Obstetrics and Gynaecology 4 Flashcards
How should you counsel a women after miscarriage?
1) women should be told it was not the result of anything they did or did not do and could not have been prevented
2) Reassurance as to the high chance of success of further pregnancies
3) Miscarriage is relatively common so investigation for those with 3+ and those after 12 weeks gestation.
Mark schemes include: Introduction confirm patient details convey empathy check understanding of diagnosis confirmed/inform diagnosis asks relevant hx including prev pregnancies offers another scan but avoids false reassurance advises conservation, medical and surgical management offers opportunities for thinking time offers opportunities for questions offers repeat appointment offers information leaflets
What is recurrent miscarriage?
When 3 or more miscarriage occur in succession, the 4th pregnancy has a 40% chance of miscarriage but still investigations are required.
What is an ectopic pregnancy?
Where are the locations?
Pathology?
Where the embryo implants outside the uterine cavity
Occurring in 11.1/1000
Fallopian tube (95%) cornual ectopic (interstitial) cervical ovarian intra-abdominal
There can be an heterotrophic pregnancy where a ectopic is also in the presence of an intra-uterine pregnancy.
The thin walled tube cannot support the invading trophoblast and may cause catastrophic blood loss.
What signs and symptoms predict ectopic pregnancy?
Suspect in women who are pregnancy, or have symptoms of pregnancy (amenorrhoea, missed period, breast tenderness) w/
Common:
- abdominal or pelvic pain(may be colicky then constant)
- vaginal bleeding with or without clots
Less common:
- gastrointestinal symptoms
- dizziness fainting or syncope
- shoulder tip pain
- urinary symptoms
- passage of tissue
- rectal pressure or pain on defecation
O/e
- Cervical excitation pain
- don’t examine the adnexa as you may rupture the ectopic [NICE]
Confirm with a pregnancy test!
-
What are the risk factors for ectopic pregnancy?
- Previous ectopic pregnancy
- Pelvic Inflammatory Disease
- Appendicitis
- Assisted conception
- previous pelvic surgery
- smoking
- Cooper IUD
What are the investigations for ectopic pregnancy
History
Examination - Primary care
TA TV Ultrasound
What are the investigations for ectopic pregnancy
History
Examination - Primary care
Pregnancy test
TA TV Ultrasound
Quantitative serum HCG
Laparoscopy
What is the management for ectopic pregnancy?
Admission Intravenous access - with FBC, group and save, Cross-Match Anti-D if rhesus negative (250 IU) NIL by mouth if prep for surgery.
Surgical: (salpingostomy - removal of the ectopic from the tube or salpingectomy - removal of the whole tube)
Suitable when the hCG is >5000 iu/L, adnexal mass >3.5 cm, fetal heart beat visible and significant pain.
- Consider risk of recurrent ectopics (1 in 5 may need further treatment anyway) or fertility in either case.
Medical:
Suitable when hCG is <1500 iu/L, adnexal mass < 3.5 cm and no significant pain.
-Methotrexate
- serial hCG
- long follow up via EPAU until hCG is negative, drop of >15% each visit is necessary
- counselling
Either is suitable when the women is asymptomatic
Conservative/ Expectant management:
Suitable in asymptomatic women whom have hCG < 1000 iu/L and a small adnexal mass of 2cm or less.
Follow up in EPAU until hCG is <25 IU/mL
At what gestation is a fetus visible on ultrasound?
Normally 5 weeks for an intra-uterine pregnancy.
What test should be done 6 - 8 weeks postpartum?
TFT - to check for postpartum thyroiditis.
What are the complications of hyperthyroidism in pregnancy?
- A increased risk of:
- Miscarriage
- Pre-eclampsia
- pre-term delivery
- intrauterine growth restriction
- low birthweight
- fetal death
- TSH ABs can cross the placenta
- heart failure
- osteoporosis
