Obstetrics Flashcards
Missed miscarriage
the uterus still contains foetal tissue, but the fetus is no longer alive.
the woman is asymptomatic so does not realise something is wrong.
The cervical os is closed
Threatened miscarriage
vaginal bleeding with a closed cervix and a fetus that is alive,the cervical os is closed. There may be little or no pain
Inevitable miscarriage
often heavy vaginal bleeding and pain with an open cervix.foetus is currently intrauterine but the cervical os is open
Incomplete miscarriage
retained products of conception remain in the uterus after the miscarriage
Complete miscarriage
full miscarriage has occurred, and there are no products of conception left in the uterus.The os is usually closed.The patient may have been alerted to the miscarriage by pain and bleeding.
Cause of miscarriage
Embryo chromosomal abnormalities
Endocrine factors - PCOS, poor diabetes, thyroid dysfunction
Immunological causes autoimmune/alloimmune
Uterine anomalies
Cervical incompetence
Infections
unexplained
Risk factors for miscarriage
Previous miscarriage
Age
Occupational and environmental factors (such as heavy metals, pesticide, high dose radiation, and lack of micronutrients)
Advanced paternal age
Lifestyle factors, such as stress, obesity, and smoking
Cervical trauma is a second trimester risk
Radiation
Clinical presentation miscarriage
Pain
Vaginal bleeding
Vaginal discharge
Discharge of tissue from vagina
No longer experiencing symptoms of pregnancy like sickness and breast tenderness
Miscarriage Ix
transvaginal ultrasound scan
looking for
- Mean gestational sac diameter
- Fetal pole and crown-rump length
- Fetal heartbeat
Serial serum hCG measurements 48 hours apart can help give an indication of the location and prognosis of the pregnancy
Repeated HCG indicating miscarriage
A fall of more than 50%
Repeated HCG indicating intrauterine pregnancy
A rise of more than 63% after 48 hours
Repeated HCG indicating indicating ectopic
A rise of less than 63% after 48 hours
Less Than 6 Weeks Gestation
miscarriage mx
expectant if no pain or other risk factors
A repeat urine pregnancy test is performed after 7 – 10 days, and if negative, a miscarriage can be confirmed
More Than 6 Weeks Gestation
miscarriage mx options
expectant
medical (misoprostol)
surgical
Misoprostol MOA
prostaglandin analogue
soften the cervix and stimulate uterine contractions
Surgical mx of miscarriage
manual vacuum aspiration (<10w g)
Electric vacuum aspiration
Prostaglandins (misoprostol) are given before surgical management to soften the cervix
Ix for recurrent miscarriage
Antiphospholipid antibodies
Cytogenetics analysis Genetic testing of the products of conception from the third or future miscarriages
Genetic testing on parents, Parental blood karyotyping
Pelvic USS - uterine anatomy
Inherited thrombophilias
The four major sources of bleeding in early pregnancy are
- Ectopic pregnancy.
- Miscarriage (threatened, inevitable, incomplete, complete).
- Implantation of the pregnancy.
- Cervical, vaginal, or uterine pathology (eg, polyps, inflammation/infection, trophoblastic disease).
Ectopic pregnancy
pregnancy is implanted outside the uterus. The most common site is a fallopian tube
Risk factors for ectopic pregnancy
PID
Genital infection e.g. gonorrhoea
Pelvic surgery
Having an intrauterine device e.g. copper coil or Levonorgestrel-releasing intrauterine system (e.g. Mirena©) in situ
Assisted reproduction e.g. IVF
Previous ectopic pregnancy
Endometriosis
Smoking
older age
Clinical presentation ectopic
typically presents around 6 – 8 weeks gestation
Pelvic iliac fossa pain may be unilateral
Shoulder tip pain
Abnormal vaginal bleeding
Haemodynamic instability caused by blood loss if the ectopic ruptures
D &V
Abdominal examination may reveal unilateral tenderness
Cervical tenderness (chandelier sign) on bimanual examination
options for ectopic pregnancy mx
Expectant management (awaiting natural termination)
Medical management (methotrexate)
Surgical management (salpingectomy or salpingotomy)
Conservative mx ectopic pregnancy
criteria
Follow up needs to be possible to ensure successful termination
The ectopic needs to be unruptured
Adnexal mass < 35mm
No visible heartbeat
No significant pain
HCG level < 1500 IU / l
Medical mx ectopic pregnancy
one-off dose of methotrexate
criteria
same as expectant management, except:
HCG level must be < 5000 IU / l
Confirmed absence of intrauterine pregnancy on ultrasound
Surgical Mx for an advanced ectopic pregnancy
An advanced ectopic is suspected if any of the following are present:
The patient is in a significant amount of pain
There is an adnexal mass of size ≥35mm
B-hCG levels are ≥5000IU/L
Ultrasound identifies a foetal heartbeat
complete mole
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
partial mole
two sperm cells fertilise a normal ovum (containing genetic material) at the same time. The new cell now has three sets of chromosomes (it is a haploid cell). The cell divides and multiplies into a tumour
Clinical presentation of molar pregnancy
More severe morning sickness
Vaginal bleeding, especially in first of early second trimester
Increased enlargement of the uterus
Abnormally high hCG
Thyrotoxicosis
US findings molar pregnancy
“snowstorm appearance” of the pregnancy.resulting from the presence of a complex vesicular intrauterine mass containing many ‘grape-like’ cysts
Mx molar pregnancy
evacuation of the uterus to remove the mole
histological examination to confirm a molar pregnancy
hCG levels are monitored until they return to normal
Occasionally the mole can metastasise, and the patient may require systemic chemotherapy
abortion can be performed before 24 weeks if
continuing the pregnancy involves greater risk to the physical or mental health of:
The woman or
Existing children of the family
An abortion can be performed at any time during the pregnancy if:
Continuing the pregnancy is likely to risk the life of the woman
Terminating the pregnancy will prevent “grave permanent injury” to the physical or mental health of the woman
There is “substantial risk” that the child would suffer physical or mental abnormalities making it seriously handicapped
Marie Stopes UK
charity that provides abortion services. They offer a remote service for women less than 10 weeks gestation, where consultations are held by telephone and medication are issued remotely to be taken at home.
Medical abortion
Mifepristone (anti-progestogen,blocks the action of progesterone, halting the pregnancy and relaxing the cervix)
Misoprostol (prostaglandin analogue) 1 – 2 day later
Surgical abortion
first medications are used for cervical priming (softening and dilating the cervix with misoprostol, mifepristone or osmotic dilators)
then suction of the contents of the uterus (usually up to 14 weeks)
or
evacuation using forceps (between 14 and 24 weeks)
First line anti emetics in pregnancy
cyclizine, prochlorperazine or promethazine.
Congenital rubella syndrome features
affects the developing foetus, most commonly causing deafness, eye abnormalities and congenital heart defects.
congenital toxoplasmosis
Infected mothers may be asymptomatic or have mild flu-like symptoms. Early infection with toxoplasma can lead to congenital toxoplasmosis, a severe condition typically presenting with hydrocephalus, seizures, visual and hearing impairment
Reproductive health and HIV
Caesarean section should be used unless the mother has an undetectable viral load =????
a ???? infusion should be started four hours before beginning the caesarean section
Caesarean section should be used unless the mother has an undetectable viral load, less than 50 copies/ml at 36 weeks.
a zidovudine infusion should be started four hours before beginning the caesarean section.
Newborns to HIV positive mothers should receive ART for 4 weeks after birth to reduce the risk of vertical transmission.zidovudine is usually administered orally to the neonate if maternal viral load is <50 copies/ml.Otherwise triple ART should be used.
dizygotic twins
Fertilization of two separate eggs with two separate sperm
Twin-Twin Transfusion Syndrome
occurs when the fetuses share a placenta
The recipient gets the majority of the blood, and can become fluid overloaded, with heart failure and polyhydramnios. The donor has growth restriction, anaemia and oligohydramnios
Delivery for Monoamniotic twins
require elective caesarean section at between 32 and 33 + 6 weeks.
delivery for dichorionic twin pregnancy
Women with dichorionic twin pregnancies should be offered elective birth from 37 weeks 0 days
delivery for monochorionic twin pregnancy
c section 36 w
gestational age
refers to the duration of the pregnancy starting from the date of the LMP
Gravida
is the total number of pregnancies a woman has had
Para
number of times the woman has given birth after 24 weeks gestation, regardless of whether the fetus was alive or stillborn
first trimester
start of pregnancy until 12 weeks gestation
second trimester
13 weeks until 26 weeks gestation
third trimester
27 weeks gestation until birth
Preconception Lifestyle advice
folic acid supplementation (400 micrograms/day), ideally at least 3 months before conception and continue until at least 12 weeks’ gestation
vit d
avoid alcohol and smoking
Whooping cough (pertussis) from 16 weeks gestation and Influenza (flu) vaccine available
Live vaccines, such as the MMR vaccine, are avoided in pregnancy
avoid unpasteurised milk, soft cheeses, raw or undercooked meat, poultry, and shellfish
can fly safely until 36 weeks’ gestation
Features of congenital varicella syndrome include:
Low birth weight
Limb hypoplasia
Skin scarring
Microcephaly
Eye defects
Learning disability
If a non-immune pregnant woman comes into contact with someone infected with varicella zoster
immunoglobulin can be given as prophylaxis.
if more than 20w g then can also give acyclovir
timepoints for routine anti D prophylaxis
offered to all non‑sensitised pregnant women who are rhesus D‑negative between 28 and 34 weeks
booking test
8-10w
The visit includes BP, urine dipstick, BMI check. Bloods include FBC, blood group, Rhesus status, red cell alloantibodies, hepatitis B, syphilis, rubella, HIV test is offered, and urine culture
Anomaly scan
18-20 +6w
evaluates anatomical structures of the foetus, placenta, and maternal pelvic organs
combined test
offered in the first trimester to assess the chance of the baby having Down’s syndrome, Edwards’ syndrome or Patau’s syndrome
nuchal translucency ( higher result= greater risk) beta‑human chorionic gonadotrophin, pregnancy‑associated plasma protein‑A ( lower result= greater risk)
happens between 11-13 w
triple or quadruple test
offered between 14 weeks and 20 weeks
1. b-hcg (higher is increased risk)
2. Alpha-fetoprotein (AFP) (lower result= greater risk
3. Serum oestriol (female sex hormone) (lower result =greater risk)
4. for quadruple test, add inhibin A (higher result= greater risk)
Chorionic villus sampling
involves an ultrasound-guided biopsy of the placental tissue. This is used when testing is done earlier in pregnancy (before 15 weeks).
Amniocentesis
involves ultrasound-guided aspiration of amniotic fluid using a needle and syringe. This is used later in pregnancy once there is enough amniotic fluid to make it safer to take a sample.
