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Early Pregnancy > Miscarriage and ectopic pregnancy > Flashcards

Miscarriage and ectopic pregnancy Flashcards

1
Q

When should you be able to see a FHB?

A
  • TVUSS at 6 weeks gestation
  • MSD >18 mm
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2
Q

When should a yolk sac be seen?

A

When MSD >7 mm

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3
Q

When should a fetal pole be seen?

A
  • 6 weeks on TVUS
  • MSD >= 16 mm on TVUS
  • MSD >=25 mm on TAUS
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4
Q

What is a discriminatory zone and define cut offs for TA and TVUSS

A
  • BhCG level at which a gestational sac of a viable pregnancy should be seen.
  • TVUSS: BhCG >2000
  • TAUSS: BhCG <6000
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5
Q

At what gestation does BhCG levels usually peak?

A

12 weeks

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6
Q

What 48 hour BhCG rise pattern indicates an intrauterine pregnancy is likely developing?

A

An increase in BhCG >63% after 48 hours.

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7
Q

Regarding misoprostol:

What is a common dose?

What is its mode of action?

What are its indications for use in O&G?

What are the contraindications to its use?

A
  • Dose: 600 mcg PO/SL/PV, repeat in 3 hours
  • Mode of action: synthetic prostaglandin E1 analogue that causes uterine contractions and cervical softening and dilatation.
  • Indications: miscarriage medical management, medical TOP, IOL for IUD, PPH management.
  • Contraindications: adrenal insufficiency, long term glucocorticoid therapy, haemoglobinopathies, anticoagulation therapy, porphyria, mitral stenosis, glaucoma, allergy to misoprostol/PGs, breastfeeding.
  • Do not give if heavy bleeding already, anaemia or unable to have blood transfusion.
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8
Q

Regarding mifepristone:

What is a common dose?

What is its mode of action?

What are its indications for use in O&G?

What are the contraindications to its use?

A
  • Dose: 200 mg po stat 24-48 hours prior to misoprostol .
  • Mode of action: anti-progesterone. Sensitises myometrium to misoprostol actions. In first trimester also softens and dilates cervix.
  • Indications: medical TOP up to 9 weeks, prior to surgical TOP <12 weeks, priming of misoprostol for TOP after 12 weeks, IOL for IUD.
  • Contraindications: adrenal insufficiency, severe uncontrolled asthma, porphyria, allergy to mifepristone, breastfeeding.
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9
Q

What is the success rate of medical management of miscarriage as per the Landmark trial by Zhang et al. 2005?

A

84%

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10
Q

What is the success rate of surgical management of miscarriage as per the Landmark trial by Zhang et al. 2005?

A

97%

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11
Q

What is the sucess rate for expectant management of a symptomatic woman with miscarriage?

What is the success rate for expectatnt management of an asymptomatic woman with missed miscarriage or anembryonic pregnancy?

A
  • Success rate for symptomatic miscarriage: 80%
  • Success rate for asymptomatic missed miscarriage or anembryonic pregnancy: 30-70%
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12
Q

What is the incidence of ectopic pregnancy?

A

11 per 1000 pregnancies

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13
Q

What is the maternal mortality rate associated with ectopic pregnancy?

A

0.2 per 1000

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14
Q

What are the risk factors for an ectopic pregnancy?

A
  • Previous ectopic
  • Smoking
  • PID and STIs
  • Contraception:
    • Copper IUD
    • Progesterone: POP, Mirena
  • Tubal: previous tubal surgery, ligation
  • IVF
  • Increasing maternal age
  • In-utero exposure to DES / DES daughter
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15
Q

What are the possible anatomical locations of an ectopic pregnancy and their respective frequency of occurence (%)?

A
  • Tubal 96%: ampullary > isthmic > fimbrial.
  • Caesarean section scar ectopic 6%
  • Ovarian 3%
  • Interstitial and cornual 2%
  • Cervical ?%
  • Abdominal 1%
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16
Q

What ultrasonographic findings are consistent with an ectopic pregnancy?

A

No evidence of IUP on TVUS and any of the following:

  • Extra-ovarian adnexal mass: complex heterogenous +/- gestational sac +/- FHB seen.
    • Bagel sign: echogenic ring/adnexal mass with empty GS.
  • Free fluid in pelvis
17
Q

What is the criteria for expectant management of an ectopic pregnancy?

Outline an appropriate follow-up plan.

A

Criteria for expectant management:

  • No pain
  • Haemodynamically stable
  • Ectopic size <35 mm, no FHB seen
  • BhCG <1500
  • Access to phone and emergency transport; does not live remotely.
  • Will be compliant with follow-up plan and return advice.

Follow-up plan:

  • Serial BhCG levels day 2, 4, 7
  • If BhCG level drops by 15% or more from previous value, then proceed to weekly BhCG levels until negative <20.
  • If BhCG level does not drop by 15%; plateaus or rises, organise review.
18
Q

What is the criteria for medical management of an ectopic pregnancy?

A

Criteria for medical management:

  • No pain
  • Haemodynamically stable
  • BhCG between 1500 - 5000
  • Ectopic size <35 mm with no FHB
  • IUP excluded
  • No contraindications to methotrexate
  • Access to phone and emergency transport; does not live remotely
  • Will be compliant with follow-up and return advice.
19
Q

Regarding methotrexate for medical management of an ectopic pregnancy:

What is its mode of action?

How is it dosed?

What are common side-effects?

What are contraindications for its use?

A
  • Mode of action: folic acid antagonist.
    • It inhibits DNA synthesis and cell replication primarily in rapidly dividing cells e.g. trophoblasts, fetal but also bowel, liver etc.
  • Dosing: by body surface area. Administered IM.
  • Common side-effects: usually mild and self-limiting.
    • Stomatitis
    • GI upset
    • Transient mild liver derangement
  • Less common side-effects:
    • Bone marrow suppression and pancytopaenia
    • Pulmomary fibrosis
    • Pneumonitis
    • Liver cirrhosis
    • Renal failure
    • Gastric ulceration
  • Contraindications:
    • Liver disease/dysfunction
    • Renal disease/dysfunction
    • Immunosuppression
    • Bone marrow suppression
    • Breastfeeding
    • Allergy to MTX.
20
Q

Regarding methotrexate for medical management of an ectopic pregnancy:

Outline a follow-up plan.

A
  • Day 1:
    • Baseline FBC, LFTs and renal function tests normal
    • Baseline BhCG level
    • Administration of MTX.
  • Day 4: BhCG level
  • Day 7:
    • FBC, LFTs and renal function tests
    • BhCG level:
      • If fall between day 4 and day 7 >=15%, continue to weekly BhCGs.
      • If fall between day 4 and day 7 <15%, administer second dose of MTX if no contraindications.
  • Day 14:
    • BhCG level: if fall between day 7 and 14 >=15%, continue weekly BhCgs until negative.
      • If BhCG level is rising, a TVUSS should be performed.
21
Q

How long would you advise a woman not to conceive after receiving methotrexate?

A

Three months

22
Q

What is the criteria for surgical management of an ectopic pregnancy?

A

Criteria for surgical management:

  • Pain
  • Haemodynamically unstable
  • Evidence of significant free fluid in pelvis
  • BhCG level >=5000
  • Ectopic size >35 mm and/or FHB seen.
23
Q

Regarding surgical management for an ectopic pregnancy:

What are the indications for a salpingectomy?

What are the indications for a salpingostomy?

What are the advantages and disadvantages of each?

A
  • Salpingectomy indications:
    • Tube ruptured/damaged
    • Bleeding uncontrolled
    • Ectopic too large to remove with salpingostomy (>3 cm)
  • Salpingostomy indications:
    • Damaged or removed contralateral tube and wanting to preserve fertility.
  • Advantages of salpingectomy:
    • Definitive management
    • Controls bleeding
    • Lower rate of recurrent ectopic
  • Disadvatages of salpingectomy:
    • Lower rate of spontaneous intrauterine pregnancy
  • Advantages of salpingostomy:
    • Higher rate of spontaneous intrauterine pregnancy
  • Disadvatages of salpingostomy:
    • 1 in 5 need further management: MTX or salpingectomy due to persistent trophoblast. Risk of rupture.
    • Higher rate of recurrent ectopic pregnancy
24
Q

What is the incidence of Caesarean section scar ectopic?

A

1:2000

25
Q

What ultrasound features might you see with a Caesarean section scar ectopic?

A
  • Enlarged hysterotomy scar with embedded mass
    • May bulge beyond anterior contour of the uterus.
  • Mass located in:
    • Lower half of uterus with vascularity or FHB seen.
    • No fetal parts in uterine cavity.
    • Absence of myometrium between sac and bladder or sac between bladder and anterior uterine wall.
26
Q

There is a lack of evidence recommending optimal treatment of a Caesarean section scar ectopic.

What options are available for management?

A
  • Surgical:
    • Evacuation of uterus +/- adjuncts (cervical cerclage, Foley catheter balloon tamponade, uterine artery embolisation)
    • Hysteroscopic resection
    • Laparoscopic or open wedge resection +/- hysterectomy.
  • Medical:
    • Methotrexate: direct or indirect, single or multiple treatment
    • KCl if FHB seen.
  • Conservative
27
Q

What are the risks with conservatively managing a Caesarean section scar ectopic?

A
  • Haemorrhage
  • Uterine rupture
  • Hysterectomy
  • Progresses to placenta accreta spectrum
28
Q

What is the definition of an interstitial ectopic pregnancy?

Why can they be misdiagnosed as an intrauterine pregnancy>

What clue might there be on ultrasound that this is an interstitial ectopic pregnancy?

A

A pregnancy embedded within the proximal/interstitial portion of the Fallopian tube which is within the muscular wall of the uterus.

These are partially implanted in endometrium and can be misdiagnosed as intrauterine.

Interstitial ectopic pregnancies are eccentrically located with a thin (<5 mm) myometrial mantle. (Interstitial line sign).

28
Q
A
29
Q

Describe the surgical management of an interstitial ectopic pregnancy

A
  • Laparotomy if ruptured/unstable or laparoscopic approach.
  • Adjuncts to reduce bleeding:
    • Vasopressin injection into myometrium.
    • Ligation of ascending branch of the uterine artery.
  • Wedge resection:
    • V-shaped excision of pregnancy
    • Reapproximate myometrium with figure of 8 sutures.
    • Same-side salpingectomy
    • Suture round ligament to cornu and uterine serosa with interrupted sutures.
    • Close broad ligament with continuous locking suture.
30
Q

Define cornual ectopic pregnancy.

What is the incidence of a cornual ectopic pregnancy?

A

Cornual ectopic pregnancy: pregnancy located within the rudimentary horn of a unicornuate uterus.

Incidence: 1 in 76,000 (rarest type of ectopic).

31
Q
A
31
Q

What is the surgical management of a cornual ectopic pregnancy?

A

Open or laparoscopic resection of rudimentary horn

32
Q

What are the management options for a heterotropic pregnancy?

A
  • Conservative: if non-viable and woman stable.
  • Medical management: if woman stable.
    • Methotrexate: if intra-uterine pregnancy non-viable or woman does not want to continue pregnancy.
    • Intra-sac KCl or hyperosmolar glucose with aspiration of sac contents.
  • Surgical management: salpingectomy.
33
Q

Define cervical ectopic pregnancy.

What is the incidence of cervical ectopic pregnancy?

A

Ectopic pregnancy located below the internal cervical os.

Incidence 1 in 9,000 pregnancies.

1% of all ectopic pregnancies.

34
Q

Describe the clinical findings associated with a cervical ectopic pregnancy

A
  • Profuse, painless vaginal bleeding.
  • Bulging, hyperaemic cervix +/- products of conception at the os.
35
Q

What ultrasonographic features are associated with a cervical ectopic pregnancy?

A
  • Absence of an intrauterine pregnancy with visualisation of an endometrial stripe.
  • Sac or placenta below the level of the internal cervical os with cardiac activity or blood flow around the sac.
  • Hour-glass shaped uterus with ballooned cervical canal.
36
Q

What prognostic feature is associated medical management failure of a cervical ectopic pregnancy?

A

BhCG >10,000

37
Q

There is a lack of evidence to support an optimal management approach to cervical ectopic pregnancies.

Outline the management options available.

A
  • Medical management: methotrexate (multidose) +/- KCl intra-sac if FHB present.
  • Surgical management: high rate of failure but indicated if unstable or bleeding.
    • Hysterectomy: if fertility not desired.
    • D&C with adjuncts (intracervical vasopressin injection, transvaginal ligation of cervicovaginal branches of the uterine artery, uterine artery embolisation, Foley catheter or Cook’s balloon).

Early Pregnancy (3 decks)

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