Chapter 4: Early Pregnancy Loss Flashcards
EARLY PREGNANCY LOSS. You are a trainee intern in a general practice seeing Sarah, a 23-year-old nulliparous New Zealand European woman. Sarah has had heavy vaginal bleeding for 48 hours. It was associated with lower abdominal pain and uterine cramps that were “much worse than period pain”. Overnight she passed some large clots and tissue. Sarah is now pain free and her vaginal loss has also settled Sarah’s last period was seven weeks ago. A home pregnancy test was positive five days ago. This was a planned pregnancy. Sarah had a miscarriage last year. Sarah’s observations are normal. Her abdomen is soft and non-tender. Speculum examination shows a small amount of blood coming through a closed cervical os. The uterus is anteverted and of normal size. From the following options, what is the most likely diagnosis?
A complete miscarriage
Recurrent miscarriage
A threatened miscarriage
An incomplete miscarriage
Gestational trophoblastic disease
A missed miscarriage
A complete miscarriage
EARLY PREGNANCY LOSS. You are a trainee intern in an early pregnancy clinic in your hospital. Earlier today, you saw Amala, a 26 year old New Zealander of Indian ethnicity, who is exactly 6 weeks pregnant by certain dates. Amala presented with a 24 hour history of colicky nagging pain in the right iliac fossa. She had no shoulder tip pain. She had some light vaginal spotting. Amala’s GP was concerned that she might have an ectopic pregnancy. On examination, Amala was haemodynamically stable with normal observations. Her abdomen was soft with some tenderness in the right iliac fossa. A speculum exam showed a normal appearing closed cervix and no bleeding. On bimanual examination Amala had a normal sized uterus and some right adnexal tenderness. An ultrasound, FBC, ßHCG and Group and Hold were arranged. You are now about to discuss the results with Amala. From the following options, what are the serum ßHCG and ultrasound results that would be MOST consistent with an ectopic pregnancy? (Note - Assume no adnexal abnormality on ultrasound examination)
Ultrasound shows an intrauterine pregnancy with fetal heart activity, ßHCG is normal for 6 weeks gestation
Ultrasound shows endometrial thickness < 4mm; ßHCG is 0 iu/l
Uterine cavity filled with multiple grape-like clusters (a ‘snowstorm’ appearance); ßHCG is high for gestation
Ultrasound shows empty uterus and some fluid in Pouch of Douglas. ßHCG is low for 6 weeks gestation
Ultrasound shows 1cm empty sac with yolk sac in uterus, ßHCG is normal for 6 weeks gestation.
Ultrasound shows empty uterus and some fluid in Pouch of Douglas. ßHCG is low for 6 weeks gestation
You are a trainee intern in an early pregnancy clinic seeing Marama, a 24 year old Māori wahine, who is 6 weeks pregnant. This is Marama’s first pregnancy. It is planned. Her period dates are certain. She had a positive urine pregnancy test last week. Last night Marama started bleeding. It became heavier overnight and this morning she has passed some clots and tissue. She continues to have crampy lower abdominal pains and has ongoing bleeding. When you examined Marama her observations were within the normal range. Marama’s abdomen was soft but she had some suprapubic tenderness. Speculum examination showed an open cervix with moderate bleeding. On bimanual examination the uterus was bulky. You arranged a FBC, Group and Hold, ßHCG and a pelvic ultrasound. You are now reviewing Marama with the results of your investigations. From the following options, what are the most likely results of the tests to confirm your clinical diagnosis?
Ultrasound shows empty uterus, 3cm left adnexal mass and free fluid. ßHCG low for 6 weeks gestation
Ultrasound shows heterogeneous retained products in the uterine cavity measuring 20 by 12mm, ßHCG low for 6 weeks gestation
Ultrasound shows intrauterine grape like vesicles (a “snowstorm” appearance), ßHCG high for 6 weeks
Ultrasound shows an empty uterine cavity, ßHCG is 0
Ultrasound shows intrauterine sac with fetal heart activity present, ßHCG normal for 6 weeks
Ultrasound shows heterogeneous retained products in the uterine cavity measuring 20 by 12mm, ßHCG low for 6 weeks gestation
You are a trainee intern in an early pregnancy clinic seeing Maria, a 22 year old Pākehā woman who is 8 weeks pregnant. This is Maria’s second pregnancy. It is planned. Her period dates are certain. She had a positive urine pregnancy test last week. Maria had an uncomplicated pregnancy 2 years ago and a normal birth of term infant. Last night Maria had some light bleeding. It has settled. Maria did not have any pain. Maria continues to feel nauseated, as she has for the past week. The nausea is similar to her first pregnancy. When you examined Maria her observations were normal. Maria’s abdomen was soft and non-tender. Speculum examination showed a closed cervix and no bleeding. On bimanual examination the uterus was 8 week sized. You arranged a FBC, Group and Hold and ßHCG and a pelvic ultrasound. You are now reviewing Maria with the results of your investigations. From the following options, what are the MOST LIKELY results of the tests to confirm your clinical diagnosis?
Ultrasound shows heterogeneous retained products in the uterine cavity measuring 20 by 12mm, ßHCG low for 8 weeks gestation
Ultrasound shows an empty uterine cavity, ßHCG is 0
Ultrasound shows intrauterine sac and fetal pole with absent fetal heart, ßHCG low for 8 weeks
Ultrasound shows an intrauterine sac with fetal heart activity present, ßHCG normal for 8 weeks
Ultrasound shows empty uterus, 3cm left adnexal mass and free fluid. ßHCG low for 8 weeks gestation
Ultrasound shows an intrauterine sac with fetal heart activity present, ßHCG normal for 8 weeks
You are a trainee intern in an early pregnancy clinic, seeing Jye, an 18-year-old woman of Chinese ethnicity. Jye is 6 weeks pregnant in an unplanned pregnancy. Jye presents with some light vaginal bleeding. She has no pain. She has been troubled by nausea and vomiting and is taking anti-emetic medication. She had a positive urine pregnancy test last week. On examination her pulse is 110 and her bp 125/80. On abdominal examination the abdomen is soft. Speculum exam shows a normal cervix with no bleeding. On bimanual examination the uterus is anteverted and bulky and a 10 week pregnancy size. You arrange an ultrasound pelvis and bloods for FBC, ßHCG and blood group. From the following options, what are the MOST LIKELY results of the tests to confirm your clinical diagnosis?
Ultrasound shows intrauterine grape like vesicles (a “snowstorm” appearance), ßHCG high for 6 weeks
Ultrasound shows an empty uterine cavity, ßHCG is 0
Ultrasound shows an intrauterine sac with fetal heart activity present, ßHCG normal for 6 weeks
Ultrasound shows empty uterus, 3cm left adnexal mass and free fluid. ßHCG low for 6 weeks
Ultrasound shows echodense retained products in the uterine cavity measuring 20 by 12mm, ßHCG low for 6 weeks gestation
Ultrasound shows intrauterine grape like vesicles (a “snowstorm” appearance), ßHCG high for 6 weeks
You are a trainee intern in the emergency department seeing Pania, a 22 year old G1P0 Māori woman. Pania is 8 weeks pregnant. Pania’s periods were irregular so her dates are from a scan at 6 weeks (which showed a viable intrauterine pregnancy) because she had no idea of her last menstrual period (LMP) date. Pania usually keeps good health. Yesterday she had some light bleeding. Overnight the bleeding was heavy with clots. Pania had crampy lower abdominal pains. The bleeding is now light and the pain has improved. On examination the BP is 120/70 and the pulse 80. Pania’s abdomen is soft and non-tender. Speculum exam shows a closed cervix and light bleeding. Bimanual exam reveals an anteverted uterus that is not enlarged and there are no adnexal masses. Blood tests reveal a Hb of 115 (N), ßHCG of 650 (L), Blood group A Rh +ve. A trans-vaginal scan showed an empty uterus, no free fluid and no adnexal masses. From the following options, what is the BEST management option?
Misoprostol orally
ERPOC (Evacuation of Retained Products of Conception)
IM Methotrexate
Conservative management
Diagnostic laparoscopy +/- proceed
Conservative management
You are a trainee intern in the emergency department seeing Emma, a 38 year old nulliparous Pākehā woman who is 6 weeks pregnant following her first cycle of IVF. Emma presents to the emergency department with lower abdominal pain that is worse in the left iliac fossa. The pain has been niggling for 2 days but this morning became much more severe. She has had some light vaginal bleeding for 3 days. Her wife brought her into the emergency department and Emma found the car trip very uncomfortable particularly going over bumps in the road. She has also developed bilateral shoulder tip pain. On examination, Emma has a bp of 90/60 and a pulse of 120. She looks pale. She has a peritonitic abdomen with generalised rebound and guarding in her left iliac fossa. Two large bore IV lines are sited and aggressive IV fluid resuscitation is commenced. Blood is sent for FBC, ßHCG and 4 units of RBC are cross matched. A urine ßHCG is positive. There is no ultrasound machine available in the emergency department. From the following options, what is now the most appropriate management?
Arrange a trans-vaginal ultrasound scan tomorrow in the radiology department.
Admit her to hospital for oral misoprostol
Transfer to theatre for an ERPOC (Evacuation of Retained Products of Conception)
Transfer to theatre for a diagnostic laparoscopy + salpingectomy
Admit her to hospital for observation and IM Methotrexate
Transfer to theatre for a diagnostic laparoscopy + salpingectomy
You are a trainee intern in the early pregnancy clinic seeing Amandeep, a 28 year old Indian lady who is pregnant for the first time. Amandeep’s LMP was 5 weeks ago. She has some left iliac fossa (LIF) pain and vaginal spotting. She has no shoulder tip pain. On examination her bp is 120/80 and her pulse is 70. Her abdomen is soft and there is mild tenderness in her left iliac fossa. Speculum exam shows a closed cervix and no bleeding is evident. Amandeep finds a bimanual examination uncomfortable but there is no cervical excitation. You arrange blood tests and an ultrasound scan. Amandeep’s blood group is O+ve. Her Hb is 125 (normal) and her ßHCG is 600. An ultrasound shows an empty uterus. The ovaries appear normal. There are no adnexal masses. There is no free fluid. From the following options, what is most appropriate management?
Offer Amandeep prophylactic antibiotics for suspected pelvic infection
Book Amandeep for an ERPOC (Evacuation of Retained Products of Conception)
Take Amandeep to theatre for a diagnostic laparoscopy +/- salpingectomy
Discharge from early pregnancy clinic as Amandeep has had a complete miscarriage
Give safety-netting advice and arrange a follow up ßHCG in 48 hours
Give safety-netting advice and arrange a follow up ßHCG in 48 hours
You are a trainee intern at a hospital acute assessment unit admitting Sariska, a 35-year-old Pākehā woman who is 7 weeks pregnant in her first pregnancy. Sariska has presented with one week of left iliac fossa pain associated with light spotting. The pain increased overnight and Sariska has now developed shoulder tip pain. On examination Sariska has a bp of 100/60 and a pulse of 90. On abdominal examination there is peritonism with rebound tenderness, worse in the left iliac fossa. You arrange an urgent ultrasound and bloods. Of the following options, which ultrasound findings are MOST LIKELY to fit with your clinical diagnosis?
No intrauterine pregnancy. Left adnexal mass 4x3 cm. Free fluid in the Pouch of Douglas. Ovaries normal.
No intrauterine pregnancy. No free fluid. Normal ovaries.
Single intrauterine pregnancy with crown rump length consistent with 7 weeks. Fetal heart seen. No free fluid. Left ovary contains a 6cm cyst consistent with a dermoid.
Single intrauterine pregnancy with crown rump length consistent with 6 weeks. No fetal heart seen. No free fluid. Normal ovaries.
Empty uterus. 3 x 4 cm left adnexal mass. No free fluid. Normal ovaries.
No intrauterine pregnancy. Left adnexal mass 4x3 cm. Free fluid in the Pouch of Douglas. Ovaries normal.
You are a trainee intern on a gynaecology ward round doing a post -operative review. Michelle is a 28-year-old Chinese woman who had surgery last night for a ruptured ectopic pregnancy. Michelle had presented via ambulance with severe lower abdominal pain and shoulder tip pain at 7 weeks gestation. In the emergency department she was haemodynamically unstable and was quickly transferred to theatre for a laparoscopy and salpingectomy. The intra-operative findings included a 1500 ml haemoperitoneum. You discuss the surgery with Michelle. She asks you what was causing her shoulder tip pain yesterday. Of the following options, which is the MOST ACCURATE answer?
Intra-abdominal blood was irritating the diaphragm. The shoulder tip pain is referred pain from the nerve innervated by C3-C5
The pain is referred from her distended fallopian tube which is innervated by T11-L1
Lying awkwardly because of pain caused a bilateral subacromial bursitis
She had splinted breathing secondary to her haemoperitoneum and this strained her accessory muscles bilaterally.
The haemoperitoneum caused irritation of the phrenic nerve which is innervated by T3-T4. The shoulder pain is referred pain from the phrenic nerve.
Intra-abdominal blood was irritating the diaphragm. The shoulder tip pain is referred pain from the nerve innervated by C3-C5
You are a trainee intern on a gynaecology ward round doing a post -operative review. Anya is a 28-year-old Pākehā woman who had surgery last night for a ruptured ectopic pregnancy. Anya had presented via ambulance with severe lower abdominal pain and shoulder tip pain at 7 weeks gestation. In the emergency department she was haemodynamically unstable and was quickly transferred to theatre for a laparoscopy and salpingectomy. The intra-operative findings included a 1500 ml haemoperitoneum. You discuss the surgery with Anya. Anya is aware that she is Rhesus negative as she required Anti D after her 2 year old son was born. She asks you whether she requires Anti-D Of the following options, which is the CORRECT answer?
Anya will require Anti-D.
As the pregnancy was so early, there is no chance of fetal and maternal blood mixing so Anti-D is not required.
A Kleihauer test will be checked as part of the routine post-operative bloods and if this is positive then Anti-D should be given.
Anya’s partner’s blood group should be checked. If he is Rhesus positive then Anti-D is required.
You will await the histology from surgery which will estimate the fetal size. This will tell you whether Anti-D is required.
Anya will require Anti-D.
You are a trainee intern in general practice seeing Suyin, a 20-year-old Malaysian woman who is 10 weeks pregnant in her first pregnancy. Suyin was seen yesterday following 2 episodes of painless vaginal bleeding. On examination the uterus was palpable suprapubically. The abdomen was soft. On speculum examination, the os was closed. On bimanual examination the uterus was a 12 week size. Blood tests and ultrasound were arranged. These showed that her ßHCG level was 140,000 IU/l (N for 10 weeks <100000 IU/l). Ultrasound examination report says that the uterus is enlarged with no identifiable gestation sac and a snowstorm appearance. There are three 1-2 cm cysts in the left ovary that are echodense and suggestive of haemorrhage.” From the following options, what is the MOST LIKELY diagnosis?
Ectopic pregnancy
Haemorrhagic corpus luteum cysts
Incomplete miscarriage
Gestational trophoblastic disease
Threatened miscarriage
Missed miscarriage
Gestational trophoblastic disease
You are a trainee intern in general practice seeing Cindy, a 20-year-old Melanesian woman who is 10 weeks pregnant in her first pregnancy. Cindy was seen yesterday following 2 episodes of painless vaginal bleeding. On examination the uterus was palpable suprapubically. The abdomen was soft. On speculum examination, the os was closed. On bimanual examination the uterus was a 12 week size. Blood tests and ultrasound were arranged. These showed that her ßHCG level was 240,000 IU/l (N for 10 weeks <100000 IU/l). Ultrasound examination report says that the uterus is enlarged with no identifiable gestation sac and a snowstorm appearance. There are three 1-2 cm cysts in the left ovary that are echodense and suggestive of haemorrhage.” Cindy is booked for an ERPOC (Evacuation of Retained Products of Conception). Blood tests are arranged as part of the pre-operative work-up. Of the following options, which blood tests are MOST LIKELY to be abnormal?
Urea and Creatinine
HPL - human placental lactogen
Progesterone
TSH and T4
Full Blood Count
TSH and T4
You are a trainee intern in early pregnancy clinic seeing Ngarangi, a 32 year old Māori woman who has been diagnosed with an ectopic pregnancy. Ngarangi is keen to avoid surgical management of her ectopic pregnancy. You discuss methotrexate as an alternative. Of the following options, which clinical scenario is MOST APPROPRIATE to use methotrexate as outpatient management?
Ultrasound shows an empty uterus and a 6cm right sided adnexal mass. There is no free fluid. ßHCG level is 3000. Ngarangi lives a 2 hour drive from hospital.
Ultrasound shows an empty uterus and a 3cm right sided adnexal mass. There is no free fluid. ßHCG level is 800. Ngarangi lives a 10 minute drive from hospital.
Ultrasound shows an empty uterus, a 3cm right sided adnexal mass and a large volume of free fluid. ßHCG level is 4500. Ngarangi lives a 10 minute drive from hospital.
Ultrasound shows an empty uterus, a right sided live ectopic pregnancy with a fetal heart seen and no free fluid. ßHCG level is 20000. Ngarangi lives a 10 minute drive from hospital.
Ultrasound shows an empty uterus and a 6cm right sided adnexal mass. There is no free fluid. ßHCG level is 3000. Ngarangi is going on holiday to Fiji next week.
Ultrasound shows an empty uterus and a 3cm right sided adnexal mass. There is no free fluid. ßHCG level is 800. Ngarangi lives a 10 minute drive from hospital.
Caitlin is a 33 year old Pākehā woman is 5 weeks pregnant by certain dates in an IVF pregnancy conceived on her third cycle of IVF. She has had some light PV bleeding and is anxious. On examination her observations are normal. Her abdomen is soft. Speculum exam shows a closed cervix and no bleeding. Bimanual examination is unremarkable. You arrange blood tests and a transvaginal ultrasound scan. Caitlin has a ßHCG level of 3000. Her blood group is A +ve. Her ultrasound shows an intrauterine gestational sac with a yolk sac. No fetal pole is seen. Of the following options, what should you tell Caitlin regarding her diagnosis?
Unfortunately the results suggest a molar pregnancy and Caitlin will need to have an ERPOC (evacuation of retained products of conception).
The results are consistent with a 5 week gestation. Caitlin should have a scan in 2 weeks to confirm viability.
Unfortunately Caitlin has a missed miscarriage and this pregnancy is non-viable
The presence of both a gestational sac and a yolk sac suggests a twin pregnancy.
Unfortunately Caitlin has an ectopic pregnancy and will require surgery.
The results are consistent with a 5 week gestation. Caitlin should have a scan in 2 weeks to confirm viability.
