nr 2 Mehl + UW ectopic pregnancy 03-24 (2)

Question 1

UW. What level of hCG has to be to vizualize pregnancy by TVUG?

Answer 1

β-hCG >3,500 mIU/mL

Question 2

UW. last menstr 7 weeks + 1000 hCG + TVUG does not vizualize anything. why is it?

Answer 2

because her quantitative β-hCG level (ie, 1,000 mIU/mL) is below the threshold at which an intrauterine pregnancy can be visualized by TVUS (ie, below the discriminatory zone [β-hCG <3,500 mIU/mL]).

Question 3

UW. last menstr 7 weeks + 1000 hCG + TVUG does not vizualize anything. so where is pregnancy?

Answer 3

She has a pregnancy of unknown location

Question 4

UW. last menstr 7 weeks + 1000 hCG + TVUG does not vizualize anything. best next step?

Answer 4

repeat quantitive bhCG in 48 hours.

wrong - tranabdominal UG

Question 5

UW. last menstr 7 weeks (aka first trimester) + vaginal bleeding + positive hCG (buvo 1000). requires what evaluation? 2

Answer 5

Evaluation with TVUS and serum β-hCG measurements to determine pregnancy location.

Question 6

UW. The most common cause of a pregnancy of unknown location …..?

Answer 6

early gestation of a normal intrauterine pregnancy.

Question 7

UW. pregnancy of unknown location other etiologies?

Answer 7

completed spontaneous abortion,
nonviable intrauterine pregnancy (missed abortion), and ectopic pregnancy,
all of which require further evaluation for definitive diagnosis.

Question 8

UW. Because each type of pregnancy follows a characteristic β-hCG pattern, quantitative β-hCG levels are repeated every 48 hours. 1. intrauterine?

Answer 8

Early but viable intrauterine pregnancies typically have a ≥35%-50% rise in β-hCG every 48 hours.

Question 9

UW. Because each type of pregnancy follows a characteristic β-hCG pattern, quantitative β-hCG levels are repeated every 48 hours. 2. complete spontaneous abortions?

Answer 9

Completed spontaneous abortions cause β-hCG levels to decrease precipitously because the pregnancy has been evacuated

Question 10

UW. Because each type of pregnancy follows a characteristic β-hCG pattern, quantitative β-hCG levels are repeated every 48 hours. 3. Ectopic and nonviable intrauterine pregn.?

Answer 10

Ectopic and nonviable intrauterine pregnancies (eg, anembryonic gestations) usually cause <35% rise in β-hCG due to abnormal pregnancy development.

Question 11

UW. Patients typically require serial quantitative β-hCG measurements until ……?

Answer 11

the level reaches the discriminatory zone, at which point a repeat transvaginal ultrasound is performed

Question 12

UW. Those with an abnormally rising β-hCG level require close follow-up due to the risk of ectopic pregnancy.

Answer 12

.

Question 13

UW. when used methotrexate?

Answer 13

typically used in patients with an unruptured ectopic pregnancy

Question 14

UW. what is done in ruptured ectopic or contraindications of methotrexate?

Answer 14

hemodynamic instability (ie, ruptured ectopic pregnancy)
or
patients with contraindications to methotrexate (eg, immunodeficiency, breastfeeding).

Question 15

UW. Educational objective: Patients with vaginal bleeding and positive β-hCG require TVUG to determine pregnancy location.
Patients with a nondiagnostic ultrasound result (eg, no intrauterine pregnancy, free fluid, or adnexal masses) require a repeat quantitative β-hCG level in 48 hours to evaluate for potential ectopic pregnancy.

Answer 15

.

Question 16

UW. typically have a ≥35%-50% rise in β-hCG every 48 hours.?

Answer 16

Early but viable intrauterine pregnancies

Question 17

UW. β-hCG levels to decrease precipitously because the pregnancy has been evacuated.?

Answer 17

Completed spontaneous abortions

Question 18

UW. cause <35% rise in β-hCG due to abnormal pregnancy development?

Answer 18

Ectopic and nonviable intrauterine pregnancies (eg, anembryonic gestations

Question 19

UW. case. TVUG negative + hCG is 1,100 mIU/mL and a repeat 48 hours later is 1,370 mIU/mL. location of pregnancy? 2

Answer 19

She has pregnancy of unknown location (no visible intrauterine or extrauterine gestation on ultrasound)

Rise of hCG is abnormal (less than < 35 proc. after 48h) = probably ECTOPIC or NONVIABLE INTRAUTERINE PREGNANCIES (eg, anembryonic gestations.

Question 20

UW. case. TVUG negative + hCG is 1,100 mIU/mL and a repeat 48 hours later is 1,370 mIU/mL. best next step?

Answer 20

pregnancy is ectopic or nonviable.
DO Diagnostic dilation and curettage to differenctiate.

Question 21

UW. case. TVUG negative + hCG is 1,100 mIU/mL and a repeat 48 hours later is 1,370 mIU/mL. + done Diagnostic dilation and curettage. next step?

Answer 21

evaluate hCG again

Question 22

UW. case. TVUG negative + hCG is 1,100 mIU/mL and a repeat 48 hours later is 1,370 mIU/mL. + done Diagnostic dilation and curettage, next day β-hCG level is 1,566 mIU/mL.
hCG is increased. what is conclusion? next step?

Answer 22

Persistent rise in β-hCG level after dilation and curettage is diagnostic for an ectopic pregnancy –> additional Mx = HD stable, give methotrexate

Question 23

UW. case. TVUG negative + hCG is 1,100 mIU/mL and a repeat 48 hours later is 1,370 mIU/mL. + done Diagnostic dilation and curettage, next day β-hCG level is decreased. What is conclusion? next step?

Answer 23

A negative or decreased β-hCG level confirms that the patient had a nonviable intrauterine pregnancy –> reassurance and observation

Question 24

UW. methotrexate mechanism?

Answer 24

A folate antagonist that inhibits DNA synthesis and cell growth preferentially in rapidly dividing cells (eg, trophoblasts)

Question 25

UW. methotrexate for ectopic. what is next after you give it?

Answer 25

Require monitoring of β-hCG levels until they become undetectable to ensure that treatment is complete.

Question 26

UW. when is used misoprostolis/mifespristonas?

Answer 26

cause uterine contractions and are used for the medical management of spontaneous abortions; they are not used to treat ectopic pregnancy.

Question 27

UW. Misoprostol mechanism?

Answer 27

misoprostol (prostaglandin E1 agonist)

Question 28

UW. mifepristone mechanism?

Answer 28

Mifepristone (progesterone antagonist)

Question 29

UW. is progesterone levels important in diagnosing pregnancy/detecting location?

Answer 29

Higher serum progesterone levels are usually associated with normal, viable intrauterine pregnancies (and lower levels with ectopic or nonviable intrauterine pregnancies). However, levels are not diagnostic for ectopic pregnancy due to low sensitivity and specificity; therefore, measurement is not indicated.

Question 30

UW. educational: Ectopic pregnancy (ie, pregnancy implanted in an extrauterine location) can be diagnosed by a persistent rise in β-hCG level following diagnostic dilation and curettage.

Answer 30

.

Question 31

UW. 39y/o + vaginal spotting and a positive pregnancy test. Seen 2 days ago: vaginal spotting, β-hCG level of 3,033 mIU/mL, TVUG thickened endometrial stripe with no intrauterine pregnancy or adnexal masses. Today: continues to have vaginal spotting but no pelvic pain or cramping, minimal amount of dark red blood in the posterior vaginal vault Vitals = normal. Now β-hCG 3,582 mIU/mL, TVUG unchanged from the previous findings. Diagnostic dilation and curettage is performed and examination of the intrauterine contents reveals benign endometrial tissue and no chorionic villi. Cause?

Answer 31

ECTOPIC PREGNANCY note: abnormal rise 3033 -> 3582 (less 35 proc.)

Question 32

UW. Abnormal intrauterine pregnancy (including a recent complete spontaneous abortion) will have chorionic villi, a finding consistent with intrauterine placental development.

Answer 32

Ectopic pregnancy will have no chorionic villi due to extrauterine pregnancy implantation.

Question 33

UW. The most common reason for early pregnancy monitoring is first-trimester bleeding, as in this patient with vaginal spotting. biski siitas mindfuckino

Answer 33

.

Question 34

UW. ectopic pregn. table. risk factors, 3?

Answer 34

Previous ectopic pregnancy previous pelvic/tubal surgery PID

Question 35

UW. ectopic pregn. table. CP 4?

Answer 35

Abdominal pain, amenorrhea, vaginal bleeding Hypovolemic shock in ruptured ectopic pregnancy Cervical motion, adnexal and/or abdominal tenderness +/- palpable adnexal mass

Question 36

UW. ectopic pregn. table. Dx?

Answer 36

Positive hCG TVUG - adnexal mass, empty uterus

Question 37

UW. ectopic pregn. table. MX in stable?

Answer 37

methotrexate

Question 38

UW. ectopic pregn. table. Mn in unstable?

Answer 38

surgery

Question 39

UW. ectopic and IUD. risk?

Answer 39

Although patients with an intrauterine device (IUD) have a lower absolute risk for ectopic pregnancy (due to overall lower rates of pregnancy), they are at higher risk for extrauterine implantation if pregnancy occurs.

Question 40

UW. Pregnancy normally induces endometrial thickening (ie, decidualization) to encourage intrauterine implantation; however, patients with a progestin-containing IUD develop endometrial atrophy (ie, thinning), which can induce amenorrhea but also promote extrauterine implantation.

Answer 40

.

Question 41

UW. IUD + changes in bleeding pattern. Case: Hx of heavy menstrual bleeding for which she had a progestin-containing IUD placed 3 years ago. She has been amenorrhoeic for the past 2 years but started having vaginal spotting a few days ago and some mild pelvic cramping. what suspect??

Answer 41

Because an ectopic pregnancy can present with vaginal bleeding, patients with an IUD who develop an abrupt change in bleeding pattern and concomitant adnexal tenderness require evaluation.

Question 42

UW. If transabdominal UG cannot locate the pregnancy, TVUG is performed because it is more sensitive and can better visualize the adnexa, particularly in obese patients or those with an early gestation.

Answer 42

.

Question 43

UW. Endometrial biopsies are used to evaluate for endometrial hyperplasia/cancer in nonpregnant women with abnormal uterine bleeding. Although this patient has vaginal bleeding and obesity (a risk factor for endometrial hyperplasia), hyperplasia is unlikely in this patient with a progestin-containing IUD (protective against hyperplasia) and thin endometrium.

Answer 43

.

Question 44

UW. FSH, TSH, and prolactin levels used to evaluate what?

Answer 44

abnormal uterine bleeding.

Question 45

UW. IUD removal?

Answer 45

recommended for patients with an ultrasound-confirmed intrauterine pregnancy who wish to continue pregnancy. This patient's pregnancy should be located prior to offering IUD removal because an IUD can be left in place with no additional adverse effects if the pregnancy is extrauterine.

Question 46

Mehl. ectopic definition?

Answer 46

Implantation of conceptus outside the uterus, including the parametrium of the uterus and cervix.

Question 47

Mehl. b-hCG levels will be much.....???

Answer 47

lower than expected for gestational age

Question 48

Mehl. b-hCG should double approximately every .....

Answer 48

2-3 days in early pregnancy, so the Q can also mention something about poor rate of change of increase.

Question 49

Mehl. Highest yield point for USMLE is that ectopic risk is incr. (2 arrows up) in what Hx?

Answer 49

women who have Hx of PID. this is due to scarring of the Fallopian tubes and disruption of the cilia.

Question 50

Mehl. most common location of ectopic?

Answer 50

ampulla (70-80%).

Question 51

Mehl. - Methotrexate is given for Tx (asked once on 2CK form) for what ectopic?

Answer 51

“small, stable ectopics” – i.e., mother is hemodynamically stable, there is no evidence of tubal rupture / fluid in the peritoneal cavity, the ectopic is <3.5 cm, and b-hCG is <5000 mIU/mL.

Question 52

Mehl. - Methotrexate is given for Tx (asked once on 2CK form) for what ectopic size?

Answer 52

<3.5 cm

Question 53

Mehl. - Methotrexate is given for Tx (asked once on 2CK form) for what ectopic hCG levels?

Answer 53

b-hCG is <5000

Question 54

Mehl. Laparoscopic salpingostomy/salpingectomy is done when?

Answer 54

if methotrexate cannot be given.

Question 55

Mehl. IF HD unstable?

Answer 55

If the female is hemodynamically unstable (i.e., low BP), the answer is laparotomy, not laparoscopy. UW RASO KAD LAPAROSCOPY!!!