Obstetrics Flashcards
What is an ectopic pregnancy?
Implantation of a fertilised ovum outside the uterus
typical history of ectopic pregnancy
explain too
6-8 wk hx amenorrhoea present with lower abdo pain and later vaginal bleed
lower abdo pain:
- tubal spasm
- 1st sx
- constant unilateral (right or left iliac fossa)
vaginal bleed:
- less than normal period
- dark brown
hx of recent amenorhoea
- 6-8 weeks
- if longer - inevitable abortion?
peritoneal bleeding: shoulder tip pain and pain on defecation/urination
dizziness
fainting
syncope
sx of pregnancy poss like breast tenderness
what would you find in an examination in ectopic pregnancy?
abdo tenderness
cervical excitation
adnexal mass: dont examine for it though theres a risk of rupturing pregnancy.
do pelvic exam for cervical excitation.
in a pregnancy of unknown location what serum bhcg level points towards a diagnosis?
over 1500
risk factors of ectopic pregnancy
damage to tubes like through pelvic inflammatory disease, surgery
previous ectopic
endometriosis
IUCD
progesterone only pill
IVF
smoking
intrauterine devices - coils
pathophysiology of ectopic pregnancy
how can it end up? 3 ways
which 2 are dangerous
and its side effect
97% tubal - most in ampulla. more dangerous in isthmus.
3% in ovary,cervix or peritoneum
trophoblast invades tubal wall, produce bleeding - dislodge the embryo poss
mc - absorption or abortion
tubal abortion - move to abdo cavity - can cause internal bleeding
tubal absorption - tube dont rupture, blood and embryo shed or converted into tubal mole and absorbed
tubal rupture - internal bleed
ix for ectopic pregnancy
transvaginal uss
pregnancy test - positive
poss see gestational sac - yolk sac or fetal pole.
sometime non specific mass. (blob/bagel/tubal ring sign)
how would you manage ectopic pregnancy
if hcg is 1500 or less - methotrexate im to the buttock. (teratogenic) - dont get pregnant for 3 months.
if hcg is over 5000, visible fetal heartbeat, pain, can be ruptured, size is over 35mm : surgical management - salpingectomy 1st line (if not risk for infertility) or salpingotomy ( if infertility risk like 1 tube damage already)
if they do salpingotomy theyll prob still need methotrexate and/or salpingectomy
hcg levels and associated pregnancy
repeat after 48 hrs
rise of over 63% after 47 hrs = intrauterine pregnancy. pregnancy should be visible after its more than 1500.
rise of less than 63% could be ectopic.
fall of more than 50% is miscarriage. do urine pregnancy test after 2 weeks to confirm.
common side effects to methotrexate
vaginal bleeding
n+v
abdo pain
stomatitis - inflammation of mouth
what prophylaxis is given to surgical mx of ectopic pregancy pts?
anti-rhesus d prophylaxis
what is miscarriage?
early
late
spontaneous termination of pregnancy
before 12 weeks gestation.
12-24 weeks
definitions in miscarriage
missed
threatened
inevitable
incomplete
complete
anembryonic
missed - fetus not alive - no sx - dead fetus in gestiational sac before 20 weeks. light bleed vaginal poss.
threatened - vaginal bleed. closed cervix. alive fetus painless
inevitable - heavy vaginal bleed clots and pain . open cervix.
incomplete: retained conception products - still in uterus post miscarriag.
complete: full miscarriage. no products.
anembryonic - gestational sac no embryo
how would you investigate for miscarriage?
3 features sonographer looks for in early pregnancy
transvaginal uss
mean gestational sac diameter
fetal pole and crown rump length
fetal heartbeat
talk to me about viability of pregnancy with regards to 3 features
when is fetal heartbeat expected?
when do you expect fetal pole
fetal heartbeat visible = viable pregnancy.
heartbeat expected when crown rump length 7mm or more.
if crown rump less than 7 and no heartbeat, repeat 1 week later to see heartbeat - if not its non viable.
fetal pole expect once mean gestational sac diameter is 25mm or more. if its this without fetal pole repeat after 1 week before confirming anembryonic pregnancy.
How would you manage miscarriage?
less than 6 weeks with bleeding but no pain or comps: expectant management.
repeat urine pregnancy test after 7-10 days, to confirm.
if more than 6 weeks:
uss. - confirm location and viability.
expectant
medical - misoprostol
surgical
explain expectant management in miscarriage
first line without rf for heavy bleeding or infection.
repeat urine pregnancy - 3 weeks after bleeding and pain settle.
risk factors for miscarriage
advanced maternal age, over 35
hx of previous miscarriage
previous large cervical cone biopsy
lifestyle: smoking, alcohol, obesity
meds: uncontrolled diabetes, thyroid
chromosomal abnormalities: 50% of early miscarriages.
medical management for miscarriage
missed miscarriage:
oral mifepristone - progesterone receptor antagonist - weakens attachement to endometrial wall and causes cervical softening and dilation and induces uterine contractions.
48 hrs later: misoprostol - vaginal oral or sublingual - unless gestational sac already passded.
prostaglandin analogue - binds to myometrial cels - strong myometrial contractions - expulsion of products of conception.
incomplete:
- single dose of misoprostol
antiemetics and pain relief
pregnancy test at 3 weeks
surgical management for miscarriage
vaccuum aspiration - suction curettage - local anaesthetic
surgery: general - evacuation of retained products of conception - electric vacuum.
key side effects of misoprostol
heavier bleeding
pain
vomiting
diarhoea
key complication of electrical vaccum of retained products of conception
endometritis - infection of endometrium after procedure
recurrent miscarriage defined as?
causes
3 or more consecutive spontaneous abortions.
antiphospholipid syndrome
hereditary thrombophilia
endo : poorly controlled dm/thyroid. pcos
sle
uterine abnormality: uterine septum
parental chromosomal abnormality
chronic histiocytic intervillositis
smoking
how does antiphospholipid syndrome related to miscarriage and what is it?
what hx should i be thinking?
how to reduce risk?
disorder of antiphospholipid antibodies - blood prone to clotting.
hypercoagulable state.
thrombosis.
can occur evai or secondary to sle.
reduce risk by :
low dose aspirin
LMWH
hx of reccurent miscarriages.
pmh of dvt.