OB-GYN Revision 6

Question 2

Describe some risk factors for ectopic pregnancy [+]

Answer 2

Previous ectopic

Tubal factors:
- scarring or adhesions from PID
- congenital anomalies,

Tubal surgery:
- salpingectomy
- tubal ligation
- reconstructive surgery

Assisted reproductive technology (ART):
- Fertility treatments, particularly in vitro fertilization (IVF)

Intrauterine device (IUD) use

Smoking

Endometriosis

Question 3

Describe the pathophysiology of ectopic pregnancy [3]

Answer 3

Implantation outside the uterine cavity occurs when the fertilized ovum is unable to reach the endometrial lining due to impaired tubal transport or abnormal embryo-tubal interactions:
- Abnormal embryo migration (disrupted tubal motility, due to factors such as PID, endometriosis, or smoking)
- Impaired tubal environment: Inflammatory processes, including infection or endometriosis, can alter the tubal milieu, promoting ectopic implantation.
- Embryo-tubal interactions: Alterations in the expression of adhesion molecules and chemokines, such as integrins and L-selectin, may affect the embryo-tubal relationship, leading to ectopic pregnancy.

Question 4

Describe the clinical features of ectopic pregnancies [+]

Answer 4

Female with a history of 6-8 weeks amenorrhoea who presents with lower abdominal pain and later develops vaginal bleeding

Constant lower abdominal pain:
- in the right or left iliac fossa
- often FIRST symptom
- pain is constant

Vaginal bleeding:
* usually less than a normal period
* may be dark brown in colour

Recent amenorrhoea
- if longer (e.g. 10 wks) this suggest another causes e.g. inevitable abortion

Cervical motion tenderness (pain when moving the cervix during a bimanual examination)

Dizziness or syncope (blood loss)

Shoulder tip pain(peritonitis)

Question 5

Describe how you interpret serum bHCG levels with ectopic pregnancies [2]

Answer 5

If the initial β-HCG level is >1500 iU (discriminatory level)
- & there is no intrauterine pregnancy on transvaginal ultrasound –> consider ectopic pregnancy until proven otherwise

If the initial β-HCG level is < 1500 iU:
- and the patient is stable, a further blood test can be taken 48 hours later
- Viable pregnancy: HCG level would be expected to double every 48 hours.
- Miscarriage: HCG level would be expected to halve every 48 hours

Question 6

Describe the criteria that needs to be met to indicate expectant managment for ectopic pregnancy [5]

Answer 6

• Clinical stable and pain free AND
• Unruptured tubal ectopic pregnancy measuring less than 35mm with no
  visible heartbeat in TVUS AND
• Serum b-hCG levels of ≤1,000 IU/L AND
• Able to return for follow up

Question 7

What is the criteria to meet medical management of EP? [3]

Answer 7

Have no significant pain AND
* Unruptured tubal ectopic pregnancy measuring less than 35mm with no visible heartbeat in TVUS AND
* Serum b -hCG levels of ≤1,500 IU/L AND
* Able to return for follow up

Question 8

Which patients require surgery for an ectopic pregnancy? [4]

Answer 8

This include those with:
* Pain
* Adnexal mass > 35mm
* Visible heartbeat
* HCG levels > 5000 IU / l

Question 9

Answer 9

Question 10

Describe the short term complications of a untreated ectopic pregnancy [2]

Answer 10

Tubal rupture:
- The most severe and life-threatening complication of ectopic pregnancy, tubal rupture occurs when the growing conceptus causes the fallopian tube to burst, leading to severe intraperitoneal haemorrhage.
- Usually occurs between 6-10 weeks gestation. Clinical manifestations include sudden, severe abdominal pain, signs of hypovolemic shock (tachycardia, hypotension, pallor), and peritoneal irritation.
- Prompt surgical intervention is crucial to prevent maternal mortality.

Haemoperitoneum:
- Bleeding into the abdominal cavity from trophoblast invasion.
- Internal bleeding due to ectopic pregnancy can lead to a significant accumulation of blood in the peritoneal cavity, causing hemodynamic instability and potential hypovolemic shock.
- Hemoperitoneum warrants immediate surgical intervention.

Question 11

Describe the intermediate-term complications of an ectopic pregnancy [2]

Answer 11

Persistent trophoblastic tissue:
* Following treatment with methotrexate or surgical management, residual trophoblastic tissue may remain and continue to produce hCG.
* This can necessitate further medical or surgical intervention to ensure complete removal of the ectopic pregnancy
.
Infection:
- Post-surgical infection or an undiagnosed tubo-ovarian abscess may complicate ectopic pregnancy management, requiring antibiotic therapy or additional surgical procedures.

Question 12

Explain the long-term complications of an ectopic pregnancy [3]

Answer 12

Damage to reproductive organs:
- Surgical intervention for ectopic pregnancy, particularly salpingectomy, can impact future fertility.
- Moreover, ectopic pregnancy itself increases the risk of subsequent ectopic pregnancies.

Rh sensitization:
- In Rh-negative women with an ectopic pregnancy, there is a risk of developing Rh isoimmunization.
- Administering Rh immunoglobulin prophylaxis is crucial to prevent complications in future pregnancies.

Question 13

Describe the US findings of an ectopic pregnancy [3]

Answer 13

gestational sac containing a yolk sac or fetal pole may be seen in a fallopian tube
- A mass representing a tubal ectopic pregnancy moves separately to the ovary. The mass may look similar to a corpus luteum; however, a corpus luteum will move with the ovary

Features that may also indicate an ectopic pregnancy are:
* An empty uterus
* The tubal ring sign, also referred to as a bagel sign or blob sign, is one of the ultrasound signs of a tubal ectopic pregnancy.
* Fluid in the uterus, which may be mistaken as a gestational sac (“pseudogestational sac”)

Question 14

What follow up management do all patients who require a salpignotomy require? [1]

What other management needs to be considered post-ectopic pregnancy? [1]

Answer 14

Patients who have required salpingotomy require weekly b-hCG measurements until negative. Approximately 1 in 5 will need further treatment

Anti-D Rhesus Prophylaxis - Rhesus D negative women may require anti-D rhesus prophylaxis if surgical management and/or repeated, heavy bleeding and/or pain

Question 15

Define the following terms:
- hydatidiform mole
- complete mole
- partial mole

Answer 15

A hydatidiform mole:
- is a type of tumour that grows like a pregnancy inside the uterus. This is called a molar pregnancy. There are two types of molar pregnancy: a complete mole and a partial mole.

A complete mole:
- occurs when two sperm cells fertilise an ovum that contains no genetic material (an “empty ovum”).
- These sperm then combine genetic material, and the cells start to divide and grow into a tumour called a complete mole
- No fetal material will form.

A partial mole:
- occurs when two sperm cells fertilise a normal ovum (containing genetic material) at the same time.
- The new cell now has three sets of chromosomes.
- The cell divides and multiplies into a tumour called a partial mole.
- In a partial mole, some fetal material may form.

Question 16

Molar pregnancy behaves like a normal pregnancy. Periods will stop and the hormonal changes of pregnancy will occur.

There are a few things that can indicate a molar pregnancy versus a normal pregnancy - what are they? [4]

Answer 16

There are a few things that can indicate a molar pregnancy versus a normal pregnancy:
* More severe morning sickness
* Vaginal bleeding
* uterus large for dates
* Abnormally high hCG
* Thyrotoxicosis (hCG can mimic TSH and stimulate the thyroid to produce excess T3 and T4)

Question 17

How do you manage molar pregnancies? [3]

Answer 17

• Surgical evacuation of the uterus to remove the mole and histological confirmation
• Referral to to gestational trophoblastic disease centre for management and follow-up (hCG levels are monitored until they return to normal)
• If the mole metastasises, systemic chemotherapy may be required

Question 18

What advice do you give about contraception following complete molar pregnancies? [1]

Answer 18

effective contraception is recommended to avoid pregnancy in the next 12 months

Question 19

What is the difference between N&V and hyperemesis gravidarum? [3]

Answer 19

The RCOG guideline (2016) criteria for diagnosing hyperemesis gravidarum are “protracted” NVP plus:
* More than 5 % weight loss compared with before pregnancy
* Dehydration
* Electrolyte imbalance

Question 20

Which scoring system can be used to assess HG severity? [1]

What are mild, moderate and severe scores? [3]

Answer 20

The severity can be assessed using the Pregnancy-Unique Quantification of Emesis (PUQE) score. This gives a score out of 15:

< 7: Mild
7 – 12: Moderate
> 12: Severe

Question 21

Describe what blood tests might be like for a patient with HG

Answer 21

FBC:
↑ haematocrit – to exclude infections, anaemia
* U&Es: to guide IV fluids and electrolyte replacement (↓or ↑K+,↓Na+, AKI)

In refractory cases OR >1 hospital admission
* LFTs: ↑ transaminases, ↓albumin
* Amylase, bilirubin
* Thyroid profile (hypo or hyperthyroidism)
* Bone profile (Calcium and Phosphate)
* Magnesium
* ABG/VBG (metabolic hypochloremic alkalosis)

Question 22

Describe the mx of mild cases of HG

Answer 22

The following are all first line anti-emetics:
* Prochlorperazine (stemetil)
* Cyclizine
* Doxylamine and pyridoxine
* Promethazine

2nd line:
- Metoclopramide
- Ondansetron

NB: Initially select a 1st line antiemetic - Use a combination of drugs in women who do not respond to a single drug (synergistic effect) – add drugs rather than replacing them

Question 23

Describe the managment of moderate - server HG

Answer 23

IV Fluids
- NaCl or Hartmann’s [avoid glucose containing fluid as they precipitate Wernicke’s encephalopathy] +/- KCl as necessary.

* Anti-emetics IM or IV

• Daily U&Es
• Thiamine supplementation to prevent Wernicke Korsakoff syndrome
  (Thiamine Hydrochloride 25-50mg PO TDS or thiamine 100mg infusion
  weekly)
• Ranitidine or Omeprazole if acid reflux is a problem
• Laxatives as required
• NBM for 24hr then introduce food as tolerated – enteral or parenteral
  nutrition maybe considered in refractory cases
• VTE prophylaxis (TEDS and LMWH)

Question 24

How do you manage future pregnancies if they have previously had severe HG? [2]

Answer 24

Pre-emptive use of doxylamine and pyridoxine to reduce severity of
disease (20/20 mg PO at night should be started when positive pregnancy test)

Question 25

Describe the different types of miscarriage [6]

Answer 25

**Missed miscarriage** – the fetus is no longer alive, but no symptoms have occurred **Threatened miscarriage** – vaginal bleeding with a closed cervix and a fetus that is alive **Inevitable miscarriage** – vaginal bleeding with an open cervix **Incomplete miscarriage** – retained products of conception remain in the uterus after the miscarriage **Complete miscarriage** – a full miscarriage has occurred, and there are no products of conception left in the uterus **Anembryonic pregnancy** – a gestational sac is present but contains no embryo

Question 26

Why does vaginal bleeding occur in a miscarraige? [2]

Answer 26

**Haemorrhage** in the **decidua** **basalis** leading to necrosis and inflammation **Ovum is unable to continue to develop in the uterus** * Initiates uterine contractions * Cervix begins to dilate causing the loss of fetus and pregnancy tissu

Question 27

Why are complete miscarriages more likely before 12 weeks [1] than 12-24 weeks? [1]

Answer 27

**prior to 12 weeks** - a complete miscarriage is more likely as the **placenta** is **unlikely** to have been **independently developed**, thus being **expelled together with the fetus** **12-24 weeks**: - **gestation** **sac** is more likely to **rupture** and the **fetus** then **expelled** while **parts of the placenta remain in the uterus**

Question 28

Describe the presentation of: * complete miscarriage [1] * incomplete miscarriage [1]

Answer 28

**complete miscarriage:** - **Bleeding** **stops** and further treatment is not needed **incomplete** **miscarriage**: - **Placenta** is **not** fully **expelled** and **bleeding persists** - Surgical management needed

Question 29

Describe the presentation of: * missed miscarriage [2] * threatened miscarriage [2]

Answer 29

**Missed miscarriage:** - **no** **symptoms** have occurred - the **cervix** is **closed** **Threatened miscarriage:** - **Vaginal bleeding +/- pain** - **Closed cervical os** - **Viable** **pregnancy**

Question 30

Describe the presentation of: * inevitable miscarriage [2]

Answer 30

**Inevitable miscarriage**: - **vaginal** **bleeding** - **open cervical os** - Progresses to an incomplete or complete miscarriage

Question 31

Describe the clinical features of a miscarriage:

Answer 31

* **Vaginal bleeding** - brownish light spotting to heavy bright-red blood with clots; * **Lower abdominal cramping pain** * **Vaginal fluid discharge/tissue discharge** * **Loss of pregnancy symptoms** (eg. No more nausea/breast tenderness) * **Lower back pain** ## Footnote Should be suspected in all women with bleeding in early pregnancy

Question 32

What are the two key ddx of an miscarriage? [2]

Answer 32

**Ectopic pregnancy** **Molar pregnancy** - both present with PV bleeding Ruptured ovarian corpus luteum cyst Ovarian torsion Fibroid degeneration

Question 33

How do you differentiate an ectopic pregnancy from a miscarriage? Similarities: [2] Differences [4]

Answer 33

**Ectopic pregnancy**: * **Similarities**: vaginal bleeding and lower abdominal pain * **Differences**: **pain** is usually **unilateral**, more **severe**, and **before** **bleeding** **presents**. The bleeding in an ectopic pregnancy also tends to be **darker and less heavy**. There is also **cervical excitation in ectopic pregnancy.**

Question 34

How do you differentiate an molar pregnancy from a miscarriage? Similarities: [2] Differences [4]

Answer 34

**Similarities**: * vaginal bleeding * abdominal pain. **Differences**: - **heavy and prolonged bleeding** with **clots** - **± brown watery vaginal discharge**. - The **uterus** is **large** for its **gestational** **dates**. - There are **exaggerated symptoms** of **pregnancy** such as **extreme morning sickness.**

Question 35

There are three key features that the sonographer looks for in an early pregnancy. What are they? [3]

Answer 35

There are **three key features that the sonographer** looks for in an early pregnancy: * **Mean gestational sac diameter** * **Fetal pole and crown-rump length** * **Fetal** **heartbeat**

Question 36

When would you repeat a scan with regards to the following on TVUS: [3] Mean gestational sac diameter Fetal pole and crown-rump length Fetal heartbeat

Answer 36

* When the **crown-rump length is less than 7mm**, **without** a **fetal** **heartbeat**, the scan is repeated after at least one week to ensure a heartbeat develops. * When there is a **crown-rump length of 7mm** or **more**, **without** a **fetal** **heartbeat**, the scan is **repeated after one week before confirming a non-viable pregnancy.** * A **fetal pole is expected** once the mean **gestational sac diameter is 25mm or more**. When there is a **mean gestational sac diameter of 25mm or more, without a fetal pole**, the scan is repeated after one week before confirming an **anembryonic pregnancy.**

Question 37

Describe the management of a miscarriage if its a < 6 weeks gestation [3]

Answer 37

**Less Than 6 Weeks Gestation**: - Women with a pregnancy less than 6 weeks’ gestation **presenting** with **bleeding** can be managed **expectantly** provided they have **no pain and no other complications or risk factors** (e.g. previous ectopic) - involves **awaiting** the **miscarriage** without **investigations or treatment** - **A repeat urine pregnancy test** is performed **after 7 – 10 days**, and if **negative**, a **miscarriage can be confirmed** ## Footnote **NB**: An ultrasound is unlikely to be helpful this early as the pregnancy will be too small to be seen.

Question 38

In which scenerios are miscarriages medically or surgically managed? [3]

Answer 38

**increased risk of haemorrhage** * she is in the **late first trimester** * if she has **coagulopathies** or is unable to have a blood transfusion **previous adverse and/or traumatic experience** **associated with pregnancy** (for example, stillbirth, miscarriage or antepartum haemorrhage) **evidence of infection**

Question 39

Describe the management of a missed miscarriage [2]

Answer 39

**1. oral mifepristone** **2. 48 hours later: misoprostol** (unless the gestational sac has already been passed) **3.** if bleeding has **not started within 48 hours** after **misoprostol** **treatment**, they should **contact their healthcare professional**

Question 40

Describe the medical management of incomplete miscarriage [2]

Answer 40

**a single dose of misoprostol** (vaginal, oral or sublingual) women should be offered **antiemetics and pain relief**

Question 41

Describe the medical management of a threatened miscarriage [4]

Answer 41

* If patient **stable**: **observe** symptoms * In women with a **previous miscarriage**, use of **vaginal micronized progesterone** (400mg twice daily) NICE 2021 * **Advise to return if symptoms worse**n or do not settle after **14** **days** * Analgesia, written information, contact details and safety netting advice should be given

Question 42

Describe the surgical managment that can be offered for miscarriages [2]

Answer 42

**Manual vacuum aspiration** under **local** **anaesthetic** as an outpatient: - A **tube** attached to a specially designed syringe is **inserted through the cervix into the uterus.** - **manually** uses the syringe to **aspirate** **contents** of the **uterus** **Electric vacuum aspiration** under **general** **anaesthetic**: - performed through the vagina and cervix without any incisions - The **cervix** is gradually **widened** using dilators, and the **products of conception** are **removed** through the **cervix** using an **electric-powered vacuum.**

Question 43

Which drug is given prior to surgical treatment of miscarriage? [1] Why? [1]

Answer 43

**Prostaglandins** (**misoprostol**) are given before surgical management to **soften the cervix.**

Question 44

When is manual vacuum aspiration not indicated? [1]

Answer 44

After 10 weeks gestation

Question 45

What is the definition of recurrent miscarriage? [1]

Answer 45

**Recurrent miscarriage** is defined as **3 or more consecutive spontaneous abortions**. It occurs in around 1% of women

Question 46

Name 5 causes of recurrent miscarriages [5]

Answer 46

* **antiphospholipid syndrome** * **endocrine** **disorders**: poorly controlled diabetes mellitus/thyroid disorders. Polycystic ovarian syndrome * **uterine abnormality**: e.g. uterine septum * **parental chromosomal abnormalities** * **smoking**

Question 47

Which inheritied thrombophilias should you remember that could cause recurrent miscarriages? [3]

Answer 47

**Factor V Leiden** (most common) **Factor II** (prothrombin) gene mutation **Protein S deficiency**

Question 48

Describe the different uterine miscarriages that could cause recurrent miscarriages [6]

Answer 48

**Uterine septum** (a partition through the uterus) **Unicornuate uterus** (single-horned uterus) **Bicornuate uterus** (heart-shaped uterus) **Didelphic uterus** (double uterus) **Cervical insufficiency** **Fibroids**

Question 49

Describe what is meant by Chronic Histiocytic Intervillositis [1]

Answer 49

Chronic histiocytic intervillositis is a **rare cause of recurrent miscarriage,** particularly in the **second** **trimester**. It can also lead to intrauterine growth restriction (IUGR) and intrauterine death. **Histiocytes** and **macrophages** build up in the **placenta**, causing **inflammation and adverse outcomes**. It is **diagnosed** by **placental** **histology** showing **infiltrates of mononuclear cells in the intervillous spaces.**