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A. MLA Map Obstetrics and Gynaecology > Termination of Pregnancy and Pregnancy Loss > Flashcards

Termination of Pregnancy and Pregnancy Loss Flashcards

1
Q

The Abortion Act 1967 relates to legalising abortions on certain grounds by registered practitioners. The most common is ground C, accounting for 98% of absortions in 2021. Which of the following is ground C?

1 - baby and/or mother is at serious risk of illness and disease
2 - continuance of pregnancy involves risk to the life of the pregnant woman greater than if the pregnancy were terminated
3 - substantial risk that baby will have physical/mental abnormalities if pregnancy continues
4 - pregnancy has NOT exceeded 24 wks and continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman

A

4 - pregnancy has NOT exceeded 24 wks and continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman

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2
Q

How common is pregnancy loss?

1 - 10%
2 - 25%
3 - 50%
4 - 60%

A

2 - 25%
- 1 in 4

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3
Q

What is the major cause of death in women worldwide?

1 - infection
2 - pregnancy loss causing haemorrhage/infection
3 - cardiovascular
4 - cancer

A

2 - pregnancy loss causing haemorrhage/infection
- ectopic pregnancy is the most common

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4
Q

What is the definition of a miscarriage in the UK?

1 - death of a baby before 26 weeks with no outside intervention
2 - death of baby before 23wks + 6 days with no outside intervention
3 - death of a baby before 20 weeks
4 - death of a baby before 32 weeks with no outside intervention

A

2 - death of baby before 23wks + 6 days with no outside intervention

Any loss of a baby beyond 24 weeks is classed as a stillbirth

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5
Q

What is threatened miscarriage?

1 - patient considering an abortion
2 - pain and bleeding are present, foetus is visible on ultrasound and the cervix is closed
3 - pain and bleeding are present, cervix is open
4 - pain and bleeding are present, no foetus on ultrasound

A

2 - pain and bleeding are present, foetus is visible on ultrasound and the cervix is closed
- pregnancy could continue as normal or woman could have a miscarriage

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6
Q

What is an inevitable miscarriage?

1 - patient considering an abortion
2 - pain and bleeding are present, foetus is visible on ultrasound and the cervix is closed
3 - pain and bleeding are present, cervix is open and contents are visible on ultrasound abnd abdominal examination
4 - pain and bleeding are present, no foetus on ultrasound

A

3 - pain and bleeding are present, cervix is open and contents are visible on ultrasound abnd abdominal examination

  • can follow a threatened miscarriage
  • pregnancy will proceed to incomplete or complete miscarriage
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7
Q

What is an incomplete miscarriage?

1 - patient considering an abortion
2 - pain and bleeding are present, but foetus is visible on ultrasound
3 - pain and bleeding are present, cervix is open but tissue remains in uterus
4 - pain and bleeding, uterine contents begin passing through open cervix

A

4 - pain and bleeding, uterine contents begin passing through open cervix

  • if the uterus becomes infected at this point it is called a septic abortion
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8
Q

What is a complete miscarriage?

1 - patient considering an abortion
2 - pain and bleeding are present, but foetus is visible on ultrasound
3 - pain and bleeding are present, cervix is open and uterus contracts and uterus is empty
4 - pain and bleeding are present, no foetus on ultrasound

A

3 - pain and bleeding are present, cervix is open and uterus contracts and uterus is empty

  • bleeding can continue for several days
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9
Q

What is a missed miscarriage?

1 - foetus had died but remains in the uterus
2 - pain and bleeding are present, but foetus is visible on ultrasound
3 - pain and bleeding are present, cervix is open but tissue remains in uterus
4 - pain and bleeding are present, no foetus on ultrasound

A

1 - foetus had died but remains in the uterus

  • patient may be asymptomatic, diagnosed on an ultrasound
  • also referred to as a silent miscarriage
  • patient likely to have brownish discharge, nausea and tiredness
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10
Q

What is a late miscarriage?

1 - patient likely to be asymptomatic, diagnosed on an ultrasound
2 - pain and bleeding are present, but foetus is visible on ultrasound
3 - loss of baby in 2nd trimester (12-24 weeks)
4 - pain and bleeding are present, no foetus on ultrasound

A

3 - loss of baby in 2nd trimester (12-24 weeks)
- also referred to as 2nd trimester miscarriage

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11
Q

What is a stillbirth?

1 - lose of baby between >12 weeks
2 - lose of baby >24 weeks
3 - lose of baby between >28 weeks
4 - lose of baby between >32 weeks

A

2 - lose of baby >24 weeks

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12
Q

What is a molar pregnancy?

1 - patient likely to be asymptomatic, diagnosed on an ultrasound
2 - pain and bleeding are present, but foetus is visible on ultrasound
3 - loss of baby in 2nd trimester (12-24 weeks)
4 - multiple sperm fertilise the egg, abnormal development and no survival

A

4 - multiple sperm fertilise the egg, abnormal development and no survival

  • complete mole = no maternal chromosomes, so only paternal chromosomes
  • incomplete mole = multiple sperm fertilise a normal egg
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13
Q

A molar pregnancy can be either:

  • partial = multiple sperm fertilise one health egg
  • complete = sperm fertilises an empty egg

In either molar pregnancy, why is it important to ensure all pregnancy tissue is removed?

1 - distressing for parents
2 - mother unable to conceive until it is removed
3 - can become malignant
4 - can cause infection

A

3 - can become malignant

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14
Q

Which of the following are risk factors for a miscarriage?

1 - foetal anomaly
2 - anatomical
3 - maternal age 20 y/o = 11-12% and >45 = 93%
4 - obesity
5 - antiphospholipid syndrome
6 - poorly controlled systemic disease
7 - diabetes, renal disease or hypertension
8 - infection
9 - smoking, alcohol and drug use
10 - all of the above

A

10 - all of the above

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15
Q

What happens to the risk of miscarriage with age?

A
  • increases with age
  • 20 y/o = 11-12% and >45 = 93%
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16
Q

Which of the following is NOT a sign of a miscarriage?

1 - bleeding (light, spotting, clotting)
2 - abdominal mass
3 - pain/cramping (stabbing or throbbing)
4 - general malaise (generally not well)
5 - loss of pregnancy symptoms
6 - acute collapse (cervical shock)
7 - infection/sepsis

A

2 - abdominal mass

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17
Q

Some of the most common signs of a miscarriage are:

  • bleeding
  • pain
  • general malaise
  • loss of pregnancy symptoms
  • acute collapse
  • infection/sepsis

Even if a patient has these symptoms, as a doctor what must we assume until proven otherwise?

1 - the patient is always right
2 - the doctor is incorrect until confirmed by a 2nd opinion
3 - assume pregnancy is still viable in woman of child-birthing age
4 - all of the above

A

3 - assume pregnancy is still viable in woman of child-birthing age

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18
Q

If we suspect a miscarriage, what are the 3 key areas that we must include in out history taking?

1 - pain, vaginal loss, gynaecological history
2 - lifestyle, vaginal loss, gynaecological history
3 - pain, vaginal loss, lifestyle
4 - pain, lifestyle, gynaecological history

A

1 - pain, vaginal loss, gynaecological history

  • Pain = cramping, contractions, foetal movements
  • vaginal loss – discharge, amniotic fluid, bleeding
  • gynaecological history (invasive procedures, cervical surgery, uterine anomalies)
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19
Q

If we suspect a miscarriage, what are the 3 key tests should we perform in our examination?

1 - pain assessment, blood tests, ultrasound
2 - hCG, swabs (bleeding, cervix), ultrasound
3 - pain assessment, swabs (bleeding, cervix), X-ray
4 - pain assessment, swabs (bleeding, cervix), ultrasound

hCG = human chorionic gonadotrophin hormone

A

4 - pain assessment, swabs (bleeding, cervix), ultrasound

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20
Q

A 1st trimester (0-12 weeks) miscarriage is a loss of foetus within 1st trimester (<12 weeks). What % of all pregnancy losses are attributed to 1st trimester pregnancy loss?

1 - 10%
2 - 30%
3 - 65%
4 - 85%

A

4 - 85%

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21
Q

A 1st trimester (0-12 weeks) miscarriage is a loss of foetus within 1st trimester. What is the most common cause of a miscarriage?

1 - lifestyle choices
2 - medication
3 - genetic mutation
4 - chromosomal abnormality

A

4 - chromosomal abnormality

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22
Q

What is the first line treatment for someone with a suspected 1st trimester miscarriage?

1 - conservative/expectant/wait and see what happens approach
2 - prescribe misopristol
3 - prescribe mifepristone
4 - surgical intervention

A

1 - conservative/expectant/wait and see what happens approach

  • here patients may continue with their pregnancy or the dead foetus will be delivered naturally
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23
Q

The first line treatment for someone with a suspected 1st trimester miscarriage is a conservative/expectant approach, which is essentially wait and see what happens approach. How long is this approach implemented for and what is the general success of this approach?

1 - wait 7 days with a 100% success
2 - wait 7-14 days with a 40-80% success
3 - wait 14 days with 40-80% success
4 - wait 21 days with a 50% success

A

2 - wait 7-14 days with a 40-80% success

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24
Q

What medical management (medication) is provided to a patient who is confirmed of having a 1st trimester miscarriage beyond the 14 days of conservative management?

1 - ultrasound
2 - prescribe misopristol
3 - prescribe mifepristone
4 - surgical intervention

A

2 - prescribe misopristol

  • a synthetic prostaglandin called misoprostol
  • causes uterus to contract and cervix softens and dilates
25
Q

Medical management is provided to a patient who is confirmed as having a 1st trimester miscarriage is a synthetic prostaglandin called Misoprostol. This medication causes the uterus to contract and the cervix thins and dilates and can be used for an abortion (home or hospital). What are the common side effects of Misoprostol?

1 - pain
2 - bleeding
3 - risks of failure and subsequent surgery
4 - all of the above

A

4 - all of the above

26
Q

Which 2 surgical management options would be suitable for a patient who has a 1st trimester misacarriage confirmed and where misoprostol has failed, or the patient has declined this as an option?

1 - hysterectomy
2 - myomectomy
3 - manual vacuum aspiration
4 - surgical management

A

3 - manual vacuum aspiration
4 - surgical management

  • patients are provided with sedation/anaesthetic and foetus is removed
  • conducted in hospital
  • can cause bleeding, infection, uterine+ perforation, cervical damage, retained products and incomplete treatment
27
Q

Is any support offered to women who have experienced a miss-carriage?

A
  • no
  • women may be physically and psychologically affected
28
Q

What hormone can women be provided with if a woman is at risk of subsequent miscarriage in early pregnancy?

1 - vaginal progesterone
2 - vaginal oestrogen
3 - vaginal COC
4 - intrauterine system

A

1 - vaginal progesterone
- stabilises endometrium

29
Q

What is an ectopic pregnancy?

1 - pregnancy where 2 eggs have been fertilised
2 - development of foetus outside of the uterus
3 - developiment of foeuts at entrance of uterus, over the cervix
4 - all of the above

A

2 - development of foetus outside of the uterus

30
Q

Ectopic pregnancies are the development of pregnancy outside of the uterus. What is the most common form of ectopic pregnancy?

1 - fallopian tubes
2 - ovaries
3 - cervical
4 - abdominal

A

1 - fallopian tubes = 97%
- ectopic pregnancies occur 11 per 1000 pregnancies

31
Q

Ectopic pregnancies are the development of pregnancy outside of the uterus. Which of the following is NOT a common risk factors for ectopic pregnancies?

1 - previous ectopic (15%)
2 - tubal damage
3 - subfertility/IVF
4 - previous cervical cancer
5 - intra-uterine copper device/Intrauterine system
6 - progesterone only contraception
7 - cystic fibrosis

A

4 - previous cervical cancer
- no clear evidence for this

32
Q

What is the risk of mortality for the mother in an ectopic pregnancy?

1 - 0.2 per 1000
2 - 5 per 1000
3 - 10 per 1000
4 - 20 per 1000

A

1 - 0.2 per 1000

33
Q

Ectopic pregnancies are the development of pregnancy outside of the uterus. Some of the most common risk factors for ectopic pregnancies are:

  • previous ectopic (15%)
  • tubal damage
  • subfertility/IVF
  • intra-uterine copper device/Intrauterine system
  • progesterone only contraception
  • cystic fibrosis

What % of women where an ectopic pregnancy occurs do not have risk factors?

1 - 5-10%
2 - 20-40%
3 - 50-75%
4 - >90%

A

3 - 50-75%

34
Q

We always need to suspect an ectopic pregnancy as this has a 0.2 per 1000 risk of mortality. What is the classical presentation of an ectopic pregnancy?

1 - pain and bleeding 6-8 weeks, negative pregnancy test, foetus in uterus on ultrasound
2 - pain and bleeding >12 weeks, positive pregnancy test, empty uterus on ultrasound
3 - pain and bleeding 6-8 weeks, negative pregnancy test, empty uterus on ultrasound
4 - pain and bleeding 6-8 weeks, positive pregnancy test, empty uterus on ultrasound

A

4 - pain and bleeding 6-8 weeks, positive pregnancy test, empty uterus on ultrasound

35
Q

We always need to suspect an ectopic pregnancy as this has a 0.2 per 1000 risk of mortality. What is the emergency presentation of an ectopic pregnancy?

1 - collapse, hypotensive or tachycardia, chronic abdomen
2 - collapse, hypotensive or tachycardia, acute abdomen
3 - blood loss, hypertensive or tachycardia, acute abdomen
4 - collapse, hypotensive or bradycardia, acute abdomen

A

2 - collapse, hypotensive or tachycardia, acute abdomen

36
Q

If someone has an ectopic pregnancy, confirmed with a positive test, what would be monitored to assess the viability of the ectopic pregnancy?

1 - progesterone
2 - human chorionic gonadotrophin hormone
3 - oestrogen
4 - human placental lactogen

A

2 - human chorionic gonadotrophin (hCG) hormone

  • monitor hCG >1000iu/L should correlate with visible intrauterine pregnancy
  • hCG should double every 48 hours in normal intrauterine pregnancy
37
Q

If someone has an ectopic pregnancy with a human chorionic gonadotrophin (hCG) of <1500 and no foetal HR, what would the medical management be?

1 - methotrexate
2 - misopristol
3 - mifepristone
4 - manual vacumn

A

1 - methotrexate
- stops cell division causes cell death

38
Q

If someone has an ectopic pregnancy with a confirme3d HR and a hCG of >5000, what would surgical management be?

1 - salpingectomy/salpingotomy
2 - hysterectomy
3 - myomectomy
4 - 4 - manual vacumn

A

1 - salpingectomy/salpingotomy

Salpingectomy = removal of fallopian tubes
Salpingotomy = creating opening of fallopian tube

39
Q

What is the definition of a 2nd trimester miscarriage?

1 - loss of baby between 0-12 weeks
2 - loss of baby between 12-24 weeks
3 - loss of baby between 24-38 weeks

A

2 - loss of baby between 12-24 weeks
- less common than 1st trimester miscarriage

40
Q

A 2nd trimester miscarriage is the loss of a baby between 12-24 weeks. What are the 3 most common causes of 2nd trimester miscarriage caused by intrauterine death?

1 - foetal abnormality, infection, placental dysfunction
2 - alcohol/smoking, infection, placental previa
3 - foetal abnormality, infection, placental dysfunction
4 - genetic defect, trauma, placental dysfunction

A

1 - foetal abnormality, infection, placental dysfunction

41
Q

A 2nd trimester miscarriage is the loss of a baby between 12-24 weeks. Which of ther following is a common cause of 2nd trimester miscarriage caused by preterm labor where regular contractions result in the opening of the cervix after week 20 and before week 37 of pregnancy?

1 - cervical weakness (previous surgery)
2 - uterine anomaly
3 - infection
4 - rupture of membranes (can be linked to infection and cervical weakness)
5 - invasive procedures
6 - bleeding
7 - all of the above

A

7 - all of the above

42
Q

In a second trimester miscarriage what medical management can be used to induce the labour?

1 - ultrasound
2 - prescribe misopristol
3 - prescribe mifepristone
4 - surgical intervention

A

2 - prescribe misopristol

  • a synthetic prostaglandin called misopristol
  • causes uterus to contract and cervix softens and dilates
43
Q

Which 2 surgical management options would be suitable for a patient who has a 2nd trimester miscarriage confirmed and where misoprostol has failed, or the patient has declined this as an option?

1 - hysterectomy
2 - myomectomy
3 - cervical cleavage and vacuum aspiration
4 - surgical management

A

3 - cervical cleavage and vacuum aspiration
4 - surgical management

44
Q

A 2nd trimester miscarriage is the loss of a baby between 12-24 weeks. Following the miscarriage, why is lactation suppression important to consider offering as a treatment?

1 - distress as breast milk will begin to be made
2 - breast feeding will not be possible again
3 - galactorrhoea is likley to occur
4 - all of the above

A

1 - distress as breast milk will begin to be made
- can be very distressing for them

45
Q

A 2nd trimester miscarriage is the loss of a baby between 12-24 weeks. Following the miscarriage, what common tests are performed?

1 - karyotyping
2 - post-mortem and placental histology
3 - infection screening, blood tests (Anti-D (rhesus + vs -)
4 - all of the above

A

4 - all of the above

46
Q

What is the definition of recurrent miscarriage?

1 - 2 consecutive miscarriages
2 - 3 or more consecutive miscarriages
3 - 5 consecutive miscarriages
4- >5 consecutive miscarriages

A

2 - 3 or more consecutive miscarriages
- no full gestation periods between (births essentially)
- patients only offered karyotyping to assess for chromosomal abnormalities if 3 or more miscarriages has occured

47
Q

Recurrent miscarriage is defined as 3 consecutive miscarriages with no full gestation periods between (births essentially). Patients will be screened for antiphospholipids syndrome, which is where the body produces antiphospholipids antibodies against phospholipids. What type of hypersensitivity is this classed as?

1 - Type I: IgE mediated hypersensitivity
2 - Type II: IgG mediated cytotoxic hypersensitivity
3 - Type III: immune complex mediated hypersensitivity
4 - Type IV: delayed reaction mediated hypersensitivity

A

3 - Type III: immune complex mediated hypersensitivity
- immune complexes build up and cause blood clots

Can be treated with aspirin and Low Molecular Weight Heparin

48
Q

Recurrent miscarriage is defined as 3 or more consecutive miscarriages with no full gestation periods between (births essentially). What hormone can these patients be offered between 5-16 weeks in future pregnancies?

1 - levonorgestrel IUS
2 - vaginal ostrogen
3 - vaginal progesterone
4 - oral osterogen and progesterone

A

3 - vaginal progesterone

49
Q

Stillbirth is when a baby dies before birth (>24 weeks of pregnancy) or during labour. What is the incidence of stillbirths?

1 - 1:10
2 - 1:150
3 - 1:225
4 - 1:300

A

3 - 1:225
- many cases of stillbirths are avoidable

50
Q

Stillbirth is when a baby dies before birth (>24 weeks of pregnancy) or during labour. What is a common factor is non-modifiable that is a risk factor for stillbirth?

1 - ethnicity
2 - medications
3 - maternal age
4 - family history

A

3 - maternal age

51
Q

Ground E of the abortion act allows termination at any gestational age. Which of the following is ground E?

1 - baby and/or mother is at serious risk of illness and disease
2 - continuance of pregnancy involves risk to the life of the pregnant woman greater than if the pregnancy were terminated
3 - substantial risk that baby will have physical/mental abnormalities if pregnancy continues
4 - pregnancy has NOT exceeded 24 wks and continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman

A

3 - substantial risk that baby will have physical/mental abnormalities if pregnancy continues

52
Q

The abortion act allows termination at any gestational age under ground E, which is when there is a substantial risk that if the child was born it would suffer from such physical and mental abnormalities as to be severely handicapped. What % of total termination of pregnancy does this account for?

1 - 10%
2 - 2%
3 - 25%
4 - 50%

A

2 - 2% (works out at 3183 terminations in 2019)

53
Q

What is the most common cause for a termination of pregnancy under ground E?

1 - congenital malformations
2 - chromosomal abnormalities
3 - genetic mutations
4 - intrauterine growth restriction

A

1 - congenital malformations (53%)
- chromosomal abnormalities is 2nd with 29% (down syndrome is most common)

54
Q

What age group are at highest risk of having a termination on grounds E?

1 - <16 y/o
2 - 17-21 y/o
3 - 25-35 y/o
4 - >35 y/o

A

4 - >35 y/o

55
Q

If a patient has had a termination on ground E they will normally be tested for what assessment of the blood?

1 - rhesus status
2 - U&Es
3 - LFTs
4 - HIV status

A

1 - rhesus status

56
Q

If a patient has had a termination on ground E they will normally be tested for what condition that affects blood clotting?

1 - von willebrand disease
2 - venous thrombo embolism
3 - hemophilia
4 - antiphospholipid syndrome

A

2 - venous thrombo embolism

57
Q

Nice recommend that women are offered a choice between medical or surgical abortion up to and including what week of gestation?

1 - 12+5 weeks
2 - 20+10 weeks
3 - 23+6 weeks
4 - 28+6 weeks

A

3 - 23+6 weeks

58
Q

If a patient has had a termination on ground E, this will normally be performed using medical interventions using what 2 drugs?

1 - mifepristone and misoprostol
2 - misoprostol and sertraline
3 - mifepristone and olanzapine
4 - misoprostol and ramipril

A

1 - mifepristone and misoprostol
- 95-99% effective
- mifepristone 1st then misoprostol 48h later

59
Q

If a patient has had a termination on ground E, this will normally be performed using medical interventions, However, surgical interventions are also performed. What is the normal process for surgical management of a termination?

1 - salpingectomy/salpingotomy
2 - hysterectomy
3 - myomectomy
4 - cervical priming with mifepristone and misoprostol and then manual vacumn

A

4 - cervical priming with mifepristone and misoprostol and then manual vacumn

  • vacuum aspiration normally up to 14 weeks
  • dilatation and evacuation 15-24 weeks

A. MLA Map Obstetrics and Gynaecology (29 decks)

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