Miscarriage, Ectopic Pregnancy, Molar Pregnancy, Hyperemesis Gravidarum Flashcards
What is typical appearance of molar pregnancy on USS?
snowstorm appearance
What is the marker for detecting pregnancy?
beta human chorionic gonadotrophin (beta HCG)
The beta HCG urine test can detect pregnancy as early as __ IU as it is highly sensitive.
20
Minimal bleeding is very common in early pregnancy and occurs in about 20%. List some causes of bleeding that aren’t abnormal pregnancy (ectopic, molar and miscarriage). (6)
implantation bleeding, sub-chorionic haematoma, cervical causes (infection, malignancy, polyp), vaginal causes (infection, malignancy), haematuria, PR bleeding
How do miscarriages present?
Positive urine pregnancy test with bleeding > cramping,
period type cramps
What investigations are done and why to determine if there is a miscarriage?
Ultrasound to identify pregnancy in-uterio, +/- fetal heartbeat, in process of expulsion or empty uterus,
Speculum to assess stage.
Outline the stages of miscarriage assessed by speculum exam.
Threatened - os closed - risk to pregnancy
Inevitable - os open and products sited
Complete miscarriage - os closed and products sited
If os products remain at cervix the patient may present with cervical shock. Outline presentation and treatment for this.
Presentation: cramps, n & v, sweating, fainting. Treatment: resolves when os products removed, resus with IVI, maybe uterotonics
List 7 causes of miscarriage.
chromosomal embryonic abnormality,
immune cause e.g. Antiphospholipid syndrome,
infections,
severe emotional distress,
iatrogenic loss e.g. chorionic villus sampling,
uncontrolled diabetes,
associated with heavy smoking, cocaine, alcohol misuse
List 4 infectious organisms that can cause miscarriage.
cytomegalovirus, rubella, toxoplasmosis, listeria
What is the pathophysiology of miscarriage?
Unclear but know that bleeding from placental bed or chorion causes hypoxia and villous/placental dysfunction and embryo breaks down
In early foetal demise or non continuing pregnancy (NCP) there is a pregnancy in-situ with no heartbeat. However to diagnose this the mean sac diameter and the fetal pole must both be greater than what?
Mean sac diameter >25mm and fetal pole >7mm
What is an anembryonic pregnancy?
sac is empty and no foetal poles seen
What investigations should be carried out after miscarriage? (5)
FBC, group & save, serum hCG, USS, histology
What is the management of miscarriage?
discharge if complete, if not need conservative, medical, MVA or surgical treatment, emotional support
What is the definition of recurrent miscarriage?
When 3 or more pregnancies are lost
What are 5 risk factors for recurrent miscarriage?
antiphospholipid syndrome, uterine abnormality (late first trimester loss), balanced translocation (rare), age, previous miscarriages
What is used to prevent miscarriage in viable IUP and APS?
use of low dose aspirin and daily fragmin injections
In what situation is progesterone pessary used to try and prevent recurrent miscarriage?
unexplained causes if >35 years and 2 or more losses
List 6 sites of ectopic pregnancy.
fallopian tube, ovary, peritoneum, liver, cervix, C-section scar
In which 4 parts of the fallopian tube may an ectopic pregnancy occur and which is most common?
interstitium, isthmus, ampulla (most common) or fimbriae
What are symptoms of ectopic pregnancy? (4)
pain > bleeding,
dizziness/collapse,
shoulder tip pain,
SOB
What are signs of ectopic pregnancy? (3)
pallor,
haemodynamic instability,
signs of peritonism, guarding & tenderness
What investigations are carried out when suspicious of ectopic pregnancy and what is gold standard test?
Bloods (FBC, G&s, betahCG), gold standard: transvaginal USS
What are findings in transvaginal USS that point towards ectopic pregnancy? (3)
empty uterus/pseudo sac,
+/- mass in adenexa,
free fluid in pouch of douglas
When is PUL (pregnancy of unknown location) diagnosed?
halfway diagnosis when no pregnancy is located on ultrasound
Why is serum hCG carried out 48hrs apart when investigating ectopic pregnancy?
to assess doubling, hCG normally doubles every 2 days in first few weeks of pregnancy
What are management options per presentation (acutely unwell, stable & unruptured ectopic, well patient) of ectopic pregnancy?
Surgical management if patient acutely unwell either laparoscopic salpingectomy/salpingectomy. Medical management if stable & unruptured ectopic which is 1/2 doses of methotrexate and conservative if well and will return for follow-up
How does a PUL present and how are they managed?
amenorrhoea and abdo pain with no evidence of pregnancy in common ectopic pregnancy sites but does have raised hCG. Managed conservatively or medically with methotrexate
What type of disease is molar pregnancy?
Gestational trophoblastic disease
What is the pathology of molar pregnancy?
outcome of a non-viable fertilised egg. There is an overgrowth of placental tissue with chorionic villi swollen with fluid - “grape like clusters”
There are two types of molar pregnancy: complete and partial. A partial mole has a 2.5% risk of developing into a choriocarcinoma. True/false?
False - a complete mole has this risk
What is a complete mole? (type of egg, fertilisation with sperm, foetus presence)
An egg without DNA, 1 or 2 sperms fertilise it resulting in diploid with only paternal DNA. There is no foetus but there is overgrowth of placental tissue
What is a partial mole? (type of egg, fertilisation with sperm, foetus presence)
A haploid egg, 1 sperm that reduplicates itself or 2 sperms fertilise egg making triploidy. May have foetus and do have overgrowth of placental tissue.
Classic presentation of molar pregnancy? (6)
hyperemesis,
hyperthyroidism,
early onset pre-ecclampsia,
varied bleeding +/- history of passage of grapelike tissue,
fundus > gestation dates on abdo palpation,
rarely SOB due to lung clot or seizures
USS can diagnose molar pregnancy. What is appearance of molar pregnancy on USS?
“snow-storm appearanc” +/- fetus, theca lutein cysts
What is management of molar pregnancy?
Surgical uterine evacuation and histology, need registration with molar pregnancy services
What is implantation bleeding? (what, when, presentation)
What: occurs when fertilised egg implants in uterine, When: about 10 days post-ovulation,
Presentation: bleeding is light/brownish and self limiting, can be mistaken as a period
What is chorionic haematoma and how does it present?
Pooling of blood between endometrium and embryo due to separation. Presents as bleeding, cramping and threatened miscarriage
What is prognosis of chorionic haematoma?
Usually self limiting but large haematomas may cause infection, irritability and miscarriage
How is bacterial vaginosis treated in pregnancy?
Metronidazole 400mg twice daily/7 days.
How is chlamydia treated during pregnancy?
erythromycin, amoxycillin and test of cure after 3 weeks
When is torsion of existing ovarian cyst most likely to occur in pregnancy?
At end of first trimester when uterus climbs out of the pelvis into abdomen
What are rhesus negative women more likely to suffer from?
miscarriage, ectopic pregnancy and molar pregnancy
When is anti-D advised in surgical management of abnormal pregnancies and why?
Anti-D is given to Rhesus negative woman undergoing surgical management. Anti-D neutralises the anti-D antigen and prevents sensitisation of the immune system from forming anti-D antibody. This prevents subsequent pregnancies ending with haemolytic disease of newborn
When is anti-D advised in surgical management of abnormal pregnancies and why?
Anti-D is given to Rhesus negative woman undergoing surgical management. Anti-D neutralises the anti-D antigen and prevents sensitisation of the immune system from forming anti-D antibody. This prevents subsequent pregnancies that could result with haemolytic disease of newborn
What is hyperemesis gravidarum & how can it present?
excessive vomiting in pregnancy that alters quality of life. Present as dehydration, ketosis, electrolyte and nutritional imbalance, weight loss, altered liver function (50% of people), can cause emotional instability
Hyperemesis Gravidarum is a diagnosis of exclusion. What are the principles of management?
rehydration with IV and electrolyte replacement, parenteral antiemetics, nutritional supplement and thiamine, NG feeding/TPN, steroids if severe, thromboprophylaxis
What are first and second line antiemetic medications for HG?
first line: cyclizine and prochlorperazine, second line: metoclopramide.
What are first and second line antiemetic medications for HG?
first line: cyclizine and prochlorperazine, second line: metoclopramide.
What are options for VTE prevention?
Thrombo-embolic deterrent stockings, hydration, mobility +/- fragmin injections
