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JUST4MED clinical cases > O+G- Miscarriage + Ectopic Pregnancy + Molar Pregnancy > Flashcards

O+G- Miscarriage + Ectopic Pregnancy + Molar Pregnancy Flashcards

1
Q

When is a pregnancy loss considered a miscarriage up until?

a) 24 weeks
b) 23 weeks
c) 22 weeks
d) 21 weeks

A

a) 24 weeks

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2
Q

What is the commonest cause of miscarriage?

a) Trauma ie fall
b) Antiphospholipid syndrome
c) Sporadic lethal chromosome abnormalities
d) Increasing age

A

c) Sporadic lethal chromosome abnormalities

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3
Q

____ _________ is a late cause of miscarriage

A

Cervical weakness is a late cause of miscarriage

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4
Q

Increasing maternal age increases miscarriage risk What % of pregnancies result in miscarriage above age 40?

a) 26%
b) 33%
c) 54%
d) 41%

A

d) 41%

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5
Q

What is a ‘Miscarriage’?

A
  • It is an early pregnancy loss, the official definitions are:
  • A pregnancy loss occurring before 24 weeks gestation
  • Expulsion of foetus weighing 500g or less.
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6
Q

Any pregnancy loss after 23 weeks and 6 days is considered a _______

A

stillborn!

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7
Q

What types of miscarriage are there?

A

Threatened

Inevitable

Incomplete

Complete

MIssed/silent

Early fetal demise

Blighted Ovum

Septic

Recurrent

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8
Q

What is the threatened miscarriage?

A

A miscarriage may happen- some vaginal bleeding but cervical os is closed and USS reveals viable intrauterine pregnancy.

• 90% of threatened miscarriages will continue to grow to normal gestation.

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9
Q

What is Inevitable miscarriage?

A

A miscarriage is going to happen. Vaginal bleeding +/- cramps/abdo pain + open cervical os but the products of conception have not passed.

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10
Q

What is an incompelete miscarriage?

A

Miscarriage is currently happening. Heavy and increased vaginal bleeding, lower abdo pain, passage of some products of conception. Cervical os open and there are products present in the canal.

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11
Q

What is complete miscarriage?

A

Products of conception have been passed. Cervical os closed. USS reveals empty uterine cavity.

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12
Q

What is missed/silent miscarriage?

A

Non-viable intrauterine pregnancy has remained inside the uterus (fetus has not spontaneously aborted). Patient is amenorrhoeic (absence of menstruation) but no vaginal bleeding or abdominal pain. Cervical os closed. USS confirms non viable intrauterine pregnancy.

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13
Q

What is early fetal demise miscarriage?

A

Empty sac in uterus, no fetal tissue. Pregnancy but no embryo.

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14
Q

What is Blighed ovum?

A

Missed miscarriage in which embryonic development stopped before embryonic pole was visible. Gestational sac may continue to grow

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15
Q

What is septic miscarriage?

A

Miscarriage and sepsis (fever, abdo tenderness)

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16
Q

What is recurrent miscarriage?

A

3 or more losses in a row.

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17
Q

What are the causes of miscarriage?

A
  • Chromosomal abnormality
  • Uterine structural abnormalities
  • Maternal health factors
  • Active infection
  • Iatrogenic
  • Social factors
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18
Q

Name examples of chromosomal abnormalities that cause miscarriage?

A
  • autosomal trisomy is commonest abnormality (trisomy 16 especially), the commonest single chromosomal anomaly is 45X karyotype, increasing maternal age increases aneuploidy risk (abnormal number of chromosomes)
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19
Q

Name examples of Uterine structural abnormalities that cause miscarriage?

A

eg asherman’s syndrome, fibroids, uterine septum

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20
Q

Name examples of Maternal health factors that cause miscarriage?

A

eg Thrombophilia, antiphospholipid syndrome, SLE, PCOS, thyroid dysfunction

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21
Q

Name examples of Active infection that cause miscarriage?

A

eg herpes simplex, rubella, CMV, listeria

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22
Q

Name examples of Iatrogenic that cause miscarriage?

A

amniocentesis, chorionic villus sampling

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23
Q

Name examples of Social factors that cause miscarriage?

A

tobacco, alcohol, cocaine

24
Q

What are they symptoms of miscarriage?

A
  • Vaginal bleeding with or without clots
  • Amenorrhoea • In some but not all:
  • Suprapubic pain (cramp like)- pain is commoner with an ectopic!
  • Low back pain
  • Recent post-coital bleed (odds double in women who report bleeding after intercourse during pregnancy)
  • If they have a fever too question septic miscarriage!
25
Q

Pain without vaginal bleeding does suggest a miscarriage

TRUE OR FALSE

A

FALSE

(but may suggest an ectopic pregnancy!)

26
Q
  • 32 yo woman just been confirmed by USS as being pregnant with twins at gestational age 10 weeks. On the way home, she notices bright red vaginal bleeding. She’s in no pain and has no postural dizziness.
  • During a 12 week scan the midwife appears concerned and obtains a second opinion. The second sonographer confirms the absence of visible heart activity.

Which is the diagnosis?

A

Miscarriage

27
Q

Ix Miscarriage?

A
  • Urine pregnancy test- confirms pregnancy
  • FBC- indicates degree of blood loss and probable need to transfuse
  • Rhesus blood group- indicates need for anti-D immunoglobulin administration
  • Serum beta hCG titres- order if uncertain about miscarriage status. Drop in >50% in 48h suggests failing pregnancy. May be positive up to 21 days after a complete miscarriage!
  • Trans-vaginal ultrasound scan- differentiates between stages and types of miscarriage.
28
Q

What are the differential diagnosis for miscarriage?

A
  • Ectopic pregnancy- would have suprapubic pain, unexplained pallor, tachycardia or syncope
  • Hydatidiform mole (complete or partial)- uterine size larger than expected for GA
  • Cystitis- suprapubic pain with dysuria, fever and possible haematuria

• Pregnancy co-existing with a bleeding polyp/large ectropion- determined by speculum

29
Q

Miscarriage

When taking a history, don’t forget to ask about:

A
  • Menstrual cycle: Last menstrual period, cycle length, days bleeding, clots
  • Past obstetric history eg previous miscarriage or ectopic (increases risk)
  • Past gynaecological history eg cervical/uterine surgery, contraception, any abnormal smear results, previous STI or PID.
30
Q

Miscarriage

On examination:

A
  • Abdominal exam should be unremarkable, if there is rebound tenderness consider ectopic pregnancy.
  • Don’t forget to assess vitals for pyrexia
31
Q

True or False: An ectopic Pregnancy Implantation and maturation of fertilized ovum outside the uterus cavity

a) True
b) False

A

a) True

32
Q

The commonest location of an Ectopic pregnancy?

a) Abdominal
b) Ovarian
c) Fallopian tube
d) Cervical

A

c) Fallopian tube

33
Q

What is ‘Ectopic Pregnancy’

A

Implantation and maturation of fertilized ovum outside the uterus cavity, occurring in 11 per 1000 pregnancies.

• Fallopian tube (97%) • Ovary (3.2%) • Abdomen (1.3%)

34
Q

What happens if you leave ectopic pregancy untreated?

A

• If untreated may lead to maternal death due to rupture of implantation site or intraperitoneal hemorrhage, therefore this is and EMERGENCY

35
Q

Symptoms of ectopic pregnancy?

A

• Abdominal or pelvic Pain

• Vaginal bleeding with or without clots

• Amenorrhoea

Other:

• Fainting • Breast tenderness • Shoulder tip pain • Urinary symptoms • Asymtomatic

36
Q

What do you look out for in history for ectopic pregnancy?

A

Symptoms and signs can resemble other conditions

  • Presents 6-8 weeks after last period
  • Lower abdominal pain – unilateral, constant
  • Vaginal bleeding – dark brown
  • shoulder tip pain and syncope suggest intraperitoneal hemorrhage

Risk factors: factors that have damaged fallopian tubes

37
Q

What are the RF for ectopic pregnancy?

A

Pelvic inflammatory disease, previous ectopic pregnancy, smoking, tubal sterilization surgery

38
Q

Ix for ectopic pregnancy?

A
  • Urine or serum pregnancy test - On all women of reproductive age who present with pain bleeding or collapse.
  • Cervical excitation
  • High resolution transvaginal ultrasound
  • NB: examination of adnexal mass not performed due to increasing risk of rupture

• A positive pregnancy test and symptoms of pain and abdominal tenderness Or pelvic tenderness Or cervical motion tenderness, need urgent referral to an early pregnancy assessment service.

39
Q

Differential Diagnosis for ectopic pregnancy?

A
  • UTI
  • Gastrointestinal conditions: RIF pain conditions, LIF pain conditions
  • Threatened miscarriage – vaginal bleeding and pain
40
Q

What to look out for on clinical examination for ectopic pregnancy?

A
  • INSPECTION: Pallor, Distended Abdomen
  • PALPATION: Abdominal, pelvic and adnexal tenderness, Rebound tenderness, Cervical tenderness

Tachycardia

Hypotension

41
Q

OSCE tips : Ectopic pregnancy

A

Ectopic pregnancy is an important differential diagnosis to consider in women of child bearing age who present with lower abdominal pain.

42
Q

Which cells secrete hCG?

a) Syncytiotrophoblasts
b) placental trophoblasts
c) Theca cells
d) Granulosa cells

A

a) Syncytiotrophoblasts

hCG is used as a tumor marker for Persistent Trophoblastic disease

43
Q

A complete molar has fetal tissue

a) True b) False

A

b) False

Think about the definition of a complete molar

44
Q

What is ‘Molar pregnancy’

A

Chromosomal abnormal pregnancies that have the risk of becoming malignant • Arise form placental trophoblasts

45
Q

Molar pregnancy forms what type of disease?

A

• Forms part of Gestational trophoblastic Disease (GTD)

46
Q

How can you classify Gestational trophoblaastic disease?

A
  • Premalignant – hydtidiform mole
  • Malignant – GTN
47
Q
  • Premalignant – hydtidiform mole
  • Malignant – GTN

these can be further divided into?

A

Premalignant – hydtidiform mole

  • Complete hydatidiform mole (CHM).
  • Partial hydatidiform mole (PHM)

Malignant – GTN

  • Invasive
  • Chroicoarcinoma
  • Placental site trophoblastic tumour (PSTT).
  • Epithelioid trophoblastic tumour (ETT)
48
Q

What is a complete molar pregnancy?

A

all genetic material comes from father.

  • Empty oocyte lacking maternal genes is fertilized
  • Single sperm fertilizes with an empty ovum and undergoes mitosis resulting in diploid tissue. 46 XX
  • No fetal tissue
49
Q

What is Partial moral Pregnanc?

A

trophoblast cells have 3 sets of chromosomes (triploid)

  • 2 sperm fertilize ovum.
  • Evidence of fetal tissue or fetal blood cells
50
Q

Symptoms of molar pregnancy?

A
  • Vaginal bleeding in 1st trimester
  • Hyperemesis
  • Abnormal uterine enlargement
  • Hyperthyroidism
  • Anaemia
  • Respiratory distress
  • Pre-eclampsia
51
Q

What to look out for in a history for molar pregnancy?

A
  • Vaginal bleeding
  • Hyperemesis: Severe vomiting
  • Detected on routine ultrasound
  • Presence of Risk factors: • Any age: common on >45 or 12, light menstruation • Oral contraception pill • Asian
52
Q

Ix for molar pregnancy?

A
  • Urine and blood levels or hCG
  • FBC
  • Serum TSH
  • Ultrasound
  • Histology
  • Staging investigations if metastatic disease
53
Q

Differentials for molar pregnancy?

A
  • Hyperemesis Gravidarum
  • Hyperthyroidism and thyrotoxicosis
  • Multiple gestation – large uterus
  • Spontaneous abortion
  • Pelvic Tumour
54
Q

What do you see in molar pregnancy clinical exam?

A

PALPATION • Uterus large • Early pre-eclapmisa and hyperthyroidism may occur

55
Q

What could persistent or high levels of molar pregnancy suggest

and what are the tunour markers?

A

malignancy

Syncytiotrophoblasts secret hCG therefore it is used as a tumour marker

56
Q

Which cells secrete hCG?

a) Syncytiotrophoblasts
b) placental trophoblasts
c) Theca cells
d) Granulosa cells

A

a) Syncytiotrophoblasts

57
Q

A complete molar has fetal tissue

a) True b) False

A

b) False

JUST4MED clinical cases (15 decks)

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