Obs & Gynae Flashcards
Ante-partum haemorrhage differentials
Implantation Ectopic Miscarriage Genital trauma/fissures/haemorrhoids Cervical ectropion or malignancy Placental abruption Placenta previa Vasa previa PID Labour
Typical presentation of implantation bleeding
Dark spotting with pink/brown tint 6-12 days after conception (around where the next period is expected), light and short lived
Pain in pregnancy differentials
Ectopic Miscarriage Placental abruption Labour Braxton Hicks Uterine rupture Ovarian torsion/haemorrhage/rupture Appendicitis IBD/IBS Pre-eclampsia Round ligament pain/symphysis pubis dysfunction
Risk factors for miscarriage
Smoking Increased maternal/paternal age Multiple pregnancy Cervical insufficiency Stress Previous TOP Previous miscarriage Alcohol Assisted conception Chronic illness - thyroid, DM Uterine malformations Fibroids High BMI
Causes of cervical insufficiency
LLETZ Previous obstetric cervical trauma - e.g. tear Previous D+C Hypermobility syndromes Cervical damage during emergency CS Genetically weak/short cervix
USS diagnosis of miscarriage
a) CRL of 7mm or more with NO fetal heart beat
b) Mean gestational sac diameter of 25mm with no yolk sac or embryo
How can hCG and progesterone levels aid diagnosis of miscarriage
hCG should double every 48hrs in the first 10 weeks - if its not or is falling this suggests miscarriage
Progesterone <20 suggests failing pregnancy
Progesterone >25 likely to predict viable pregnancy
Progesterone >60 strongly suggests viable pregnancy
What hCG level is needed for transvaginal USS to be able to visualise the gestational sac, and roughly how many weeks gestation does this correlate to
hCG >1500
Roughly 5 weeks gestation
What is a threatened miscarriage
Vaginal bleeding but cervical os is closed and USS shows viable pregnancy
What % of threatened miscarriages carry to term
90%
What is an inevitable miscarriage
Vaginal bleeding +/- cramping
Cervical os is open but no POC have passed yet
What is an incomplete miscarriage
Heavy and increased bleeding and pain and some POC have passed
Cervical os is open and some POC have passed but some tissue remains in uterus
What is a complete miscarriage
POC have been passed
Cervical os is closed
USS shows empty uterine cavity
What is a missed miscarriage
A non-viable pregnancy has remained in the uterus
No bleeding or pain
Cervical os closed
No POC passed
What is a blighted ovum
A missed miscarriage where embryonic development stopped before the embryonic pole was visible. The gestational sac may continue to grow
What is a septic miscarriage
Miscarriage + sepsis - fever, significant abdo pain
What is recurrent miscarriage
3 or more miscarriages
Describe the expectant management of a miscarriage
Can be days-weeks before miscarriage begins Bleeding can continue for several weeks May pass POC or may be reabsorbed (in which case not much bleeding) Follow up in 7-10 days 60-80% miscarriage 1% infection 2% haemorrhage Risk of retained tissue
Describe the medical management of a miscarriage
Can be done as outpatient or inpatient Mifepristone blocks progesterone (stops pregnancy hormones) Misoprostol (prostaglandin) leads to uterine contractions + cervical effacement causing passage of POC and bleeding/cramping 80-90% effective 1% infection 2% haemorrhage Follow up in 7 days Bleeding/pain may last up to 3 weeks
Describe the surgical management of a miscarriage
Dilation and curettage (D&C) - dilate cervix and remove uterine contents +/ part of lining
Risks - infection, Ashermans syndrome (adhesions), uterine perforation, VTE, retained products, GA risks, 1in30,000 require hysterectomy
Indications = haemodynamically unstable, excessive bleeding, infected retained tissue, suspected molar pregnancy, unsuccessful expectant/medical management
What findings would make you consider a molar pregnancy (hydatidiform mole)
Hyperemesis
Abdo large for gestational age
Really raised hCG
PV bleeding
Where can an ectopic pregnancy implant and which is the most common of these
Most common is ampulla of fallopian tube Can implant anywhere along the fallopian tube Ovaries Interstitium of uterus Cervical
Risk factors for ectopic pregnancy
PID Previous OBGYN surgery Previous ectopic Endometriosis Smoking Previous tubal ligation
What is the % risk of recurrence of ectopic pregnancy
10%
Describe conservative/expectant management of an ectopic pregnancy
Only if <6 weeks and minimal sx
Measure hCG every 48hrs until it starts to fall then weekly until its less than 15
Describe the medical management of an ectopic pregnancy
IM Methotrexate
hCG measured on day 4 and day 7 - may need second dose
Need to use reliable contraception for 3 months afterwards
Side effects of methotrexate
Conjunctivitis
Stomatitis
Diarrhoea
Abdo pain
Describe the surgical management of an ectopic pregnancy
If symptomatic or unstable
Laparoscopic salpingectomy or salpingotomy OR Laparotomy
When you would manage an ectopic with a) salpingectomy b) salpingotomy
Salpingectomy is other tube is health
Salpingotomy if other tube not healthy
Salpingotomy has higher risk of leaving tissue and of future ectopics
Can try for another baby as soon as bleeding stops and feel ready
Describe the scans involved if found to have placenta praevia
If at 20-23 weeks placenta is completely covering the cervix then 11% will still be covering at 32-36weeks
Re-scan at 32 and 36weeks - of those still covering at 32-36 weeks 90% will still be covering at delivery. This would mean need to have a CS.
So if 20wk scan shows low lying placenta need another scan at 32 and another at 36 – these scans are transvaginal as more accurate.
