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Gwen - Reproductive Medicine (Obs, Gyn, Breast) > Early bleeding in pregnancy, Ectopic pregnancy, PUL and molar pregnancy > Flashcards

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

1
Q

What is an ectopic pregnancy?

A

A fertilised ovum implants outside the uterine cavity

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2
Q

What are predisposing factors for ectopic pregnancy?

A

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

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3
Q

Wha are common sites for ectopic pregnancies to implant?

A
  • Ampulla (most)
  • Tubal
  • Isthmus (dangerous)
  • Ovary
  • Abdomen
  • Cervix
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4
Q

What is the most common site of ectopic pregnancy?

A

Tubal ectopic pregnancy

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5
Q

What is the pathophysiology of ectopic pregnancy?

A

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.

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6
Q

What are symptoms of ectopic pregnancy?

A

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?)
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7
Q

Symptoms of molar pregnancy

A

PV bleeding

Hyperemsis

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8
Q

What are signs of a ectopic pregnancy?

A
  • 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
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9
Q

What is the classical presentation of ectopic pregnancy?

A

Sexually active woman

  • Abdominal pain
  • Bleeding
  • Fainting
  • Diarrhoea and vomiting
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10
Q

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

A

Yes - it does not rupture ectopic pregnancies

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11
Q

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

A
  • Bedside - Pregnancy test
  • Bloods - FBC, Group and save, serum progesterone, serum BHCG
  • Imaging - Transvaginal Ultrasound scan
  • Other - laparoscopy
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12
Q

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

A

To see if the pregnancy is failing

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13
Q

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

A

<20 nmol/L

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14
Q

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

A

>60 nmol/L

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15
Q

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

A

May confirm pregnancy

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16
Q

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

A

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

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17
Q

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

A

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

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18
Q

What might a steady decrease in serial BHCG values suggest?

A

Miscarriage (failing pregnancy)

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19
Q

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

A
  • Location
  • Adnexal mass but no gestational sac
  • Presence of free fluid (in pouch of douglas)
  • Donut sign
20
Q

What are causes of early bleeding in pregnancy?

A
  • Miscarriage
  • Ectopic pregnancy
  • PUL
  • Implantation bleeding
  • Non-pregnancy cause - cervical polyp, GU tract trauma
  • Molar pregnancy - rare
21
Q

What is cervical excitation?

A

Pain elicited when the uterine cervix is manipulated during pelvic examination

22
Q

How would you manage an ectopic pregnancy?

A
  • 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)
23
Q

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

A

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
24
Q

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

A

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

25
Q

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

A

Methotrexate

26
Q

Why is methotrexate used?

A

Destroys trophoblastic tissue

27
Q

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

A

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

28
Q

What dose of methotrexate is given in ectopic pregnancy?

A

50 mg/m2 IM

29
Q

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

A

Laparoscopy

30
Q

When is a salpingectomy indicated in managing ectopic pregnancy?

A
  • Tube is severely damaged
  • Contralateral tube is healthy
  • No plan for future family
  • Ectopic >5cm/recurrent
31
Q

What is pregnancy of unknown location?

A

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

32
Q

What are the main causes of the presentation of PUL?

A
  • Early intrauterine pregnancy
  • Complete miscarriage
  • Failing PUL which will never be seen
  • Ectopic pregnancy
  • Persistent PUL
  • HCG secreting tumour
33
Q

How would you manage someone with pregnancy of unknown location?

A
  • If abdo pain/haemoperitoneum - Laparoscopy
  • If well - intial BHCG, repeated every 48hrs
34
Q

How much should BHCG rise by in pregnancy?

A

Should double every 48hrs

35
Q

What is a molar pregnancy?

A

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

36
Q

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

A

Cholangiocarcinoma

37
Q

How is definitive diagnosis of a molar made?

A

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

38
Q

Whats the difference between complete and partial molar pregnancy?

A

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

39
Q

What is seen on ultrasound in a molar pregnancy?

A

Snowstorm appearance

40
Q

Management of molar pregnancy

A
  • Monitor B-hCG levels for 1 year
  • Should return to normal in 6 months
  • May need surgical evaculation
41
Q

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

A

Repeat transvaginal scans, serial hCG levels, and laparoscopy

42
Q

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

A

bHCG will double (>63%)

43
Q

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

A

B-hCG will fall (decreases by 50%)

44
Q

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

A

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

45
Q

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

A

Grossly elevated

46
Q
A

Gwen - Reproductive Medicine (Obs, Gyn, Breast) (49 decks)

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