OB-GYN Revision 6 Flashcards
Describe some risk factors for ectopic pregnancy [+]
Previous ectopic
Tubal factors:
- scarring or adhesions from PID
- congenital anomalies,
Tubal surgery:
- salpingectomy
- tubal ligation
- reconstructive surgery
Assisted reproductive technology (ART):
- Fertility treatments, particularly in vitro fertilization (IVF)
Intrauterine device (IUD) use
Smoking
Endometriosis
Describe the pathophysiology of ectopic pregnancy [3]
Implantation outside the uterine cavity occurs when the fertilized ovum is unable to reach the endometrial lining due to impaired tubal transport or abnormal embryo-tubal interactions:
- Abnormal embryo migration (disrupted tubal motility, due to factors such as PID, endometriosis, or smoking)
- Impaired tubal environment: Inflammatory processes, including infection or endometriosis, can alter the tubal milieu, promoting ectopic implantation.
- Embryo-tubal interactions: Alterations in the expression of adhesion molecules and chemokines, such as integrins and L-selectin, may affect the embryo-tubal relationship, leading to ectopic pregnancy.
Describe the clinical features of ectopic pregnancies [+]
Female with a history of 6-8 weeks amenorrhoea who presents with lower abdominal pain and later develops vaginal bleeding
Constant lower abdominal pain:
- in the right or left iliac fossa
- often FIRST symptom
- pain is constant
Vaginal bleeding:
* usually less than a normal period
* may be dark brown in colour
Recent amenorrhoea
- if longer (e.g. 10 wks) this suggest another causes e.g. inevitable abortion
Cervical motion tenderness (pain when moving the cervix during a bimanual examination)
Dizziness or syncope (blood loss)
Shoulder tip pain(peritonitis)
Describe how you interpret serum bHCG levels with ectopic pregnancies [2]
If the initial β-HCG level is >1500 iU (discriminatory level)
- & there is no intrauterine pregnancy on transvaginal ultrasound –> consider ectopic pregnancy until proven otherwise
If the initial β-HCG level is < 1500 iU:
- and the patient is stable, a further blood test can be taken 48 hours later
- Viable pregnancy: HCG level would be expected to double every 48 hours.
- Miscarriage: HCG level would be expected to halve every 48 hours
Describe the criteria that needs to be met to indicate expectant managment for ectopic pregnancy [5]
- Clinical stable and pain free AND
-
Unruptured tubal ectopic pregnancy measuring less than 35mm with no
visible heartbeat in TVUS AND - Serum b-hCG levels of ≤1,000 IU/L AND
- Able to return for follow up
What is the criteria to meet medical management of EP? [3]
Have no significant pain AND
* Unruptured tubal ectopic pregnancy measuring less than 35mm with no visible heartbeat in TVUS AND
* Serum b -hCG levels of ≤1,500 IU/L AND
* Able to return for follow up
Which patients require surgery for an ectopic pregnancy? [4]
This include those with:
* Pain
* Adnexal mass > 35mm
* Visible heartbeat
* HCG levels > 5000 IU / l
Describe the short term complications of a untreated ectopic pregnancy [2]
Tubal rupture:
- The most severe and life-threatening complication of ectopic pregnancy, tubal rupture occurs when the growing conceptus causes the fallopian tube to burst, leading to severe intraperitoneal haemorrhage.
- Usually occurs between 6-10 weeks gestation. Clinical manifestations include sudden, severe abdominal pain, signs of hypovolemic shock (tachycardia, hypotension, pallor), and peritoneal irritation.
- Prompt surgical intervention is crucial to prevent maternal mortality.
Haemoperitoneum:
- Bleeding into the abdominal cavity from trophoblast invasion.
- Internal bleeding due to ectopic pregnancy can lead to a significant accumulation of blood in the peritoneal cavity, causing hemodynamic instability and potential hypovolemic shock.
- Hemoperitoneum warrants immediate surgical intervention.
Describe the intermediate-term complications of an ectopic pregnancy [2]
Persistent trophoblastic tissue:
* Following treatment with methotrexate or surgical management, residual trophoblastic tissue may remain and continue to produce hCG.
* This can necessitate further medical or surgical intervention to ensure complete removal of the ectopic pregnancy
.
Infection:
- Post-surgical infection or an undiagnosed tubo-ovarian abscess may complicate ectopic pregnancy management, requiring antibiotic therapy or additional surgical procedures.
Explain the long-term complications of an ectopic pregnancy [3]
Damage to reproductive organs:
- Surgical intervention for ectopic pregnancy, particularly salpingectomy, can impact future fertility.
- Moreover, ectopic pregnancy itself increases the risk of subsequent ectopic pregnancies.
Rh sensitization:
- In Rh-negative women with an ectopic pregnancy, there is a risk of developing Rh isoimmunization.
- Administering Rh immunoglobulin prophylaxis is crucial to prevent complications in future pregnancies.
Describe the US findings of an ectopic pregnancy [3]
gestational sac containing a yolk sac or fetal pole may be seen in a fallopian tube
- A mass representing a tubal ectopic pregnancy moves separately to the ovary. The mass may look similar to a corpus luteum; however, a corpus luteum will move with the ovary
Features that may also indicate an ectopic pregnancy are:
* An empty uterus
* The tubal ring sign, also referred to as a bagel sign or blob sign, is one of the ultrasound signs of a tubal ectopic pregnancy.
* Fluid in the uterus, which may be mistaken as a gestational sac (“pseudogestational sac”)
What follow up management do all patients who require a salpignotomy require? [1]
What other management needs to be considered post-ectopic pregnancy? [1]
Patients who have required salpingotomy require weekly b-hCG measurements until negative. Approximately 1 in 5 will need further treatment
Anti-D Rhesus Prophylaxis - Rhesus D negative women may require anti-D rhesus prophylaxis if surgical management and/or repeated, heavy bleeding and/or pain
Define the following terms:
- hydatidiform mole
- complete mole
- partial mole
A hydatidiform mole:
- is a type of tumour that grows like a pregnancy inside the uterus. This is called a molar pregnancy. There are two types of molar pregnancy: a complete mole and a partial mole.
A complete mole:
- occurs when two sperm cells fertilise an ovum that contains no genetic material (an “empty ovum”).
- These sperm then combine genetic material, and the cells start to divide and grow into a tumour called a complete mole
- No fetal material will form.
A partial mole:
- occurs when two sperm cells fertilise a normal ovum (containing genetic material) at the same time.
- The new cell now has three sets of chromosomes.
- The cell divides and multiplies into a tumour called a partial mole.
- In a partial mole, some fetal material may form.
Molar pregnancy behaves like a normal pregnancy. Periods will stop and the hormonal changes of pregnancy will occur.
There are a few things that can indicate a molar pregnancy versus a normal pregnancy - what are they? [4]
There are a few things that can indicate a molar pregnancy versus a normal pregnancy:
* More severe morning sickness
* Vaginal bleeding
* uterus large for dates
* Abnormally high hCG
* Thyrotoxicosis (hCG can mimic TSH and stimulate the thyroid to produce excess T3 and T4)
How do you manage molar pregnancies? [3]
- Surgical evacuation of the uterus to remove the mole and histological confirmation
- Referral to to gestational trophoblastic disease centre for management and follow-up (hCG levels are monitored until they return to normal)
- If the mole metastasises, systemic chemotherapy may be required
What advice do you give about contraception following complete molar pregnancies? [1]
effective contraception is recommended to avoid pregnancy in the next 12 months
What is the difference between N&V and hyperemesis gravidarum? [3]
The RCOG guideline (2016) criteria for diagnosing hyperemesis gravidarum are “protracted” NVP plus:
* More than 5 % weight loss compared with before pregnancy
* Dehydration
* Electrolyte imbalance
Which scoring system can be used to assess HG severity? [1]
What are mild, moderate and severe scores? [3]
The severity can be assessed using the Pregnancy-Unique Quantification of Emesis (PUQE) score. This gives a score out of 15:
< 7: Mild
7 – 12: Moderate
> 12: Severe
Describe the mx of mild cases of HG
The following are all first line anti-emetics:
* Prochlorperazine (stemetil)
* Cyclizine
* Doxylamine and pyridoxine
* Promethazine
2nd line:
- Metoclopramide
- Ondansetron
NB: Initially select a 1st line antiemetic - Use a combination of drugs in women who do not respond to a single drug (synergistic effect) – add drugs rather than replacing them
Describe the different types of miscarriage [6]
Missed miscarriage
– the fetus is no longer alive, but no symptoms have occurred
Threatened miscarriage
– vaginal bleeding with a closed cervix and a fetus that is alive
Inevitable miscarriage
– vaginal bleeding with an open cervix
Incomplete miscarriage
– retained products of conception remain in the uterus after the miscarriage
Complete miscarriage
– a full miscarriage has occurred, and there are no products of conception left in the uterus
Anembryonic pregnancy
– a gestational sac is present but contains no embryo
Describe the presentation of:
* missed miscarriage [2]
* threatened miscarriage [2]
Missed miscarriage:
- no symptoms have occurred
- the cervix is closed
Threatened miscarriage:
- Vaginal bleeding +/- pain
- Closed cervical os
- Viable pregnancy
Describe the presentation of:
* inevitable miscarriage [2]
Inevitable miscarriage:
- vaginal bleeding
- open cervical os
- Progresses to an incomplete or complete miscarriage
