Early bleeding in pregnancy, Ectopic pregnancy, PUL and molar pregnancy

Question 1

What is an ectopic pregnancy?

Answer 1

A fertilised ovum implants outside the uterine cavity

Question 2

What are predisposing factors for ectopic pregnancy?

Answer 2

Anything which slow’s ovum’s passage to the uterus

• Salpingitis
• Previous surgery
• Previous ectopic
• Endometriosis
• IUCD
• POP
• Tubal ligation

PIPPA
Previous ectopic pregnancy
IUD/IUS
PID
Pelvic or tubal surgery
Assisted reproduction
Endometriosis

Question 3

Wha are common sites for ectopic pregnancies to implant?

Answer 3

• Ampulla (most)
• Tubal
• Isthmus (dangerous)
• Ovary
• Abdomen
• Cervix

Question 4

What is the most common site of ectopic pregnancy?

Answer 4

Tubal ectopic pregnancy

Question 5

What is the pathophysiology of ectopic pregnancy?

Answer 5

Trophoblast invades the tubal wall, weakening it and producing haemorrhage which dislodges the embryo.

If the tube does not rupture, the bleed and embryo are shed or converted into a tubal mole and absorbed

Rupture can be sudden and catastrophic, or gradual.

Question 6

What are symptoms of ectopic pregnancy?

Answer 6

Typical history of 6-8 of amenorrhoea presenting with lower abdo pain and later developing vaginal bleeding.

• Abdominal pain
• PV bleeding (small amount, often brown) or Amenorrhoea
• Fainting/dizziness
• Diarrhoea +/- vomiting
• Shoulder tip pain (iritated diaphragm from blood?)

Question 7

Symptoms of molar pregnancy

Answer 7

PV bleeding

Hyperemsis

Question 8

What are signs of a ectopic pregnancy?

Answer 8

• Abnormal uterine enlargement
• Cervical excitation +/- adnexal tenderness (advised not to examine for an adnexal mass due to increased risk of rupturing)
• Adnexal mass - rare
• Peritonism

Question 9

What is the classical presentation of ectopic pregnancy?

Answer 9

Sexually active woman

• Abdominal pain
• Bleeding
• Fainting
• Diarrhoea and vomiting

Question 10

Can you do a vaginal examination if ectopic pregnancy is suspected?

Answer 10

Yes - it does not rupture ectopic pregnancies

Question 11

What investigations would you consider doing in someone who you suspected had an ectopic pregnancy?

Answer 11

• Bedside - Pregnancy test
• Bloods - FBC, Group and save, serum progesterone, serum BHCG
• Imaging - Transvaginal Ultrasound scan
• Other - laparoscopy

Question 12

Why might you do a serum progesterone in someone with suspected ectopic pregnancy?

Answer 12

To see if the pregnancy is failing

Question 13

On serum progesterone, what might indicate that a pregnancy was failing (about to miscarry)?

Answer 13

<20 nmol/L

Question 14

On serum progesterone, what might suggest a pregnancy was ongoing?

Answer 14

>60 nmol/L

Question 15

What might you find on investigation of BHCG in someone with an ectopic pregnancy?

Answer 15

May confirm pregnancy

Question 16

What is important to do when investigating using BHCG and there is no sign of intrauterine gestation?

Answer 16

Do serial measurement - used to differentiate between ectopic pregnancy and miscarriage

Question 17

What is the diagnostic tool of choice for investigating for ectopic pregnancy?

Answer 17

Transvaginal ultrasound is the diagnostic tool of choice for a suspected ectopic pregnancy.

Question 18

What might a steady decrease in serial BHCG values suggest?

Answer 18

Miscarriage (failing pregnancy)

Question 19

What might you see on TVUS in someone with ectopic pregnancy?

Answer 19

• Location
• Adnexal mass but no gestational sac
• Presence of free fluid (in pouch of douglas)
• Donut sign

Question 20

What are causes of early bleeding in pregnancy?

Answer 20

• Miscarriage
• Ectopic pregnancy
• PUL
• Implantation bleeding
• Non-pregnancy cause - cervical polyp, GU tract trauma
• Molar pregnancy - rare

Question 21

What is cervical excitation?

Answer 21

Pain elicited when the uterine cervix is manipulated during pelvic examination

Question 22

How would you manage an ectopic pregnancy?

Answer 22

• Expectant
• Conservative - only if stable asymptomatic pateint with falling B-hCg (<200(
• Medical - methotrexate (stops cells dividing), anti-D for Rh -ve mother (B-hCg <1500)
• Surgical - laparoscopy>laparotomym, salpingectomy, salpingotomy (severe pain, fetal hb, bGcH>1500)

Question 23

How is the decision made to adopt expectant and medical management of ectopic pregnancy?

Answer 23

Based on strict criteria

• Asymptomatic/mild symptoms
• HCG < 3000
• Ectopic pregnancy <3cm on scan with no FH activity
• No haemoperitoneum on TVS
• Falling HCG levels

Question 24

What trend in BHCG levels would you want to see to consider managing with expectant management?

Answer 24

Falling HCG - take levels every 48 hrs until confirmed fall, then weekly until <15 IU

Question 25

What medication would you use to medically manage someone with ectopic pregnancy?

Answer 25

Methotrexate

Question 26

Why is methotrexate used?

Answer 26

Destroys trophoblastic tissue

Question 27

What is important to bear in mind in terms of fertility following methotrexate treatment?

Answer 27

Need to be on contraception for 3 months minimum - methotrexate is teratogenic

Question 28

What dose of methotrexate is given in ectopic pregnancy?

Answer 28

50 mg/m² IM

Question 29

What is regarded as the gold standard treatment for ectopic pregnancy?

Answer 29

Laparoscopy

Question 30

When is a salpingectomy indicated in managing ectopic pregnancy?

Answer 30

* **Tube is severely damaged** * **Contralateral tube is healthy** * **No plan for future family** * **Ectopic \>5cm/recurrent**

Question 31

What is pregnancy of unknown location?

Answer 31

There is no sign of intrauterine or ectopic pregnancy or retained products of conception in the presence of a positive pregnancy test, or serum hCG \> 5IU

Question 32

What are the main causes of the presentation of PUL?

Answer 32

* **Early intrauterine pregnancy** * **Complete miscarriage** * **Failing PUL which will never be seen** * **Ectopic pregnancy** * **Persistent PUL** * **HCG secreting tumour**

Question 33

How would you manage someone with pregnancy of unknown location?

Answer 33

* **If abdo pain/haemoperitoneum** - Laparoscopy * **If well** - intial BHCG, repeated every 48hrs

Question 34

How much should BHCG rise by in pregnancy?

Answer 34

Should double every 48hrs

Question 35

What is a molar pregnancy?

Answer 35

Abnormal form of pregnancy in which a non-viable fertilized egg implants in the uterus and will fail to come to term. A molar pregnancy is a gestational trophoblastic disease. which grows into a mass in the uterus that has swollen chorionic villi

Question 36

What is the worry that a molar preganncy develops in to?

Answer 36

Cholangiocarcinoma

Question 37

How is definitive diagnosis of a molar made?

Answer 37

By histological examination - all forms of GTD have distinct morphological features

Question 38

Whats the difference between complete and partial molar pregnancy?

Answer 38

In a normal pregnancy there is normally half chromosomes from mother and father In a **complete molar pregnancy** ALL genetic material from father (single sperm, empty ovum) In a **partial molar pregnany** 2 sperm fertilise ovum at one time so 2paternal chromosomes, 1 maternal

Question 39

What is seen on ultrasound in a molar pregnancy?

Answer 39

Snowstorm appearance

Question 40

Management of molar pregnancy

Answer 40

* Monitor B-hCG levels for 1 year * Should return to normal in 6 months * May need surgical evaculation

Question 41

What investigations could you use to distinguish between a normal intrauterine pregnancy, an ectopic pregnancy, a miscarriage, and a molar pregnancy?

Answer 41

Repeat transvaginal scans, serial hCG levels, and laparoscopy

Question 42

If you take B-hCG levels twice in 48 hours what will happen in a normal pregnancy

Answer 42

bHCG will double (\>63%)

Question 43

If you take B-hCG levels twice in 48 hours what will happen in miscarriage

Answer 43

B-hCG will fall (decreases by 50%)

Question 44

If you take B-hCG levels twice in 48 hours what will happen in an ectopic pregnancy

Answer 44

B-hCG will rise but not a lot (\<63%)

Question 45

If you take B-hCG levels twice in 48 hours what will happen in molar pregnancy

Answer 45

Grossly elevated