pregnancy, early pregnancy and pregnancy loss Flashcards
1
Q
At what gestation should prophylaxis anti-D be given to Rh negative women in normal pregnancy?
A
28/40 on single dose protocol, 28/40 and 34/40 on two dose protocol. Both 500iu.
2
Q
List the scenarios where <12/40 anti-D is recommended in Rh negative women?
A
SMM/MVA/STOP/surgical Ectopic
3
Q
From what gestation is anti-D recommended in Rh negative women with PVB?
A
> 12/40
4
Q
Within what timeframe should anti-D be administered?
A
<72hrs
5
Q
Weight of uterus by end of pregnancy?
A
1000g (10x non-pregnant size)
6
Q
% increase in cardiac output in pregnancy?
A
30-50%
7
Q
A woman has a raised combined antenatal screening, the pregnancy date 12+3, what definitive testing can be offered at this gestation?
A
CVS (amniocentesis >15/40)
8
Q
A woman has a raised combined antenatal screening, her pregnancy is currently 15+3, what definitive testing can be offered at this gestation? Amniocentesis
A
> 15/40
9
Q
What gestation is CRL used up until for dating?
A
7-13/40
10
Q
What is used to calculate gestation on USS at 14+6/40 by dates?
A
HC and femur length after 13/40
11
Q
What conditions does the combined antenatal screening test look for?
A
Downs, Pateu and Edwards.
12
Q
What trisomy is Edwards?
A
18
13
Q
What trisomy is downs?
A
21
14
Q
What trisomy is Pateu?
A
13
15
Q
What screening bloods are performed in pregnancy?
A
STS/HIV/Hep B, rubella susceptibility, sickle cell and thalassaemia
16
Q
What gestation can the combined antenatal screening test be performed?
A
Up till 14+1 USS
11+2-14+1, bloods 10-14+1
17
Q
What non-invasive antenatal screening test is conducted at 15/40?
A
Quadruple test (14+2-20/40, less accurate than combined)
18
Q
What blood tests are collected in the combined antenatal screening test?
A
PAPP-A, bHCG
19
Q
What blood tests are collected in the quadruple antenatal screening test?
A
Inhibin-A, AFP, bHCG, unconjugated estriol
20
Q
What gestation can the anomaly USS be conducted?
A
18-20+6/40
21
Q
Mechanism of action of metoclopramide?
A
Dopamine antagonist
22
Q
Mechanism of action of ondansetron?
A
5HT3 (serotonin) antagonist
23
Q
Mechanism of action of cyclizine?
A
H1 antagonist
24
Q
Complications of severe hyperemesis?
A
Central pontine demyelination and Wernicke’s encephalopathy
25
What causes Wernicke’s encephalopathy?
B1 deficiency
26
What can precipitate Wernicke’s encephalopathy?
Dextrose IV
27
Signs and symptoms of Wernicke’s encephalopathy?
Ophthalmoplegia, ataxia, confusion
28
Foetal death rate with Wernicke’s encephalopathy?
40%
29
Investigations for N&V in pregnancy?
FBC, U&E, LFT, TFT, calcium, USS (exclude molar/multiple pregnancy), Udip (>1+ ketones suggests needs hydrating), glucose
30
% women affected by nausea and vomiting in pregnancy?
90%
31
First line antiemetics in nausea and vomiting in pregnancy/hyperemesis?
Cyclizine/stemitil/metoclopramide
32
2nd line antiemetics in nausea and vomiting in pregnancy/hyperemesis?
Ondansetron with spr/cons input – cleft lip/palate risk additional 3 cases for 10000 women (11/10000 without, 14/10000 with)
33
What age should metoclopramide be avoided in and why?
<20s, risk of oculogyric crisis
34
Medication to treat oculogyric crisis precipitated by metoclopramide?
Procyclidine
35
3rd line treatment in nausea and vomiting in pregnancy/hyperemesis?
Glucocorticoids
36
Additional treatment required in in nausea and vomiting in pregnancy/hyperemesis along side antiemetics and rehydration?
Thiamine (or pabrinex if unable to tolerative oral), folic acid high dose. Consider LMWH depending on VTE risk.
37
Categories causing abdo pain in pregnancy?
Gynae (ovarian cyst accident/torsion, PID, fibroid, OHSS)
early pregnancy (ectopic, miscarriage)
obs (pre eclampsia labour, uterine rupture, placental abruption, chorioamnionitis, fatty liver of pregnancy),
MSK (ligamental stretch),
surgical abdo (appendix cholecystitis, pancreatitis, diverticulitis, IBD, hernia),
```
UTI,
constipation,
gastroenteritis,
cardiac,
pneumonia.
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38
What % increase in bHCG suggests an ongoing IUP over what time scale?
>63% in 48hrs
39
What % decrease in bHCG suggests a miscarriage over what timescale?
>50% reduction in 48 hrs
40
6 types of miscarriage?
Threatened, complete, incomplete, inevitable, missed, recurrent.
41
Criteria to meet recurrent miscarriage?
3 consecutive losses
42
% couples with recurrent miscarriage?
1%
43
Define missed miscarriage on USS findings?
CRL 7mm or more with no FH, MSD 25mm or more with no content. If under 25mm MSD or 7mm CRL rescan 7-14 days to confirm.
44
% miscarriage under 12/40?
85%
45
Risk factors for miscarriage?
Maternal age >30 (more so if >35) paternal age >45, smoker, etoh use, low BMI, connective tissue disorders, controlled diabetes, stress/trauma.
46
What % pregnancies miscarry?
25%
47
3 types of management of miscarriage?
Expectant, medical, surgical
48
Success rate of expectant management of miscarriage?
70-80%
49
Follow up of expectant management of miscarriage?
If bleeding and POC passed PT 3/52, if positive USS.
If no bleeding/POC rescan 10-14 days.
If not passed pregnancy at USS should have CRP and USS every 2/52 until complete, if signs of infection antibiotics and medical or surgical mx.
50
Success rate of medical management of miscarriage?
80%
51
Dose of misoprostol in 1st trimester medical management of miscarriage?
800mcg (NICE state 600mcg but most unit use 800mcg to avoid dose confusion)
52
Mechanism of action of miso?
E1 prostaglandin analogue
53
When is anti D required in medical management of miscarriage of Rh negative women?
>12/40 gestation
54
When should contraception be started following early pregnancy loss if a woman does not wish to conceive again?
<5/7
55
Success rate of surgical management of miscarriage?
95%
56
Contraindications to medical management of miscarriage?
Hb <100, coagulopathy, suspected molar, severe asthma, cardiac problems
57
bHCG level at which an IUP should be visible on USS?
1500
58
% recurrent miscarriage due to antiphospholipid syndrome?
15%
59
Autoantibodies to test for in antiphospholipid syndrome?
Lupus anticoagulant, anticardiolipin antibodies, anti B2 glycoprotien-1 antibodies
60
Clinical hx associated with adverse pregnancy outcomes and autoantibodies in antiphospholipid syndrome?
3 or more <10/40 miscarriage,
1 or more >10/40 miscarriage,
1 or more <34/40 delivery due to placental insufficiency or pre-eclampsia
61
Causes of recurrent miscarriage?
Antiphospholipid syndrome, gentetic, endocrine (diabetes/thyroid if uncontrolled, PCOS), female reproductive tract abnormalities (fibroid, cx incompetence, septum/bicornuate), infection (BV), maternal and paternal age, thrombophillias (factor V leiden, protein c/s)
62
Baseline ix for recurrent miscarriage?
Day 2-5 FSH,
USS (uterine abnormalities, account for 15-27% of recurrent miscarriage)
parental karyotype,
thrombophilia screen (factor v leiden, prothrombin, protein c/s),
antiphospholipid screen (lupus anticoagulant, anticardiolipin antibodies, anti B2 glycoprotien-1 antibodies).
Do not routinely do DM /thyroid screening, prolactin or TORCH (toxoplasmosis, other rubella, CMV, HSV), STI screen. Amies swab if discharge.
63
If raised antiphospholipid screen what should be done?
Repeat 6-12 weeks.
64
Women with positive antiphospholipid antibodies or thrombophilia should be offered what treatment to help prevent recurrent miscarriage?
Aspirin and LWMH (combined 70% successful pregnancy rate compared to 10% without)
65
Progesterone pessaries are useful in the prevention of recurrent miscarriage?
No PROMISE study found no benefit.
66
Criteria to expectant management of ectopic pregnancy?
HCG <1000, minimal symptoms, <2cm mass/no FH, minimal free fluid.
67
Criteria for medical management of ectopic pregnancy?
<3.5cm mass with no FH, HCG <5000 (<1500 should have medical mx, 1500-5000 choice of surgery or medical), minimal symptoms and well
68
Advice regarding trying to conceive after medical ectopic management?
Avoid 3/12 (MTX is a folate inhibitor)
69
Criteria for surgical management of ectopic pregnancy?
>3.5cm HCG >5000, pain, moderate free fluid, FH present.
70
Baseline ix before medical management of ectopic pregnancy?
FBC, U&E, LFT, HCG, G&S
71
Follow up protocol for medical management of ectopic pregnancy?
Day 4 HCG, if <15% increase, day 7 HCG, then weekly with 15% decrease each time until <5. If >15% increase day 7 consider repeat mtx dose.
72
Follow up for expectant management of ectopic pregnancy?
48hr HCG if >15% decreased continue until HCG <25. If <15% decrease consider medical/surgical management.
73
Follow up after salpingotomy for ectopic?
weekly HCG until negative, should fall by >15% each time, otherwise methotrexate.
74
Risk of future ectopic pregnancy if had one previously?
1/10
75
Management of PUL on USS if well?
0 & 48hr HCG,
if >50% decrease likely failing IUP, home PT 2/52.
If less than 50% decrease but less than 63% increase ?ectopic, another 48hr HGC and if still less than 50% decrease but less than 63% increase repeat USS (will be ectopic or PUL),
if more than 63% increase likely IUP, rescan 7-10 days.
76
If a woman has had 2 x 48hr HCG with suboptimal rise and decrease and USS is still inconclusive what next?
Consider MVA and urgent histology or lap if symptoms.
77
If a woman undergoing an evacuation of the uterus for suspected molar pregnancy bleeds briskly, what management options are available intraoperatively?
Hemodynamic support and blood if needed, run up uterus, do not use synto unless absolutely needed – has the potential to seed malignancy.
78
Two types of premalignant GTD?
Partial and complete mole
79
Chromosomal make up of partial mole?
3 sets of chromosomes; 2 sperm, 1 oocyte
80
Chromosomal make up of complete mole?
2 sperm fertilise empty ovum or single sperm duplicates in empty ovum.
81
UKMEC IUC for woman with partial molar treated with evac HCG falling but raised?
3
82
UKMEC IUC for woman with partial molar treated with HCG persistently raised?
4
83
UKMEC IUC for woman with partial molar treated with negative HCG? Risk of pregnancy with mole?
ukmec 1
| 1/1000
84
Risk of another molar pregnancy if previously had?
1/100
85
How long after being treated for molar pregnancy should a women be advised to avoid trying to conceive?
6/12 after HCG negative
86
What should a woman with a previous molar pregnancy be advised after the end of any future pregnancy?
HCG should be monitored for 6-8/52 and they should contact their specialist centre to inform them they are pregnant.
87
UKMEC for woman with molar pregnancy and HCG raised but falling for implant/depo/pop/CHC?
1
88
Reasons to give 5mg folic acid?
Mother or the baby's biological Father have a neural tube defect.
Mother has previously had a pregnancy affected by a neural tube defect.
Mother or the baby's biological Father have a family history of neural tube defects.
Mother has diabetes.
Mother is taking anti-epilepsy medicine.
Mother has a BMI ≥ 30
Mother is taking sulfasalazine or has malabsorption following small bowel resection
Mother has sickle cell disease, thalassaemia, or thalassaemia trait
89
How many major and minor indications for aspirin in pregnancy do you need to have to qualify
1 major
| 2 minor
90
list the minor indications for aspirin in pregnancy
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First pregnancy
Pregnancy interval of more than 10 years
Family history of pre-eclampsia
IVF pregnancy
Age 40 years or older
Multiple pregnancy
Body Mass index (BMI) of 35Kg/m2 or more at first contact
```
91
list the major indications for aspirin in pregnancy
Hypertensive disease during your previous pregnancy
Chronic kidney disease
Autoimmune disease such as systemic lupus erythematosis or antiphospholipid syndrome
Type 1 or Type 2 diabetes
Chronic hypertension
Low Pregnancy Associated Plasma Protein (PAPP-A) screening blood test
Previous Intrauterine growth restriction (IUGR) (either birth weight <2.5kg or <10th centile)
Previous stillbirth
Previous pre-eclampsia/eclampsia
92
Dose of aspirin in pregnancy and what gestation to start from
75mg >12/40 if 1 major risk factor or 2 minor risk factors.
93
risk of preeclampsia in any pregnancy
Mild pre-eclampsia affects up to 6% of pregnancies, and severe cases develop in about 1 to 2% of pregnancies
94
risk of recurrence of preeclampsia
15%
If severe and delivery <28/40 = 50%
If severe and delivery <34/40 = 25%
95
risk of obstetric cholestasis
<1% (1/5% if asian ethnicity)
96
risk of recurrence obstetric cholestasis
45–90%
97
risk of fetal lacerations at c/s
1-2%
98
risk of bladder injury at c/s
1/ 1000
99
risk of emergency hysterectomy at c/s
7-8/1000
100
risk of infection at /cs
6/100
