WH: Early Pregnancy Flashcards
What is an ectopic pregnancy ?
it is pregnancy implanted outside of the uterus
possible implantation site for ectopic pregnancy? (5) most common?
- Fallopian tube (most common)
- Ovaries
- Cervix
- Abdo
- in myometrium (implant in CS scar)
What can happen if ectopic pregnancy goes undiagnosed?
rupture of implantation site + intraperitoneal haemorrhage => maternal death
ectopic pregnancy RF?
- Prev ectopic
- Prev PID
- Prev fallpain tube surgery
- IUD (coils)
- Increased age
- Smoking
How does IUD increased risk of ectopic pregnancy ?
make uterus uninhabitable => implant elsewhere
at how many weeks gestation will ectopic pregnancy usually present?
6 - 8 weeks
What is the common presentation of ectopic pregnancy ?
- Missed period
- Constant lower abdo/pelvic pain (R or LIF)
- Vaginal pain
- Cervical motion tenderness
What investigations would you do for suspected ectopic pregnancy? diagnostic ?
- Urine or serum pregnancy test
- TVUS (diagnostic)
what would be found on TVUS for Px with ectopic pregnancy?
TVUS (diagnostic): gestational sac containing yolk sac or fetal pole
what is a pregnancy of unknown location? what is important differential?
+ve pregnancy test but no sings on USS (need to consider ectopic as can’t exclude)
describe the hCG levels in a normal pregnancy ?
double every 48 hrs
describe the hCG levels in a miscarriage?
halves every 48 hrs
describe the hCG levels in ectopic pregnancy
continue to increased (<63%) but not at rate of normal pregnancy
What is the management of ectopic pregnancy? general 3 categories? what determines which management?
all ectopic pregnnaes need to be terminated (not viable)
- Expectant
- Medical
- Surgical
(depends on haemodynamic stability of patientand level of pain)
What happens in expectant management of an ectopic pregnancy? what condition does this need?
awaiting natural termination (ectopic needs to be unruptured)
What drug is used in medical management of ectopic pregnancy? what lifestyle advice after this?
methotrexate (highly teratogenic) IM injection
- advised not to get pregnant for following 3 months (harmful effects of methotrexate can last a long time)
what are the SE of medical management of ectopic pregnancy? (4)
methotrexate
- vaginal bleeding
- Nausea + vomiting
- abdo pain
- Stomatitis
when should surgical management of ectopic be considered?
- Pain
- Visible Heart beat
- High levels of hCG
- Size >35mm
describe the surgical management of ectopic pregnancy ? (2) plus what additional thing?
- laparoscopic salpingectomy
- laparoscopic slpingotomy
- Anti-rhesus D prophylaxis given to rhesus -ve women after surgical management
which type of management of ectopic pregnancy is most common
depends how late on
- methotrexate is most common in early pregnncy
- surgical if haemodynamically stable
(kinda stupid question rly)
blob sign, bagel, tubal ring sign found on TVUS. what most likely diagnosis ?
ectopic pregnancy
What is a miscarriage ?
It is the spontaneous involuntary termination of pregnancy
What counts as early miscarriage? late? which more common?
- Before 12 weeks => early miscarriage (more common)
- 12 - 24 weeks => late
What is a missed miscarriage?
fetus is no longer alive but no symptoms occurred
What is a threatened miscarriage? cervix?
Vaginal bleeding but vertical os is closed (pregnancy may continue)
What is inevitable miscarriage? cervix?
Vaginal bleeding with open cervix (pregnancy loss will occur => inevitable)
What is incomplete miscarriage ?
retained products of conception after miscarriage (=> infection risk)
What is a complete miscarriage?
no products of conception left in uterus
what is an anembryonic miscarriage?
gestational sac present but contains no embryo
name some RF for miscarriage ?
- maternal age (>30 - 35)
- Prev misscarriage
- Obesity
- Smoking
- Fetal malformations (trisomy 16)
What is the main presenting symptoms of miscarriage ?
vaginal bleeding
miscarriage présentation?
- Vaginal bleeding
- Cramping abdo pain
- Passage of fetal tissue
- symtoms of ectopic
what investigation might you do in a miscarriage? diagnostic?
- hCG levels
- TVUS (diagnostic)
What are you looking for on TVUS of a miscarriage ?
lack of fetal cardiac heart beat (at 5.5-6 weeks) check again in a week
- mean gestation sac diameter
what 3 general types of management is there for miscarriage ?
- Expectant
- Medical
- Surgical
what is involved in expectant manamgent of miscarriage?
await spontaneous miscarriage
- more than 6 weeks: USS confirm location + viability of pregnancy (+exclue ectopic)
what drugs used in medical management of miscarriage (2) ? what type of drug is this? action?
- misoprostol (prostaglandin analogue) => soften cervix + stimulate contractions
- mifepristone (anti-progestogen that blocks action of progesterone => halt pregnancy + enhances effects of prostaglandins)
SE of medical mandgemt of miscarriage?
misoprostol
- SE: heavier bleeding, pain, vomiting, diarrhoea
Surgical management of miscarriage ?
manual vacuum aspiration (local)
or
elector vacuum aspiration (GA)
possible complication of miscarriage? (3)
- retain produces of conception => may require surgery
- rhesus sensitisation
- emotional stress
Definition of recurrent miscarriage ?
it is 3 or more consecutive miscarriages (before 24 weeks gestation)
RF for recurrent miscarriage?
increase with age
Causes of recurrent miscarriages? (4)
- Idiopathic (particularly in older women)
- Antiphospholipi syndrome (APS)
- Hereditary thrombophillias
- Uterine abnormalities (fibroids)
What is antiphospholipid syndrome ?
APS: disorder associated with antiphospholipid antibodies => blood becomes prone to clotting (hypercoagulbale state)
what condition should you suspect in a Px pressing with recurrent miscarriage or recurrent DVT?
APS
what investigations would you do for recurrent miscarriage?
think of the causes
- Antiphosphlipid antibodies
- Testing for hereditary thrombophillia
- Pelvic US (used to assess uterine anatomy)
- Genetic testing of parents (karyotyping)
Mangagment of recurrent miscarriage ?
depends on underlying cuase
- consider using vaginal progesterone pessaries during early pregnancy
What are mothers with APS advised to take?
low does aspirin plus heparin antenatally
what anticoagulant should be avoided in pregnancy ?
warfarin as v teratogenic !
What is termination of pregnancy ? (TOP)
TOP (abortion): is an elective procedure to end a pregnancy
What legal framework is used for TOP?
The 1967 Abortion Act
Which legal framework reduced the latest gestational age you can have a TOP? from what to what?
1990 Human Feritlisation + embryology act reduced latest GA from 28 to 24 weeks
What criteria need to be met for aboriton to be performed? for the patient
aboriton can be performed before 24 weeks if continuing pregnancy involves create risk to the physical or mental health of:
- the woman
- or existing children of the family
When can a TOP be performed any time during pregnancy (3)
- Likely to risk the life of the woman
- TOP will preven “grave permanent injury” to physical or mental health of the woman
- Substantial risk that the child will suffer physical or mental abnormalities
What 2 legal requirements are required for TOP?
- 2 Medical practitioners must sign to say TOP is indicated
- Carried out by registered medical practitioner in NHS hospital or approved practice
What types of aboriton are there?
Medical
Surgical
What is involved in a medical TOP? what drugs? what type of drug?
- Mifepristone (anti-progestogen)
- Misoprolol (Prostaglandin analogue 1-2 days later)
- Rhesus -ve women with GA >10 weeks having medical TOP should have anti-D prophylaxis
What is the action of mifepristone and misoprolol in TOP ?
- Mifepristone (anti-progestogen): halt pregnancy + relax cervix
- Misoprostol (prostaglandin analogue): Prostaglandins soften the cervix + stimulate uterine contractions
What is involved in surgical TOP?
local (+/- sedation) or GA
- cervical dilatation + suction or evacuation of the contents
- Rhesus -ve women should have anti-D prophylaxis (irrelevant of GA)
what are the post-TOP symptoms like?
may experience vaginal bleeding + abdominal cramps (<2 weeks)
Complications of TOP? (5)
- Bleeding
- Pain
- Infection
- Failure of abortion
- Damage to cervix/uterus
when does nausea and vomitng in pregnancy (NVP) peak?
around week 9
(8 - 12)
When does nausea and vomiting in pregnancy (NVP) usually settle ?
usually settles by week 20
What is hyperemesis Gravidarum? causes what 3 things?
Severe nausea and vomiting in pregnancy leading to weight loss, dehydration + electrolyte imbalances
What is thought to cause NVP?
rapidly rising levels of hCG
- Placenta secretes hCG
which pregnancies are associated with higher levels of hCG?
- Molar pregnancies
- Multiple pregnancies
how is hyperemesis gravid arum diagnosed?
clinical (+exclusion of other differentials)
NVP plus:
- >5% weight loss compared with before pregnancy - Dehydration
- Electrolyte imbalances
what score can be used to assess severity of NVP?
PUQE
- Pregnancy-unique Quantification of Emesis
describe the mangagement of NVP? what drug?
- Antiemetics to suppress nausea (prochlorperazine or cyclizine)
When consider admission for hyperemesis gravid arum ?
- Unable to tolerate oral aniemetics
- Cant keep fluids down
- > 5% weight loss compared to before pregnancy
- ketones present on urine dipstick
What does a molar pregnancy arise from ?
arrises from an abnormality in chromosomal number in fertilisation
what is a hydatidiform mole ?
it is a type of tumour that grows like a pregnancy in the uterus(and can metastasize)
What is a complete mole (pregnancy) ? describe
when 1 sperm with duplicates (or 2 sperm) fertilise an ovum with no genetic material => grow into tumour => complete mole formation
Does fetal material form from a complete mole pregnancy?
no fetal material will form
What is a partial mole pregnancy ? describe
when 2 sperm fertilise a normal ovum => new cell has 3 sets of chromosomes (triploid) => grow into tumour
Does fetal material form from a partial mole pregnancy ?
some fetal material may form
how does molar pregnancy initially present ?
initially behaves like normal pregnancy (menstural periods stop + normal pregnancy hormonal changes occur)
differences between normal and molar pregnancy ? (early preg signs) (3)
- More severe morning sicness
- Vaginal bleeding
- Abnormally high hCG
What will be seen on US of a molar pregnancy?
Snowstorm appearance
What is the management of a molar pregnancy ?
Evacuation of uterus to remove molar pregnancy
- Anti-D prophylaxis
what is the diagnostic test for molar pregnancy ?
after uterine evacuation: products of conception sent for histological examination to confirm molar pregnancy
what is a serious complication of a molar pregnancy?
occasionally the mole can metastasise and patient may require systemic chemotherapy :/
