450 SBAs in Clinical Specialties - Early Pregnancy Flashcards
- Early pregnancy loss
A 24-year-old woman attends accident and emergency 4 weeks after having a positive urinary pregnancy test. She has had 3 days of painless vaginal bleeding and is passing clots. Over the past 2 days the bleeding has settled. An ultrasound scan shows an empty uterus. What is the correct diagnosis?
A. Threatened abortion
B. Missed miscarriage
C. Septic abortion
D. Complete abortion
E. Incomplete miscarriage
D. Complete abortion
Early pregnancy loss
1 D
The terms abortion and miscarriage have historically been used interchangeably in gynaecology, which is as confusing to students as it is to patients. Most clinicians use miscarriage to mean a spontaneous fetal loss before 24 weeks’ gestation and termination of pregnancy to use what the layman may call an ‘abortion’ – that is a deliberate termination of the pregnancy. Threatened abortion (A) refers to any vaginal bleeding before viability (traditionally 24 weeks, though this is decreasing) whereas after this point vaginal bleeding is referred to as antepartum haemorrhage. Missed miscarriage (B) is loss of the pregnancy without the passage of products of conception or bleeding. Often erroneously referred to in the media as a miscarriage ‘that you didn’t know happened’, many women in fact experience the fetal loss as the sudden decline of pregnancy-related symptoms: early morning nausea, breast tenderness and vomiting. Septic abortion (B) refers to the loss of an early pregnancy complicated by infection of a retained conceptus. It is a serious complication of termination or miscarriage and must be managed actively: around the world, many women still die from this treatable condition. Incomplete miscarriage (E) is the loss of an early pregnancy with bleeding and/or passage of some but not all products of conception. It can be managed conservatively, medically (with misoprostol to expedite expulsion of the products) or surgically (with suction evacuation of the uterus). Complete abortion (D) refers to loss of the pregnancy where all products of conception have been expelled from the uterus.
- Complications of pregnancy
A 51-year-old woman in her 12th week of an assisted-conception triplet pregnancy presents to accident and emergency with severe nausea and vomiting. She has mild lower abdominal and back pains. Urine dipstick shows blood –ve, protein –ve, ketones ++++, glucose +. What is the most appropriate management plan?
A. Intravenous crystalloids and doxycycline, urgent ultrasound assessment
B. Discharge with 1 week’s course of ciprofloxacin
C. Referral to the medics for investigation of viral gastroneteritis
D. Intravenous crystalloids, oral antiemetics
E. Referral to the surgeons for investigation of appendicitis
D. Intravenous crystalloids, oral antiemetics
2 D This woman is suffering from hyperemesis gravidarum (HG), a condition affecting around 2 per cent of pregnancies where vomiting in pregnancy becomes so severe that a woman may develop signs and symptoms of dehydration and may not be able to keep any fluid down. The ketonuria and triplet pregnancy are clues to this diagnosis as multiple fetuses are associated with hyperemesis. Mild lower abdominal and back pains are common at this stage in the pregnancy when the uterus grows out of the pelvis and stretches attached ligaments, and are usually of no consequence. The management of HG involves restoring fluid volume and preventing further nausea and vomiting (D). Diarrhoea and/or signs of sepsis might point in the direction of a gastroenteritis (C) or appendicitis (E). The latter would normally present with a more pronounced pain and less significant vomiting. Quinolones (e.g. ciprofloxacin) (B) and tetracyclines (e.g. doxycycline) (A) should be avoided in pregnancy as they are teratogenic.
- Threatened miscarriage
A 19-year-old woman is referred to your early pregnancy unit as she is having some vaginal bleeding. This is her first pregnancy, she has regular menses and the date of her last menstrual period suggests she is 8 weeks gestation today. She is well apart from her bleeding and is naturally concerned. A transvaginal ultrasound reveals an intrauterine gestational sac of 18 mm with a yolk sac. What is the most likely explanation of these findings?
A. A viable intrauterine pregnancy
B. A pseudosac
C. A blighted ovum
D. A pregnancy of uncertain viability
E. An anembryonic pregnancy
D. A pregnancy of uncertain viability
3 D Abdominal pain and vaginal bleeding are very common in early pregnancy, with a miscarriage rate near one in five (20 per cent). This woman is having vaginal bleeding and has an intrauterine gestational sac, so is having a threatened miscarriage. There is no fetal pole and no fetal pulsation so we cannot say that this is viable (A). Although by 6 weeks we should see a fetal pole and a fetal heart, it may be that her dates are indeed wrong and that she is less pregnant than assumed. A blighted ovum (C) and an anembryonic pregnancy are the same thing, showing a gestational sac with no developing embryonic pole or yolk sac development. As there is a yolk sac this is unlikely. In view of uncertainties relating to status of pregnancy, it is imperative that people with suspected anembryonic pregnancies (E) have two scans 10–14 days apart to increase certainty that there is no embryo development. A pseudosac (B) is seen in 10–20 per cent of ectopic pregnancies. It is a decidual reaction rather than an embryonic sac – hence there would be no yolk sac. This is a pregnancy of uncertain viability that is in the uterus (D). This woman needs to have a repeat vaginal ultrasound scan in 10–14 days to confirm whether the pregnancy is viable.
- Pre-termination assessment
A 31-year-old woman is seen in the termination of pregnancy (TOP) clinic requesting a termination. She is 5 weeks pregnant in her first pregnancy. She is otherwise well but does have some lower abdominal pain on the right hand side. On examination her abdomen is soft and non-tender. An ultrasound reveals a small sac in the uterus which might be a pseudosac. What would be your next management step?
A. Urgent referral to hospital to rule out ectopic pregnancy
B. Rescan in 10 days time
C. Blood test for beta human chorionic gonadotrophin (hCG) now and in 48 hours time
D. Arrange for her to come in for a medical termination
E. Arrange a surgical termination of pregnancy
C. Blood test for beta human chorionic gonadotrophin (hCG) now and in 48 hours time
4 C The concern is that the sac in the uterus may not be an early gestational sac but may be a pseudosac which would suggest an ectopic pregnancy. A pseudosac represents decidualized reactive tissue. Although she is only 5 weeks pregnant, with this scan result you are committed to ruling out an ectopic pregnancy. If the woman is well, is haemodynamically stable and understands what the symptoms are, that should prompt her immediate hospital attendance, then she can be managed as an outpatient. If this is not the case she should be referred to hospital. This woman needs a beta hCG and ideally a progesterone level, with a repeat beta hCG 48 hours afterwards. If there is more than a 67 per cent rise in beta hCG it is likely that the sac seen on the scan is that of a normal viable intrauterine pregnancy. If this is the case she will need an ultrasound in 10 days to confirm the diagnosis and then her TOP can be arranged if she still does not wish to continue her pregnancy. If there is a suboptimal rise in beta hCG she should be seen at hospital for further assessment. Surgical terminations should be performed after 7 weeks while medical terminations can be performed up to 9 weeks. The important message here is that you must always confirm the diagnosis of an intrauterine pregnancy before offering a TOP.
- Emergency gynaecology (1)
A 28-year-old woman with a history of pelvic inflammatory disease is 6 weeks into her third pregnancy. She previously had two terminations. She presents with lower abdominal pain and per vaginam bleeding. Her beta hCG is 1650 mIU/mL, progesterone 11 nmol/l. An ultrasound reveals a small mass in her left fallopian tube with no intrauterine pregnancy seen. There is no free fluid in the Pouch of Douglas. She is diagnosed with an ectopic pregnancy and is clinically stable but scared of surgery. How would you manage this case?
A. Laparoscopic salpingectomy
B. Methotrexate
C. Laparotomy + salpingectomy
D. Laparoscopic salpingotomy
E. Beta hCG in 48 hours
B. Methotrexate
5 B Risk factors for ectopic pregnancies include a previous ectopic pregnancy, previous tubal surgery, intrauterine use, pelvic infection and in vitro fertilization. The main concern with an ectopic is that as it grows it may rupture and lead to intra-abdominal bleeding, acute collapse and occasionally death. We know that some people will undergo a tubal miscarriage and avoid rupture. A laparoscopic salpingectomy (A) would be a definitive procedure but would leave a young girl with only one fallopian tube. However, this may not significantly after her fertility as it may be that as a result of her pelvic inflammatory disease the tube is damaged already. She does not need a laparotomy (C) as she is stable. A salpingotomy (D) involves opening the affected tube and removing the ectopic pregnancy. This would leave the tube in situ but there is the concern of a another ectopic in the future. This woman is an ideal candidate for methotrexate (B). Methotrexate is given IM as an anti-metabolite, and a further dose may need to be given a week later. There are strict criteria about its use, including a small ectopic, no fetal pulse, no clinical compromise and no free fluid in the Pouch of Douglas. Another option is to keep her in hospital and repeat her beta hCG in 48 hours (E). If the hCG falls, a tubal miscarriage is a possibility. The benefits of methotrexate compared to surgery are that there is an increased chance of future fertility.
- Dyspareunia
A 24-year-old woman attends her GP complaining of deep dyspareunia and post-coital bleeding. She has crampy lower abdominal pain. Of note, she has been treated in the past for gonorrhoea on more than one occasion. On speculum examination there is no visible discharge, but the cervix bleeds easily on contact. What is the most appropriate management?
A. IM cefotaxime, oral doxycycline and metronidazole
B. 1 g oral metronidazole stat
C. Urgent referral to the gynaecology clinic
D. Referral to a sexual health clinic
E. Admission to hospital under the gynaecologists
C. Urgent referral to the gynaecology clinic
6 C The important part of this woman’s presentation is that her cervix bleeds easily on contact. She has a significant history of (albeit treated) sexually transmitted infections. Although her presentation today could represent another sexually transmitted infection or pelvic inflammatory disease, the history of deep dyspareunia and post-coital bleeding, coupled with a cervix which bleeds on contact in a woman who is sexually active, should immediately raise suspicion of cervical cancer. She is 24 so it is unlikely that she will previously have had a cervical smear. Answers A, B, D and E are all potential management options in suspected pelvic inflammatory disease, and although it is likely that a competent clinician would initiate treatment immediately (most likely with option A) only option C reflects and addresses the urgent requirement to investigate and rule out cervical cancer.
- Investigation in emergency gynaecology
A 16-year-old girl attends accident and emergency complaining of mild vaginal spotting. Her serum beta hCG is 4016 mIU/mL. She is complaining of severe left iliac fossa pain and stabbing sensations in her shoulder tip. What is the most appropriate definitive investigation?
A. Diagnostic laparoscopy
B. Serial serum beta hCG measurement
C. Computed tomography of the abdomen and pelvis
D. Clinical assessment with speculum and digital vaginal examination
E. Transvaginal ultrasonography
E. Transvaginal ultrasonography
7 E Apart from (C) all the options are potential diagnostic tools in assessing this woman: computed tomography is avoided if at all possible in pregnancy as it exposes the fetus to unacceptably high doses of ionizing radiation, the teratogenicity of which is highest in the first trimester. This woman is pregnant with vaginal bleeding and abdominal pain. Such patients should be treated as having an ectopic pregnancy until otherwise proven. Clinical assessment (D) and serial beta hCG measurements (B) would be the routine initial measures in assessing this woman, but they are by no means definitive in providing a diagnosis. In addition, meaningful information can only be drawn with a second beta hCG measurement, some 48 hours later. At this level of serum beta hCG an intrauterine pregnancy should be visible on transvaginal ultrasound (E), so it offers in this case the highest chance of providing a definitive answer to the ectopic pregnancy question. Diagnostic laparoscopy (A) may be employed if an ectopic pregnancy is suggested by the ultrasound scan, but it is not appropriate to perform this on a stable patient without first performing imaging. An early pregnancy is usually visible on transvaginal ultrasound if the serum beta hCG is above 1000 mIU/mL, and certainly above 1500 mIU/mL. Women with this level of hCG in whom no pregnancy can be detected on ultrasound scan should be managed as having a pregnancy of unknown location, which may included inpatient admission until ectopic pregnancy is definitively excluded.
- Early pregnancy
An 18-year-old woman presents to accident and emergency having fainted at work. She is complaining of pain in the lower abdomen. A serum beta hCG performed in the emergency department is 3020 mIU/mL. The on-call gynaecologist performs transvaginal ultrasonography in the resuscitation area which shows free fluid in the Pouch of Douglas and no visible intrauterine pregnancy. Her pulse is 120 bpm and blood pressure 90/45 mmHg. What is the most likely diagnosis?
A. Ruptured ovarian cyst
B. Cervical ectopic pregnancy
C. Ruptured tubal pregnancy
D. Perforated appendix
E. Ovarian torsion
C. Ruptured tubal pregnancy
8 CThis woman has lower abdominal pain and a positive pregnancy test with signs of haemodynamic instability: an ectopic pregnancy (C) should therefore be excluded urgently. Ovarian torsion (E) and ruptured ovarian cysts (A) classically present with a sudden onset abdominal pain, and are not commonly associated with a significant tachycardic hypotension. Differentiating between them can be difficult. However, the natural history of the pain is often helpful. Both may present with sudden onset pain, but usually the pain of ovarian torsion will be out of keeping with the clinical findings and will not improve with simple analgesia. Indeed it does not normally decrease significantly at all. By contrast, the pain of cyst rupture, while being of sudden onset, is often reduced by simple analgesia and may decrease gradually as the peritoneal lining (having been irritated by leaking fluid or blood from the cyst, causing pain) absorbs intraperitoneal free fluid. A woman with a perforated appendicitis (D) would often show signs of sepsis, including fever and peritonitis, and pain is normally localized initially to the central abdomen or right iliac fossa. At this level of beta hCG, an intrauterine pregnancy would normally be visible on transvaginal ultrasonography. Of the two ectopic pregnancy options available, cervical ectopics (B) would normally be demonstrable on transvaginal ultrasound. Ruptured ectopic pregnancy is a surgical emergency requiring prompt assessment, resuscitation and urgent surgery. The urgency of the situation is even more pronounced if there are signs of haemodynamic instability, such as in this case where there is evidence of hypovolaemic shock.
- Menopause
A 50-year-old woman comes to your clinic with a 2-year history of no periods. Her GP has confirmed that her luteinizing hormone and follicle-stimulating hormone levels are menopausal. Her night sweats and hot flushes are unbearable and are preventing her from going to work. She would like to start hormone replacement therapy (HRT) but is very worried about the side effects. Which of the following is incorrect?
A. There is evidence that HRT prevents coronary heart disease
B. There is a small increase in the risk of strokes
C. There is an increased risk of breast cancer
D. There is an increase in the risk of ovarian cancer
E. There is an increase in the rate of venous thromboembolism
A. There is evidence that HRT prevents coronary heart disease
9 A All of the above are true except (A). There is no evidence that HRT prevents heart disease. In fact there is an increased risk of heart disease in women who start HRT 10 years after the menopause. In addition to the above there is a risk of endometrial cancer in oestrogen-only HRT which is related to duration of treatment. In general, if the woman still has her uterus progestogens must be given to prevent endometrial cancer developing. The risk of stroke (B) depends on age but there are additional 1–4 cases per 1000 women on HRT. The risk of breast cancer (C) is higher for patients in their 60s taking combined HRT. The risk with combined HRT taken over the age of 60 for 10 years will lead to an extra 36 cases of breast cancer per 1000 women. The risk of ovarian cancer (D) increases very slightly with an extra case per 1000 women. The risk of venous thromboembolism (E) is larger in the combined HRT group with an additional 7–10 cases per 1000 women.
- Emergency gynaecology (2)
A 24-year-old woman who is 9 weeks pregnant is brought to accident and emergency by ambulance with left iliac fossa pain and a small vaginal bleed. An abdominal ultrasound scan performed at the bedside demonstrates a cornual pregnancy and free fluid in the pelvis. Her observations are: pulse 119 bpm, blood pressure 74/40 mmHg, respiratory rate 24/minute. What is the most appropriate definitive management?
A. Transvaginal ultrasound scan
B. Serum beta hCG estimation
C. Diagnostic laparoscopy
D. Admission to the gynaecology ward and fluid resuscitation
E. Urine pregnancy test
C. Diagnostic laparoscopy
10 C This woman is clearly in extremis. She has a tachycardic hypotension, which in the presence of a sonographically demonstrated ectopic pregnancy must be assumed to be due to a ruptured ectopic pregnancy causing significant haemorrhage. Emergency management is required to stop the woman bleeding to death. The woman has a visible pregnancy, so neither serum beta hCG (B) nor urinary confirmation of pregnancy (E) are required. Transvaginal ultrasound (A) would give a clearer picture of the pregnancy’s location and the amount of pelvic blood, but in a pregnancy this far along, abdominal sonographic detection of an ectopic pregnancy coupled with the clinical findings confirm the diagnosis. Admission to a ward (D) is inappropriate for a woman who is so unwell: this woman requires concurrent resuscitation and transfer to theatre for stabilization and surgical management (C).
- Pain in early pregnancy
A 26-year-old woman presents to accident and emergency with left-sided lower abdominal pain and a single episode of vaginal spotting the day before. A urinary beta hCG is positive, and her last period was 6 weeks ago. A transvaginal ultrasound shows two gestational sacs. What is the most likely diagnosis?
A. Ruptured theca lutein cyst
B. Appendicitis
C. Diverticulitis
D. Complete miscarriage
E. Urinary tract infection
A. Ruptured theca lutein cyst
11 A Functional ovarian cysts are common in women of childbearing age. A theca lutein cyst is a kind of ovarian cyst made of multiple luteinized follicular cells and is most common when the ovary is exposed to raised levels of beta hCG, as in multiple pregnancy. These cysts, like any other ovarian cyst, can rupture and bleed slowly onto the peritoneum where they cause irritation manifested as lower abdominal pain. Appendicitis (B) classically produces central pain localizing to the right iliac fossa. It is less common in pregnant women than non-pregnant women. Urinary tract infection (E) can cause lower abdominal pain, although this is usually central and associated with dysuria and frequency, which are not present here. Diverticulitis can cause left-sided pain, but patients are often febrile and commonly have a raised C-reactive protein and leukocytosis. Diverticulitis is an uncommon presentation at this age.
