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Obstetrics and Gynaecology > Pregnancy > Flashcards

Pregnancy Flashcards

1
Q

What is the definition of an ectopic pregnancy and how common are they?

A

Embryo implants outside of endometrial cavity

1 in 100

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2
Q

What are the three most common locations for ectopic pregnancy?

A
  1. Ampulla
  2. Isthmus
  3. Fimbriae
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3
Q

List 6 risk factors for an ectopic pregnancy

A
  1. Previous ectopic pregnancy
  2. Smoking
  3. Endometriosis
  4. Gynaecologic: IUD use, history of PID (chlamydia!)
  5. Previous procedures - fallopian tube surgery or abdominal surgery
  6. IVF pregnancies
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4
Q

What investigations would you consider in the work-up of an ectopic pregnancy? (4)

A
  1. Bloodwork: FBE, LFT, UECs, blood type
  2. Serial Beta-HCG: prolonged doubling time, plateau or decreasing levels (normal doubling time with intrauterine pregnancy is 1.6-2.4d)
  3. US - empty uterus, adnexal mass. Intrauterine sac should be visible when serum beta-HCG is over 2000 (transvaginal) or over 6000 (transabdominal)
  4. Laparoscopy for definitive diagnosis
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5
Q

What are the three features of an ectopic pregnancy?

A
  1. Positive urine beta-HCG
  2. Abdominal pain
  3. Vaginal bleeding
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6
Q

How is an ectopic pregnancy managed? (3)

A
  1. Haemodynamically unstable - surgery (salpingectomy)
  2. Haemodynamically stable - MTX (ensure pretreatment evaluation conducted - FBE, LFT, UEs) OR surgery
    - dependent on features of ectopic pregnancy
  3. If patient is Rh -, give anti D
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7
Q

List 7 indications for the use of MTX in the management of an ectopic pregnancy

A
  1. Less than 3.5 cm unruptured ectopic
  2. No foetal heart rate
  3. Beta-HCG less than 5000-6000
  4. No hepatic/renal/haemotolic disorders
  5. Compliance assured
  6. Able and willing to follow-up
  7. No free fluid in abdomen
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8
Q

What are the four features of a ruptured ectopic pregnancy?

A
  1. . Acute abdomen with increasing pain
  2. Shoulder pain due to diaphragmatic irritation by blood in peritoneal cavity
  3. Abdominal distension potentially
  4. Shock
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9
Q

What percentage of patients who’ve had a previous ectopic pregnancy will go on to have another?

A

10-20%

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10
Q

What is Hellin’s rule?

A

Probability of multiple gestation

Twins 1 in 80
Triplets 1 in 80 squared
etc

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11
Q

Prevalence of dizygotic vs monozygotic twins

A

2/3 twins are dizygotic, 1/3 monozygotic

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12
Q

List 4 risk factors for dizygotic twins

A

IVF, increased maternal age, family Hx, increased parity

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13
Q

List 7 maternal complications associated with multiple gestation

A
  1. Hyperemesis gravidarum
  2. GDM
  3. Gestational HTN
  4. Anaemia
  5. Increased physiological stress on all systems
  6. Increased compressive symptoms
  7. C/S
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14
Q

List 7 utero-placental complications associated with multiple gestation

A
  1. Increased PROM/PTL
  2. Polyhydramnios
  3. Placenta previa
  4. Placental abruption
  5. PPH
  6. Umbilical cord prolapse
  7. Cord anomalies
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15
Q

List 8 foetal complications associated with multiple gestation

A
  1. Prematurity
  2. IUGR
  3. Malpresentation
  4. Cognitive anomalies
  5. Twin-twin transfusion
  6. Increased perinatal morbidity and mortality
  7. Twin interlocking (twin A breech, twin B vertex)
  8. Single foetal demise
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16
Q

What does monochorionic mean?

A

Sharing one chorion = placenta

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17
Q

What does monoamniotic mean?

A

Sharing one amniotic sac

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18
Q

What is the chorionicity of dizygotic twins usually?

A

ALL dichorionic

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19
Q

What is the chorionicity of monozygotic twins?

A

2/3 monochorionic

1/3 dichorionic

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20
Q

What is the preferred gestation at birth for MC vs DC twins?

A

DC twins - 38 weeks

MC twins - 37 weeks

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21
Q

What is pre-eclampsia? (diagnostic criteria) (3)

A

2 of 3 criteria after 20 W gestation (confirmed on 2 or more occasions)

  1. Blood pressure of systolic 140 +/- diastolic 90 or increase in 25/15
  2. Proteinuria - 24h collection (300mg/d) or spot urine Pr:Cr 0.03
  3. Oedema
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22
Q

List 6 risk factors of pre-eclampsia

A
  1. primagravida
  2. Extremes of age less than 18 or more than 35
  3. Family history
  4. New paternity
  5. Past history of pre-eclampsia
  6. Medical hx - HTN, DM, CRF, immunological, thrombophilia
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23
Q

Define miscarriage

A

Clinically recognised pregnancy loss before 20th week of gestation

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24
Q

List 3 risk factors for having a spontaneous abortion

A
  1. Advancing maternal age
  2. Previous spontaneous abortion
  3. Smoking, alcohol
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25
Q

List 5 causes of a spontaneous abortion/miscarriage

A
  1. Chromosomal abnormalities
  2. Congenital anomalies e.g. from teratogenic exposure or drugs
  3. Trauma - from invasive uterine procedures
  4. Uterine structural issues - e.g.uterine septum
  5. Maternal disease - e.g. acute maternal infections (toxoplasmosis, Listeria, TORCH) hypercoagulable states such as SLE and antiphospholipid syndrome
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26
Q

What symptoms are often reported in a miscarriage? (2)

A
  1. Vaginal bleeding +/- passage of foetal tissue (can be mistaken for blood clot)
  2. Pelvic pain - typically crampy or dull in character
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27
Q

What is a threatened abortion?

A

Diagnostic criteria for spontaneous abortion has not been met, but vaginal bleeding has occurred and the cervical os is closed

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28
Q

What is IUFD?

A

Intrauterine foetal death = after 20 weeks GA

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29
Q

How is IUFD diagnosed?

A

Absent cardiac activity and foetal movement on U/S required for diagnosis

30
Q

What are the diagnostic criteria for antiphospholipid syndrome? (5)

A

Clinical features: arterial/venous/small vessel thrombosis; recurrent pregnancy loss

Lab: anti-caridolipin/anti-beta2 glycoprotein/lupus anticoagulant antibodies

31
Q

How do you manage IUFD? (5)

A
  1. Diagnosis: absent cardiac actvity and foetal movement on U/S required for diagnosis
  2. Determine secondary cause - maternal - INR/PTT, serum/urine toxicology, cervical and vaginal cultures, TORCH screen, antibody screens (?APS)
    - foetal - chromosomes
    - placenta
  3. IoL
  4. Monitor for maternal coagulopathy
  5. Parental psychological care
32
Q

What is placental abruption?

A

Premature separation of a normally implanted placenta after 20 weeks GA

33
Q

What is the aetiology behind placental abruption?

A

Rupture of maternal blood vessels in decidua basalis, where it interfaes with anchoring villi –> accumulating blood splits decidua (separates thin layer of decidua with placental attachment from uterus)

34
Q

List 5 risk factors for placental abruption

A
  1. Previous abruption
  2. maternal hypertension
  3. smoking, alcohol, cocaine
  4. trauma
  5. multiparity and/or increasing maternal age
35
Q

What is the clinical presentation of placental abruption? (5)

A
  1. Painful vaginal bleeding - but not all abruptions present with bleeding (concealed)
  2. Pain: sudden onset, constant and localised to lower back and uterus
  3. Uterine tenderness, increased tone and rigidity and contractions
  4. +/- evidence of DIC
  5. +/- evidence of foetal distress/demise
36
Q

How is placental abruption diagnosed?

A

Clinical diagnosis, U/S can be used to investigate but not very sensitive

37
Q

What is the most common cause of DIC in pregnancy?

A

Placental abruption

38
Q

How is placental abruption managed? (initial approach - 6)

A
  1. Continuous foetal monitoring
  2. IV access - bloods: FBE, bood type, Rh, coags
  3. Notify blood bank to get blood replacement products ready
  4. Monitor maternal haemdynamic status (BP, HR, urine output)
  5. O2
  6. Treat DIC if present
39
Q

How is a mild placental abruption managed?

A

If mild, greater than 34 weeks, CTG ok - deliver, vaginally if possible

If mild, less than 34 weeks, CTG ok and loss settling - watchful waiting/give steroids

40
Q

How is a moderate or severe placental abruption managed?

A

If moderate or continuing significant loss - deliver by emerg CS unless imminently delivering

Severe at any gestational age or nonsevere at greater than 36 weeks - deliver by lowest risk method

41
Q

What is placenta previa?

A

Abnormal location of placenta - in relation to internal cervical os

42
Q

What are the 4 grades or degrees of placenta previa?

A
  1. Low-lying: edge not near internal os, but can be palpated by finger through cervix
  2. Marginal - edge of placenta reaches but does not cover os
  3. Partial - placenta partially covers internal os
  4. Total - placenta completely covers internal os
43
Q

What is the most characteristic clinical feature of placental praevia? When does this usually occur?

A

Painless PV bleeding - first episode usually mild
1/3 =less than 30 weeks
1/3 = 30-35 weeks
1/3 = more than 36 weeks

Dependent on degree of praevia (total bleeds earlier)

44
Q

List 5 risk factors for placenta praevia

A
  1. Previous uterine surgery
  2. Previous placenta praevia
  3. Multiple gestation
  4. Multiparity
  5. Increased maternal age
45
Q

How is placenta praevia diagnosed?

A

Ultrasound - if at 18-20 weeks, placenta is found to be low-lying, repeat scan at 34 weeks unless bleeding

(relative migration as lower uterine segment forms 28-32 weeks)

46
Q

How is placenta praevia managed? (4)

A
  1. Admit to hospital - NO VAGINAL EXAMINATION
  2. IV access
  3. Placental localisation
  4. Conservative treatment until foetal maturity if possible
47
Q

What kind of delivery should be done in someone with placenta praevia?

A

Best by C/S (usu around 37) - occ. hysterectomy may be necessary

48
Q

What is placenta accreta?

A

Chorionic villi attach to the myometrium (rather than being restricted within the decidua basalis)

49
Q

What is placenta increta?

A

Chorionic villi invade into myometrium

50
Q

What is placenta percreta?

A

Chorionic villi invade through myometrium

51
Q

What is vasa praevia?

A

Unprotected foetal vessels pass over cervical os

52
Q

List 2 clinical features of vasa praevia

A
  • can cause painless bleeding and foetal distress (i.e. tachy or bradyarrhythmia) because loss if foetal blood
53
Q

How is vasa praevia investigated? (2)

A
  1. Apts test (NaOH mixed with blood) - if source of bleeding is foetal, supernatant turns pink; if bleeding is maternal, turns yellow
  2. Wright stain in blood smear - look for nucleated RBC (in cord, not maternal blood)
54
Q

How does GDM develop?

A

Usually around 24-28 weeks GA, anti-insulin factors (e.g. HPL, progesterone) produced by placenta and high maternal cortisol levels create increased peripheral insulin resistance –> higher fasting glucose –> GDM and/or exacerbating pre-existing DM

55
Q

How are T1/T2 diabetics managed during pregnancy?

A
  1. If already on medication, generally switch to insulin therapy - teratogenicity unknown for oral anti-hyperglycaemics
  2. Tight glycaemic control and monitoring
  3. Monitor as for normal pregnancy plus initial 24 h uring protein and creatinine clearance, retinal exam, HbA1c and TFTs in T1DM
56
Q

How is GDM diagnosed?

A

At 24-28 weeks, 75g OGTT.

Either:
Fasting blood glucose more than 8.1
1 hour post-prandial more than 10
2 hour post-prandial more than 8.5

57
Q

How is GDM managed? (5)

A
  1. Given glucose meter, measure 4x/day
  2. Aim for good glycaemic control: fasting less than 5, 2 hour post-prandial less than 6.7
  3. Additional monitoring with monthly HbA1c
  4. Insulin
  5. Follow-up with 2h, 75g OGTT 8 weeks postpartum. Also monitor for development of T2DM (50% risk in next 20 years)
58
Q

What are the features of a threatened abortion?

A

Vaginal bleeding +/- cramping

Cervix closed and soft with U/S showing viable foetus

59
Q

What are the features of an inevitable abortion?

A

Increasing bleeding and cramps +/- rupture of membranes

Cervix closed until products start to expel, then external os opens

60
Q

What are the features of an incomplete abortion?

A

Extremely heavy bleeding and cramps +/- passage of tissue noticed
Cervix opened

61
Q

What are the features of a complete abortion?

A

Bleeding and complete passage of sac and placenta

Cervix open

62
Q

How is a septic abortion managed?

A

Cervical swabs for assessment of appropriate antibiotic therapy
Antibiotic therapy
D and C

63
Q

What is congenital varicella syndrome?

A 
Limb aplasia
Chorioretinitis
Cataracts
Cutaneous scars
Cortical atrophy
IUGR
Hydrops
64
Q

How is a pregnant woman exposed to chickenpox managed?

A

VZIG decreases congenital varicella syndrome (NOT VACCINE)

65
Q

What are the clinical features of a foetus exposed to CMV in utero?

A

Intracranial calcifications

Can also have: mental retardation hydrocephalus, microcephaly, deafness

66
Q

What needs to be considered in a pregnant woman with a history of genital herpes?

A

If no active lesion at time of labour - vaginal delivery
If active lesions present - C/S recommended
Suppressive therapy can be initiated at around 36 weeks - acyclovir (controversial)

67
Q

What is congenital rubella syndrome?

A

Hearing oss, cataracts, IUGR, osseous changes

68
Q

Is there an increased risk of congenital anomalies in GDM? Explain.

A

NO. GDM develops after critical period of organogenesis (screening at 24-28 weeks)

69
Q

What congenital anomalies can be expected in DM1 and DM2 pregnancies?

A

In creased risk of cardiac (VSD), NTD, GU (cystic kidneys), GI (anal atresia) and MSK (sacral agenesis) anomalies due to hyperglycaemia

70
Q

What is a blighted ovum?

A

Aka anembryonic pregnancy

Gestational sac with no developing embryonic pole or yolk sac development

71
Q

What differential diagnoses should be considered in a woman who is bleeding during T1/T2? (6)

A
  1. Physiological bleeding - reassure, check serial B-HCG
  2. Trauma (post-pelvic exam or post-coital)
  3. Abortion (threatened, inevitable, incomplete, complete)
  4. Ectopic pregnancy
  5. Molar pregnancy/gestational trophoblastic disease
  6. Genital lesion e.g. Cervical polyps, neoplasm
72
Q

What differential diagnoses should be considered in vaginal bleeding a woman who is more than 20 weeks pregnant? (7)

A
  1. Bloody show (shedding of cervical mucous plug) - most common in T3
  2. Placental previa
  3. Placental abruption
  4. Vasa previa
  5. Cervical lesion (polyp, ectropion, cancer)
  6. Uterine rupture
  7. Other: bleeding from bowel or bladder, placenta accreta abnormal coagulation

Obstetrics and Gynaecology (10 decks)

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