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1. Senior Block- O&G > Infertility, TOP and Early Pregnancy Problems > Flashcards

Infertility, TOP and Early Pregnancy Problems Flashcards

1
Q

What is the definition of infertility?

A

A couple cannot conceive despite having regular (2/3 times a week) unprotected sex for a year. Affects 1 in 7 couples

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2
Q

What is primary infertility?

A

Someone who has not conceived in the past and is having difficulty to

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3
Q

What is secondary infertility?

A

Someone who has had 1 or more pregnancies but is now struggling to conceive

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4
Q

Give 4 risk factors for infertility

A

Age- fertility decreases after 30 years old
Weight- BMI >30 or <18
STIs
Smoking and passive smoking
Alcohol excess
Stress
Environmental factors- pesticides, solvants, metals

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5
Q

Give 5 potential causes for infertility in women

A 
PCOS
Premature ovarian failure
Thyroid problems 
Phx of pelvic surgery- adhesions 
Cervical mucus problems
Fibroids
Endometriosis
PID
Sterilisation- hard to reverse
Drugs- long term NSAIDs, chemotherapy, antipsychotics, spironolactone, illegal drugs (cocaine, marijuana)
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6
Q

Give 5 potential causes for infertility in a man

A 
Low sperm count 
Abnormal sperm shape
Testicular cancer
Undescended testis
Testicular injury 
Vasectomy
Ejaculation disorder, erectile dysfunction 
Hypogonadism
Drugs- sulfasalazine, anabolic steroids, chemotherapy, some herbal remedies, illegal drugs
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7
Q

How is infertility investigated in a woman?

A

Progesterone levels- check ovulation
Rubella status
Prolactin levels
Testosterone levels
Gonadotropin levels- FSH/LH on day 2 of cycle
Chlamydia swab
USS- look for fibroids, endometriosis + blocked fallopian tubes
Hysterosalpingogram- x-ray of uterus and fallopian tubes with dye inserted to check for blockages

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8
Q

How is infertility in a man investigated?

A

Semen analysis x2 3 months apart
If no sperm- FSH/LH/Testosterone/USS
Chlamydia test

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9
Q

How is infertility managed pharmacologically?

A 
Clomifene- encourages ovulation 
Tamoxifen- alternative to clomifene
Metformin 
Gonadotrophins
Gonadotropin-releasing hormone + dopamine agonists
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10
Q

How is infertility managed surgically?

A

Fallopian tube surgery
Laparoscopic surgery to treat fibroids, endometriosis, PCOS
Correct epididymal blockage
Surgical extraction of sperm.

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11
Q

What is intrauterine insemination (IUI)?

A

Sperm inserted into the womb via a fine blastic tube passed through the cervix

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12
Q

What is in vitro fertilisation (IVF)?

A

Eggs removed from ovaries and fertilised with sperm in a lab. Embryo then returned to woman’s womb to grow

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13
Q

What is an abortion?

A

The termination of a pregnancy by removal or expulsion of a fetus from the uterus. Can be done medically or surgically. Legal up to 24 weeks of pregnancy, unless fetal abnormality found or severe consequences for the mother

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14
Q

What things are covered in the pre-assessment for an abortion?

A 
Reasons for abortion 
Offer counselling 
Pregnancy test and ultrasound to confirm pregnancy
Test for STIs
Blood type 
Anaemia screen 
Antibiotics given to reduce risk of infection 
Sign consent form
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15
Q

Describe what happens in a medical abortion

A

Used at any time but better <7 weeks

Take the anti-progesterone Mifepristone in the hospital clinic. 24-48 hours later, Misoprostol is taken which is a prostaglandin. In 4-6 hours the womb lining breaks down and the pregnancy is lost.

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16
Q

Describe a vacuum/suction aspiration surgical abortion

A

Used up to 15 weeks

Tube inserted into the uterus and pregnancy removed via suction. Medication to relax the cervix is given beforehand.

Oral analgesia and local anaesthetic used

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17
Q

Describe a Dilation and evacuation (D+E) surgical abortion

A

Used after 15 weeks

Forceps inserted into the uterus to remove the pregnancy. The cervix is dilated for several hours before and it is done under general anaesthetic.

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18
Q

What advice is given to the patient after an abortion?

A

Symptoms:
May experience nausea and diarrhoea
GA side effects
Vaginal cramps and stomach cramps

Advice: 
Avoid tampons for 4 weeks 
Can take extra OTC analgesia
Counselling available 
Monitor symptoms
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19
Q

Give 5 potential complications of abortions

A 
Infection of uterus 
Failure of TOP (continuing pregnancy) 
Retained products of pregnancy
Excessive bleeding 
Damage to cervix
Damage to the uterus- perforation 
Psychological trauma
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20
Q

What is a spontaneous miscarriage?

A

Fetus dies or delivers dead before 24 weeks of pregnancy. Mainly occur before 12 weeks.

Happens to 15% of clinically recognised pregnancies

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21
Q

What is a threatened miscarriage?

A

Bleeding but fetus still alive. Uterus normal size and cervix closed

22
Q

What is an inevitable miscarriage?

A

Heavy bleeding, clots and pain. Fetus may be alive or dead. Cervical os open so not viable

23
Q

What is an incomplete miscarriage?

A

Some fetal tissue is passed, cervical os open

24
Q

What is a complete miscarriage?

A

All fetal tissue passed. Hx of bleeding, clots and pain. No products of conception seen in uterus on USS

25
Q

What is a septic miscarriage?

A

the products of conception are infected causing endometritis. Fevers, rigors, uterine tenderness, bleeding/discharge, pain. Need IV Abx and fluids

26
Q

What is a missed miscarriage?

A

Fetus has not developed or died in utero but no symptoms to indicate miscarriage. Uterus smaller than in should be and cervical os closed.

27
Q

Give 4 risk factors for miscarriage

A 
Maternal age >35
PMHx of miscarriage 
PHx of uterine surgery 
Antiphospholipid syndrome 
Obesity 
Smoking 
Coagulopathies 
Chromosomal abnormalities 
Uterine anomalies
28
Q

Give 3 clinical features of a miscarriage

A

Vaginal bleeding while pregnant
Cramping abdominal pain
Increased blood loss- dizzy, pale, SOB
Can be found incidentally on USS

29
Q

How is a suspected miscarriage investigated?

A

Sent to Early Pregnancy Assessment Unit

Transvaginal USS- will show viable fetus, retained products, non-viable pregnancy, ectopic pregnancy
Serum beta-HCG
Bloods- FBC, blood group, Rh status, triple swabs, CRP

30
Q

If a miscarriage is confirmed, how might it be managed conservatively? What are the positives and negatives of using this method?

A

Allow products of conception to pass naturally

\+ = can stay at home, no side effects, no surgical risk 
- = unpredictable timing, heavy bleeding and pain, can be unsuccessful
31
Q

If a miscarriage is confirmed, how might it be managed medically? What are the positives and negatives of using this method?

A

Use of vaginal Misoprostol to stimulate cervical ripening and myometrial contractions. Mifepristone taken 24 hours before

\+ = can do at home, avoid surgical risk 
- = side effects of medication (N+V), pain, heavy bleeding on passing POC, risk of needing surgery
32
Q

If a miscarriage is confirmed, how might it be managed surgically? What are the positives and negatives of using this method?

A

Manual vacuum aspiration (<12 weeks)- under LA
Evacuation of retained POC (ERPC)- under GA, suction tube placed into uterus to remove POC

+ = planned procedure, no symptoms of passing POC

  • = anaesthetic risk, uterine infection, uterine perforation, haemorrhage, Asherman’s syndrome, bowel or bladder damage
33
Q

What is the definition of recurrent miscarriages?

A

The occurrence of 3 or more consecutive pregnancies that end in miscarriage before 24 weeks gestation.

34
Q

Give 4 risk factors for recurrent miscarriage

A 
Advancing maternal age 
Paternal age >40
Previous miscarriages- risk of  further miscarriage increases after each one 
Maternal smoking
Heavy alcohol intake
35
Q

Give 5 potential causes of recurrent miscarriage

A

Antiphospholipid syndrome
Parental chromosomal rearrangements- Robertsonian translocation
Embryonic chromosomal abnormalities- Trisomy 21
Uncontrolled DM and thyroid disease
PCOS
Uterine malformations
Cervical weakness
Acquired uterine abnormalities- fibroids, adhesions
Bacterial vaginosis
Inherited thrombophilias

36
Q

How is recurrent miscarriage investigated?

A 
Antiphospholipid antibodies 
Inherited thrombophilia screen 
Cytogenetic analysis 
Parental peripheral blood karyotyping 
Pelvic USS
37
Q

Give 4 predisposing factors for Ectopic pregnancy

A 
Previous ectopic 
PID
Endometriosis 
IUD 
Progesterone contraception 
Pelvic surgery 
IVF
Advanced age 
Lower socioeconomic class
38
Q

What is the pathophysiology of an ectopic pregnancy?

A

Embryo implants outside the uterine cavity most commonly in the fallopian tube. The tube is unable to sustain trophoblastic invasion and so ruptures. Can lose lots of blood intraperitoneally

39
Q

Give 4 clinical features of ectopic pregnancy

A 
Lower abdominal/pelvic pain 
Dark, scanty vaginal bleeding 
Amenorrhoea
Syncope 
Shoulder tip pain
40
Q

How is ectopic pregnancy diagnosed?

A

Pregnancy test- urine Beta-HCG
Pelvic USS- visualise where pregnancy is implanted
Serum beta-HCG

If b-HCG >1500 with no pregnancy visualised= pregnancy of unknown location

If b-HCG <1500 with no pregnancy visualised= take test again in 48 hours. Viable pregnancy will double, miscarriage will half every 48 hours

41
Q

How is an ectopic pregnancy managed medically, who is it offered to and what are the positives and negatives to this?

A

IM Methotrexate given to cause miscarriage

Offered to women who are stable, well controlled pain, b-HCG<1500, unruptures, no fetal heartbeat

\+ = avoids surgery, no hospital stay 
- = side effects of methotrexate (abdo pain, hepatitis), treatment can fail
42
Q

How is an ectopic pregnancy managed surgically, who is it offered to and what are the positives and negatives to this?

A

Laparoscopic salpingectomy- remove fallopian tube and ectopic.
Salpingotomy- just removes pregnancy, maintain fertility

Offered to women with severe pain, serum b-HCG >5000, adnexal mass >34mm, fetal heartbeat present

\+ = high success rate, definitive treatment 
- = surgical and anaesthetic complications, can damage nearby structures
43
Q

How is an ectopic pregnancy managed conservatively, who is it offered to and what are the positives and negatives to this?

A

Watch and wait for the ectopic to resolve naturally. Take serum b-HCG every 48 hours

Offered to stable women, very low serum b-HCG, well controlled pain, small ectopic visualised on USS

\+ = avoid medical and surgical risks and side effects
- = method failure, ectopic rupture
44
Q

Give 4 risk factors for gestational trophoblastic disease

A 
Maternal age <20 or >35
Previous gestational trophoblastic disease
Previous miscarriage 
Use of oral contraceptive pill 
Asian women
45
Q

What is a partial molar pregnancy?

A

1 ovum with 23 chromosomes is fertilised by 2 sperm each with 23 chromosomes. Cell has a total of 69 chromosomes.

46
Q

What is a complete molar pregnancy?

Hydatidiform Mole

A

1 ovum with no chromosomes is fertilised by 1 sperm which duplicates. Leads to 46 chromosomes of paternal origin only.

The trophoblastic tissue proliferates aggressively and secretes excessive b-HCG. Benign tumours which can become malignant.

47
Q

What is a choriocarcinoma?

A

Malignancy of the intermediate trophoblasts which normally attach the placenta to the uterus. Presents 3 years after pregnancy

48
Q

Give 2 clinical features of gestational trophoblastic disease in early and late pregnancy

A

Early:
Vaginal bleeding
Abdominal pain

Late:
Hyperemesis
Hyperthyroidism
Anaemia

49
Q

When examining a woman with gestational trophoblastic disease, what do you expect the uterus to be like?

A

Larger than expected

Softer

50
Q

How is gestational trophoblastic disease investigated?

A

Urine + serum b-HCG
USS
Histology of POC after removal
MRI/CT if metastatic spread suspected

51
Q

How is a molar pregnancy managed?

A

Removal via suction curettage (ERPC)
Post evacuation anti-D prophylaxis if Rhesus neg.
Specialist management and long term follow up

1. Senior Block- O&G (11 decks)

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