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Year 4 - O&G > O&G - Early Pregnancy + Complications > Flashcards

O&G - Early Pregnancy + Complications Flashcards

1
Q

What does miscarriage mean?

A

Definitions:

  • UK - Loss of intrauterine pregnancy < 24-weeks gestation
  • WHO - Expulsion of fetus / embryo weighing 500g or less
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2
Q

What is an early miscarriage vs a late miscarriage?

A
  • Early miscarriage = pregnancy loss before 12-weeks gestation
  • Late miscarriage = pregnancy loss occurs between 12-24 weeks
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3
Q

How common is miscarriage?

A

Miscarriage is the most common complication of pregnancy

~ 15% of recognised pregnancies miscarry

~ 25% of women will experience a miscarriage

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4
Q

What can cause a pregnancy to miscarry?

A
  1. Chromosomal abnormalities (~50%)
  2. Fetal malformations (excluding chromosomal abnormalities)
  3. Placental abnormalities
  4. Infection e.g. Listeria, VZV, toxoplasma, malaria
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5
Q

Name some risk-factors for miscarriage.

A
  • Multiple pregnancy
  • ↑ maternal age / paternal age
  • Smoking & Alcohol
  • Stress
  • ↑ BMI
  • Previous TOP
  • Hx of miscarriage
  • Medication
  • Thyroid disorders / diabtes / antiphospholipid syndrome / chronic illness
  • Uterine malformations / fibroids
  • IVF conception
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6
Q

How is a miscarriage diagnosed?

A

On ultrasound either of the following:

  1. Crown-Rump length of embryo ≥ 7mm + NO fetal heart action
    • ​Seek 2nd opinion of scan
    • Repeat scan > 7-days later before diagnosing
  2. Avg gestational sac diameter of 25mm + NO yolk sac or embryo visible
    • ​Seek 2nd opinion of scan
    • Repeat scan > 7-days later before diagnosing
    • You can only say the yolk sac/embyo has not developed if the gestational sac is beyond a certain size - here that is 25mm
    • When above is the case it is sometimes called ‘blighted ovum’ or ‘anembryonic pregnancy’
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7
Q

What types of miscarriage are there?

A
  1. Threatened miscarriage
  2. Inevitable miscarriage
  3. Incomplete miscarriage
  4. Missed (delayed) miscarriage
  5. Complete miscarriage
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8
Q

What is a ‘threatened miscarriage’ ?

A

Threatened Miscarriage:

  • Any PV (per vaginum) bleeding at < 24-weeks = ‘threatened miscarriage’
    • ~ 25% of women experience PV bleeding < 24-weeks, this most often occurs at 6-9 weeks
    • less blood than menstruation

Features:

  • PV bleeding (< menstruation)
  • +/- Pain - commonly painless in ‘threatened’
  • Closed cervical OS
  • No products of conception visible in vaginal vault i.e. placental tissue, fetal / embryonic tissue
  • US show viable intrauterine (IU) pregnancy
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9
Q

What is an inevitable miscarriage?

A

Inevitable Miscarriage:

  1. Heavy PV bleeding +/- clots
  2. Pain!
  3. Open cervical OS
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10
Q

What is an Incomplete miscarriage?

A

Incomplete Miscarriage:

  1. PV bleeding - continuous, more than other miscarriage types due to process of expelling products of conception
  2. Pain!!
  3. Open cervical OS
  4. Not all products of conception have been expelled (some in vaginal vault and some in uterus)
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11
Q

What is a Missed / Delayed miscarriage?

A

Missed / Delayed miscarriage:

  • Missed miscarriage = gestational sac containing dead fetus (no heart activity) < 24-weeks gestation WITHOUT symptoms of expulsion i.e. no signs of bleeding or products of conception in vagina

Features:

  1. NO or light PV bleeding
  2. NO pain
  3. Closed cervical OS
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12
Q

What is a complete miscarriage?

A

Complete miscarriage:

  1. NO PV bleeding
  2. NO pain
  3. Closed cervical OS
  4. No products of conception in cervical vault
  5. US shows no pregnancy
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13
Q

When taking a Hx from a pt with Vaginal bleeding what are some important questions to ask?

A

FULL gynaecological Hx!!

  • Bleeding:
    • Onset, character (heavy, clots, does it soak tampons/pads), timing (menstrual, inter-menstrual, post-coital)
  • Period / Pregnancy:
    • Last period?
    • Periods regular? duration? heavy?
    • Pregnancy test? Dates?
    • Menarche age?
  • Pain:
    • Abdo pain? Where? - SOCRATES
    • Pain during or after sex?
  • Sexual Hx:
    • When was last cervical smear? results?
    • Sexually active?
    • Partner/s?
    • Contraception?
  • Discharge (other than blood):
    • Onset, colour, odour, amount?
  • Obstetric:
    • Gravidity (pregnancies)?
    • Parity (pregs > 24-weeks)?
    • Multiple pregnancies?
    • Pregnancy complications?
    • TOP?
  • PMH + conditions developed during pregnancy?
  • PSH - e.g. LSCS
  • FHx - e.g. ovarian / cervical cancer
  • DH
  • SH:
    • Smoking?
    • Alcohol?
    • Occupation?
    • Support at home?
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14
Q

What examinations might you do for a pregnant woman presenting with PV bleeding?

A
  1. Abdominal examination
  2. Speculum examination
  3. Digital vaginal examination
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15
Q

Why might a pregnant woman with PV bleeding experience rectal pain?

A

Bleeding into Pouch of Douglas (Rectouterine pouch) causing irritation

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16
Q

What is a ‘Group and Save’?

A

A blood test to determine pt’s blood group and serum antibodies so that an appropriate blood transfusion can be provided

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17
Q

What are the 3 management options for a miscarriage?

A
  1. Expectant management
    • is 1st line –> wait for 7-14 days for spontaneous miscarriage + symptom management (e.g. OTC painkillers)
    • Can vary from days-weeks for spontaneous miscarriage
    • Follow-up in 2-3 weeks
  2. Medical management
    • Vaginal misoprostol (prostagladin analogue) –> stims myometrial contractions –> epulsion of tissue
      • Also give antiemetics + analgesia
    • Contact doctor is bleeding hasn’t started in < 24-hrs !
  3. Surgical management
    • Vacuum aspiration (suction curettage) under local anaesthetic
      • OR
    • ‘Surgical management of miscarriage’ i.e. theatre GA
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18
Q

What are the risks associated with each management option of miscarriage i.e. expectant, medical and surgical?

A

Risks of miscarriage management:

Expectant:

  • Infection 1%
  • Haemorrhage 2%
  • Retained tissue
  • Can be distressing when passed at home

Medical:

  • Infection 1%
  • Haemorrhage 2%

Surgical:

  • Infection
  • Haemorrhage
  • Uterine perforation
  • Uterine adhesions (~5%)
  • Retained tissue (5%)
  • GA risk
  • Hysterectomy (1 in 30,000)
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19
Q

Why might a pregnant woman with PV bleeding have shoulder-tip pain?

A

An ectopic pregnancy can cause peritoneal bleeding –> peritoneal + diaphragmatic irritation (experienced as referred pain to shoulder-tip)

20
Q

To what does right / left adnexae refer to?

A

Left / right uterine appendages

i.e. left or right fallopian tube + ovary + connective tissues (vessels, ligaments etc)

21
Q

What is Cervical Excitation?

A

Instructions:

  • Warn pt this may feel uncomfortable
  • Place a finger either side of the pt’s cervix
  • Push cervix from side to side - this stretches the fallopian tubes one at a time
    • Push to pt’s left = stretches right fallopian tube
  • Watch pt’s face for sign of pain
  • Avoid pushing forward or back - could give false +ve

Pain = +ve sign –> indication of either

1) Ectopic pregnancy or
2) Pelvic inflammatory disease

22
Q

What are some common categories of ovarian cysts?

A
  1. Physiological cysts (functional cysts)
  2. Benign Germ cell tumours
  3. Benign Epithelial tumours
23
Q

Name 2 examples of Physiological ovarian cysts and their features.

A

Follicular cyst:

  • Commonest ovarian cyst
  • Forms due to non-rupture of dominant follicle OR failure of atresia of non-dominant follicle
  • Commonly regress after several menstrual cycles

Corpus Luteum cyst:

  • Normally - if preg doesn’t occur then corpus luteum breaks down –> if this doesn’t happen the corpus luteum can fill with blood / fluid –> forming cyst
  • Intra-peritoneal bleeding - higher tendency (than follicular cyst)
24
Q

Name an example of a Benign germ cell ovarian tumour cyst and its features.

A

Benign germ cell tumour

e.g. DERMOID cyst

  • Most common benign germ cell tumour in women < 30-yrs
  • Also called mature cystic teratoma

Features:

  • Usually asymptomatic
  • Torsion more likely
  • Bilateral in 10-20%
  • Often lined with epithelial tissue (thus can contain skin appendages), hair and teeth
25
Q

Name 2 examples of Benign epithelial tumours and their features.

A

Benign Epithelial Tumours:

Serous Cystadenoma:

  • Commonest benign epithelial tumour
  • May mimic features / looks like serous carcinoma (commonest ovarian cancer)
  • Bilateral ~20%

Mucinous Cystadenoma:

  • Typically large & can become massive
  • If ruptures –> can cause pseudomyxoma peritonei (cancerous cells that produce abundant mucin or galatinous ascities - fill abdominal cavity and compress abdo organs)
26
Q

What is an Ectopic Pregnancy?

A

Implantation of a fertilized ovum outside the uterus

27
Q

What are the features of an Ectopic Pregnancy?

A
  • Typical Hx of 6-8 weeks amenorrhoea (from last period)
    • if > 8-weeks then consider inevitable miscarriage
  • Lower abdo pain - often constant / colicky + unilateral
    • due to tubal spasm
    • often is 1st symptom
  • PV bleeding (less than normal period) +/- clots
    • may be dark-brown colour
  • Peritoneal bleeding - can cause pain due to irritation:
    1. rectal pain
    2. shoulder-tip pain
    3. pain on urination / defecation
    4. rectal pressure / feeling of need to defecate
  • Symptoms of pregnancy e.g. breast tenderness & early morning nausea
  • Dizziness & syncope may be seen
  • Examination:
    • Abdominal tenderness e.g. RIF
    • Cervical excitation - i.e. cervical motion tenderness
    • Tachycardia
    • Hypotension
    • Orthostatic hypotension
    • Abdominal distension

DO NOT do bimanual exam for adnexal mass –> ↑ risk of rupturing the ectopic pregnancy

28
Q

Where do the majority of Ectopic pregnancies implant?

A

~97% are tubal i.e. fallopian tubes (most in ampulla)

  • Ectopic is more dangerous if in isthmus
  • other 3% are ovarian, cervix or abdominal
29
Q

What are some risk fators for Ectopic pregnancies?

A
  1. damage to tubes (salpingitis, surgery)
  2. Hx of ectopic
  3. previous PID (pelvic inflammatory disease) - dmgs fallopian tube cilia
  4. smoking - can damage cilia in fallopian tubes
  5. Hx of genital infections e.g. chlamydia
  6. endometriosis
  7. IUCD (intrauterine contraceptive device)
  8. progesterone only pill
  9. IVF (3% of pregnancies are ectopic)
30
Q

What are the investigations of choice in a suspected ectopic pregnancy?

A
  1. Serum beta-HCG (pregnancy test) - confirm pregnancy & repeat 48h later:
    • Rise of > 66% over 48h = suggestive of intrauterine pregnancy (IUP)
    • Suboptimal rise = suspicious (does not confirm ectopic)
    • Decline = likely miscarriage
    • Lesson: the rate of change of beta-hCG and direction are more important than absolute values
  2. Transvaginal ultrasound
  3. FBC - check haemoglobin amongst other things
  4. Group + Save - gives Rhesus status
31
Q

What does Expectant management of an Ectopic pregnancy involve?

What are the criteria for choosing this management?

A

Expectant management of Ectopic pregnancy:

  • Repeated serum beta-hCG every 48h until ↓ observed then weekly until beta-hCG < 15 IU
  • If beta-hCG plateaus –> can still use expectant management (wait for pregnancy failure + keep monitoring)
  • If beta-hCG ↑ or symptoms manifest then intervention is performed (medical or surgical)
  • Expectant is compatible if there is another intrauterine pregnancy

Offer Expectant management if:

  • Size < 35mm
  • Unruptured
  • Asymptomatic
  • No fetal heartbeat
  • serum B-hCG < 1000 IU/L and declining
32
Q

What does Medical management of an Ectopic pregnancy involve?

What are the criteria for choosing this management?

A

Medical management of Ectopic pregnancy:

  • Methotrexate (unliscenced) + follow-up appointment
    • Methotrexate dose = ​50 mg/m2
    • Measure B-hCG at 4 & 7 days post methotrexate –> if B-hCG ↓ < 15% between day 4 & day 7 –> 2nd dose of methotrexate or surgical
  • Pt MUST be on contraception for 3-months after dose as methotrexate is teratogenic
  • Methotrexate side-effects:
    • Conjunctivitis
    • Stomatitis
    • GI upset
  • Expectant is not compatible if there is another intrauterine pregnancy

Offer Medical managment IF:

  • Size < 35mm
  • Gestational age < 12-weeks
  • Unruptured
  • No significant pain
  • No fetal heartbeat
  • serum B-hCG < 1500 IU/L and declining
  • No intrauterine pregnancy
33
Q

What does Surgical management of an Ectopic pregnancy involve?

What are the criteria for choosing this management?

A

Surgical management of Ectopic pregnancy:

  • Salpingectomy (remove fallopian tube) or Salpingotomy (make hole in tube to excise ectopic)
    • Salpingectomy is preferred is other fallopian tube is normal - due to ↓ rates of recurrent ectopic
  • Expectant is compatible if there is another intrauterine pregnancy

Offer Surgical management IF:

  • Size > 35 mm
  • Can be ruptured
  • Severe pain
  • Visible fetal heartbeat
  • serum B-hCG > 5000 IU/L and declining
    • If B-hCG is > 1500 but < 5000 AND no significant pain AND unruptured AND no intrauterine pregnancy –> can offer Methotrexate (medical)
34
Q

If unable to identify an ectopic pregnancy on transvaginal US, what could reassure you that the pt is suffering from an ectopic?

A

If serum beta-hCG is > 1500

take this as a strong indication of ectopic pregnancy

35
Q

How common are ectopic pregnancies?

A

~ 0.5 - 1 % of all pregnancies

36
Q

What is a heterotopic pregnancy?

A

Rare complication of pregnancy in which an intrauterine + an extrauterine (ectopic) pregnancy occur simultaneously

37
Q

What happen to serum beta-hCG levels in a failing pregnancy during 1st trimester?

A

Serum beta-hCG levels fall in a failing pregnancy

38
Q

How do serum beta-hCG levels behave in an ectopic pregnancy?

A
  • 15-20% behave like intrauterine pregnancy i.e. beta-hCG increases significantly every 48hrs
  • 10% behave like failing pregnancy i.e. beta-hCG falls

~ 70% of cases the beta-hCG does something in between the above

39
Q

Once a woman has had an ectopic pregnancy managed via salpingectomy

what is the risk of recurrence of another ectopic?

A

~ 10% –> hence future pregnancies need

US scan at 7-weeks to screen for ectopics

  • ~15% recurrence with Salpingotomy
40
Q

If a woman with a pregnancy < 6-weeks presents with PV bleeding, no pain, no risk factors (e.g. previous ectopic pregnancy) what is the best course of management?

What should the pt be advised?

A

Expectant management IF:

  • < 6-weeks gestation
  • PV bleeding (no clots or not severe)
  • No pain
  • No risk factors for ectopic pregnancy

Advise:

  1. return if bleeding continues or pain develops
  2. to repeat a urine pregnancy test after 7–10 days and to return if +ve
  3. a negative pregnancy test means that the pregnancy has miscarried
41
Q

When should you refer a pt to early pregnancy assessment service (or out-of-hours gynaecology service if unavailable)?

A

Refer immediately if:

  • +ve pregnancy test + 1 of following on examination:
    1. pain & abdominal tenderness or
    2. pelvic tenderness or
    3. cervical motion tenderness

Refer if:

  • PV bleeding + 1 sign of early pregnancy complication:
    1. pain or
    2. pregnancy > 6-weeks gestation or
    3. pregnancy of uncertain gestation
42
Q

Who should Anti-D rhesus prophylaxis be offered to in the context of miscarriage / ectopic pregnancy?

A

Anti-D immunoglobulin (250 IU i.e. 50 mcg)

should be given to all Rh -ve women having a surgical procedure for ectopic pregnancy or miscarriage

Don’t give if:

  • Medical management only
  • Threatened miscarriage
  • Complete miscarriage
  • Pregnancy of unknown location
43
Q

What is Pregnancy of Unknown Location (PUL)?

A

Woman has +ve pregnancy test (beta-hCG) AND there are no signs of the following:

  1. Intrauterine pregnancy
  2. Ectopic pregnancy
  3. Retained products of conception
44
Q

Regardless of the type of management for miscarriage, Anti-D immunoglobulin must be given when?

A

Anti-D immunoglobulin must be given in

any miscarriage of gestation > 12-weeks

45
Q

If a pt has an ectopic pregnancy at what B-hCG can rupture not occur?

A

TRICK QUESTION!

There is no B-hCG level at which ectopic rupture can not occur!

Symptoms = MOST IMPORTANT (for monitoring for rupture)

46
Q

What might the features of pregnancy of unknown location (PUL) be?

A
  1. +ve serum B-hCG i.e. > 5 mIU/ml
  2. Asymptomatic - common
  3. PV bleeding - can occur in normal pregnancy, ectopic, threatened miscarriage
  4. Abdo pain

Year 4 - O&G (12 decks)

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