O&G: Early Pregnancy Flashcards
Ectopic pregnancy
what is it
when a pregnancy is implanted outside the uterus
Ectopic pregnancy
where can an ectopic pregnancy implant
- fallopian tube (most common)
- cornual region (entrance to fallopian tube)
- ovary
- cervix
- abdomen
Ectopic pregnancy
RFs (6)
- Previous ectopic pregnancy
- Previous PID
- Previous surgery to the fallopian tubes
- Intrauterine devices (coils)
- Older age
- Smoking
Ectopic pregnancy
when does it typically present
around 6-8w gestation
Ectopic pregnancy
classic features (5)
- Missed period
- Constant lower abdominal pain in the right or left iliac fossa
- Vaginal bleeding
- Lower abdominal or pelvic tenderness
- Cervical motion tenderness (pain when moving the cervix during a bimanual examination)
Ectopic pregnancy
other features (2)
- dizziness or syncope (blood loss)
- shoulder tip pain (peritonitis)
Ectopic pregnancy
inx of choice for diagnosing a miscarriage
TVUS
Ectopic pregnancy
what may be seen in the fallopian tube on a TVUS
a gestational sac containing a yolk sac or fetal pole
Ectopic pregnancy
what is a ‘blob sign’ / bagel sign / tubal ring sign
TVUS: mass containing an empty gestational sac
Ectopic pregnancy
how to tell the difference between a tubal ectopic pregancy vs a corpus luteum on TVUS
the mass moves separately to the ovary if its an ectopic
the corpus luteum will move with the ovary
Ectopic pregnancy
US findings that may indicate an ectopic
- an empty uterus
- fluid in the uterus, which may be mistaken as a gestational sac (pseudogestational sac)
Ectopic pregnancy
what is a PUL
Pregnancy of Unknown Location
when the woman has a +ve pregnancy test and there is no evidence of pregnancy on the USS
Ectopic pregnancy
what can be monitored in a PUL
hCG repeated after 48h to measure change from baseline
Ectopic pregnancy
what produces hCG
the developing syncytiotrophoblast of the pregnancy
Ectopic pregnancy
hCG levels every 48hrs in an intrauterine pregnancy
hCG will double every 48hrs
this will not be the case in a miscarriage or ectopic
Ectopic pregnancy
what will a rise of >63% after 48hrs likely to indicate
an intrauterine pregnancy
repeat US after 1-2w to confirm
Ectopic pregnancy
at what hCG level should a pregnancy be visible on an USS
once the hCG level is >1500 IO/L
Ectopic pregnancy
what will a rise of <63% hCG after 48hrs indicate
an ectopic pregnancy
Ectopic pregnancy
a fall of >50% hCG after 48hr indicates
a miscarriage
urine pregnancy test should be performed after 2w to confirm the miscarriage is complete
Ectopic pregnancy
mnx of women with pelvic pain/tenderness and a +ve pregnancy test
refer to a early pregnancy assessment unit (EPAU) or gynae service
Ectopic pregnancy
mnx options
all need to be terminated
- expectant
- medical
- surgical
Ectopic pregnancy
what is expectant mnx
awaiting natural termination
Ectopic pregnancy
what is the criteria for expectant mnx (6)
- Follow up needs to be possible to ensure successful termination
- The ectopic needs to be unruptured
- Adnexal mass < 35mm
- No visible heartbeat
- No significant pain
- HCG level < 1500 IU / l
Ectopic pregnancy
what does medical mnx involve
IM methotrexate into buttock which results in spontaneous termination
Ectopic pregnancy
common SEs of methotrexate
- vaginal bleeding
- N+V
- abdo pain
- Stomatitis (inflammation of the mouth)
Ectopic pregnancy
what advice to give when methotrexate is given
don’t get pregnant for 3m following trx because the harmful effects on pregnancy can last this long
Ectopic pregnancy
what is the criteria for methotrexate
- Follow up needs to be possible to ensure successful termination
- The ectopic needs to be unruptured
- Adnexal mass < 35mm
- No visible heartbeat
- No significant pain
- hCG levels <5000 IU/L
- confirmed absence of intrauterine pregnancy on US
Ectopic pregnancy
when do you perform surgical mnx
anyone that does not meet the criteria for expectant or medical mnx
most pts will require it
- pain
- adnexal mass >35mm
- visible heartbeat
- hCG levels >5000 IU/L
Ectopic pregnancy
what are the 2 surgical options
1st line: laparoscopic salpingectomy: removal of affected fallopian tube along with ectopic
laparoscopic salpingotomy: remove ectopic
Miscarriage
what is it
the spontaneous termination of pregnancy
define early miscarriage
before 12w
define late miscarriage
beween 12-24w
define missed miscarriage
the fetus is no longer alive
but no sx have occurred
define threatened miscarriage
vaginal bleeding
closed cervix
fetus is alive
define inevitable miscarriage
vaginal bleeding
open cervix
define incomplete miscarriage
retained products of conception remain in the uterus after the miscarriage
define complete miscarriage
a full miscarriage has occurred
no products of conception left in the uterus
define anembryonic pregnancy
a gestational sac is present
but contains no embryo
Miscarriage
what is the inx of choice for diagnosing a miscarriage
TVUS
Miscarriage
what 3 key features do sonographers looks for in an early pregnancy
- mean gestational sac diameter
- fetal pole and crown-rump length
- fetal heartbeat
Miscarriage
when is a pregnancy considered viable
when a fetal heartbeat is visible
Miscarriage
when is a fetal heartbeat expected
once the crown rump length is 7mm or more
Miscarriage
when the CRL <7mm, without a fetal heartbeat, what happens
the TVUS is repeated after at least 1 week to ensure a heartbeat develops
Miscarriage
when the CRL is >7mm, without a fetal heartbeat, what happens
the scan is repeated after one weak before confirming a non-viable preganncy
Miscarriage
when is a fetal pole expected to appear
once the mean gestational sac diameter is 25mm or more
Miscarriage
when the mean gestational sac diameter is 25mm or more, without a fetal pole. what happens
the scan is repeated after 1 week before confirming an anembryonic pregnancy
Miscarriage
mnx for women with a pregnancy <6w gestation presenting with bleeding
expectant mnx
provided they have no pain or no other complications or RFs
Miscarriage
mnx for women with a +ve pregnancy test (more than 6w gestation) and bleeding
refer to an early pregnancy assessment service
USS decides:
- expectant
- medical
- surgical mnx
Miscarriage
1st line for women without RFs for heavy bleeding or infection
expectant mnx
A repeat urine pregnancy test should be performed 3w after bleeding and pain settle to confirm the miscarriage is complete.
Miscarriage
what is given in medical mnx
a dose of misoprostol to expedite the process of miscarriage.
vaginal suppository or oral dose
Miscarriage
what is Misoprostol
prostaglandin analogue
binds to prostaglandin receptors and activates them
Prostaglandins soften the cervix and stimulate uterine contractions
Miscarriage
SEs of misoprostol
- Heavier bleeding
- Pain
- Vomiting
- Diarrhoea
Miscarriage
what are the 2 options for surgical mnx
- Manual vacuum aspiration under local anaesthetic as an outpatient
- Electric vacuum aspiration under general anaesthetic
Miscarriage
what is given before surgical mnx and why
prostaglandins (misoprostol) to soften the cervix
Miscarriage
what does manual vacuum aspiration involve
a local anaesthetic applied to the cervix.
A tube attached to a specially designed syringe is inserted through the cervix into the uterus.
manually use the syringe to aspirate contents of the uterus.
Miscarriage
when should you consider manual vacuum aspiration
- woman must accept process
- <10w gestation
- more appropriate for women that have previously given birth
Miscarriage
what does electric vacuum aspiration involve
general anaesthetic.
performed through the vagina and cervix without any incisions
cervix is gradually widened using dilators, and the products of conception are removed through the cervix using an electric-powered vacuum
incomplete miscarriage: what do retained products create a risk of
infection
incomplete miscarriage
what are the 2 options for treating an incomplete miscarriage
- medical mnx (misoprostol)
- surgical mnx (evacuation of retained products of conception )
incomplete miscarriage
what is ERCP
Evacuation of retained products of conception
a surgical procedure involving a general anaesthetic.
cervix is gradually widened using dilators, and the retained products are manually removed through the cervix using vacuum aspiration and curettage (scraping).
incomplete miscarriage
what is a key complication of ERPC
endometritis
recurrent miscarriage
when is it classed as recurrent miscarriage
3 or more conescutive miscarriages
recurrent miscarriage
when are inx initiated
- 3 or more 1st trimester miscarriages
- 1 or more 2nd trimester miscarriages
recurrent miscarriage
causes (7)
- idiopathic (esp in older women)
- antiphospholipid syndrome
- hereditary thrombophilias
- uterine abnormalities
- genetic factors in parents (e.g. balanced translocations in parental chromosomes
- chronic histiocytic intervillositis
- other chronic diseases: diabetes, thyroid, SLE
recurrent miscarriage
what is antiphospholipid syndrome
a disorder associated with antiphospholipid antibodies, where blood becomes prone to clotting
the pt is in a hyper-coagulable state
recurrent miscarriage
what is antiphospholipid syndrome associated with
recurrent miscarriages and thrombosis
recurrent miscarriage
what can antiphospholipid syndrome occur secondary to
an autoimmune conditon such as SLE
recurrent miscarriage
how do you reduce the risk of miscarriage in pts with antiphospholipid syndrome
- low dose aspirin
- LMWH
recurrent miscarriage
inx for antiphospholipid syndrome
- antiphospholipid antibodies
recurrent miscarriage
3 key inherited thrombophilias to remember
- Factor V Leiden (most common)
- Factor II (prothrombin) gene mutation
- Protein S deficiency
recurrent miscarriage
name some uterine abnormalities that can cause recurrent miscarriages
- uterine septum: partition through the uterus
- unicornuate uterus: single-horned uterus
- bicornuate uterus: heart shaped uterus
- didelphic uterus: double uterus
- cervical insufficiency
- fibroids
recurrent miscarriage
what is Chronic Histiocytic Intervillositis
a rare cause of recurrent miscarriage , esp in 2nd trimester
histiocytes and macrophages build up in the placenta, causing inflammation + adverse outcomes
recurrent miscarriage
Chronic Histiocytic Intervillositis: what can it lead to
IUGR and intrauterine death
recurrent miscarriage
Chronic Histiocytic Intervillositis: how is it diagnosed
placental histology showing infiltrates of mononuclear cells in the intervillous spaces
recurrent miscarriage
inx
refer to specialist in recurrent miscarriages
- antiphospholipid antibodies
- test for hereditary thrombophilias
- pelvic US
- genetic testing for products of conception from the 3rd or future miscarriages
- genetic testing on parents
recurrent miscarriage
mnx
depends on underlying cause
PRISM trial suggests benefit of vaginal progesterone pessaries
Termination of pregnancy
what is it
aka abortion
an elective procedure to end a pregnancy
Termination of pregnancy
what gestational age is an abortion legal
24 weeks and under
Termination of pregnancy
an abortion can be performed at any time during the pregnancy if…(3)
- likely to risk the life of the woman
- Terminating the pregnancy will prevent “grave permanent injury” to the physical or mental health of the woman
- There is “substantial risk” that the child would suffer physical or mental abnormalities making it seriously handicapped
Termination of pregnancy
what are the legal requirements for an abortion ?
- 2 registered medical practitioners must sign to agree abortion in indicated
- it must be carried out by a registered medical practitioner in an NHS hospital or approved premise
Termination of pregnancy
what does medical abortion involve
- mifepristone
- misoprostol
Termination of pregnancy
what is mifepristone
anti-progestogen that blocks the action of progesterone, halting the pregnancy and relaxing the cervix
Termination of pregnancy
what is misprostol
a prostaglandin analogue: binds to prostaglandin receptors and activates them
Prostaglandins soften the cervix and stimulate uterine contractions.
Termination of pregnancy
Rhesus negative women with a gestational age of 10 weeks or above having a medical TOP should have
anti-D prophylaxis.
Termination of pregnancy
prior to surgical abortion, what cervical priming medications are used
misoprostol, mifepristone or osmotic dilators.
Termination of pregnancy
what are osmotic dilators
devices inserted into the cervix, that gradually expand as they absorb fluid, opening the cervical canal.
Termination of pregnancy
mnx for surgical abortion (up to 14w)
Cervical dilatation and suction of the contents of the uterus
Termination of pregnancy
mnx for surgical abortion (14-24w)
Cervical dilatation and evacuation using forceps
Termination of pregnancy
post abortion care
- urine pregnancy test 3w after
- discuss contraception
- support and counselling
Termination of pregnancy
complications (5)
- bleeding
- pain
- infection
- failure of abortion (pregnancy continues)
- damage to cervix, uterus or other structures)
Molar pregnancy
what is a hydatidiform mole
a type of tumour that grows like a pregnancy inside the uterus. This is called a molar pregnancy.
Molar pregnancy
what are the 2 types
complete and partial
Molar pregnancy
what is a complete mole
when 2 sperm cells fertilise an empty ovum
cell divides and grow into a tumour
no fetal material will form
Molar pregnancy
what is a partial mole
when 2 sperm cells fertilise a normal ovum
the new cell has 3 sets of chromosomes (it is a haploid cell)
the cel divides and grows into a tumour
some fetal material may form
Molar pregnancy
what may indicate a molar pregnancy versus a normal pregnancy
- more severe morning sickness
- vaginal bleeding
- increased enlargement of the uterus
- abnormally high hCG
- thyrotoxicosis
Molar pregnancy
why may there by thyrotoxicosis
hCG can mimic TSH and stimulate the thyroid to produce excess T3 and T4
Molar pregnancy
what would US of the pelvis show
‘snowstorm appearance’
Molar pregnancy
dx
provisional dx with US
confirmed with histology of the mole after evacuation
Molar pregnancy
mnx
- evacuation of uterus to remove the mole
- send products of conception for histology to confirm
- refer to gestational trophoblastic disease centre
- monitor hCG levels until they return to normal
Nausea and Vomiting of Pregnancy
when does N+V peak
8-12w
Nausea and Vomiting of Pregnancy
what is the severe form of N+V in pregnancy called
hyperemesis gravidarum
hyper: lots
emesis: vomiting
gravida: pregnancy
Nausea and Vomiting of Pregnancy
Which hormone is thought to be responsible for N+V
hCG
Nausea and Vomiting of Pregnancy
who gets it more severe
- molar pregnancies
- multiple pregnancies
- 1st pregnancy
- overweight women
Nausea and Vomiting of Pregnancy
dx
clinical - needs to start in 1st trimester
rule out other causes
Nausea and Vomiting of Pregnancy
dx for hyperemesis gravidarum
protracted N+V during pregnancy +
- > 5% weight loss compared with before pregnancy
- dehydration
- electrolyte imbalance
Nausea and Vomiting of Pregnancy
how can severity be assessed
Pregnancy-Unique Quantification of Emesis (PUQE) score
Nausea and Vomiting of Pregnancy
Pregnancy-Unique Quantification of Emesis (PUQE) score cut offs
<7: mild
7-12: moderate
> 12: severe
Nausea and Vomiting of Pregnancy
mnx: antiemetics (in order of preference)
- prochlorperazine (stemetil)
- cyclizine
- ondansetron
- metoclopramide
Nausea and Vomiting of Pregnancy
mnx: what can be used if acid reflux is a problem
- ranitidine
- or omeprazole
Nausea and Vomiting of Pregnancy
mnx: recommended complementary therapies
- ginger
- Acupressure on the wrist at the PC6 point (inner wrist) may improve symptoms
Nausea and Vomiting of Pregnancy
when should admission be considered
- unable to tolerate oral antiemetics or keep down any fluids
- > 5% weight loss compared with pre-pregnancy
- ketones present
- Other medical conditions need treating that required admission
Nausea and Vomiting of Pregnancy
why may moderate-severe cases require ambulatory care (e.g. early pregnancy assessment unit) or admission
- IV or IM antiemetics
- IV fluids (normal saline with added potassium chloride)
- Daily monitoring of U&Es while having IV therapy
- Thiamine supplementation to prevent deficiency (prevents Wernicke-Korsakoff syndrome)
- Thromboprophylaxis (TED stocking and low molecular weight heparin) during admission
