abormal implantation pregnancy

Question 1

ectopic pregnancy

Answer 1

pregnancy outwith endometrial cavity
- severity varies
98% tube

Question 2

ectopic pregnancy risk factors

Answer 2

previous ectopic
tubal damage - infection, endometriosis, surgery
intrauterine contraceptive devices
smoking
infertility treatment
extremes of reproductive age

Question 3

presentation of ectopic pregnancy

Answer 3

pain > bleeding
dizziness
collapse - shoulder tip pain
SOB

pallor, haemodynamically unstable
signs of peritonism + tenderness

Question 4

gold standard investigation for ectopic pregnancy

Answer 4

transvaginal scan
-> empty uterus/pseudo sac +/- mass in adenexa, free fluid pouch of Douglas

serum hCG - comparative assessment 48hrs apart to assess doubling - only if haemodynamically stable
(healthy fetus serum hCG should double every 24hrs)

pregnancy of unknown location - hallway diagnosis if no pregnancy is located US

Question 5

management of ectopic pregnancy

Answer 5

acutely unwell = surgery
- laparoscopic salpingesctomy
- conservative - salpingotomy (preserve tube) with follow up

stable - low levels of beta-hCG+small+unruptured
–> methotrexate

“well” patient –> counselling + follow up for 48hrs

Question 6

pregnancy of unknown location (PUL)

Answer 6

positive pregnancy test + no evidence of pregnancy on US
- exclude ectopic + careful follow up
- hCG will NOT double every 48hrs

no in uterus, fallopian tube, cervix, c section scar, abdo cavity

Question 7

management of pregnancy of unknown location

Answer 7

M6 model
hCG + progesterone level guides progress/regression on pregnancy

mx - methotrexate if no clinical deterioration

Question 8

molar pregnancy

Answer 8

abnormal form of pregnancy in which a non-viable fertilised egg implants in uterus (or tube)

types -
- complete - 2.5% risk of developing into a choriocarcinoma
- partial

Question 9

complete mole

Answer 9

1 or 2 sperm fertilise egg withOUT DNA, result in diploid -> PATERNAL CONTRIBUTION ONLY

no feotus
overgrowth of placenta tissue

Question 10

partial mole

Answer 10

haploid egg
1 sperm (reduplicating DNA material) or 2 sperm fertilising egg - genotype 69XXY
- results in triploidy
- may have fetus

maternal AND paternal DNA
overgrowth of placental tissue

Question 11

molar pregnancies on US

Answer 11

complete = snow strom appearance (multiple placental vesicles)

partial = may show fetus AND mole

Question 12

molar pregnancy presentation

Answer 12

hypermesis, hyperthyroidism, early onset pre-eclampsia
varied bleeding + occasional passage of “grapelike tissue”
fundus > dates on abdo palpation

rare - SOB (PE in lungs), seizure (mets in brain)

Question 13

molar pregnancy investigation

Answer 13

USS “snowstorm” appearance +/- fetus, theca lutein cysts

Question 14

management of molar pregnancies

Answer 14

surgery - uterine evacuation
- tissue sent to histology
- in higher gestation where fetus present in partial mole, medical management can be undertaken

Question 15

implantation bleeding

Answer 15

occurs when fertilised egg implants in endometrial lining

10 days post ovulation
bleeding is light/brownish + selflimiting

Question 16

chorionic haematoma

Answer 16

pooling of blood between endometrium + embryo due to separation

• bleeding, cramping, threatened miscarriage
• symptoms + course follow size + perpetuation

large haematomas may be source of infection

management = reassurance + surveillance

Question 17

cervical causes of bleeding in early pregnancy

Answer 17

ectopy
infections - chlamydia, gonococcus, bacterial
polyp
malignancy - growth of generalised angry erosion

**Hx of missed attendance at colposcopy or never had smear

Question 18

strawberry vagina

Answer 18

trichomoniasis

Question 19

pain in misscariage

Answer 19

varied intensity, frequency depending on stage
bleeding >pain usually

described as period cramps

Question 20

pain in ectopic pregnancy

Answer 20

pain is predominant symptom
dull ache to sharp stabbing
peritonism in cases cause rigidity, rebound tenderness

Question 21

adenomyosis

Answer 21

endometrial tissue inside myometrium
- commoner in late reproductive years + multiparous
- hormone dependent - symptoms tend to resolve after menopause

occur in 10% of women
may occur alongside endometriosis or fibroids

Question 22

adenomyosis presentation

Answer 22

painful periods - dysmenorrhoea
heavy periods - menorrhagia
pain during intercourse - dyspareunia

may present with infertility or pregnancy related complications
1/3rd asymptomatic

enlarged tender uterus - softer than a uterus containing fibroids