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Y5 Gynae & Obstetrics > Implantation and Early Pregnancy > Flashcards

Implantation and Early Pregnancy Flashcards

1
Q

What is the main hormone produced by the corpus luteum after ovulation?

A

PROGESTERONE

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2
Q

What is the function of progesterone?

A

Prepare the endometrium to support the pregnancy

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3
Q

When does the blastocyst implant in the endometrium?

A

7-11 days post fertilisation

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4
Q

What is the blastocyst made up of?

A

Inner cell mass > foetus

Trophoblast > placenta

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5
Q

What does the trophoblast secrete?

A

hCG

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6
Q

What is the function of hCG?

A

To maintain the corpus luteum, thereby continuing progesterone secretion

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7
Q

How long does the corpus luteum maintain the pregnancy for?

A

Up to 8-9 weeks

Then the placenta takes ov r

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8
Q

When does a urine pregnancy test first detect prgegnancy?

A

1-2 days before the expected date of menstruation

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9
Q

When does a TVUSS first detect pregnancy=?

A

at 5 weeks

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10
Q

When is the foetal heartbeat first visible on USS?

A

6 weeks

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11
Q

When is gestational age calculated from?

A

From the last menstrual period (LMP)

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12
Q

How fast do serum hCG concentration increase in pregnancy?

A

DOUBLE every 48h

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13
Q

When does hCG peak in pregnancy?

A

at 9 weeks

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14
Q

What happens to hormonal sercretion when the placenta takes over at 9 weeks?

A

Synctitiotrophoblasts produce

  • progestogen
  • estriol
  • hCG
  • Human placental lactogen
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15
Q

What is the purpose of Human placental lactogen?

A

To counter the effect of maternal insulin, ensuring sufficient glucose

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16
Q

What is a miscarriage?

A

Pregnancy that ends spontaneously before 24 week gestation

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17
Q

What is the clinical presentation in a threatened miscarriage?

A

Vaginal bleeding and abdominal pain

Speculum: closed cervical os

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18
Q

What is the clinical presentation in an inevitable miscarriage?

A

Vaginal bleeding and abdominal pain

Speculum: open cervical os

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19
Q

What is the clinical presentation in an incomplete miscarriage?

A

vaginal bleeding and abdominal pain

Speculum: cervical os open, product of conception in cervical os

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20
Q

What is the clinical presentation in a complete miscarriage?

A

Empty uterus (need serum hCG to exclude extopic)
Pain and bleeding has resolved
Speculum: cervical os closed

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21
Q

What is the clinical presentation in a missed miscarriage?

A

Asymptomatic, often diagnosed at booking USS

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22
Q

What is the management for a threatened miscarriage?

A

If confirmed intrauterine pregnancy with foetal heartbeat

Tell woman to return for assessment if bleeding gets worse/persists beyond 14 days

Continue routine antenatal care if bleeding stops

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23
Q

How can you manage miscarriage=

A

Expectant
Medical
Surgical

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24
Q

What is first line treatment for confirmed miscarriage?

A

EXPECTANT

Tell woman bleeding should stop in 7-14 days
Then take a pregnancy test after 3 weeks, should be negative

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25
Q

What is medical management for a miscarriage?

A

Vaginal / PO misoprostol

+ pain relief / anti emetics

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26
Q

What are symptoms of a medical management of miscarriage?

A

Vaginal bleeding, pain, diarrhoea, vomiting

27
Q

When should a lady take a pregnancy test after miscarriage?

A

3 weeks

28
Q

What is surgical management of miscarriage?

A

Manual vacuum aspiration OR surgical evacuation in theatre

29
Q

What medications must you give for surgical management of miscarriage?

A
  • MISOPROSTOL (to ripen cervix)

- ANTI-D PROPHYLAXIS (to all RhD- women)

30
Q

What is a recurrent miscarriage?

A

Loss of 3+ consecutive pregnancies

31
Q

How many couples are affected by recurrent miscarriage?

A

1%

32
Q

What are risk factors for recurrent miscarriage=

A

Advancing age
obesity
Uterine structural abnormalities
antiphospholipid syndorme

33
Q

How do you screen for APS?

A

Lupus anticoagulant

Anti-cardiolipin antibodies

34
Q

What is management of APS?

A

Low dose ASPIRIN + LMWH

35
Q

What is an ectopic pregnancy?

A

Implantation of a pregnancy outside the womb

36
Q

What are locations for an ectopic pregnancy=

A 
Fallopian tube (98%)
Rarer sites: ovary, cervix, abdominal cavity, C section scar
37
Q

What is a heterotopic pregnancy ?

A

Simultaneous development of 2 pregnancies, 1 within and one outside the uterus

38
Q

What are RF for ectopic pregnancy

A

Prior ectopic
Prior abdo surgery
Fallopian tube damage
- PID, prior ectopic, prior tubal surgery
Functional alterations to Fallopian tube
- Smoking
- Advanced maternal age
Sufertility
Endometriosis
IUD, conception on OCP/morning after pill
IVF

39
Q

What is the clinical presentation of an ectopic?

A

Abdominal pain and / or vaginal bleeding in early pregnancy

40
Q

How does a rupture of an ectopic pregnancy present?

A

MASSIVE INTRAPERITONEAL BLEEDING

  • massive abdominal pain (ACUTE ABDOMEN)
  • Hypovolaemic shock
  • shoulder tip pain (due to Diaphragmatic irritation)
  • Dysuria, diarrhoea (due to impingement of other organs)
41
Q

what is hCG like in ectopic pregnancy=

A

LOW, increases slightly but does not double every 24h

So taking 2 separate hCG measurements 48h apart will show this

42
Q

How do you manage ectopic pregnancy?

A

EXPECTANT
MEDICAL
SURGICAL

43
Q

Who is expectant management of an ectopic appropriate for?

A

Some ectopics resolve without treatment
Suitable if patient is haemodynamicaly stable, asymptomatic, pain free, ectopic <35mm, no visible heartbeat, hCG <1500IU/L

44
Q

What is expectant management of ectopic?

A

serial hCG measurements

45
Q

What is medical management of ectopic’

A

Methotrexate IM

46
Q

What are criteria for methotrexate in ectopic management

A

No significant pain
Unruptured ectopic with adnexal mass <35 mm and no visible heartbeat
no intrauterine pregnancy
Serum b hCG <1500 iU/L

47
Q

What are criteria for surgery in ectopic?

A

Significant pain
adnexal mass >35 mm and visible heartbeat
Serum b hCG >5000 iU/L

48
Q

What kinds of surgery are used for ectopic?

A

Salpingectomy

Salpingostomy (creating an opening in FT)

49
Q

How do you follow up a salpingectomy?

A

urine hCG at 3 weeks

50
Q

How do you follow up a salpingostomy?

A

1 serum hCG every week until negative result

51
Q

When do you offer choice between methotrexate and surgery?

A

If beta hCG is between 1500-5000
and no significant pain
Unruptured ectopic with adnexal mass <35 mm and no visible heartbeat
No intrauterine pregnancy

52
Q

How do you investigate an ectopic?

A 
ABCDE
Abdominal and pelvic exam 
Vaginal (bimanual + speculum) 
Urine hCG
Bloods - Serum hCG, Hb, G&S (or XM if urgent)
TVUSS
53
Q

Why do you need to do both urine and serum bhCG?

A

urine hCG is rapid and immediately tells you if she is pregnant

serum hCG gives precise level and allows you to track it rise/drop in hCG

54
Q

What commonly happens in 40% of ectopics at first presentation? How do you investigate them?

A

40% of ectopics are pregnancy of unknown location

Shows an empty uterus with no evidence of an adnexal mass + positive pregnancy test

Investigate with consecutive measurements of serum hCG

55
Q

What must you do about RhD in ectopic pregnancy?

A

Offer 250iU of anti-D Ig to all RhD negative women who have surgical management of ectopic

DO NOT do Keihauer

56
Q

When is there no need to offer anti-D prophylactic with ectopic / miscarriage?

A

Solely medical management of ectopic
Threatened / complete miscarriage
Pregnancy of unknown origin

57
Q

What are symptoms of a molar pregnancy?

A 
Light PV bleed 
May be asymptomatic 
Large for date uterus 
Hyperemesis (due to large placenta releasing hCG) 
Hyperthyroidism (due to high hCG) 
Anaemia
58
Q

What are the types of gestational trophoblastic disease (molar pregnancy)

A
  • Partial mole: ovum fertilised by 2 sperm > 69 chr
  • Complete mole: ovum has no chromosomes, so sperm chromosomes double
  • Choriocarcinoma
  • Invasive mole
59
Q

What is a choriocarcinoma

A

Malignancy of trophoblastic cells, which can co-exist with molar pregnancy

60
Q

Where does a choriocarcinoma metastasise to’

A

To the lungs

Haematogeneously

61
Q

What are Ix for Gestational Trophoblastic Disease?

A
  • urine beta hCG
  • serum hCG
  • TVUSS
62
Q

What is Gestational Trophoblastic Disease like on USS?

A

Snowstorm appearance

63
Q

How do you manage Gestational Trophoblastic Disease

A

Evacation of POC (partial curettage) + histology

Monitor hCG > give chemo if it does not fall

Y5 Gynae & Obstetrics (34 decks)

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