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RCPSC > early pregnancy > Flashcards

early pregnancy Flashcards

1
Q

prevalence of ectopic pregnancy

A

1-2% of all pregnancies

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2
Q

ectopic pregnancy accounts for what proportion of maternal death

A

9-13%

(75% of all first trimester death)

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3
Q

tubal ectopic account for what proportion of ectopic pregnancies

A

98%

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4
Q

what proportion of women having a TV USS will have a PUL diagnosis

A

15%

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5
Q

outcomes of pUL

A
  1. IUP (viable/nonviable) - 34-40%
  2. ectopic - 8-14%
  3. persistent PUL 2%
  4. failed PUL 44-69%
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6
Q

outcomes of persistent PUL

A
  1. nonvisualized ectopic
  2. resolution (Rx or Spont)
  3. confirmation IUP
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7
Q

incidence of C-Scar pregnancy

A

1/2000

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8
Q

incidence of abdominal pregnancy

A

1/5000

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9
Q

incidence of ovarian pregnancy

A

1/7000

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10
Q

M6 regression model for ectopic - high probable % and management

A

> =5%

hCG and USS in 48h

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11
Q

M6 regression model for ectopic - low risk EP, probably FPULL management

A

UPT in 2weeks

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12
Q

M6 regression model for ectopic - low risk, probable IUP; management

A

USS in 1 week

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13
Q

spontaneous resolution rates for unruptured asymptomatic tubal pregnancies

A

30-70%

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14
Q

criteria for expectant management of tubal ectopic

A

1) asymptomatic
2) hCG <1000
3) decreasing hCG >15-20%
4) no significant free fluid, hematosalpinx
5) no FHR
6) patient characteristic

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15
Q

consider active management of tubal ectopic if

A
  1. symptomatic
  2. hcg >=1000
  3. plateau or increasing hCG over 48h
  4. large hematosalpinx or hemoperitoneum
  5. Detectable FHR
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16
Q

consider MTX for ectopic management criteria

A
  1. normal obs and no pain
  2. hCG <1500
  3. adnexal size <35mm
  4. empty GS or heterogenous mass
  5. no free fluid
  6. hCG <20% increase in 48h

consider single or double dose MTX

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17
Q

use MTX with caution for ectopic management criteria

A
  1. mild/transient pain
  2. hcg 1500-5000
  3. yolk sac +/- FP
  4. minimal free fluid
  5. mild anemia or thrombocytopenia
  6. hcg >50% increase in 48h
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18
Q

MTX absolute contraindications

A
  1. significant renal/liver disease
  2. blood dyscrasias or bone marrow suppression
  3. pulmonary fibrosis
  4. concurrent IUP or BF
  5. PUD
  6. immunosuppression
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19
Q

single dose MTX for ectopic, when to check hcg?

A

day 1, 4, 7, 10, 14

if >=15% drop from day 4, stop protocol and then do weekly hCG until negative

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20
Q

double dose MTX for ectopic, when to check hCG?

A

day 1, 4, 7, 10, 14

second dose given on day 4

recheck hCG on day 7, if >=15% drop, weekly hCG until negative

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21
Q

multiple dose MTX regimen, when to check hCG

A

Day 1, 3, 5, 7, 9

if hCG>=15% drop anytime after day 1, do weekly hCG until negative, otherwise proceed with repeat dose

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22
Q

single dose MTX regimen, when to repeat dose?

A

on day 7

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23
Q

single dose MTX, criteria for failure

A
  • symptoms of rupture
  • failure to achieve >=15% decrease after 2 doses
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24
Q

double dose MTX, when to repeat doses?

A

on day 4, 7, 10

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25
Q

double dose MTX, criteria for fialure

A
  • symptoms of rupture
  • failure to achieve >=15% decrease after 4 doses
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26
Q

multi dose MTX, when to repeat doses?

A

on day 3, 5, 7;

if =<15% decrease in hCG

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27
Q

multi dose MTX - when to give folinic acid

A

day 2, 4, 6, 8.

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28
Q

multi dose MTX regimen, criteria for failure

A
  • symptoms of rupture
  • failure to achieve >=15% decrease after 4 doses
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29
Q

MTX dose for multi-dose regimen

A

1mg/kg
+
0.1mg/kg folinic acid

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30
Q

single or double dose MTX regimens, dose required

A

50mg/m2

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31
Q

after salpingostomy, persistent ectopic pregnancy

A

7%

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32
Q

after salpingectomy, persistent ectopic pregnancy

A

1%

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33
Q

criteria for ovarian ectopic [name]

A

spiegelberg

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34
Q

name of criteria for interstital/cornual ectopic

A

timor/tritsch

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35
Q

complete molar pregnancy

A

2x paternal haploid
(46XX or 46XY)

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36
Q

partial molar pregnancy

genetic composition

A

3x haploid
(2 pat/1mat)

(69XXX / XXY / XYY)

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37
Q

EC: copper IUD effective up to ____ post UPSI

A

7/7

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38
Q

EC: LNG effective up to ____ post UPSI

A

5/7 (120h)

but not after ovulation

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39
Q

EC: UPA effective up to ____ post UPSI

A

5/7 (120h)

but not after ovulation

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40
Q

EC: LNG less effective in….

A

BMI >25

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41
Q

EC: UPA less effective in…

A

BMI >=35

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42
Q

EC: first choice in women with BMI >30

A

copper IUD

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43
Q

EC: first choice in women with BMI >=25

A

UPA

44
Q

EC: hormonal contraception can be started after LNG

A

within 24h,
backup contraception for 7/7

45
Q

EC: hormonal contraception can be started after UPA

A

5 days after,
backup contraception for 14/7

46
Q

Female condoms - when to insert/remove

A

up to 8h before sex
remove immediately after

47
Q

diaphragm - when to insert/remove

A

up to 2h before sex
leave in for at least 6h
remove by 24h

48
Q

cap - when to insert/remove

A

uptown 2h before sex
leave in for at least 6h
remove by 48h

49
Q

sponge - when to insert/remove

A

insert up to 24h before sex,
leave in for at least 6h
remove by 30h

50
Q

N9 film - use

A

insert 15 min before sex,
reapply q3h

51
Q

N9 foam - use

A

effective immediately up to 1h after insertion

52
Q

10 year cumulative failure rate for female permanent contraception

A

<2%

53
Q

low risk GTN defined as WHO score?

A

0-6

54
Q

high risk GTN defined as who score?

A

> =7

55
Q

low risk GTN: treatment options

A
  1. single agent chemo
    or
  2. hysterectomy
56
Q

low risk GTN: single agent chemo options

A

MTX or Dactinomycin

57
Q

high risk GTN: most common chemo options

A
  1. EMA-CO
    (etoposide, MTX, dact, cyclophos, vincristine)
  2. EMA-EP
    (cisplatin)
58
Q

most common sites of metastases for GTN

A

lungs and vagina

hematogenous spread

59
Q

post-molar persistent disease criteria: what rise in hCG?

A

> 10% increase vs previous two weeks

60
Q

post-molar persistent disease: what classifies as plateau hCG

A

<10% decrease over 3 consecutive weeks

61
Q

post-molar persistent disease: what threshold level of hCG and after how many weeks?

A

> 20 000 mIU
4 weeks after evac

62
Q

incidence of GTD

A

1/1000 pregnancies

63
Q

incidence of choriocarcinoma

A

1/20 000 pregnancies

64
Q

initial workup for post-molar GTN

A
  1. CXR
  2. Pelvic USS
65
Q

risk of GTN following complete molar

A

15-20%

66
Q

risk of GTN following partial mole

A

1-5%

67
Q

after evac for COMPLETE molar, what followup?

A

weekly hCG starting 2/52 post-op
continue until undetectable for 3/52
then monthly for 6/12

68
Q

after evac for PARTIAL molar, what followup

A

weekly hCG starting 2/52 post-op
continue until undetectable for 3/52
then x1 monthly

69
Q

USS appearance of complete molar pregnancy

A
  • absence of fetus
  • no LV
  • enlarged uterus
  • snowstorm/multicystic mass
  • cluster of grapes
    +/- theca lutein cysts
70
Q

USS appearance of partial molar pregnancy

A
  • empty GS
  • sac with amorphous fetal parts or IUGR or nonviable
  • reduced LV and increased placental size
  • swiss cheese appearance of placenta
71
Q

RF’s for invasive mole

A
  • Age >40
  • uterine size >4/52 discrepancy GA
  • hcg >=100 000
  • bilateral theca lutein cysts >=6cm
72
Q

post-molar GTN: when to do CTCAP

A

if >=6mm lesions on CXR

(+MRI brain)

73
Q

post-non molar GTN: workup

A

CTCAP + MRI brain

74
Q

molar pregnancy Rx - hysterectomy preferred if over what age?

A

40

75
Q

molar pregnancy Rx - before discharge, arrange…

A
  1. effective/immediate contraception
  2. weekly hCG from 2/52
  3. postop visit at 3-6 weeks
76
Q

molar followup visit

A
  • at 3-6 weeks
  • review bloods and pathology
  • pelvic exam to check for involution
77
Q

GTD in twins - what proportion pregnancies that continued resulted in live birth

A

60%

78
Q

risk of GTD in subsequent pregnancy (after molar)

A

1/100
(10x baseline risk)

79
Q

subsequent pregnancy management after molar

A
  1. early USS
  2. placenta examined and sent for histology if any clinical abnormalities
80
Q

persistently low hCG postmolar defined as

A

<1000 x 3 or more weeks

81
Q

quiescent hCG post molar defined as

A

<50

(no Rx, just monitor)

82
Q

GTN workup: if neuro imaging equivocal, next step?

A

LP for hCG ratio >1:60

83
Q

GTN FIGO stage 1

A

disease confined to uterus

84
Q

GTN FIGO stage 2

A

disease spread to other genital structures

85
Q

GTN FIGO stage 3

A

disease extends to LUNGS

86
Q

GTN FIGO stage 4

A

all other mets

87
Q

WHO score ultra-high risk GTN

A

> =12

88
Q

GTN WHO scoring - Age

A

Age <40 = 0
Age >=40 = 1

89
Q

GTN WHO scoring - antecedent pregnancy

A

Mole = 0
Abortion = 1
Term = 2

90
Q

GTN WHO scoring - interval (months)

A

<4 = 0
4-6 = 1
7-12 = 2
>12 = 4

91
Q

GTN WHO scoring - initial hCG

A

<1000 = 0
1000 - 10 000 = 1
10 000 - 100 000 = 2
>100 000 = 4

92
Q

GTN WHO scoring - size of tumor

(largest tumor, cm)

A

<3 = 0
3-5 = 1
>5 = 2

93
Q

GTN WHO scoring - mets

A

Lung = 0
spleen, kidney = 1
GI = 2
brain, liver = 4

94
Q

GTN WHO scoring number of mets

A

0 = 0
1-4 = 1
5-7 = 2
>8 = 4

95
Q

GTN WHO scoring - previously failed chemo

A

single drug = 2
multi drug = 4

96
Q

GTN risk factors for chemo resistance

A
  • increased tumor vascularity
  • WHO 5-6
  • hcg >400 000
  • nonmolar chorioca
  • suboptimal response
97
Q

staging/workup for PSTT/ETT

A
  • CTCAP
  • USS pelvis with doppler
  • MRI brain +/- LP
98
Q

how long to do consolidation chemo cycles for low risk disease

A

2-3 cycles
(4-6 weeks)

99
Q

how long to do consolidation chemo cycles for high risk disease

A

3 cycles
(?6 weeks)

100
Q

how long to do consolidation chemo for PSTT/ETT

A

8 weeks post normalization

101
Q

how often to check hCG during chemo/GTN

A

weekly

102
Q

PSTT/ETT is characterized by

A
  • slower growth
  • late mets
  • increased resistance
103
Q

risk of GTN relapse

A

3%, usually within 12 months

104
Q

hCG monitoring following GTN chemo completion

A
  • weekly for 4-6 weeks
  • then monthly for 12-24 months (for low/high risk)

imaging should be completed for baseline at completion as well

105
Q

secondary malignancies associated with GTN

A
  • leukemia
  • breast ca
  • colon ca
  • melanoma
106
Q

overall cure rate for GTN (low vs high risk)

A
  1. low risk ~100%
  2. high risk = 70-95%

RCPSC (17 decks)

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