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Finals > O&G: Early Pregnancy > Flashcards

O&G: Early Pregnancy Flashcards

1
Q

Ectopic pregnancy

what is it

A

when a pregnancy is implanted outside the uterus

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2
Q

Ectopic pregnancy

where can an ectopic pregnancy implant

A
  • fallopian tube (most common)
  • cornual region (entrance to fallopian tube)
  • ovary
  • cervix
  • abdomen
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3
Q

Ectopic pregnancy

RFs (6)

A
  • Previous ectopic pregnancy
  • Previous PID
  • Previous surgery to the fallopian tubes
  • Intrauterine devices (coils)
  • Older age
  • Smoking
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4
Q

Ectopic pregnancy

when does it typically present

A

around 6-8w gestation

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5
Q

Ectopic pregnancy

classic features (5)

A
  1. Missed period
  2. Constant lower abdominal pain in the right or left iliac fossa
  3. Vaginal bleeding
  4. Lower abdominal or pelvic tenderness
  5. Cervical motion tenderness (pain when moving the cervix during a bimanual examination)
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6
Q

Ectopic pregnancy

other features (2)

A
  • dizziness or syncope (blood loss)

- shoulder tip pain (peritonitis)

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7
Q

Ectopic pregnancy

inx of choice for diagnosing a miscarriage

A

TVUS

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8
Q

Ectopic pregnancy

what may be seen in the fallopian tube on a TVUS

A

a gestational sac containing a yolk sac or fetal pole

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9
Q

Ectopic pregnancy

what is a ‘blob sign’ / bagel sign / tubal ring sign

A

TVUS: mass containing an empty gestational sac

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10
Q

Ectopic pregnancy

how to tell the difference between a tubal ectopic pregancy vs a corpus luteum on TVUS

A

the mass moves separately to the ovary if its an ectopic

the corpus luteum will move with the ovary

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11
Q

Ectopic pregnancy

US findings that may indicate an ectopic

A
  • an empty uterus

- fluid in the uterus, which may be mistaken as a gestational sac (pseudogestational sac)

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12
Q

Ectopic pregnancy

what is a PUL

A

Pregnancy of Unknown Location

when the woman has a +ve pregnancy test and there is no evidence of pregnancy on the USS

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13
Q

Ectopic pregnancy

what can be monitored in a PUL

A

hCG repeated after 48h to measure change from baseline

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14
Q

Ectopic pregnancy

what produces hCG

A

the developing syncytiotrophoblast of the pregnancy

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15
Q

Ectopic pregnancy

hCG levels every 48hrs in an intrauterine pregnancy

A

hCG will double every 48hrs

this will not be the case in a miscarriage or ectopic

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16
Q

Ectopic pregnancy

what will a rise of >63% after 48hrs likely to indicate

A

an intrauterine pregnancy

repeat US after 1-2w to confirm

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17
Q

Ectopic pregnancy

at what hCG level should a pregnancy be visible on an USS

A

once the hCG level is >1500 IO/L

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18
Q

Ectopic pregnancy

what will a rise of <63% hCG after 48hrs indicate

A

an ectopic pregnancy

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19
Q

Ectopic pregnancy

a fall of >50% hCG after 48hr indicates

A

a miscarriage

urine pregnancy test should be performed after 2w to confirm the miscarriage is complete

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20
Q

Ectopic pregnancy

mnx of women with pelvic pain/tenderness and a +ve pregnancy test

A

refer to a early pregnancy assessment unit (EPAU) or gynae service

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21
Q

Ectopic pregnancy

mnx options

A

all need to be terminated

  • expectant
  • medical
  • surgical
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22
Q

Ectopic pregnancy

what is expectant mnx

A

awaiting natural termination

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23
Q

Ectopic pregnancy

what is the criteria for expectant mnx (6)

A
  1. Follow up needs to be possible to ensure successful termination
  2. The ectopic needs to be unruptured
  3. Adnexal mass < 35mm
  4. No visible heartbeat
  5. No significant pain
  6. HCG level < 1500 IU / l
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24
Q

Ectopic pregnancy

what does medical mnx involve

A

IM methotrexate into buttock which results in spontaneous termination

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25
Q

Ectopic pregnancy

common SEs of methotrexate

A
  • vaginal bleeding
  • N+V
  • abdo pain
  • Stomatitis (inflammation of the mouth)
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26
Q

Ectopic pregnancy

what advice to give when methotrexate is given

A

don’t get pregnant for 3m following trx because the harmful effects on pregnancy can last this long

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27
Q

Ectopic pregnancy

what is the criteria for methotrexate

A
  • 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
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28
Q

Ectopic pregnancy

when do you perform surgical mnx

A

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
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29
Q

Ectopic pregnancy

what are the 2 surgical options

A

1st line: laparoscopic salpingectomy: removal of affected fallopian tube along with ectopic

laparoscopic salpingotomy: remove ectopic

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30
Q

Miscarriage

what is it

A

the spontaneous termination of pregnancy

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31
Q

define early miscarriage

A

before 12w

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32
Q

define late miscarriage

A

beween 12-24w

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33
Q

define missed miscarriage

A

the fetus is no longer alive

but no sx have occurred

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34
Q

define threatened miscarriage

A

vaginal bleeding

closed cervix

fetus is alive

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35
Q

define inevitable miscarriage

A

vaginal bleeding

open cervix

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36
Q

define incomplete miscarriage

A

retained products of conception remain in the uterus after the miscarriage

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37
Q

define complete miscarriage

A

a full miscarriage has occurred

no products of conception left in the uterus

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38
Q

define anembryonic pregnancy

A

a gestational sac is present

but contains no embryo

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39
Q

Miscarriage

what is the inx of choice for diagnosing a miscarriage

A

TVUS

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40
Q

Miscarriage

what 3 key features do sonographers looks for in an early pregnancy

A
  • mean gestational sac diameter
  • fetal pole and crown-rump length
  • fetal heartbeat
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41
Q

Miscarriage

when is a pregnancy considered viable

A

when a fetal heartbeat is visible

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42
Q

Miscarriage

when is a fetal heartbeat expected

A

once the crown rump length is 7mm or more

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43
Q

Miscarriage

when the CRL <7mm, without a fetal heartbeat, what happens

A

the TVUS is repeated after at least 1 week to ensure a heartbeat develops

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44
Q

Miscarriage

when the CRL is >7mm, without a fetal heartbeat, what happens

A

the scan is repeated after one weak before confirming a non-viable preganncy

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45
Q

Miscarriage

when is a fetal pole expected to appear

A

once the mean gestational sac diameter is 25mm or more

46
Q

Miscarriage

when the mean gestational sac diameter is 25mm or more, without a fetal pole. what happens

A

the scan is repeated after 1 week before confirming an anembryonic pregnancy

47
Q

Miscarriage

mnx for women with a pregnancy <6w gestation presenting with bleeding

A

expectant mnx

provided they have no pain or no other complications or RFs

48
Q

Miscarriage

mnx for women with a +ve pregnancy test (more than 6w gestation) and bleeding

A

refer to an early pregnancy assessment service

USS decides:

  • expectant
  • medical
  • surgical mnx
49
Q

Miscarriage

1st line for women without RFs for heavy bleeding or infection

A

expectant mnx

A repeat urine pregnancy test should be performed 3w after bleeding and pain settle to confirm the miscarriage is complete.

50
Q

Miscarriage

what is given in medical mnx

A

a dose of misoprostol to expedite the process of miscarriage.

vaginal suppository or oral dose

51
Q

Miscarriage

what is Misoprostol

A

prostaglandin analogue

binds to prostaglandin receptors and activates them

Prostaglandins soften the cervix and stimulate uterine contractions

52
Q

Miscarriage

SEs of misoprostol

A
  • Heavier bleeding
  • Pain
  • Vomiting
  • Diarrhoea
53
Q

Miscarriage

what are the 2 options for surgical mnx

A
  • Manual vacuum aspiration under local anaesthetic as an outpatient
  • Electric vacuum aspiration under general anaesthetic
54
Q

Miscarriage

what is given before surgical mnx and why

A

prostaglandins (misoprostol) to soften the cervix

55
Q

Miscarriage

what does manual vacuum aspiration involve

A

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.

56
Q

Miscarriage

when should you consider manual vacuum aspiration

A
  • woman must accept process
  • <10w gestation
  • more appropriate for women that have previously given birth
57
Q

Miscarriage

what does electric vacuum aspiration involve

A

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

58
Q

incomplete miscarriage: what do retained products create a risk of

A

infection

59
Q

incomplete miscarriage

what are the 2 options for treating an incomplete miscarriage

A
  • medical mnx (misoprostol)

- surgical mnx (evacuation of retained products of conception )

60
Q

incomplete miscarriage

what is ERCP

A

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).

61
Q

incomplete miscarriage

what is a key complication of ERPC

A

endometritis

62
Q

recurrent miscarriage

when is it classed as recurrent miscarriage

A

3 or more conescutive miscarriages

63
Q

recurrent miscarriage

when are inx initiated

A
  • 3 or more 1st trimester miscarriages

- 1 or more 2nd trimester miscarriages

64
Q

recurrent miscarriage

causes (7)

A
  1. idiopathic (esp in older women)
  2. antiphospholipid syndrome
  3. hereditary thrombophilias
  4. uterine abnormalities
  5. genetic factors in parents (e.g. balanced translocations in parental chromosomes
  6. chronic histiocytic intervillositis
  7. other chronic diseases: diabetes, thyroid, SLE
65
Q

recurrent miscarriage

what is antiphospholipid syndrome

A

a disorder associated with antiphospholipid antibodies, where blood becomes prone to clotting

the pt is in a hyper-coagulable state

66
Q

recurrent miscarriage

what is antiphospholipid syndrome associated with

A

recurrent miscarriages and thrombosis

67
Q

recurrent miscarriage

what can antiphospholipid syndrome occur secondary to

A

an autoimmune conditon such as SLE

68
Q

recurrent miscarriage

how do you reduce the risk of miscarriage in pts with antiphospholipid syndrome

A
  • low dose aspirin

- LMWH

69
Q

recurrent miscarriage

inx for antiphospholipid syndrome

A
  • antiphospholipid antibodies
70
Q

recurrent miscarriage

3 key inherited thrombophilias to remember

A
  • Factor V Leiden (most common)
  • Factor II (prothrombin) gene mutation
  • Protein S deficiency
71
Q

recurrent miscarriage

name some uterine abnormalities that can cause recurrent miscarriages

A
  • uterine septum: partition through the uterus
  • unicornuate uterus: single-horned uterus
  • bicornuate uterus: heart shaped uterus
  • didelphic uterus: double uterus
  • cervical insufficiency
  • fibroids
72
Q

recurrent miscarriage

what is Chronic Histiocytic Intervillositis

A

a rare cause of recurrent miscarriage , esp in 2nd trimester

histiocytes and macrophages build up in the placenta, causing inflammation + adverse outcomes

73
Q

recurrent miscarriage

Chronic Histiocytic Intervillositis: what can it lead to

A

IUGR and intrauterine death

74
Q

recurrent miscarriage

Chronic Histiocytic Intervillositis: how is it diagnosed

A

placental histology showing infiltrates of mononuclear cells in the intervillous spaces

75
Q

recurrent miscarriage

inx

A

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
76
Q

recurrent miscarriage

mnx

A

depends on underlying cause

PRISM trial suggests benefit of vaginal progesterone pessaries

77
Q

Termination of pregnancy

what is it

A

aka abortion

an elective procedure to end a pregnancy

78
Q

Termination of pregnancy

what gestational age is an abortion legal

A

24 weeks and under

79
Q

Termination of pregnancy

an abortion can be performed at any time during the pregnancy if…(3)

A
  1. likely to risk the life of the woman
  2. Terminating the pregnancy will prevent “grave permanent injury” to the physical or mental health of the woman
  3. There is “substantial risk” that the child would suffer physical or mental abnormalities making it seriously handicapped
80
Q

Termination of pregnancy

what are the legal requirements for an abortion ?

A
  • 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
81
Q

Termination of pregnancy

what does medical abortion involve

A
  • mifepristone

- misoprostol

82
Q

Termination of pregnancy

what is mifepristone

A

anti-progestogen that blocks the action of progesterone, halting the pregnancy and relaxing the cervix

83
Q

Termination of pregnancy

what is misprostol

A

a prostaglandin analogue: binds to prostaglandin receptors and activates them

Prostaglandins soften the cervix and stimulate uterine contractions.

84
Q

Termination of pregnancy

Rhesus negative women with a gestational age of 10 weeks or above having a medical TOP should have

A

anti-D prophylaxis.

85
Q

Termination of pregnancy

prior to surgical abortion, what cervical priming medications are used

A

misoprostol, mifepristone or osmotic dilators.

86
Q

Termination of pregnancy

what are osmotic dilators

A

devices inserted into the cervix, that gradually expand as they absorb fluid, opening the cervical canal.

87
Q

Termination of pregnancy

mnx for surgical abortion (up to 14w)

A

Cervical dilatation and suction of the contents of the uterus

88
Q

Termination of pregnancy

mnx for surgical abortion (14-24w)

A

Cervical dilatation and evacuation using forceps

89
Q

Termination of pregnancy

post abortion care

A
  • urine pregnancy test 3w after
  • discuss contraception
  • support and counselling
90
Q

Termination of pregnancy

complications (5)

A
  • bleeding
  • pain
  • infection
  • failure of abortion (pregnancy continues)
  • damage to cervix, uterus or other structures)
91
Q

Molar pregnancy

what is a hydatidiform mole

A

a type of tumour that grows like a pregnancy inside the uterus. This is called a molar pregnancy.

92
Q

Molar pregnancy

what are the 2 types

A

complete and partial

93
Q

Molar pregnancy

what is a complete mole

A

when 2 sperm cells fertilise an empty ovum

cell divides and grow into a tumour

no fetal material will form

94
Q

Molar pregnancy

what is a partial mole

A

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

95
Q

Molar pregnancy

what may indicate a molar pregnancy versus a normal pregnancy

A
  • more severe morning sickness
  • vaginal bleeding
  • increased enlargement of the uterus
  • abnormally high hCG
  • thyrotoxicosis
96
Q

Molar pregnancy

why may there by thyrotoxicosis

A

hCG can mimic TSH and stimulate the thyroid to produce excess T3 and T4

97
Q

Molar pregnancy

what would US of the pelvis show

A

‘snowstorm appearance’

98
Q

Molar pregnancy

dx

A

provisional dx with US

confirmed with histology of the mole after evacuation

99
Q

Molar pregnancy

mnx

A
  • 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
100
Q

Nausea and Vomiting of Pregnancy

when does N+V peak

A

8-12w

101
Q

Nausea and Vomiting of Pregnancy

what is the severe form of N+V in pregnancy called

A

hyperemesis gravidarum

hyper: lots
emesis: vomiting
gravida: pregnancy

102
Q

Nausea and Vomiting of Pregnancy

Which hormone is thought to be responsible for N+V

A

hCG

103
Q

Nausea and Vomiting of Pregnancy

who gets it more severe

A
  • molar pregnancies
  • multiple pregnancies
  • 1st pregnancy
  • overweight women
104
Q

Nausea and Vomiting of Pregnancy

dx

A

clinical - needs to start in 1st trimester

rule out other causes

105
Q

Nausea and Vomiting of Pregnancy

dx for hyperemesis gravidarum

A

protracted N+V during pregnancy +

  • > 5% weight loss compared with before pregnancy
  • dehydration
  • electrolyte imbalance
106
Q

Nausea and Vomiting of Pregnancy

how can severity be assessed

A

Pregnancy-Unique Quantification of Emesis (PUQE) score

107
Q

Nausea and Vomiting of Pregnancy

Pregnancy-Unique Quantification of Emesis (PUQE) score cut offs

A

<7: mild

7-12: moderate

> 12: severe

108
Q

Nausea and Vomiting of Pregnancy

mnx: antiemetics (in order of preference)

A
  1. prochlorperazine (stemetil)
  2. cyclizine
  3. ondansetron
  4. metoclopramide
109
Q

Nausea and Vomiting of Pregnancy

mnx: what can be used if acid reflux is a problem

A
  • ranitidine

- or omeprazole

110
Q

Nausea and Vomiting of Pregnancy

mnx: recommended complementary therapies

A
  • ginger

- Acupressure on the wrist at the PC6 point (inner wrist) may improve symptoms

111
Q

Nausea and Vomiting of Pregnancy

when should admission be considered

A
  • 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
112
Q

Nausea and Vomiting of Pregnancy

why may moderate-severe cases require ambulatory care (e.g. early pregnancy assessment unit) or admission

A
  • 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

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