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Gynae > Miscarriage and early pregnancy > Flashcards

Miscarriage and early pregnancy Flashcards

1
Q

Causes of bleeding in early pregnancy

A

Miscarriage
Molar pregnancy
Ectopic
Polyps
Vaginitis
Trauma
Cervical ectropion

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2
Q

Woman comes in with bleeding in early pregnancy what is management

A

If has
- abdo pain/tenderness
- pelvic pain or tenderness
- cervical motion tendernss
REFER immediately to early pregnany unit
Over 6 weeks pregnant then REFER
Under 6 weeks with no RFx for ectopic, pain or tenderness then repeat pregnancy test in a week and return if postive, negative or bleeding continues

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3
Q

What investigations will be done in early pregnancy unit for suspected miscarriage

A

Transvaginal USS
If it can’t be located can consider
- more TVUSS
- serial bHCG
- laparascopy if suspect ectopic

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4
Q

What do if location of a pregnancy can’t be found but suspect ectopic

A

Laparoscopy

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5
Q

What is first line for miscarriage

A

Expectant management UNLESS
- has infection
- coagulopathy or won’t have transfusion
- end of first trimester
- previous traumatic experience with a pregnancy

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6
Q

What is it when have vaginal bleeding early in pregnancy but fetal heart beat found

A

Threatened miscarriage

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7
Q

What does expectant management of miscarriage involve

A

Analgesia
Safety net about when to return
- if bleeding stops then do a pregnancy test in 3 weeks and return if positive
- if bleeding worse or persisting after 14 weeks then do a repeat scan and probable medical management

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8
Q

When do medical management of miscarriage

A

Expectant management not appropriate or 14 days of expectant did not work

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9
Q

What does medical management of miscarriage involve

A

Oral or vaginal misoprostol
Do pregnancy test in 3 weeks and return if positive

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10
Q

When would consider surgical management of miscarriage

A

Medical management did not expel products of conception
Option after expectant management did not work

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11
Q

What does surgical option for miscarriage involve

A

Either manual vacuum aspiration under LA
Surgical under GA
Given anti-d IG if rhesus negative unless complete or threatened miscarriage

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12
Q

What is difference between early and late miscarriage

A

Early- before 13 weeks
Late- 13-24 weeks

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13
Q

What are the different types of miscarriage

A

Complete- all products of conception have been expelled
Incomplete- bleeding has begiu but products of conception still there
Missed- when baby has died and evident in uterus with closed OS
Threatened- bleeding has begun but is still a viable pregnancy
Inevitable- heavy bleeding and clots with an open cervical os

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14
Q

What defines recurrent miscarriage

A

3 consecutive before 24 weeks gestation

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15
Q

How to follow-up someone who has had miscarriage

A

Can have sex when symptoms stop
Assess if want to get pregnant
- can get pregnant in 6 weeks
- if doesnt want to then offer contraception
Assess psychological side
Check anti-d IG was given

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16
Q

When offer referral for investigations for recurrent miscarriage

A

3 miscarriages before 10 weeks gestation
1 miscarriage after 10 weeks

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17
Q

What investigations are done for recurrent miscarriages

A

Anti-phospholipid antibodies
TVUSS to assess for structural problems
Genetic testing of both partners
Investigate foetal tissue if possible

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18
Q

If someone has known anti-phospholipid how treat during pregnancy

A

Low dose aspirin and LMWH as soon as becomes pregnant

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19
Q

How does misoprostol work

A

Prostaglandin analogue which causes contraction of myometrium

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20
Q

What happens to cervical os in different types

A

Complete- closed
Threatened- closed
Incomplete- open
Missed- closed
Inevtiable- open

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21
Q

What is hyperemesis gravidarum

A

Describes severe symptoms of nausea and vomiting of pregnancy

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22
Q

Rfx for nausea and vomiting of pregnancy

A

Multiple pregnancies
Trophoblastic disease
Nulliparity
Obesity
Fhx

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23
Q

How is nausea and vomiting of pregnancy diagnosed

A

If onset in first trimester of pregnancy and other causes of N&V excluded

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24
Q

What differs hyperemsis gravidarum from NVP

A

Severe vomting associated with all of
- dehydration
- electrolye imbalances
- 5% weight loss from pre pregnancy weight

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25
Q

How is severity of nausea and vomiting of pregnancy diagnosed

A

Pregnancy unique quantification of emesis

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26
Q

When does hyperemesis gravidarum typically come on and what is progression

A

Starts between 4-7th week
Peaks at 9th and finishes by 20th

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27
Q

What differentials should be excluded for NVP

A

Peptic ulcers
Hepatitis
Pancreatitis
Genitourinary conditions
Metabolic
Neuro
Drug induced

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28
Q

What should be done if severe abdo pain and vomiting or epigastric pain in pregnancy

A

Amylase levels
USS
OGD maybe
H pylori antibodies

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29
Q

Management of NVP in community

A

Assess if need for admission
If not able to tolerate oral fluids or anti-emetics then refer to ambulatory care
First line anti-emetics- H1 antihistamines or phenothiazines
Second line anti-emetics- ondensatron or metoclopramide
Recommend ginger and oral hydration

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30
Q

First line anti-emetics for NVP

A

Anti-histamines- cyclizine or promethazine
Phenothiazines- propchlorperazine or chlorpromazine

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31
Q

Second line anti-emetics for NVP

A

Ondensatron
Metoclopramide (do not use for over 5 days)

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32
Q

Problems of phenothiazines and metoclopramide as NVP

A

Extrapyramidal SEs in which case cessate immediately

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33
Q

Problem with ondensatron for NVP

A

In first trimester associated with cleft palate

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34
Q

Complications for NVP

A

Dehydration
Electrolye imbalances
Weight loss
Wernickes
AKI
Oesophagitis
Mallory-weiss tear
Very few risks to baby unless dont catch up weight in which case can get LBW

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35
Q

When admit for NVP/HG

A

Not able to keep down liquids
Continued N&V leading to weight loss over 5% or ketonuria despite oral anti-emetics
Confirmed or suspected comorbidity like not being able to tolerate abx

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36
Q

What fluids are used for HG

A

Saline with potassium chloride

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37
Q

What are options once admit for HG

A

Fluids- saline with KCl
Parenteral feeding- dextrose and thiamine supplements
Anti-emetics deliverd subcut or rectal
Do USS if haven’t had dating scan to rule out gestational trophoblastic disease
LMWH for VTE risk

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38
Q

Causes of miscarriage

A

Foetal chromosomal abnormalities- most common
Poorly controlled DM, thyroid disease, uterine abnormalities
Smoking
Drugs

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39
Q

Causes of recurrent miscarriages

A

APL- most common
Poorly controlled DM, PCOS, thyroid problems
Uterine abnormalities
Parental chromsomal abnormalities
Smoking

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40
Q

Factors associated with miscarriages

A

Alcohol
Obesity
Maternal age
Drug use
Caffeine
Uncontrolled health conditions
Uterine or cervical incompetence

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41
Q

What are the different types of gestational trophoblastic disease

A

Complete hydatidiform mole
Partial hydatidiform mole
Choriocarcinoma

42
Q

What is pathophysiology of a complete hydatidiform mole

A

Where an empty egg is fertilised by a sperm which then duplicates its genetic material forming 46 chromosomes
All genetic material belongs to father

43
Q

What is pathophysiology of partial hydatidform mole

A

Occurs when normal egg fertilised by 2 sperm or 1 which then duplicates forming 69XXX or 69XXY

44
Q

Difference between complete and partial hydatidiform mole

A

Complete- 46 chromosomes all paternal
Partial- 69 chromosomes where 2/3 paternal
Complete no fetal parts seen unlike in partial

45
Q

Difference on USS between complete and partial hydatidiform mole

A

Complete you get snowstorm apperance where lots of hydropic villi so get central hyperechoic mass with interspersed cystic areas

46
Q

What is snowstorm appearance on USS associated with

A

Complete hydatidiform mole

47
Q

How can molar pregnancy present or be suspected

A

Very high bHCG
Bleeding in first 2 trimesters
Uterus very large for date
Exaggerated symptoms of pregnancy like NVP
HTN and hyperthyroidism present

48
Q

What conditions are associated with molar pregnancy during the pregnancy

A

HTN
Hyperthyroid
Hyperemesis gravidarum

49
Q

How does molar pregnancy cause HTN

A

bHCG can mimic TSH

50
Q

How are molar pregnancies diagnosed

A

On histology

51
Q

When is histological examination of pregnancy tissue in miscariage indicated

A

Post medical or surgical removal of miscarriage where no fetal parts were identified

52
Q

What are theca lutein cysts

A

Cysts in ovaries caused by excess bHCG from molar pregnancy and twins

53
Q

What is management of molar pregnancy

A

Referral to specialist centre
Suction curettage unless partial molar where fetal tissue too large
Anti-D prophylaxis

54
Q

What is gestational trophoblastic neoplasia

A

When after failure to treat molar pregnancy fully it may remain and invade tissue. Can also be caused by live birth or non-molar miscarriage

55
Q

When should GTN be suspected

A

Persistent bleeding after any pregnancy event- perform beta hcg 8 weeks after
2 medical treatments for miscarriage have not worked
bHCG not stabilising

56
Q

Management of GTN

A

Refer to GTD center
Chemotherapy

57
Q

What can GTN progress to

A

Choriocarcinoma
Epithelioid trophoblastic tumour
Placental trophoblastic tumour

58
Q

How are choriocarcinoma, epithelioid trophoblastic tumour and placental trophoblastic tumour all managed

A

At GTD centre
If localised- hysterectomy
If spread and metastatic then intense chemo

59
Q

How long after molar pregnancy should women wait to get pregnancy

A

1 year

60
Q

When can women have hormonal contraception following molar pregnancy

A

As soon as bHCG normalised

61
Q

What suspect if beta HCG not normalising after molar or any pregnancy

A

GTD or failure to remove it

62
Q

What is management of surgical abortion before 14 weeks

A

Sublingual misoprostol 1 hour before or oral misoprostol 3 hours before
Surgical suction
3 days doxycycline
If after 10 weeks anti-rhesus
LMWH post operation for 7 days

63
Q

What is surgical management of abortion after 14-19 weeks

A

Can give osmotic dilators or oral/ vaginal misoprostol
Surgical evacuation
3 days doxyclycine
Anti-D if rhesus negative
LMWH post op

64
Q

Extra management of abortion to consider

A

Anti-rhesus if post 10 weeks and rhesus neg
LMWH for 7 days and before if at high risk
Mental health
If surgical give doxycycline for 3 days

65
Q

What is medical management of abortion

A

Before 10 weeks
-mifepristone and then 2 days later vaginal misoprostol at HOME
After 10 weeks
- mifepristone and then 2 days later vaginal misoprostol IN CLINIC

66
Q

What is mifepristone

A

Anti-progestogen

67
Q

What is advice surrounding abortion without evidence of intra-uterine pregnancy

A

Safety net about risks of ectopic so follow-up

68
Q

What do if abortion at 23+6 weeks

A

Give feticide followed by surgical management

69
Q

What is a feticide

A

Feticide is the injection of digoxin or potassium chloride into the fetus, or an injection of digoxin into the amniotic cavity, to stop the fetal heart before an abortion

70
Q

What do if do not want medication for NVP

A

Ginger
Accupuncture at P6 on wrist

71
Q

Why do USS if admitted with HG

A

If have not had dating scan needed to rule out GTD

72
Q

How do threatened miscarriages present

A

Cycical abdo pain
Some brown discharge

73
Q

How does septic miscarriage present

A

Increasing pain
Fever
Bleeding

74
Q

What causes septic miscarriage

A

Typically it getting stuck in the cervical OS

75
Q

Management of septic miscarriage

A

Surgical evacuation

76
Q

Why do you get cysts in molar pregnancy

A

Excess HCG forms multiple theca lutein cysts

77
Q

What chemo is choriocarcinoma particularly responsive to

A

Methotrexate

78
Q

Antibodies in anti-phospholipid syndrome

A

Lupus anti-coagulant
Anti-cardiolipin
Anti-beta 2 microglobulin

79
Q

How is anti-phospholipid syndrome diagnosed

A

1 of lupus anticoagulant, anti-cardiolipin or anti-beta 2 microglobulin picked up twicw in blood 12 weeks apart

80
Q

Presentation of antiphospholipid syndrome

A

Venous or arterial thrombosis
Pregnancy problems
Nephropathy
Thrombocytopenia

81
Q

A 16-year-old girl attends accident and emergency complaining of mild vaginal spotting. Her serum beta hCG is 4016mIU/mL. She is complaining of severe left iliac fossa pain and stabbing sensations in her shoulder tip. Next investigation

A

TVUSS not laparoscopy

82
Q

Woman with twin pregnancy has really bad abdominal pain

A

Ruptured theca lutein cyst

83
Q

Prolonged bleeding in early pregnancy with bilaterally enlarged ovaries

A

Molar pregnancy with theca lutein cysts

84
Q

What is seen on ERCP of hydidatiorm mole

A

genetically abnormal placenta
mixture of large and small villi with scalloped outlines
trophoblastic hyperplasia

85
Q

What is it when foetus alive but cervical OS open

A

Inevitable miscarriage

86
Q

How are inevitable and incomplete miscarriage differentiated

A

Both have an open cervical OS
In incomplete they will have passed some foetal tissue but some will remain

87
Q

At what bHCG are intrauterine pregnancies normally seen

A

1000

88
Q

With which abortion method is the bleeding worse

A

Medical

89
Q

What happens if give mifepristone and misoprostol at the same time

A

More likely to fail
Bleeding will be delayed

90
Q

What are the sections of abortion act

A

2 doctors in good faith agree
A- continuing would risk life of pregnant woman
B- necessary to prevent grave risk to life of mother
C- pregnancy not exceeded 24 weeks and continuance would involve risk of injury to physical or mental health of mother
D- not exceedd 24 weeks and would involve risk to mental/physical health of existing children
E- born handicapped

91
Q

What abortion section most commonly used

A

Section C

92
Q

Differentiating missed from complete

A

In complete the uterus is empty but in missed the foetus is still in the uterus without a HB and a lack of significant bleeding

93
Q

What do if no intrauterine or tubal pregnancy found at dating scan

A

Take 2 bHCGs 48 hours apart and safety
If proper rise then do TVUSS in 7-14 days
If decrease then explain miscarriage and do pregnancy test in 14 days

94
Q

How to calculate EDD

A

First day of LMP
Add 1 year - 3 months+7 days

95
Q

GI symptoms, spotting and cervical motion tenderness. Ectopic pregnancy or PID?

A

Ectopic pregnancy as bowel symptoms are consistent with ectopic

96
Q

Surgical management of abortion after 19+0 weeks

A

Mifepristone 200mg and osmotic dilators day before
Surgical evacuation
Doxycycline for 3 days
LMWH 7 days
Anti-D if negative

97
Q

What is the gestational sac

A

Fluid surrounding the embryonic tissue

98
Q

What is a blighted ovum

A

A gestational sac without embryonal tissue inside

99
Q

How manage termination if unknown location

A

If any signs of ectopic then must do beta HcG measurements 48 hours apart and then USS to confirm
If no signs then can proceed however must safety net about ectopic

100
Q

Bleeding post termination differentials

A

Most likely- post abortion bleeding very normal especially medical
Rule out- retained products of conception and PID

101
Q

Management of bleeding post termination bleeding

A

If well do bloods to check if inflammatory response
If unwell A-E and TVUSS to look for retained products of conception

Gynae (11 decks)

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