Early pregnancy Flashcards
(43 cards)
A 34-year-old nullipara attends the early pregnancy unit with moderate vaginal bleeding and left iliac fossa discomfort. Her LMP was 5 weeks ago on the background of regular cycles and not using contraception. A TVUSS indicates a pregnancy of unknown location with no free and no probe tenderness. The initial serum b-HCG is 380 IU/L.
What is the most appropriate investigation for this patient?
a-Diagnostic laparoscopy
b-Serum progesterone level
c-Repeat ultrasound in 7 days
d-Repeat serum β-hCG after 48 hours
e-Urinary pregnancy test in one week
For PUL, should do 2 hCGs 48 hours apart
- Rise >= 63%: likely IUP –> repeat TVUSS in 7-14 days or earlier if >1500
- Decline >50% –> unlikely viable. repeat UPT in 14 days
D
A 19-year-old primigravida presents to A+E with sudden onset severe lower abdominal pain and vaginal spotting. She is haemodynamically stable. An urgent TVUS shows an inhomogeneous mass in the left adnexa measuring 11mm, consistent with a left tubal ectopic pregnancy with minimal free fluid. The serum b-hCG level is 1200 IU/L. She has a history of a right tubal ectopic pregnancy managed with a laparoscopic right salpingectomy. She wishes for a pregnancy in the future.
What is the most appropriate management for this patient?
a-Surgical management with left salpingectomy
b-Parenteral methotrexate
c-Expectant management with repeat serum β-hCG in 48 hours
d-Surgical management with salpingotomy
e-Oral gefitinib and parenteral methotrexate
- SEVERE pain - not for expectant/MTX
- previous salpingectomy - consider salpingotomy
D
A 41-year-old Para 1+1 (one caesarean birth, one surgical termination of pregnancy) attends the early pregnancy unit with amenorrhea of 7 weeks, mild lower abdominal discomfort and vaginal spotting. On TVUS, there is a gestational sac containing a yolk sac and fetal pole measuring 8mm. No fetal heart pulsations are visible. It is sited just below the level of the internal cervical OS. There is significant peripheral vascularity and a negative sliding sign. The endometrial cavity is empty.
What is the most likely diagnosis in this patient?
Inevitable miscarriage
Caesarean scar pregnancy
Intrauterine pregnancy with low implantation
Cervical ectopic pregnancy
Delayed miscarriage
cervical ectopic
A 34-year-old Para 2 with two previous caesarean births attends the early pregnancy unit at 6 weeks of gestation due to crampy pelvic pain and vaginal spotting. She is concerned about the risk of a cesarean scar ectopic pregnancy.
What is the estimated prevalence of this type of pregnancy?
a-1 in 200 pregnancies
b-1 in 850 pregnancies
c-1 in 1200 pregnancies
d-1 in 2000 pregnancies
e-1 in 4500 pregnancies
A 35-year-old nulliparous woman with a history of primary infertility is referred to the early pregnancy unit with mild vaginal bleeding at 6 weeks gestation. A TVUSS is performed and shows a 12mm left tubal ectopic pregnancy with no free fluid.
Initial serum b-hCG: 943IU/L
48 hour serum b-hCG: 1290IU/L
She has a history of previous right salpingectomy for a tubal ectopic pregnancy
Diagnostic laparoscopy
a-Expectant management with serial β-hCGs
b-Expectant management with urinary pregnancy test in 2 weeks
c-Local injection of methotrexate under USS guidance
d-Laparoscopy and salpingectomy
e-Laparotomy and salpingectomy
f-Laparoscopy and salpingotomy
g-Laparoscopy and bilateral salpingectomy
h-Second dose of systemic methotrexate
i-Systemic methotrexate
j-Transvaginal ultrasound in 7 days
I
A 27-year-old nulliparous lady presents at 6 weeks gestation with severe lower abdominal pain. Following a transvaginal ultrasound, she is diagnosed with a left tubal ectopic pregnancy measuring 18mm. On ultrasound, a right-sided hydrosalpinx is noted, and there is no free fluid. Observations are unremarkable. The serum b-hCG level is 2563IU/L.
aa- diagnostic laparoscopy
a-Expectant management with serial β-hCGs
b-Expectant management with urinary pregnancy test in 2 weeks
c-Local injection of methotrexate under USS guidance
d-Laparoscopy and salpingectomy
e-Laparotomy and salpingectomy
f-Laparoscopy and salpingotomy
g-Laparoscopy and bilateral salpingectomy
h-Second dose of systemic methotrexate
i-Systemic methotrexate
j-Transvaginal ultrasound in 7 days
F
- hCG <1000 and well: expectant
- hCG <1,500 and well: MTX
- hCG 1,500 - 5,000: MTX or Sx
- hCG >5,000: Sx
F
A 24-year-old woman is seen in the early pregnancy unit at 6 weeks gestation with a history of heavy vaginal bleeding and minimal abdominal discomfort. She is haemodynamically stable. On TVUS, the endometrium appears regular with no evidence of an intrauterine pregnancy. The ovaries appear normal bilaterally, and no adnexal masses or free fluid are seen.
Initial serum b-hCG: 3452IU/L
48-hour serum b-hCG: 1228IU/L.
aa- diagnostic laparoscopy
a-Expectant management with serial β-hCGs
b-Expectant management with urinary pregnancy test in 2 weeks
c-Local injection of methotrexate under USS guidance
d-Laparoscopy and salpingectomy
e-Laparotomy and salpingectomy
f-Laparoscopy and salpingotomy
g-Laparoscopy and bilateral salpingectomy
h-Second dose of systemic methotrexate
i-Systemic methotrexate
j-Transvaginal ultrasound in 7 days
- drop more than 50% in PUL –> unlikely to continue. Repeat UPT in 2 weeks
B
****A 31-year-old woman with two-term vaginal deliveries is given systemic methotrexate for the management of a right tubal ectopic pregnancy. She is reviewed following her day 7 serum b-hCG results. She remains clinically well throughout her follow-up with no abdominal pain.
**Day 1 serum β-hCG: 4432IU/L
Day 4 serum β-hCG: 4728IU/L
Day 7 serum β-hCG: 5012IU/L**
aa- diagnostic laparoscopy
a-Expectant management with serial β-hCGs
b-Expectant management with urinary pregnancy test in 2 weeks
c-Local injection of methotrexate under USS guidance
d-Laparoscopy and salpingectomy
e-Laparotomy and salpingectomy
f-Laparoscopy and salpingotomy
g-Laparoscopy and bilateral salpingectomy
h-Second dose of systemic methotrexate
i-Systemic methotrexate
j-Transvaginal ultrasound in 7 days
- hCG has not fallen
- hCG is now above 5,000 therefore onlu surgery recommended
D
A 30-year-old woman with a history of irregular periods presents at 5 weeks gestation with light spotting and mild lower abdominal pain. An ultrasound scan shows an endometrial thickness of 13mm without evidence of an intrauterine pregnancy. The ovaries appear normal, with evidence of a possible corpus luteal cyst right side. No adnexal masses or free fluid are seen.
Initial serum b-hCG: 120IU/L
48-hour serum b-hCG: 302IU/L
aa- diagnostic laparoscopy
a-Expectant management with serial β-hCGs
b-Expectant management with urinary pregnancy test in 2 weeks
c-Local injection of methotrexate under USS guidance
d-Laparoscopy and salpingectomy
e-Laparotomy and salpingectomy
f-Laparoscopy and salpingotomy
g-Laparoscopy and bilateral salpingectomy
h-Second dose of systemic methotrexate
i-Systemic methotrexate
j-Transvaginal ultrasound in 7 days
- PUL –> hCG shouuld be repeated in 48 hours
- i if rising by more than 63%: likely viable, therefore repeaty USS in 7-14 days or earlier if >1500
J
A 34 year old lady is referred to the Early Pregnancy Unit at 7 weeks gestation with a 3 day history of spotting. She is diagnosed with a right interstitial ectopic pregnancy.
In regards to interstitial ectopic pregnancies which of the following is correct?
a-Surgical management can be performed via a laparoscopic or hysteroscopic route
b-Given their location, patients with an interstitial ectopic pregnancy will often present earlier than those with tubal ectopic pregnancies
c-The term cornual ectopic pregnancy is synonymous with interstitial ectopic pregnancy
d-An angular pregnancy cannot be distinguished from an interstitial ectopic pregnancy on ultrasound
e-Expectant management is not recommended
A
A 34 year old lady presents to ED at 6 weeks gestation with heavy vaginal bleeding and moderate lower abdominal pain. She undergoes a transvaginal ultrasound scan and is diagnosed with a pregnancy of unknown location. The serum β-hCG level is 4857IU/L.
Which of the following is correct regarding quantitative serum β-hCG?
a-A prolonged serum β-hCG doubling rate is diagnostic for ectopic pregnancy
b-Quantitative serum β-hCG is only of value when combined with ultrasound examination
c-Serum β-hCG levels can be used in combination with progesterone to diagnose a miscarriage
d-A negative urinary pregnancy test excludes an ectopic pregnancy
e-Following the diagnosis of a pregnancy of unknown location a drop in the serum β-hCG level after 48 hours of more than 50% excludes an ectopic pregnancy
B
A 24-year-old nulliparous woman undergoes surgical management of a tubal ectopic pregnancy. At laparoscopy, the contralateral tube is examined and noted to be damaged. The woman has strongly expressed her concern about future fertility.
Which is the single best management option?
Bilateral salpingectomy
Bilateral salpingotomy
Medical management of ectopic pregnancy
Salpingectomy with conservation of contralateral tube
Salpingotomy with conservation of contralateral tube
E
A 27-year-old woman attends the Early Pregnancy Unit at 6 weeks of gestation with mild lower abdominal pain that settles with analgesia and moderate bleeding vaginally. Abdominal and vaginal examination is normal and a urine pregnancy test is positive. A transvaginal scan shows no intrauterine gestational sac, both ovaries appear normal and there is no free fluid in the pouch of Douglas.
What is the most appropriate management?
Diagnostic laparoscopy
Diagnose complete miscarriage and advise to repeat pregnancy test in 10 days
Inpatient admission for observation with monitoring of serum βhCG
Outpatient management with monitoring of βhCG
Repeat ultrasound in 7 days
D
A 32-year-old primiparous woman presents to the emergency department with sudden onset of lower abdominal pain, mainly localised in the right iliac fossa. The pain is sharp in nature and is radiating to the right flank. Her last menstrual period was 8 weeks ago. A urine pregnancy test is positive. On transvaginal scan the right adnexa was seen to contain an ectopic pregnancy measuring 22 mm x 18 mm x 15 mm with cardiac activity and an absent haemoperitoneum. Vital signs on arrival are:
blood pressure = 128/68 mmHg
pulse = 72 beats/min
temperature = 36.5°C
respiratory rate = 16
hCG level = 5000 iu/l.
What is the treatment of choice for this woman?
Expectant management
Methotrexate regimen
Laparotomy and right salpingectomy
Laparoscopic right salpingectomy
Laparoscopic right salpingotomy
D
A 24-year-old P0 woman at 6 weeks of gestation presents to the emergency department with a 2 week history of brown vaginal discharge. On transvaginal scan, the left adnexa is seen to contain an ectopic pregnancy measuring 20 mm x 14 mm x 10 mm with absent fluid in the pouch of Douglas. Vital signs on arrival were:
blood pressure = 118/68 mmHg
pulse = 72 beats/min
temperature = 36.5°C
respiratory rate = 18.
Vaginal examination is negative for cervical excitation.
On her recent blood tests serum βHCG was 527 ui/l.
What is the treatment of choice for this woman?
Conservative management with serial βhCG tests every 48 hour until levels falls below 20 iu/l
Laparotomy and left salpingectomy
Laparoscopic left salpingectomy
Laparoscopic left salpingotomy
A
A 24-year-old woman experiences bleeding at 7 weeks of gestation and attends the Early Pregnancy Unit for a scan. On transvaginal ultrasound there is a gestational sac containing a fetal pole with a CRL of 6.5 mm without a fetal heart.
What is the next step in your management?
Arrange a follow up in >7 days for a repeat ultrasound before making a final diagnosis
Arrange a follow up in <7 days for a repeat ultrasound before making a final diagnosis
Ask a colleague for a second opinion before giving the final diagnosis
Discuss surgical management of miscarriage and book for the woman for surgery in the next available slot
Inform the woman that she had a miscarriage and discuss management options of miscarriage
A
A 32-year-old G3P0 presents at 8 weeks of gestation to the Early Pregnancy Unit for an early scan. She has previously had one miscarriage at 6 weeks of gestation that was managed expectantly, and one ectopic pregnancy that was managed by laparoscopic salpingectomy. On transvaginal ultrasound the left adnexa contains an ectopic pregnancy with fetal activity confirmed. There is an absent haemato-perinoneum.
What is the management of choice for this woman?
Expectant management with serial βhCG tests
Laparotomy and left salpingectomy
Laparoscopy and left salpingotomy
Laparoscopy with left salpingectomy
Methotrexate regimen
C
A 34-year-old woman who is G2P1 presents with mild vaginal spotting at 6 weeks of gestation. A transvaginal scan revealed no intrauterine sac but a 2 x 3 cm mass was seen in the left adnexa with no free fluid. She opted to have medical management after detailed counselling. This was undertaken the same day. The woman was asymptomatic.
The following are her serum hCG results:
Serum hCG results
At presentation 1450 IU
48 hours post-presentation
1650 IU
Day 4 post-medical management 1700 IU
Day 7 post-medical management 1500 IU
What is the most appropriate management option?
Advise patient to do pregnancy test in 2 weeks as hCG is decreasing
Continue weekly hCG until <15 if woman remains asymptomatic
Counsel and administer second dose methotrexate
hCG every 48 hours till it is undetectable
Perform laparoscopy and salpingectomy
C
A 28-year-old woman who is 7 weeks by LMP attends the early pregnancy unit with vaginal bleeding. A transvaginal ultrasound shows a right tubal ectopic pregnancy, which contains a small gestational sac. She is managed with systemic methotrexate after a discussion of the treatment choices.
Below are the serum b-HCG levels:
Initial serum b-hCG: 1012 IU/L
48 hour serum b-hCG : 1021 IU/L
Day 1 serum b-hCG (day of treatment): 1054 IU/L
Day 4 serum b-hCG: 932 IU/L
Which of the above clinical features will increase the risk of treatment failure with methotrexate?
The pre-treatment changes in b-hCG levels
Gestation at presentation
Presence of gestational sac
Initial serum b-hCG level
Day 4 serum b-HCG level
There are a number of predictors of successful treatment with methotrexate including:
Low initial serum bhCG level
Pre-treatment changes in serum bhCG levels (higher success if lower
rate of bhCG rise)
Drop in bhCG levels between Day 1 and Day 4
Absence of gestational sac, yolk sac and fetal pole
This patient has a gestational sac present on TVUSS which is known to decrease the chance of successful treatment.
C
A 32-year-old multiparous woman (two prior vaginal births) presents to the emergency department with lower abdominal pain and vaginal spotting. Her last menstrual period was 8 weeks ago. A urine pregnancy test is positive. A transvaginal ultrasound demonstrates a right tubal ectopic pregnancy measuring 22 mm x 18 mm x 15 mm with cardiac activity and no evidence of free fluid or probe tenderness. The initial serum b-hCG level is 4213IU/L. She is haemodynamically stable.
What is the most appropriate management for this woman?
Expectant management with repeat serum b-HCG in 48 hours
Laparoscopic right salpingectomy
Laparotomy and right salpingectomy
Oral gefitinib and parenteral methotrexate
Systemic methotrexate
B
A 34-year-old woman presents with mild vaginal spotting at 6 weeks gestation. A transvaginal scan shows a 22mm left tubal ectopic pregnancy with no evidence of free fluid. She opts to have medical management after a discussion of the treatment options. She has a history of two previous midline laparotomies and bowel resections due to IBD.
Serum hCG results
At presentation 1450 IU
Day 1 (methotrexate given)
1650 IU
Day 4 post-medical management 1700 IU
Day 7 post-medical management 1500 IU
She remains asymptomatic throughout follow-up and is reviewed with her serum b-hCG levels on day 7 following treatment. Her TVUS shows the mass is smaller at 17mm, with no free fluid and probe tenderness.
What is the most appropriate ongoing management option?
Laparoscopic salpingectomy
Second dose of methotrexate
Serum b-hCG every 48 hours until negative
Urine pregnancy test in 2 weeks
Weekly serum b-hCG monitoring until negative
There is less than a 15% drop in the serum b-hCG between day 4 and day 7. Further treatment is therefore recommended. A second dose of methotrexate can be given if the patient remains asymptomatic and there is no evidence of cardiac activity or haemoperitoneum on TVUS. The other option would be surgical management.
Detailed counselling is required in this scenario, and the woman’s wishes must be considered.
Given her history of abdominal surgery, surgical intervention should not be the first line option.
B
A 38-year-old lady is referred to EPU at 5 weeks gestation with moderate vaginal bleeding. She has no significant past medical history and one previous vaginal delivery at term. On transvaginal ultrasound an inhomogenous mass is seen adjacent to the left ovary, measuring 21mm. The endometrium is cystic but no clear evidence of an intrauterine pregnancy is seen. There is no free fluid or probe tenderness. Initial serum b-HCG is 990 IU/L.
What is the most appropriate management?
Systemic methotrexate
Repeat serum b-HCG in 48 hours
Laparoscopic salpingectomy
Repeat TVUSS in 48 hours
Laparoscopic salpingotomy
B
A 43 year old women is 6 weeks pregnant following IVF with a double embryo transfer. She has a reassurance ultrasound performed by the fertility unit, which shows a single viable intrauterine pregnancy and an inhomogeneous mass measuring 11mm, with increased vascularity, adjacent to the left ovary. There is no free fluid.
What is the most appropriate management for this patient?
Serum b-hCG level
Laparotomy and salpingectomy
Systemic methotrexate
Expectant management with repeat TVUSS
MRI pelvis
A heterotopic pregnancy is the development of an intrauterine pregnancy and an ectopic pregnancy simultaneously. It is a diagnosis almost universally associated with fertility treatments with an incidence of approximately 1/30,000 in spontaneous conceptions compared to 1/100 in those having IVF.
The intrauterine pregnancy must always be considered and methotrexate (systemic or local) given only if the intrauterine pregnancy is not viable or the patient does not wish to continue with the pregnancy, in which case the Abortion Act will apply.
Expectant management is an option in heterotopic pregnancies where the ultrasound findings are of a nonviable pregnancy.
Local injection of potassium chloride or hyperosmolar glucose with aspiration of the sac contents is an option for clinically stable women.
Surgical removal of the ectopic pregnancy is the method of choice for hemodynamically unstable women but is also an option for hemodynamically stable women.
Serum b-hCG is of limited value in a heterotopic pregnancy.
D
A 31 year old women, who is a Jehovah’s Witness, is referred to the early pregnancy unit at 6 weeks gestation with a history of mild RIF pain and spotting. She has had 3 previous uncomplicated vaginal deliveries at term. Following a transvaginal ultrasound she is diagnosed with a left tubal ectopic pregnancy measuring 14mm. No free fluid is seen and there is no probe tenderness. Initial serum b-HCG is 890 IU/litre and 48 hours later is 1015Iu/litre.
What is the most appropriate management?
Surgical management with salpingectomy
Outpatient medical management with systemic methotrexate
Expectant management with serial serum b-hCG levels
Surgical management with salpingotomy
Medical management with local injection of methotrexate under USS guidance
- as JW and success of medical Mx is unpredictable, best to do surgical
A
