problems e.g. antiphospholipid syndrome or thrombophilias
What are general risk factors for miscarriage? (5)
Unknown!
Increased age e.g. >30
Substance abuse - cocaine, smoking
Multiple pregnancy
More pregnancy/multips
What are the bedside investigations for miscarriage?
urine pregnancy test
Baseline observations - signs of haemodynamic instability
Which blood tests should be done to manage a miscarriage?
Group n Save - don’t have physiological increase in blood volume yet so may lost lots!
B-hCG if ectopic suspected
What imaging should be done to investigate miscarriage?
TVS or TAS
What is the conservative management of a miscarriage? (7)
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
What is the medical management of miscarriage?
Misoprostol PV/PO
Prostaglandin analogue to cause cervical ripening and myometrial contractions
Use if HAEMODYNAMICALLY STABLE
What is the surgical management of a miscarriage?
Manual vacuum aspiration if <12 weeks
Evacuation under local/GA if >12 weeks
Do if HAEMODYNAMICALLY UNSTABLE
When should anti-D be given when treating a miscarriage?
All rhesus-negative women who have a surgical procedure to manage an ectopic pregnancy or a miscarriage.
Define hyperemesis gravidarum
Persistent vomiting in pregnancy leading to weight loses that is more than 5% of pre-pregnancy weight and ketosis
What is the pathophysiology of hyperemesis?
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
What are the risk factors for hyperemesis?
FHx/Hx
Molar pregnancy
Multiple pregnancy
First pregnancy
Hx of eating disorder
Why is USS offered at 8-9 weeks if presenting with hyperemesis?
Molar pregnancy / multiple pregnancy has increased risk of HG so offered to exclude
What are the symptoms of HG?
Vomiting - can’t keep food or fluids down
Spitting/unable to swallow saliva
Weight loss
What are the signs of HG?
Nutritional deficiencies e.g. reduced B vitamins leading to growth restriction
Signs of dehydration: low BP, tachycardia, hypokalaemia and hyponatraemia
Ketosis!
What are the bedside investigations for HG?
Urinalysis - +++ ketones and UTI exclusion
Baseline obs for dehydration
What are the blood tests to investigate HG?
U&E - electrolyte disturbance
BM - Exclude DKA if diabetic
TFTs if showing symptoms of hyperthyroidism
What imaging should be done to investigate HG?
USS @ 8-9 weeks to exclude molar pregnancy or to diagnose multiple pregnancy
What is the conservative management of HG?
Primary care - eat ginger [biscuits] and psychological support
Admit if:
Can’t keep anything down + ketonuria + co-morbidities
What is the conservative management of HG in secondary care?
Rehydrate and correct electrolyte imbalances
Don’t give glucose as can precipitate Wernicke’s
TED stockings due to VTE risk
What is the medical management of HG? (4)
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
What is the surgical management of HG?
In very, VERY extreme cases and as a very, VERY last resort, can offer TOP
What are the complications of HG?
GI - GORD and Mallory-Weiss Tear
Endocrine - Hyperemesis induced hyperthyroidism
Nutritional Deficiencies - Polyneuritis (B12)
VTE - Hypercoaguable in pregnancy + dehydration
Describe decidualisation
Implantation leads to thickening and structural changes of the endometrium
Leads to formation of the decidua
What is the funcitonof the decidua?
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
What are the 3 parts of the decidua?
Basalis - maternal portion
Capsularis - grows over blastocyst after implantation
Parietals - lines pregnant uterus everywhere but implantation site
What is implantation?
Development of the placenta
Embryonic = trophoblast
Maternal = decidua basalis
What occurs during early placental development?
Pre-lacunar = until day 9
Lacunar = day 9-12. lacunae form in synctiotrophoblast which then fill with maternal blood
early villous = day 12-28
Where do primary, secondary and tertiary villi develop from?
Primary: inner = cytotrophoblast, outer = syncytiotrophoblast
Secondary = same as primary but with a mesenchymal core
Tertiary = foetal capillaries in mesenchymal core and vascularised
When does the placenta fully establish?
month 4?
What is the function of the placenta?
Hormone production
Gas and nutrient exchange
What is gestational trophoblastic disease?
Abnormal or overgrowth of all or part of the placenta causing a molar pregnancy/hydatidiform mole
What is the pathophysiology behind GTD?
Overgrowth of trophoblast cells that produce hCG
Pre-malignant - partial and complete molar
Malignant - invasive moles, choriocarcinoma and placental site trophoblastic tumours
What is a hydatidiform mole?
Commonest trophoblastic disease
Benign overgrowth
What is a partial mole?
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
What is a complete mole?
Whole placenta is abnormal and rapidly proliferating
No foetus developing
One sperm in egg but half set of chromosomes
Bigger risk of malignancy
What is an invasive mole?
Malignant
Molar tissue invades myometrium - uterine mass and raised hCG
May rupture utures
What is a choriocarcinoma?
V rare and v malignant cancer
Can arise from a molar pregnancy or an otherwise normal pregnancy
How does choriocarcinoma present?
PV bleeding
Really raised hCG
Mets?
V sensitive to chemo
What are the risk factors for molar pregnancy?
Complete = age. more common in teenage women and post menopausal
History
Ovulatory disorders
Low in vit a diet
Define recurrent miscarriage
The loss of 3 or more consecutive pregnancies.
What are the causes of recurrent miscarriage?
Maternal - uterine structural anomalies (e.g. septate uterus, fibroids), cervical incompetence, PCOS, antiphospholipid/thrombophilia, increased maternal age
Foetal - chromosomal abnormalities
