1
Q
What is early pregnancy loss?
A
pregnancy loss intrauterine or extrauterine up to 14 weeks
2
Q
What is the definition of missed miscarriage?
A
the embryo has died, but the pregnancy tissue has not passed. Some women may be asymptomatic or have small amounts of bleeding or pain.
3
Q
What is a threatened miscarriage?
A
typically refers to bleeding and cramping in an otherwise viable pregnancy before 20 weeks
4
Q
What is recurrent miscarriage RANZCOG?
A
2 or more miscarriages intrauterine pregnancies up to 20 weeks gestation (whether or not they are consecutive or a gestation sac is present)
5
Q
What % of pregnancies does early pregnancy loss effect?
A
10-25% of known pregnancies
6
Q
What % of miscarriages are early miscarriages?
A
80%
7
Q
What is the risk of pregnancy loss after 14 weeks?
A
1-2%
8
Q
what is the life time risk of miscarriage ?
A
almost 25%
9
Q
What is the risk of miscarriage at 40?
A
50%
10
Q
how common are ectopic pregnancies?
A
1 in 80
11
Q
What is miscarriage?
A
involuntary, spontaneous loss of a pregnancy before 20 weeks completed gestation.
12
Q
What advice does RANZCOG given on surgical treatment of incomplete or missed miscarriage?
A
use a suction curette not a sharp when possible to avoid IUA
13
Q
What antibiotics pre surgical management is discussed in the RANZCG guideline?
A
doxycycline +/- metro 2 hours before procedure
14
Q
what medication regime is suggested for missed miscarriage, medical management?
A
a. Mifepristone 200mg PO
b. Misoprostol 600mcg (SL or buccal) or 800mcg (PV, buccal or SL) 24-48 hours later
If bleeding has not commenced 24-48 hours after misoprostol
c. then repeat doses of misoprostol 400mcg may be administered
15
Q
what medication regime is suggested for incomplete miscarriage, medical management?
A
a. Misoprostol 600mcg (SL or buccal) or 800mcg (PV, buccal or SL)
If bleeding has not commenced 24-48 hours after misoprostol
b. then repeat doses of misoprostol 400mcg may be administered
16
Q
What intervention for miscarriage reduces the need for unplanned emergency surgical management?
A
surgical, medical doesn’t compared to expectant
17
Q
is medical management more sore than expectant?
A
no difference
18
Q
What did the cochrane review assessing psychological impact of management of pregnancy show?
A
no clear difference between management options
19
Q
What are IUA more likely after?
A
more than one miscarriage
more than one D&C
20
Q
What should be the focus in management of IUA?
A
symptoms
21
Q
Should you offer progesterone in threatened miscarriage after no or one miscarriage? Why?
A
No, no change in live birth rate, PTB or still birth
22
Q
what % of couples will have recurrent miscarriage?
A
1-4%
23
Q
Why have they changes the recurrent miscarriage definition?
A
There is limited evidence in pregnancy outcomes for women who have 2 vs 3 in respect to risk factors for recurrent loss such as APS and carrier status for structural chromosome anomaly and whether the losses were consecutive.
24
Q
What are risk factors for recurrent pregnancy loss?
A
- Age of parents
- Excessive ETOH
- Smoking
- Obstetric history
Medical conditions - diabetes, thrombophilia, hypothyroidism, uterine structural anomalies
25
Will you find a cause for recurrent miscarriage in most women?
no
26
what investigations in recurrent miscarriage are routinely recommended?
lupus anticoagulant
anti cardiolipin antibodies (IgM and IgG)
3D pelvic USS
thyroid screening - TSH, T4 free, anti TPO abs
27
what investigations in recurrent miscarriage are considered case by case recommended?
anti Beta 2 glycoprotein I antibodies
parental karyotype
sperm DNA fragmentation
ANA antibodies
28
Why are beta 2 glycoprotein I antibodies only case by case?
No difference found in recurrent miscarriage vs no RM,
29
What is the role of testing for inherited thrombophilia in RM?
increased prevalence of factor V Leiden mutation, prothrombin gene mutation and protein S deficiency but no intervention shown to change outcome so don't test
30
What trial looked at LMWH in patient with thrombophilia? what did it find
ALIVE 2 trial
no change in live birth rates, increased bruising
31
What is sperm DNA fragmentation?
damaged genetic material in sperm, double or single strand breaks.
32
Is there a link between Sperm DNA fragmentation and RM?
yes
33
What interventions have been proposed to improve Sperm DNA fragmentation?
smoking cessation, exercise, weight management, air pollution reduction, treating infection, varicocele, diabetic control, antioxidant therapy, sperm selection.
34
Why is it advised to consider Sperm DNA fragmentation in work. up for RM?
although minimal evidence can try some lifestyle changes
35
Why do we consider ANA testing in RM?
increased risk in RM population so part of the routine battery of tests to investigate causes for diagnostic purposes only.
36
What is cytogenetics?
the study of chromosomes includes karyotype, CMA, FISH
37
RANZCOG - Should cytogenetics be routinely recommended in couples with RM and why?
What does GTG say?
no
as the chance of fetal genetic anomaly reduces in couples with RM compared to people with one.
GTG you should after 3 and each one after
38
What should be discussed with couples considering cytogenetics on their POC?
benefits and harms of knowing the outcome of testing. Clinical benefit is unknown.
can help to counsel around future risk (GTG)
39
What % of POC will have a genetic anomaly in one pregnancy loss?
64%
40
What % of POC will have a genetic anomaly in recurrent pregnancy loss?
55%
41
What chromosomal anomaly is more likely in older women's POC?
autosomal trisomies
42
What chromosomal anomaly is more likely in younger women's POC?
unbalanced structural anomalies (duplications, deletions)
43
What are the difficulties with processing karyotype in RM?
fails to culture tissue, expensive, contamination of maternal cells
44
What is the limitation of FISH in RM?
limited by probes used to detect abnormalities
45
What is the limitations and benefits of CMA in RM?
includes single nucleotide polymorphism techniques and lower failure rates than karyotyping but can find VUS which are difficult to interpret.
46
Should women with TPOab and euthyroid be offered levothyroxine? Why? do RANZCOG and GTG and ESHRE agree
no. two best studies we have did not show improvement
all say no
47
Should women with subclinical hypothyroidism be offered levothyroxine? RANZCOG vs ESHRE advice? GTG ?
ranzcog no, mixed evidence
ESHRE may reduce, discuss risks and benefits
GTG if TSH >4 treat
48
What is subclinical hypothyroidism by TSH?
TSH >2.5
49
If you do not treat SCH or TPOabs with levothyroxine when should you check TSH?
7-9 weeks
50
What TFT other than TSH represent thyroid function well? Why
Free T4
present in a ration with T3
20:1 T4:T3
more reliable marker or thyroid function.
51
What % of T4 is bound to TBG?
99%
52
What is the evidence of IVIg in RM?
There is no evidence that medium dose IVIg in women with URM improves the live birth rate
possibly may improve for women with 4 or more thought to be immunological
53
Can you get IVIg for RM in NZ/Aus?
no
54
When is IVIg given in pregnancy?
pre conception or up to 4-6 weeks
55
Is IVIg a blood product?
yes from plasma
56
what is the advice for treatment of recurrent miscarriage in APS?
aspirin 75-150mg OD starting before or from the first pos UPT
and
LMWH from UPT to at least 34 weeks
57
What does the data show for pregnancy loss prevention in APS with UFH vs LMWH?
UFH has improved outcomes
58
Why is LMWH advised over UFH in APS for RM?
lower risk of thrombocytopenia and osteoporosis
mor convenient administration
doesn't need monitoring
59
What are the risks of LDA in pregnancy?
slight increase in PPH RR 1.2
no increase in congenital malformations or neonatal bleeding
60
If a patient has a balanced translocation what are the options for IVF?
PGT- structural rearrangements
PGT SR
61
Is IVF recommended in RM?
no, no improvement in outcomes
62
If you are having IVF in RM what can you consider? What is the evidence?
PGT-A
same live birth as spotaneous conception
63
What are the problems with PGT-A?
high embryo drop out rates
In 50% of patients and 57% of cycles no euploid embryos were available for transfer.
64
What are the reasons for embryo drop out in PGT?
Embryos may not be suitable for transfer due to non biopsiable or freezable blastocyst quality, failure of genetic analysis, chromosomal anomaly or mosiac.
65
If uterine septum resection recommended in RM? RANZCOG vs GTG
no, but if it is should be on a case by case
GTG says consider
66
what outcomes are a uterine septum associated with?
PTB, miscarriage
67
What is a metroplasty?
a reconstructive surgery used to repair congenital unification anomalies of the uterus, including didelphys uterus and bicornuate uterus.
68
what risk is a unicornuate uterus associated with?
PTB
69
what risks are a bicornuate uterus associated with?
PTB and miscarriage
70
What is the advice on management of other congenital malformations with RM?
case by case, there is no evidence to guide practice
71
What are included in congenital uterine malformation?
septate
bicornuate
unicornuate
didelphys
arcuate
72
What congenital malformations have no associated pregnancy outcomes?
arcuate
didelphys
73
What % of women with RM will have a congenital anatomical factor?
7-28%
74
What is the most common uterine congenital anatomical factor?
uterine septum
75
Is resection of a C section scar niche advised?
no
it doesn't improve out comes
76
What is a c scar niche associated with?
PTB, miscarriage, reduced IVF rates
larger size = worse outcomes
77
What is the advice of IUA adhesiolysis in RM? What should be discussed
can be considered on case by case, discuss recurrence rates
78
Should polypectomy or myomectomy in RM be advised?
no due to a lack of evidence. but if you are should be on a case by case
79
What are included in acquired anatomical factors?
fibroids, IUA, polyps, c scar niche
80
what % of women with RM have an acquired uterine anomaly?
6-15%
81
When should you offer progesterone in recurrent miscarriage in T1?
if 2 or more miscarriages and bleeding/threatened miscarriage
82
What dose of progesterone and until when do you give in RM with bleeding?
400mg PV BD until 16 weeks
83
What are the signs on uss that can reliably diagnose an ectopic pregnany?
1. adnexal mass that includes a: - gestation sac (with or without a yolk sac, fetal pole, FHR)
- an empty gestation sac (bagel sign)
- an adnexal mass with a sliding sign with an inhomogeneous mass (blob sign)
84
What is the specificity of an USS for ecopic showing a blob or bagel signs?
98%
85
What % of ectopics are in the fallopian tube?
97
86
What is the difference between cornual and interstitial?
Cornual - pregnancy implanted in non-communicating horn of a congenitally abnormal uterus
Intersitial - intramural part of the fallopian tube
87
What are the ways you are can confirm diagnosis of ectopic pregnancy?
- Histology confirmation of ectopic pregnancy
- Confirmation of ectopic on follow up USS
- Rising hCG levels with no chorionic villi tissue evacuated
- Suspected ectopic pregnancy which resolved after medical treatment
88
Where in the tube is the most common place to get an ectopic?
ampulla 80% of all ectopics
89
What hcg cut off is used for Mtx?
5000, if above needs surgery
90
What size cut off is used for MTX?
35mm, if above needs surgery
91
In a woman with a adnexal mass <35mm with no FHR what hCG can you consider conservative, medical or surgical?
<1500
92
in a woman with a adnexal mass <35mm with no FHR what hCG can you consider medical or surgical? (no conservative)
hCG 1500-<5000
93
Who symptoms must be absent to offer MTX in ectopic?
significant pain or signs of rupture
94
Who should be offered one dose of MTX for ectopic management?
hcg <3000
mass <20mm
95
Who should be offered two doses of MTX for ectopic management? when should they be given?
Hcg 3000-5000
Mass 20-35mm
MTX 4-7 days apart
96
What side effects can be experienced with MTX?
nausea, diarrhoea, mucositis, abdominal pain and mildly abnormal lab results
bone marrow suppression, pulmonary fibrosis, pneumonitis, cirrhosis, renal failure, gastric ulcers
97
What increases the risk of ADRs with MTX?
two doses
98
How long should women wait after MTX before TTC?
3/12
99
What ectopic management may favour IUP?
MTX
100
What ectopic management is associated with higher resolution or preganncy?
salpingectomy
101
Does MTX decrease or increase rate of recurrent ectopic compared to surgery?
unclear
102
Why is salpingectomy recommended over salpingotomy?
higher likelihood of ectopic resolution of the tubal ectopic in one procedure
103
When may salpingostomy be considered?
depending on the womans preferences, desire to avoid or lack of access to IVF and her Mhx.
risk factors of infertility (PID, previous ectopic, surgery) or subfertility hx
104
What should women requesting salpingostomy be advised?
increased risk of failure, and need for more treatment w MTX or salpingectomy
105
what is the RR in treatment failure with salpingotomy vs ectomy?
RR 12.4
106
what is there no difference in with salpingectomy, vs ostomy?
resolution of preganncy, subsequent IUP, recurrent ectopic
107
What % of ectopics are said to be non tuba?
5-8%
108
What non tubal ectopic is increasing the most?
cs scar
109
What are included in non tubal ectopics?
interstitial
CS scar pregnancy
cervical ectopic pregnancy
cornual
abdominal
110
What is a c section scar pregnancy? (CSP)
when a fertilised ovum implants into the myometrial defect from a previous uterine incision
111
What are the two types of CSP?
○ Type I (endogenic)
Type II (exogenic)
112
What is type I CSP?
CSP implants on the scar and progresses twoards the cervico-isthmic space or uterine cavity. This can result in a viable pregnancy but is high risk
113
What is type II CSP?
CSP implants on the scar and progresses towards the bladder and abdominal cavity. More likely to lead to rupture and haemorrhage
114
What is an interstitial ectopic pregnancy?
when the fertilised ovum implants in the most proximal part of the tube called the interstitial portion (1-2cm long), traversing the myometrium opening into the ostia.
115
What is a cornual ectopic?
pregnancy within the rudimentary horn or within one horn of a septate or uni or bicornuate uterus
116
When should women with interstitial ectopic have surgical management?
don't want MTX, failure of medical or expectant management or high risk of haemorrhage
117
What order should operation be offered in for interstitial ectopic?
1. cornuostomy
2. Laparoscopic wedge/cornual resection with ipsilateral salpingectomy
118
What kind of MTX can be offered in interstitial ectopic?
systemic or intra sacUSS
119
Why may cornostomy preferred to cornual resection?
as it may be less likely to damage the uterus and fallopian tube and may be more likely preserve fertility
also
shorter operating time
shorter hospital stay
same success rates
120
Which patients with interstitial ectopic may be offered expectant management?
clinically stable with a low initial hCG of <1500 and who agree to be monitored until the hCG is <20IU/L
121
How long should you tell patients having expectant management for interstitial ectopic it will take for HCG to come down?
4-6 weeks
122
Where do you track HCG in interstitial ectopic down to?
<20
123
What % of interstitial ectopic with MTX have pregnancy resolution?
86%
124
what is first line treatment of cervical ectopic?
MTX
125
How do you give MTX in cervical ectopic?
systemically (same dosing as tubal depending on size and hCG) or USS guided intra sac
126
Can you consider expectant management in cervical ectopic?
ideally not. possible if <1000 hCG and falling but high risk of haeorrhage
127
when do you consider surgery in cervical ectopic?
if MTX has failed or the woman is clinically unstable
128
What are options in OT for cervical ectopic bleeding ?
UAE
foley balloon tamponade
uterine artery ligation
129
What are the risks you need to counsel women around in CSP?
miscarriage, haemorrhage, uterine rupture, PAS, hysterectomy, perinatal death, maternal death
130
Women with type one CSP need what if they continue with the pregnancy?
MDT and access to tertiary hospital
131
What patients with a CSP are appropriate for expectant management of miscarriage?
anembryonic preganncy
aware of risks
132
Women with CSP should be offered what route of MTX?
either systemic or intra sac
if systemic same 2 dose at tubal regime 4-7 days apart
133
What surgical management is recommended for type I CSP?
D&C (+/- balloon tamponade) and uterine artery embolisation
134
What surgical management is recommended for type II CSP?
may be better treated hysteroscopic and laparoscopic resection
OR
MTX followed by hysteroscopic resection
135
What is the risk of placental disorder in Type I vs type II pregnancy management expectantly? what else did this mean
17% vs 100%
same rates of hysterectomy
136
In CSP what is the difference between intra sac and systemic MTX outcomes?
systemic has faster resolution of hcg
137
In expectant management of CSP with an embryo what % end up with a hysterectomy
66%
138
In expectant management of CSP with an embryo what % end up with uterine rupture?
10%
139
What are signs on USS of CSP? one or more needed
empty uterus and endocervix
placenta or sac located anteriorly at levels of os, embedded at site of previous scar
gestation sac fills the niche
thin or absent myometrium sac/bladder
prominent vessels on doppler empty endocervical canal
140
What is the cut off for MTX in CSP?
20,000
141
what is the cut off for size for CSP treating with MTX?
<30mm
142
What is the success rate of expectant management in uncomplicated CSP miscarriage?
69%
143
What is the success rate of MTX management in CSP?
35-40%
144
What is the success rate of D+C management in CSP type I vs type II?
I 95%
II 27%
145
What is the success rate of UAE management in CSP type I vs type II?
I 100%
II 67%
146
What has the highest success rates for managing CSP?
surgical resection/excision
147
Should you give anti D in threatened miscarriage or miscarriage <10 weeks? RAZNCOG
no
148
Should you give anti D in surgical management of ectopic?
yes
149
for medical or expectant management of ectopic should you offer anti D?
yes offer, woman can make informed decision, not enough evidence
150
When do you change from 250IU to 625IU anti D
12 weeks
151
What % of women are rh negative in aus?
13%
152
What has anti D post partum reduced the alloimmunisation to?
2%
153
What has anti D antenatal reduced the alloimmunisation to?
0.2%
154
How much blood is needed for alloimmunisation?
0.1ml
155
What is the circulating volume in a 12 week fetus?
3ml
1.5ml of RBC
156
What increases the risk of isoimmunisation?
surgical intervention
157
Does threatened miscarriage increase your risk of iso imm in rhesus neg?
no
158
What does the UK data base show the risk of isoimmunisation is from a T1 miscarriage?
1 in 4167
159
What are the criteria for miscarriage on USS able to be diagnosed with first USS?
CRL 7mm or more and no FHR
MSD 25mm or more and no fetus
160
If a pregnancy USS shows a g sac but no yolk sac, when do you do a FU scan and what would be diagnostic of a miscarriage?
14 days after. Absence of an embryo with a FHR
161
If a pregnancy USS shows a g sac with a yolk sac, when do you do a FU scan and what would be diagnostic of a miscarriage?
11 days after. Absence of an embryo with a FHR
162
what does the RANZCOG guideline use as a rise in hCG in PUL which is likely IUP?
66%
163
in a PUL with an appropriately rising hCG when does the RANZCOG guideline say to repeat the TV USS?
if hcg <2000 in 1-2 weeks
if hcg >2000 within 1 weeks
or when MSD estimated to be >25mm
NICE says something similar
164
What hcg change over 48 hours does ranzcog say is suspicious of a ectopic?
rise of <66% or fall of <50%
NICE similar
165
If you see a CRL <7mm and no heart beat when do you repeat the USS and what would confirm a miscarriage?
7 days, if no FHR
166
If you have an MSD of 12mm or more and repeat the USS In 7 days, what should you see in a viable preganncy?
yolk sac or embryo
167
What lifestyle advice should women with recurrent miscarriage be given?
healthy BMI
stop smoking
caffeine less than 200mg per day
168
What are the two types of miscarriage?
sporadic or recurrent
169
What is the risk of miscarriage in women age 20?
10%
170
which congenital uterine anomaly are associated with RM?
bicornuate and septate
171
What medical conditions increase risk of miscarriage?
APS, thrombophilia (weak)
diabetes poor control
Hypothyroidism
PCOS
prolactin imbalance
obesity
172
is sperm DNA fragmentation associated with miscarriage?
yes
173
What is there no conclusive evidence about association with miscarriage?
* Uterine NK cells
* Genital tract infections
* Peripheral immune factors: HLA, cytokines
* Luteal phase defect
Acquired uterine anomalies: fibroids, polyps, adhesions
174
What is the risk of miscarriage in pregnancy age 30-34 vs 35-39?
15%
25%
175
What happens to your risk of future miscarriage with each previous miscarriage?
your risk increases
176
what is you risk of miscarriage in the next pregnancy after:
none
1
2
3
4
5
6
none 11%
1 17%
2or 3 28%
4 39%
5 47%
6 63%
177
What is your risk after two miscarriages of having another?
28%
178
Does previous live birth improve prognosis in recurrent miscarriage?
no
179
which antibodies in APS has the strongest association with RM?
1. lupus anticoagulant
2. then aCL IgM
180
Which two inherited thrombophilia have a relationship with T1 RM?
factor V leiden
PT gene mutation
181
Which two inherited thrombophilia have a relationship with T2 miscarriage?
Factor V leiden
protein S deficiency
182
are inherited thrombophilia more associated with T1 or T2 loss?
T2
183
What parental chromosomal rearrangements are associated with miscarriage?
balanced reciprocal translocation
robertsonian translocation
mosaicism
184
What is a balanced reciprocal translocation?
46 chromosomes, two way swap between any non homologous (pairs) chromosomes
185
What is a robertsonain translocation?
only occur between acrocentric chromosomes where they fuse at the centromere to form one long chromosome, making 45 chromosomes
186
what % of parents in RM will have a balanced translocation?
5%
187
what chromosomal finding (euploid or aneuploid) in fetal tissue is associated with increased risk of recurrent miscarriage? why?
euploid
higher risk of persisting maternal pathology rather than sporadic aneuploidy
188
What is the % of congenital uterine anomaly in the:
1. general pop
2. infertile women
3. recurrent MC
4. women with both infertility and RM
1. 5%
2. 8%
3. 13%
4. 24%
189
What congenital uterine anomalies are not associated with T1 or T2 miscarriage?
uterine didelphys
unicornuate
190
Is arcuate uterus classified as abnormal? any clinical implications?
no now it is a variant of normal, no implications.
191
Is there an increase in fibroid in the RM population?
no
192
if euthyroid and TPO antibodies is there still an i ncreased risk of miscarriage?
yes
193
Is there a link with Sub clinical Hypoth and RM?
yes
194
how far apart should APS antibodies be tested?
12 weeks
195
What does RANZCOG say about parental karyotype and what does GTG say in RM?
RANZCOG - consider case by case. no beneficial intervention
GTG - only if abnormality in cytogenetics or cytogenetics not available
196
What is the rate of live birth in recurrent miscarriage with abnormal investigations?
71% GTG
197
What is the rate of live birth in recurrent miscarriage with normal investigations?
77% GTG
198
What did the prism trial show?
looked at progesterone in early pregnancy.
showed that progesterone in bleeding in early pregnancy w BG recurrent miscarriage increased live birth rate
199
What did the promise trial show?
looked at progesterone in recurrent miscarriage to 12 weeks
found no improvement in live birth rate
200
How much does clexane and aspirin reduce the risk of miscarriage in APS?
54%
201
What does up to date say ovarian stimulation may do in RM?
effective for luteal phase defects, and endometrial defects ? better implantation
202
What % of sporadic miscarriage is from chromosomal abnormalities?
50%
203
Which fibroids can effect T2 loss?
SM, can be resected which may reduce this
204
What is the guidance for polyp resection in RM? GTG
no data to link with RM, recommend management as per rest of popn
205
Is there an confirmed associated with IUA and RM?
no but plausible
206
Does treatment of BV improve RM rates?
no
207
Why do we test TPO ab if we aren't going to treat?
as it means we will monitor in pregnancy
208
What are possible treatment options in recurrent miscarriage?
lifestyle - smoking, ETOH, smoking, weight
thyroid replacement
clex and aspirin
septum resection
PGD
progesterone in bleeding
ovarian stimulation
209
What is the evidence in outcomes with RM from chromosomal rearrangements and PGT-SR?
no improvement in live birth compared to natural conception
may reduce miscarriage rates
210
overall what is the advice for IVF in RM?
no improvement in live birth
not advised
211
what is the success rate of MTX in tubal and cervical ectopic?
90%
212
What % of tubal ectopics need a repeat dose of MTX?
about 15%
213
What are signs of cervical ectopic on USS?
* Empty uterus
* Barrel-shaped cervix
* Gestational sac present below the level of the internal os
* Absence of sliding sign
Blood flow around the sac on colour Doppler
214
What USS signs are present on an interstitial ectopic?
empty uterus
POC located laterally in interstitial part of the tube with <5mm myometrium around it on all planes
interstitial line sign
215
What is the interstitial line sign?
on USS a line from the sac to the endometirum
216
What do you see on a cornual ectopic on USS?
myometrium surrounds the sac completely.
217
What should be considered in women complaining of persistent pain after TOP or miscarriage?
heterotopic
218
Is there any difference in fertility, risk of recurrence, or tubal patency between the management options in ectopic?
no if
normal other tube and no subfertility
219
If ectopic in a history of subfertility what treatment gives better outcomes?
expectant or Medical
220
What are predictors of MTX success in ectopic?
change in hCG pre treatment (small rise = better chance of success)
if no gestation sac seen, or no yolk sac
hCG <5000, best <1000
drop day 1-4 post
221
What are CI to MTX?
breast feeding
liver, active lung disease
blood dyscrazia
immunodeficiency
pepticulcers
222
What is the sliding sign?
the adnexal mass moves seperate to the ovary in ? tubal ectopic
or absence of it in a cervical ectopic
223
What are you seeing in the double decidual reaction?
Made up of the decidua parietalis (endometrial side) and the decidua capsularis (around sac)
fluid collection with an echogenic rim located within a markedly thickened decidua on one side of the endometrial cavity.
224
Is the decidua maternal or fetal?
maternal
225
What are the two layers of the amniotic sac?
amnion (inner)
chorion (outer)
226
What is the risk of persistent trophoblastic tissue after salpingotomy?
up to 11%
227
What is the pregnancy rate if no fertility reducing factors after surgical management of ectopic?
>90%
228
What is the dose of MTX for etopic?
50mg per m2
max 100mg IM
229
What can be considered if needing 2nd dose of MTX?
Imaging ? FHR or FF
230
how does MTX work?
an antifolate anti metabolite, works by inhibiting dihydrofolate reductase (DHFR) a enzyme needed for purine and thymidine bases for DNA and RNA production
231
Who does NICE say should get MTX for ectopic first line?
HCG 1500-5000
mass <35mm with no FHR
unruptured
no significant pain
no IUP
232
How can cornual ectopics be managed surgically?
excision of the rudimentary horn
best as excludes recurrence
233
What is the rate of recurrent ectopic?
18%
234
how does WHO define miscarriage?
pregnancy loss <22 weeks or <500g
235
How does RANZCOG define miscarriage?
Pregnancy loss <20 weeks
(if unknown <400g)
236
What is the rate of pregnancy los after FHR seen?
<5%
237
What % of miscarriage occur in T2?
4%
238
What are the umbrella categories of causes of miscarriage?
chromosomal
infection
maternal conditions
placental abnormalities
fetal malformations
239
How long can you offer expectant management for after diagnosis of missed miscarriage? does it increase risk of infection?
14 days, no increase of infection risk, 3%
240
Can you consider more than 2 weeks of expectant management of miscarriage?
yes if you have a clinical review
241
What risks are increased with expectant management of miscarriage?
need for RBC
prolonged bleeding
242
What does the addition or mifepristone do for improving medical management of miscarriage?
success from 75% to 80-90%
243
Would infected tissue make you more likely to recommend surgical or medical treatment in miscarriage?
surgical
244
what abx regime is recommended by NICE for ERPOC?
doxy 100mg BD 10/7
metronidazole 1g PR
245
How common is a c section scar ectopic?
1 in 2000 pregnanies
246
How common is a heterotopic pregnancy? what about with IVF
1 in 30 000
IVF 1 in 1000
247
What is an angular pregnancy?
implanted in the lateral angle of the uterine cavity, close to ostium but NOT an ectopic pregnancy
248
Why are interstitial ectopics high morbidity?
present later than tubal at higher HCG
surgical procedure more difficult
high vascularity
249
What % of ectopics will have a pseudosac?
20%
250
How common is it to see a yolk sac or embryo in ectopic?
15-20%
251
how often do you see an empty extrauterine gestation sac in ectopic?
20-40%
252
What is the PPV of the blob or the bagel sign in ectopic?
95%
253
What criteria need to be met for expectant management of ectopic?
* Tubal ectopic <35mm with no visible cardiac activity
* BhCG <1500 (level determines the success rate)
* Decreasing BhCG level
* No abdominal pain
Able to return for follow-up
254
Can you do expectant management if patient has pain in ectopic?
no
255
Can you do MTX management if patient has pain in ectopic?
if no 'significant' pain
256
What day you test hCG after MTX?
day 1 - day of MTX
day 4 and Day 7
257
What pain is common after MTX?
day 3-10 from tubal abortion.
lasts about 4-12 hours
258
Why is salpingotomy considered in subfertile patients?
increases IUP in patients with subfertility compared to salpingectomy
259
What is classed as a medium SCH? when does it increase miscarriage risk?
20-50%
25%
260
How long does it take for a SCH to resolve?
1-2 weeks
261
How do you diagnose APLS?
* Antibodies on two occasions at least 12 weeks apart
* Anticardiolipin antibodies - IgM or IgG
* Lupus anticoagulant
* Beta 2 glycoprotein
AND one of
* Thrombosis:
* Venous
* Arterial
* Small vessel
* Pregnancy morbidity:
* 3 consecutive miscarriages <10 weeks
* 1 fetal death >10 weeks, normal morphology
* 1 premature birth due to PET or severe placental insufficiency (<34 weeks, normal morphology)
262
What are other features of APLS?
thrombocytopenia, cerebral involvement, leg ulcers, mitral valve disease, pulmonary hypertension, HTN, haemolytic anaemia, livedo reticularis (mottled skin)
263
How does APLS cause miscarriage?
* Antibodies bind to trophoblasts and behave as targets for immune system
* Inflammation and activation of the complement cascade, C4 deposits in the placenta
* Antibodies effect migration, invasion and differentiation of the trophoblast and hCG release.
* Anti B2GP inhibits angiogenesis, VEGF secretion
Massive infarction anthrombosis in placental vessels
264
What is maternal uterine blood flow at term?
600ml/minute
265
What are the four functions of the placenta?
gas exchange
hormone secretion
metabolic transfer
fetal protection
266
What is the function of the synctiotrophiblast?
anchor to and invade and digest the endometrium.
267
When is embryo implantation complete?
day 12
268
When does embryo implantation start?
day 7
269
What has happened by day 16 in the embryo?
three germ cell layers have developed
the cytotrophoblast and mesoderm have formed the chorion and chorionic villi are forming
270
how does the SCTB stop maternal immune cells invading?
it has no intercellular gaps like one big cell so the immune cells can't come into contact with the fetal proteins
271
What are the functions of the SCTB? (5)
1. invade the endometrium and erode maternal blood vessels
2. hormone synthesis
3. nutrient transfer
4. gas exchange
5. immunotolerance of the maternal immune system
272
what hormones does the STCB make?
HCG
hPL
placental GH
273
What surround the entire surface of the chorionic villi and thus is in contact with maternal blood?
syncytiotrophoblasts
274
What do two cell lines do cytotrophoblasts become?
SCTB
extra villous trophoblasts
275
What do extra villous trophoblasts do?
anchor the villous tree in the decidua into the uterus
invade to the myometrium and the spiral arteries
276
What happens to the trophoblast invasion in PET?
depth of trophoblast invasion is reduced, with less spiral artery remodelling.
277
When does the embryonic blood flow through the chorionic villi?
end of the third week
278
What are the different ways that nutrient transfer across the placenta?
bulk flow (water)
passive diffusion
active transport
facilitated diffusion
pinocytosis
traumatic breaks
279
What moves across the placenta by pinocytosis?
large molecules Ig
280
What uses facilitated diffusion across the placenta?
glucose
281
What uses passive diffusion across the placenta?
resp gases eg oxygen
282
What is the success rate of miso vs ERPOC in the landmark trial NEJM 2005
miso 85% (passed by day 8)
ERPOC 97%
283
What did the MIST trial look at?
looked at infection rates at 14 days, readmission and unplanned surgery in miscarriage management of <13 week miscarriage
284
What did the MIST trial find?
no difference in infection at 14 days or 8 weeks
higher need for unplanned surgical intervention and hospital admission in medical and expectant (highest) group.
285
Which group is medical not better than conservative management in MMM?
if incomplete they are the same, about 75%
286
What is a T helper 1 cell?
'cell mediated immune response' IgG and macrophages and complement. Mediated by cytokines, interleukins, IFN-y and TNF-a
287
What is a T helper 2 cell?
'antibody immune response' recruit eosinophils, mast cells, IgE, atopy. Antibody-mediated
288
What occurs to the maternal immune system to tolerate preganncy?
Progesterone from the corpus causes negative immunomodulation. You get involution of the thymus gland. The adaptive immune response shifts from TH1 (cytokine, IL, IFN and TNF alpha) to TH2 cell response (antibody mediated).
289
How does the trophoblast avoid the maternal immune system and implant?
Selective expression of HLA molecules on the trophoblast inhibit uterine NK cells
inhibits local T cells
expresses complement inhibitors
HCG inhibits cytokine expression eg TNF alpha
290
What does NICE say to do if PUL and HCG falls >50%
repeat UPT in 14 days and if positive to represent.
291
What does RANZCOG say to do in PUL with CG fall >50%
follow hCG
TVS
292
Who does NICE guidelines say you should give anti D to in T1
any surgical intervention for miscarriage or ectopic
293
Who does the NICE giudeline say you shouldn't give anti D to in the first trimester?
* Medical management of ectopic or miscarriage
* Threatened miscarriage
* Complete miscarriage
PUL
294
What outcomes are the same with medical vs expectant management for ectopic?
* Rate of tubal rupture
* Need for additional treatment
* Depression, anxiety or health status
* Rate of pregnancies ending naturally
295
How often do women having a salpingostomy need further treatemetn?
1 in 5
296
what proportion of women with ectopic have no risk factors?
1/3
297
What follow up for salpingectomy does NICE recommend?
UPT at 3 weeks
298
Ellen's flashcards
flashcards
Decks in class (27)
# Cards
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Week 419
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Week 585
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Autoimmune medications and pregnancy11
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Landmark trials to date13
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Week 6253
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Week 7259
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Week 8232
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Week 9206
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Week 10364
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Week 258
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week 371
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Week one136
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Week 11237
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Week 12314
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Week 13381
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GONC 1395
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GONC 2259
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Week 16134
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Week 17410
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Week 18266
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Week 19347
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Week 20307
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Week 21430
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Week 22370
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Week 23298
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Week 24325
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Week 261
