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Year 4 > Obstetrics 1 > Flashcards

Obstetrics 1 Flashcards

1
Q

What is a miscarriage and what are the classifications?

A
  • Miscarriage is a spontaneous termination of pregnancy
  • <12 weeks: early
  • 12-24 weeks: late
  • > 24 weeks: stillbirth
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2
Q

What are the types of miscarriage?

A
  • Missed (no symptoms
  • Threatened (bleeding, closed cervix, foetus alive)
  • Inevitable (bleeding, open cervix)
  • Incomplete (RPOC)
  • Complete (no RPOC)
  • Anembryonic (sac present but no embryo)
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3
Q

What are the chances of miscarriage occurring at different ages?

A
  • 20-30: 10%
  • 30-35: 15%
  • 35-40: 25%
  • > 40: 50%
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4
Q

How is miscarriage diagnosed?

A
  • Transvaginal US
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5
Q

What is looked for on transvaginal USS in miscarriage?

A
  • Mean sac diameter
  • Crown-rump length
  • Foetal heartbeat
  • Once 1 is present the use of the other diminishes
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6
Q

When to expect each finding on TVUS?

A
  • Mean sac of >25mm should see foetal pole (if empty sac rescan in 1 week, if still empty then an embryonic)
  • Crown-rump length of >7mm should see foetal heartbeat (if not then rescan in 1 week, if still can’t be seen then pregnancy not viable)
  • Won’t see anything before 6 weeks
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7
Q

How is miscarriage managed before 6 weeks?

A
  • If no pain and complications then expectant management
  • Do pregnancy test 10 days later
  • If bleeding or pain then investigate
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8
Q

How is miscarriage managed >6 weeks?

A
  • Refer to EPAU for USS
  • Expectant
  • Medical
  • Surgical
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9
Q

Expectant management of miscarriage after 6 weeks?

A
  • First line in healthy women with no complications
  • Give 2 weeks
  • Retest in 3 weeks
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10
Q

Medical management of miscarriage after 6 weeks?

A
  • Misoprostol (prostaglandin analogue that softens cervix and causes contractions)
  • Side effects include bleeding, pain, diarrhoea and vomiting
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11
Q

What is the surgical management of miscarriage after 6 weeks?

A
  • MVA (outpatient procedure done under local; appropriate for pre-10 week and multiparous women)
  • EVA (requires general anesthetic)
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12
Q

Incomplete miscarriage and treatment?

A
  • Infection risk from RPOC
  • Can be managed medically
  • Surgery is MVA and curettage (risk of post-curettage endometritis)
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13
Q

What should miscarriages be investigated?

A
  • 3 consecutive first trimester miscarriages
  • Any second trimester miscarriage
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14
Q

What are some causes of miscarriage?

A
  • Idiopathic
  • Chromosomal abnormality
  • Bleeding disorders (inherited thrombophilias or antiphospholipid syndrome)
  • Chorionic histolytic intervillositis
  • Uterine abnomalities
  • DM, thyroid and SLE
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15
Q

Chromosomal abnormalities and miscarriage?

A
  • 50-60% or miscarriage
  • Trisomy most common cause (trisomy 16)
  • Turner’s is most common specific abnormality
  • Aneuploidy risk increases with age
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16
Q

Antiphospholipid syndrome?

A
  • Primary or secondary to SLE
  • APL or anticardiolipin antibodies
  • Give LMWH and aspirin in pregnancy
17
Q

What is the most common inherited thrombophilia and how is it inherited?

A
  • Factor V Leiden (activated protein C resistance)
  • Autosomal dominant
18
Q

Chorionic histiocytic intervillositis?

A
  • Rare but most common in T2
  • Histiocyte and macrophage buildup in placenta
  • This causes inflammation and poor outcomes
  • Diagnosis: placental histology showing mononuclear cell infiltrate
19
Q

How do you investigate the possible causes of recurrent miscarriage?

A
  • Antibodies (antiphospholipid syndrome)
  • Pelvic USS (uterine abnormalities)
  • Genetic testing of foetus or parents with consent (chromosomal abnormality, Factor V Leiden)
20
Q

What 2 acts are relevant to TOP?

A
  • 1967 Abortion Act
  • 1990 Human Fertilisation and Embryo Act (reduced legal age from 28 to 24 weeks)
21
Q

What is the criteria for allowing abortion before 24 weeks?

A

Continuing must present cause of significant harm to physical or mental health of the mother or unborn child

22
Q

What is the criteria for abortion after 24 weeks?

A
  • Significant risk to life of woman
  • Child likely to be born with severe disability
  • Prevent significant harm to woman’s physical or mental health
23
Q

What are the aspects of pre-abortion care?

A
  • Can be referred by self, GP, or GUM clinic
  • Marie stopes is UK charity that offer remote service pre-10 weeks
  • Offer counselling
24
Q

What its the medical management of abortion?

A
  • Mifepristone (anti-progesterone; halts pregnancy)
  • Misoprostol 2 days later (prostaglandin analogue that softens cervix and causes contractions)
  • Must give anti-D prophylaxis if before week 10
25
Q

What is the surgical management of abortion?

A
  • Priming with mifepristone, misoprostol, and dilation
  • <14 weeks: dilation and suction
  • > 14 weeks: dilation and forced evacuation
  • Must give anti-D regardless of gestation
26
Q

Post-abortion?

A
  • Bleeding and cramps for 2 weeks
  • Pregnancy test at 3 weeks
  • Bleeding, pain, infection, TOP failure and damage to structures are risk
27
Q

Where are most ectopic pregnancies?

A
  • 97% are tubal
  • Most are in the ampulla
  • Isthmus is most dangers
28
Q

What are the risk factors for ectopic pregnancy?

A
  • Previous ectopic, PID, STI or Fallopian tube surgery
  • Intrauterine coil
  • Smoking
  • IVF
  • Old age
29
Q

Presentation of ectopic?

A
  • 6-8 weeks gestation (missed LMP
  • Lower abdo pain in IF
  • Bleeding
  • CMT
  • Shoulder tip pain
  • Syncope and dizziness from bleeding
30
Q

Investigation of ectopic pregnancy?

A
  • TVUS will show gestational sac outside of uterus (if can’t be seen this pregnancy of unknown location)
  • Ectopic moves independently to ovary (if move together will be corpus luteum)
31
Q

What is the management of ectopic?

A
  • Expectant
  • Medical
  • Surgical
32
Q

What is the medical management of ectopic pregnancy?

A
  • Methotrexate IM buttock
  • Can’t get pregnant for 3 months
33
Q

What are the surgical options for ectopic?

A
  • Salpingectomy (better, removal of whole tube)
  • Salpingotomy (less definitive, ⅕ women will need methotrexate;
    done if other tube damaged/ removal of tube leaves infertile)
  • Need anti-D phophylaxis
34
Q

What criteria must be met for an expectant TOP of ectopic?

A
  • Unruptured
  • No pain
  • Sac <35mm
  • No heartbeat
  • HCG <1500
35
Q

What criteria must be met for medical TOP of ectopic?

A
  • Unruptured
  • No pain
  • Sac <35mm
  • No heartbeat
  • HCG <5000
  • USS evidence of non-intrauterine pregnancy
36
Q

What criteria must be met for medical TOP of ectopic?

A
  • If ruptured
  • If painful
  • > 35mm
  • Heartbeat present
  • HCG >5000
37
Q

What is pregnancy of unknown location?

A

When gestational sac can’t be seen on TVUS

38
Q

How is pregnancy of unknown location investigated?

A
  • 2 HCG tests 48 hours apart
  • Rise of >63% suggests intrauterine pregnancy
  • Rise <50% is likely ectopic, admit
  • Fall <50% likely miscarriage, recheck in 2 weeks

Year 4 (16 decks)

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