Module 3 Unit C 1

Question 1

What subjective and objective findings would reassure you that pregnancy is intrauterine and developing as it should be, even though a patient is experiencing first trimester bleeding?

Answer 1

We identify a readily apparent reason for bleeding

The pregnant person is physiologically stable

Beta HCG levels are rising appropriately

Ultrasound shows a gestational sac, yolk sac, embryonic pole, and cardiac activity at the expected gestational ages

There is congruence between beta HCG levels and ultrasound findings

Question 2

What are the subjective and objective data that you must assess to investigate the possibility of serious causes of first trimester bleeding for ectopic pregnancy,

Answer 2

Subjective:
Pain may be present especially unilateral adnexal pain, referred shoulder pain

Objective:
-Cervical motion, tenderness and/or adnexal tenderness or mass may be present
-Adnexal mass may or may not be visible on U/S
-Beta HCG often does not double as expected every 48 hours

To investigate: Draw CBC, blood type/RH

Question 3

What are the subjective and objective data that you must assess to investigate the possibility of serious causes of first trimester bleeding for molar pregnancy,

Answer 3

Subjective:
-Significant N/V often present
-Brown vaginal discharge may be present

Objective:
-Characteristic molar pregnancy features can be seen
-Uterus often larger than expected
-Beta HCG often much higher than expected

To investigate:
- should draw CBC, Blood type/Rh

Question 4

What are the subjective and objective data that you must assess to investigate the possibility of serious causes of first trimester bleeding for incomplete/inevitable early pregnancy loss (pregnancy loss in progress)?

Answer 4

Subjective:
- Bleeding can be heavy
-cramping/pain often present

Objective:
- Cervical os open, pregnancy tissue may be visible
- Ultrasound often definitively shows structures that are lagging behind what they should be and no cardiac activity
- Beta HCG usually not rising s expected or may be falling

To investigate:
- should draw CBC, Blood type/Rh

Question 5

What is the role of serial quantitative beta hCG testing in the setting of first trimester bleeding?

Answer 5

It increase/multiplication indicate that the pregnancy is viable

Question 6

What are the less serious caused of first trimester bleeding and how will you assess for those

Answer 6

-Implantation bleeding
-Cervical irritation from infection or intercourse
-subchorionic hemorrhage
-fibroids or endometrial polyps

Question 7

In which situations will you manage first trimester bleeding collaboratively with a physician colleague?

Answer 7

-patients who have any significant amount of bleeding (anything more than spotting)
-Pregnancy cannot be definitively determined to be intrauterine

Suspicion for an ectopic pregnancy

Question 8

How will you remain patient-centered, promote health equity, and provide anticipatory guidance to patients experiencing first trimester bleeding?

Question 9

For a patient 5 weeks from a sure LMP who has an ultrasound that does not show a definitive intrauterine pregnancy, what are the differential diagnoses?

How will you proceed clinically?

Question 10

How will you decide whether/when to attempt to hear fetal heart tones with a doppler in early pregnancy?

Question 11

What are the prenatal genetic testing options in the first trimester

Answer 11

-Nuchal translucency ultrasound + serum analytes
-Blood draw #1 of integrated and sequential screens

Question 12

which first trimester prenatal genetic testing options are screening tests and which are diagnostic?

Answer 12

Screening:
- Ultrasound to measure nuchal translucency (NT) + blood draw for maternal serum markers
-Cell-free DNA (cfDNA)
* Noninvasive prenatal testing (NIPT)
* Noninvasive prenatal screening (NIPS)

Diagnostic:
- Chorionic villus sampling (CVS)

Question 13

For which conditions do the first trimester prenatal genetic testing option test

which conditions do they NOT test for?

Answer 13

NT:
- Test for:
* Aneuploidies (trisomies 13, 18, 21)
- Not test for
* Neural tube defects

CVS:
- Test for
* Aneuploidies and other chromosomal conditions
- Not test for:
* Neural tube detects

cfDNA:
- Test for
* Aneuploidies (trisomies 13, 18, 21)
- Not test for
* Neural tube defects

Question 14

What are some techniques to avoid giving a patient a long lecture of options and details about each? ie, how will you remain patient-centered in your counseling?

Question 15

How do you assess for implantation bleeding

Answer 15

Most relevant history:
- Timing usually limited to approx 2 weeks after ovulation
-Usually small amount of bleeding for short duration

Most relevant PE
- May not need to do PE and there are usually no specific PE findings

Ultrasound:
- Usually occurs when it’s too early for ultrasound to be definitive

Labs:
- May or may not choose to draw beta hCG but if it is drawn, should rise appropriately

Question 16

How to assess for cervical irritation from infection or intercourse

Answer 16

Most relevant history:
- Timing in relation to intercourse or exam;
- STI symptoms

Most relevant PE
- Cervix may or may not appear erythematous

Ultrasound:
- No specific ultrasound findings

Labs:
STI testing may be indicated

Question 17

How to assess for subchorionic hemorrhage

Answer 17

Most relevant history:
- Timing in relation to gestational age: unusual to have subchorionic hemorrhage prior to 8-10 weeks
- usually painless bleeding

Most relevant PE
- No specific PE finding

Ultrasound:
- Identified by ultrasound:
- Usually not worrisome unless large

Labs:
- Beta hCG should rise appropriately

Question 18

How to assess for fibroids or endometrial polyps

Answer 18

Most relevant history:
- Pt may report history of fibroids or endometrial polyps

Most relevant PE:
- Uterus may be enlarged and irregular if fibroids

Ultrasound:
- Identified by ultrasound.
- Usually not worrisome unless large

Labs:
- May or may not choose to draw beta hCG but if it is drawn should rise appropriately

Question 19

Sensitivity

Answer 19

True positives
High sensitivity = few false negatives
The ability of the test to correctly identify the people who have the condition

Question 20

specificity

Answer 20

True Negatives
High specificity = few false positives
The ability of the test to correctly identify people who do NOT have the conditio

Question 21

Positive predictive value

Answer 21

The likelihood that someone with a positive test really has the condition

Question 22

Negative predictive value

Answer 22

The likelihood that someone with a negative test really does not have the condition

Question 23

Which genetic tests are screening tests

Answer 23

First trimester screen (nuchal translucency ultrasound + serum analytes)
Triple, quad, and penta screens
Integrated and sequential screens
Noninvasive prenatal testing (cell-free DNA)

Question 24

Which genetic tests are diagnostic tests

Answer 24

Chorionic villus sampling (CVS)
Amniocentesis (amnio)

Question 25

Which genetic tests can only be completed in 1st trimester

Answer 25

First trimester screen (nuchal translucency ultrasound + serum analytes)
Blood draw #1 of integrated and sequential screens

Question 26

Which genetic tests can only be completed in 2nd trimester

Answer 26

Triple screen
Quad screen
Penta screen
Blood draw #2 of integrated and sequential screens

Question 27

Which genetic tests can only be completed anytime

Answer 27

carrier screening
Noninvasive prenatal testing (cell free DNA): Anytime from 10 weeks through term

Question 28

Which genetics tests are aneuploidy tests

Answer 28

Nuchal translucency ultrasound + serum analytes
Triple,quad and penta screens
Integrated and sequential screens
Noninvasive prenatal testing (cell-free DNA)

Question 29

Which genetic tests are structural anomaly (neural tube defect) test

Answer 29

Alpha-fetoprotein (AFP) component of triple, quad, penta, integrated and sequential screens

Question 30

what is cell-free (cfDNA)

Answer 30

most sensitive and specific screening test for common fetal aneuploidies

Can identify fetal sex

Question 31

what is cfDNA assessing

Answer 31

In maternal blood, there are fragments of maternal DNA that exist outside cells and fragments of fetal DNA (it’s actually placental origin) that exist outside cells.

The test analyzes the “fetal fraction,” the DNA fragments that originate with the pregnancy rather than the mother.

A fetal fraction that is lower than expected can be due to an elevated maternal BMI, earlier gestational age, certain fetal aneuploidies and other causes

Question 32

Due to BMI effect of cfDNA what is the recommendation

Answer 32

some clinicians recommend that patients with higher BMIs wait a bit later in pregnancy (later than 10 weeks, which is considered the beginning of the testing window), to minimize the chance for a BMI related false-positive/abnormal test

Question 33

timeframe ultrasound to measure nuchal translucency (NT) + blood draw for maternal serum markers

Answer 33

10(or 11) -14 weeks

Question 34

Time frame for chorionic villus sampling (CVS)

Answer 34

10-13 (or 14) weeks

Question 35

Time frame for cell-free DNA (cfDNA)

Answer 35

Anytime between 10 weeks and term

Question 36

when is the gestational sac seen/beta HCG/clinical significance

Answer 36

4.5-5 weeks
1000
if seen intrauterine and there are no adnexal masses, ectopic is unlikely

Question 37

when is the Yolk Sac seen/beta HCG/clinical significance

Answer 37

5-5.5 weeks
1,000-7,200
If seen intrauterine, ectopic is unlikely. Until cardiac activity is seen, does not confirm viability

Question 38

when is the Embryonic/fetal pole seen/beta HCG/clinical significance

Answer 38

5-7 weeks
7,200-10,800
if fetal pole is intrauterine, ectopic is unlikely. Until cardiac activity is seen, does not confirm viability

Question 39

when is the Embryonic/fetal cardiac activity seen/beta HCG/clinical significance

Answer 39

6-7 weeks
>10,800
if fetal is intrauterine, ectopic is unlikely. Cardiac activity confirms viability of early pregnancy. Once cardiac activity is seen, risk for early pregnancy loss decreases dramatically