Obstetrics: Early Pregnancy Flashcards
What is an ectopic pregnancy?
Where is most common place for ectopic pregnancy?
- Pregnancy is implanted outside uterus
- Most common site= ampulla of fallopian tube
(but may occur in cornual region [entrance to fallopian tube], ovary, cervix or abdomen. Most dangerous if in isthmus of fallopian tube)
State some risk factors for ectopic pregnancies
- Previous ectopic pregnancy
- Previous pelvic inflammatory disease
- Previous surgery to the fallopian tubes
- Older age
- Smoking
- Endometriosis
- IUCD
- POP
- IVF
What is the leading cause in UK of ectopic pregnancy?
Chlamydia related PID
When, following conception, does ectopic pregnancy usually present?
6-8 weeks gestation
Describe typical presentation of ectopic pregnancies
- Lower abdominal pain
- Usually constant
- May be unilateral in R or L iliac fossa
- Missed period
- Vaginal bleeding (may be dark brown in colour- like prune juice. Less than normal period)
- Dizziness or syncope (blood loss)
- Shoulder tip pain (if have blood in peritoneum causing peritonitis)
- Lower abdominal or pelvic tenderness
- Cervical motion tenderness (pain when moving the cervix during a bimanual examination. In teaching, Miss Malik said it is pain when you move the cervix towards side of pathology it causes pain- CHECK)
What is the investigation of choice for diagnosing an ectopic pregnancy (if you have a positive pregnancy test)?
Transvaginal ultrasound
(may also need FBC, group & save [including rhesus status])
What features on transvaginal ultrasound suggest an ectopic pregnancy?
May see:
- Gestational sac (containing yolk sac or fetal pole) in fallopian tube
- Empty gestational sac in fallopian tube- referred to as “blob sign”, “bagel sign” or “tubal ring sign”
- Mass that looks similar to corpus luteum but moves separately to the ovary
- Empty uterus
- Fluid in uterus (may be mistaken for gestation sac)
*NOTE: to distinguish between corpus luteum and mass that looks like corpus luteum: corpus luteum will move with the ovary, other mass will not
What advice, regarding contraception, should be given to women following ectopic pregnancy?
- Avoid IUCD
- Avoid POP
- If had medical management (methotrexate) must not get pregnant for 3/12
What is a pregnancy of unknown location?
State 3 potential diagnoses
Woman has positive pregnancy test but no evidence of pregnancy on ultrasound (cannot exclude ectopic hence need careful follow up).
Three differential diagnoses:
- Very early intrauterine pregnancy
- Ectopic pregnancy
- Miscarriage
What can be measured to monitor pregnancy of unknown location?
Discuss what certain results may indicate
Measure serum hCG. If initial hCG is >1500IU/l then considered ectopic pregnancy until proven otherwise and diagnostic laparoscopy should be offered. If initial hCG is <1500IU/l and pt is stable, repeat hCG 48hrs later.
Remember hCG is produced by syncytiotrophoblast and in an intrauterine pregnancy it will roughly double every 48hrs. Hence, repeat it 48hrs later to see how it has changed. HOWEVER, monitoring symptoms & clinical signs is more important and any change needs assessment.
- Increased >63% → indicates intrauterine pregnancy hence repeat ultrasound in 1-2 weeks (should see pregnancy on ultrasound once hCG is >1500IU/l)
- Increase <63% but <50% decrease → indicates ectopic hence need close monitoring and review
- Decrease >50% → indicates miscarriage. Do pregnancy test 2 weeks later to confirm.
A pregnancy test should be performed in all women of child bearing age with abdominal or pelvic pain to rule out ectopic pregnancy; true or false?
True
All ectopic pregnancies must be terminated. State the 3 management options for terminating an ectopic pregnancy
Women should be referred to an early pregnancy assessment unit (EPAU) or gynaecology service. Options for termination:
- Expectant management (wait for natural termination)
- Medical management (methotrexate injection)
- Surgical management (salpingectomy or salpingotomy)
State the criteria for expectant management of an ectopic pregnancy
- 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
What monitoring is required in expectant management of ectopic pregnancy?
Monitor serum hCG every 48hrs to ensure it is falling by greater than or equal to 50% of level until it falls to approx. <5IU/ml
State the criteria for methotrexate use to terminate an ectopic pregnancy
-
Same as for expectant management:
- 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 (but can be considered with values < 5000 IU / l)
- Confirmed absence of intrauterine pregnancy on ultrasound
For methotrexate (in regards to being used to terminate ectopic pregnancy), discuss:
- How it is given
- How it works
- Common side effects
- Advice you should give woman
- IM injection into buttock
- Halts progression of pregnancy & results in spontaneous termination. Methotrexate is highly teratogenic.
- Common side effects:
- Vaginal bleeding
- Nausea and vomiting
- Abdominal pain
- Stomatitis (inflammation of the mouth)
- Advise woman not to get pregnant for 6/12 following treatment as harmful effects of methotrexate on pregnancy can last that long (BNF SAYS 6/12)
If pt doesn’t meet criteria for expectant or medical management of ectopic pregnancy will require surgical management. Most patients are managed with medical management; true or false?
FALSE: most pts managed with surgical management
Women that don’t meet criteria for expectant or medical management includes those with:
- Pain
- Adnexal mass >35mm
- Visible heartbeat
- HCG >5000IU/l
Discuss the two options for surgical management of an ectopic pregnancy
Two options:
- Laparoscopic salpingectomy (first line): give GA, remove affected fallopian tube and ectopic pregnancy inside tube
- Laparoscopic salpingotomy: give GA, cut fallopian tube to remove ectopic pregnancy and then close fallopian tube (used in women with increased risk of subfertility due to damage to other tube)
Salpingotomy has higher risk of failure with 1 in 5 women needed further treatment with methotrexate or salpingectomy.
What must be given to rhesus negative women having surgical management of ectopic pregnancy?
Anti-rhesus D prophylaxis
Summary of ectopic pregnancy management
State some potential complications of ectopic pregnancies
- Complications of treatment
- Methotrexate ADRs
- Methotrexate teratogenic (risk if get pregnant in 3/12 after treatment)
- General surgery risks
- Risk of damage to surrounding structures
- Risk of infertility
- Fallopian tube rupture → hypovolaemic shock, organ failure, death
Define a miscarriage
Spontaneous loss of pregnancy before 24 weeks gestation
What is an early miscarriage?
What is a late miscarriage?
Which is more common?
- Early miscarriage: occurs before 13 weeks of gestation.
- Late miscarriage: occurs between 13 and 24 weeks of gestation
Early miscarriages are more common!
Define the following:
- Missed miscarriage
- Threatened miscarriage
- Inevitable miscarriage
- Incomplete miscarriage
- Complete miscarriage
- Anembryonic pregnancy
- Missed miscarriage – the fetus is no longer alive, but no symptoms have occurred
- Threatened miscarriage – vaginal bleeding with cervical os closed and a fetus that is alive
- Inevitable miscarriage – vaginal bleeding with cervical os open
- Incomplete miscarriage – retained products of conception remain in the uterus after the miscarriage, cervical os open
- Complete miscarriage – a full miscarriage has occurred, and there are no products of conception left in the uterus
- Anembryonic pregnancy – a gestational sac is present but contains no embryo (sometimes called blighted ovum)
Are miscarriages common?
~20% pregnancies
NOTE that risk of miscarriages increases with age (10% aged 20-30yrs to 50% aged 40-45yrs)
State some risk factors for miscarriage
- Maternal Age >30-35 (largely due to an increase in chromosomal abnormalities)
- Previous miscarriage
- Obesity
- Chromosomal abnormalities (maternal or paternal)
- Smoking
- Uterine anomalies
- Previous uterine surgery
- Anti-phospholipid syndrome
- Coagulopathies (e.g. antiphospholipid syndrome)
How may a miscarriage present?
- Main symptom is vaginal bleeding (could be passing clots or products of conception)
- Excessive bleeding may lead to haemodynamic instability (pallor, SOB, tachycardia)
- Associated pain
Miscarriages may also be picked up incidentally on ultrasound
What is the investigation of choice for diagnosing a miscarriage?
Transvaginal ultrasound
Other investigations may include:
- Serum hCG: if ultrasound not available can be useful for assessing possibility of ectopic
- FBC if bleeding
- Group & save
What are the 4 key features a sonographer looks for to assess viability of pregnancy?
The three features appear sequentially as pregnancy develops so as each appears previous feature becomes less relevant in assessing viability of pregnancy.
- Mean gestation sac diameter & fetal pole
- CRL & fetal heartbeat:
Interpreting the results
- If CRL is 7mm or more a fetal heartbeat is expected. If fetal heart rate visible, pregnancy considered viable. If no fetal heart beat detected when CRL is <7mm, repeat ultrasound at least 1/52 later to ensure heartbeat develops. If CRL ≥ 7mm and no fetal heartbeat, repeat scan in 1/52 to confirm non-viable pregnancy.
- Fetal pole expected once mean gestational sac diameter is ≥25mm. If fetal pole is not visible, but intrauterine pregnancy confirmed with gestational sac & yolk sac, management depends on measn gestational sac diameter:
- If MGSD ≥ 25mm and no fetal pole, can confirm non-viable/anembryonic pregnancy
- If MGSD <25mm and no fetal pole, repeat scan after 1/52
Discuss the management of a miscarriage at < 6 weeks gestation
- Manage with expectant management as long has have no pain, complications or other risk factors (e.g. previous ectopic)
- Repeat pregnancy test after 7-10 days
- If bleeding continues or pain occurs then further investigations required
What options are available for a miscarriage at more than 6 weeks gestation?
Three options:
- Expectant management (do nothing & await spontaneous miscarriage)
- Medical management (misoprostol)
- Surgical management
Who is expectant management of miscarriage offered to?
When should you repeat pregnancy test to confirm miscarriage?
What should you do if they have persistent or worsening bleeding?
- No risk factors for heavy bleeding or infection
- Repeat pregnancy test 3/52 after bleeding stopped
- Persistent or worsening bleeding requires further assessment (may indicate incomplete miscarriage)
For misoprostol, used as medical management of miscarriage, discuss:
- Mechanism of action
- How it is given
- Side effects
- Follow up
- Prostaglandin analogue → binds to prostaglandin receptors & activates them. Prostaglandins soften cervix and stimulate uterine contractions.
- Vaginal suppository **ZtF says can give oral aswell but others say vaginal????
- Side effects:
- Heavier bleeding
- Pain
- Vomiting (prescribe antiemetic)
- Diarrhoea
- Follow up pregnancy test 3/52 later
**NOTE: inform woman she should contact doctor if bleeding not started in 24hrs. Give antiemetics & analgesia
Discuss the surgical management options for miscarriage- include when each is more suitable
Two options:
- Manual vacuum aspiration with LA: apply LA to cervix, uses syringe with tube attached to manually aspirate contents of uterus. Suitable
- Evacuation retained products conception/surgical management: in theatre, under GA, widen cervix using dilator allowing suction tube to be passed into uterus to remove products of conception
- **Manual vacuum aspiration more suitable for parous women and woman must be <10 weeks gestation (ZtoF) or <12 weeks gestation (PassMed)*
- **Depending on circumstances, some women may need misoprostol on morning to help dilate cervix (e.g. if not had vaginal delivery previously)*
Which women having a miscarriage require anti-rhesus D prophylaxis?
- Any rhesus negative woman having surgical management of miscarriage (regardless of gestation)
- Any rhesus negative woman >12 weeks gestation
What is the main risk associated with incomplete miscarriage?
Retained products of conception create risk of infection
Discuss the management options for incomplete miscarriages
- Medical management → misoprostol
- Surgical management → evacuation of retained products of conception (ERPC)
**ERPC: give GA, use dilators to widen cervix, retained products manually removed using vacuum aspiration & curettage
What is a key complication of ERPC (evacuation of retained products of conception)?
Infection of endometrium → endometritis
What is meant by recurrent miscarriage?
Three or more consecutive miscarriages (remember miscarriage is spontaneous loss of pregnancy before 24 weeks)
State the threshold for initiating investigations for miscarriages (2)
- Three or more in first trimester
- One or more in second trimester
State some risk factors for recurrent miscarriage
- Advancing maternal age
- Number of previous miscarriages
- Smoking
- Heavy alcohol consumption
State some potential causes of recurrent miscarriages
- Idiopathic
- Antiphospholipid syndrome
- Hereditary thrombophilias
- Uterine abnormalities
- Cervical weakness
- Genetic factors
- Parental chromosomal rearrangements e.g. balanced reciprocal Robertsonian translocation
- Embryonic chromosomal abnormalities
- Chronic histiocytic intervillositis
- PCOS
- Other chronic diseases:
- Diabetes
- Untreated thyroid disease
- SLE
For antiphospholipid syndrome, discuss:
- What it is
- Any associations with other diseases
- How risk of miscarriage is reduced in pts with antiphospholipid syndrome
- Syndrome in which pt produces antiphospholipid antibodies which put them in a hypercoagulable state; predisposed to both venous & arterial thromboses, recurrent miscarriages & thrombocytopenia.
- Can occur idiopathically or in association with other autoimmune conditions e.g. SLE
- Reduce risk of miscarriage using:
- Low dose aspirin (once pregnancy confirmed on urine testing)
- Low dose molecular heparin (once fetal heart seen on ultrasound)
What are the 3 key inherited thrombophilias to remember?
- Factor V Leiden (most common)
- Factor II (prothrombin) gene mutation
- Protein S deficiency
State some examples of uterine abnormalities that can cause recurrent miscarriages
- Uterine septum (a partition through the uterus)
- Unicornuate uterus (single-horned uterus)
- Bicornuate uterus (heart-shaped uterus)
- Didelphic uterus (double uterus)
- Cervical insufficiency
- Fibroids
For chronic histiocytic intervillositis, discuss:
- Whether it is common
- When, during pregnancy, it tends to cause miscarriages
- Pathophysiology
- Diagnosis
- Impact/effect on fetus
- Rare
- More commonly causes miscarriage in 2nd trimester
- Histiocytes & macrophages build up in placenta → inflammation
- Diagnosis via placenta histology which shows mononuclear cells in intervillous spaces
- Intrauterine growth restriction & intrauterine death
Patients with recurrent miscarriage should be referred to a specialist in recurrent miscarriage for investigation. What investigations may be done?
Blood tests
- Antiphospholipid antibodies
- Inherited thrombophilia screen: factor V Leiden, prothrombin gene mutation, protein S deficiency
Genetic tests (karyotpying)
- Cytogenetic analysis: test products of conception for chromosomal abnormalities (test products of conception of 3rd & subsequent miscarriages)
- Genetic testing on parents/parental peripheral blood karyotyping
Imaging
- Pelvic ultrasound: to assess uterine anatomy (may require further investigation e.g. hysteroscopy, laparoscopy etc…)
Discuss the management of recurrent miscarriages
Depends on underlying cause; examples include:
- Genetic abnormalities: refer to clinical geneticist for counselling, exploration of other options, may be offered preimplantation genetic screening with IVF treatment
- Cervical weakness: cervical cerclage may be an option (has risks so senior involvement & counselling required)
- Antiphospholipid syndrome: low dose aspirin & low dose LMWH
- Inherited thrombophilias: consider heparin during 2nd trimester
What do we mean by an abortion or termination of pregnancy (TOP)?
An elective procedure to end a pregnancy
What is the upper limit, in terms of weeks of gestation, for an abortion?
Current law surround abortion is based on the 1967 Abortion Act. In 1990 the act was amended, reducing the upper limit from 28 weeks gestation to 24 weeks
*NOTE: this upper limit of 24 weeks does not apply in some cases- these will be discussed in later FC
Discuss the simplified criteria for performing an abortion before 24 weeks
Can be performed if continuing the pregnancy involves greater risk to the physical or mental health of the pregnant woman or any existing children in her family
****The threshold for when the risk of continuing the pregnancy outweighs the risk of terminating the pregnancy is a matter of clinical judgement and opinion of the medical practitioners.
An abortion can be performed at any time during pregnancy in certain cases/circumstances; state these circumstances (3)
- Continuing pregnancy is likely to risk the life of the woman (greater than if the pregnancy were terminated)
- Termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman
- Substantial risk that the child would suffer physical or mental abnormalities making it seriously handicapped
What are the legal requirements for an abortion?
- Two registered medical practitioners must sign to agree abortion is indicated
- It must be carried out by a registered medical practitioner in an NHS hospital or approved premise
How can abortion services be accessed?
- Self-referral (most common)
- Referral by GP
- Referral by GUM
- Referral by family planning clinic
*NOTE: Marie Stopes UK is a 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.
When is a medical abortion most appropriate?
Earlier in pregnancy (but can be used at any gestation)
Discuss the treatment involved in medical abortions- for each describe how they work
Medical options involves two treatments:
-
Mifepristone
- Anti-progestogen that blocks action of progesterone and hence halts pregnancy and relaxes cervix
-
Then misoprostol 1-2 days later
- Prostaglandin analogue that binds to prostaglandin receptors and activates them; prostaglandins soften cervix and stimulate uterine contractions
- From 10 weeks gestation, additional misoprostol doses (e.g. every 3hrs) required until expulsion
Which women having medical abortions require anti-D prophylaxis?
Rhesus D negative women with a gestational age of 10 weeks or more
For surgical abortion, discuss:
- What is required prior to surgical abortion
- Surgical abortion options
- When each option is usually done
Give medications for cervical priming prior to surgical abortion; purpose of these medications is to soften & dilate the cervix. Examples include: misoprostol, mifepristone or osmotic dilators (gradually absorb fluid and hence dilate cervix).
Two options for surgical abortion:
- Cervical dilation and suction of contents of uterus (up to 14 weeks)
- Cervical dilation and evacuation using forceps (14-24 weeks)
Rhesus negative women having a surgical TOP should have anti-D prophylaxis. The NICE guidelines (2019) say it should be considered in women less than 10 weeks gestation.
When, following an abortion, is a urine pregnancy test performed?
3/52 after to confirm abortion complete
State some potential complications of abortions
- Bleeding
- Pain
- Infection
- Failure of the abortion (pregnancy continues)
- Damage to the cervix, uterus or other structures
***Women may experience vaginal bleeding and abdominal cramps intermittently for up to 2 weeks after the procedure.
What else should be discussed/covered/offered as part of post-abortion care?
- Advise that may experience bleeding & cramps for up to 2 weeks
- Contraception discussed & started where appropriate
- Support & counselling
What is a molar pregnancy?
A hydatidiform mole, type of tumour, grows like a pregnancy inside the uterus
State and describe two types of molar pregnancy
- Complete mole: occurs when 2 sperm cells fertilise an ovum that contains no genetic material. Cells start to divide and grow into tumour. No fetal material will form.
- Partial mole: two sperm cells fertilise a normal ovum at same time. Cell now has 3 sets of chromosomes (haploid). Cell starts to divide and grow into a tumour. In partial mole, some fetal material may form
Molar pregnancy behaves like normal pregnancy but there are a few things that may indicate a molar pregnancy; state these
- More severe morning sickness
- Vaginal bleeding
- Increased enlargement of the uterus
- Abnormally high hCG
- Thyrotoxicosis (hCG can mimic TSH and stimulate the thyroid to produce excess T3 and T4)
How is molar pregnancy diagnosed?
Provisional diagnosis via ultrasound
Confirmed with histology of mole after evacuation
Describe the appearance of molar pregnancy on ultrasound
Snowstorm appearance
Discuss the management of molar pregnancy
- Evacuation of uterus to remove mole & send products of conception for histology to confirm diagnosis
- Refer pt to gestational trophoblastic disease centre for further management & follow up
- hCG levels monitored until return to norrmal
- Occasionally, mole can metastasise and pt may require systemic chemotherapy
Nausea is a common symptom in pregnancy; when does it usually start, when does it usually peak and when does it usually resolve?
- Usually starts in weeks 4-7
- Peaks around 10-12 weeks
- Resolves by 16-20 weeks
Why do pregnant women experience N&V?
Placenta produces hCG and though that hCG causes N&V (hence, theoretically higher hCG levels → worse symptoms)
Why is N&V typically worse in molar pregnancies and multiple pregnancies?
Higher hCG levels
*NOTE: also tends to be worse in 1st pregnancy & in overweight/obese women
What is hyperemesis gravidarum?
Outline the RCOG diagnostic criteria for hyperemesis gravidarum
- Severe form of N&V in pregnancy.
- RCOG criteria for hyperemesis gravidarum are protracted NVP plus:
- >5% weight loss compared to before pregnancy
- Dehydration
- Electrolyte imbalance
State some risk factors for hyperemesis gravidarum
- First pregnancy
- Previous history of hyperemesis gravidarum
- Raised BMI
- Multiple pregnancy
- Hyperthyroidism
- Hydatidiform mole
What can be used to assess severity of N&V in pregnant women?
What results indicate mild, moderate & severe?
Pregnancy-Unique Quantification of Emesis (PUQE) score. This gives a score out of 15:
- < 7: Mild
- 7 – 12: Moderate
- > 12: Severe
What investigations may you do in women presenting with NVP?
Additional investigations are not needed to confirm the diagnosis if there are mild and uncomplicated symptoms.
Bedside
- Weight: needed to see if fit criteria for hyperemesis gravidarum
- Ketones: may need admission
- Glucose: particularly if diabetic
Bloods
- U&Es: electrolyte abnormalities common, part of criteria for hyperemesis gravidarum
- *OTHERS: consider midstream urine if suspect infection, FBC, LFTs, TFTs, ABG*
What antiemetics are used in N&V in pregnancy; give in order of preference/safety
- Prochlorperazine (stemetil)
- Cyclizine
- Ondansetron
- Metoclopramide
How long should metoclopramide be used for?
Should not be used for >5 days as can cause extrapyramidal side effects
There is a small increased risk of baby having ______ if ondansetron is used in 1st trimester
Cleft lip/palate
Must discuss risk with woman
Alongside antiemetics, RCOG also suggest complimentary therapies; state 2 examples
- Ginger
- Acupressure on wrist at PC6 point on inner wrist
Discuss the management of mild cases of N&V in pregnancy
Manage with general advice (see previous FC) & oral antiemetics. Consider admission if:
- Unable to tolerate oral antiemetics or keep down any fluids
- More than 5 % weight loss compared with pre-pregnancy
- Ketones are present in the urine on a urine dipstick (2 + ketones on the urine dipstick is significant)
- Other medical conditions need treating that required admission
Discuss the management of moderate to severe N&V in pregnancy
Moderate-severe cases may require ambulatory care (e.g. early pregnancy assessment unit) or admission for:
- IV or IM antiemetics
- IV fluids (normal saline with added potassium chloride)
- Daily monitoring of U&Es while having IV therapy
- Thiamine supplementation to prevent deficiency (prevents Wernicke-Korsakoff syndrome)
- Thromboprophylaxis (TED stocking and low molecular weight heparin) during admission
Summary of what to focus on in history & examination in NVP
State some maternal potential complications of NVP/hyperemesis gravidarum
State some potential fetal complications of NVP/hyperemesis gravidarum
Maternal complications
- Wernicke’s encephalopathy
- Mallory-Weiss tear
- central pontine myelinolysis
- AKI
Fetal complications
- Small for gestational age
- Pre-term birth
