Early Pregnancy Flashcards
What is the most common site of metastatic spread (90% of cases) of gestational choriocarcinoma?
Lungs
What is the USS appearance of gestational choriocarcinoma?
- Heterogenous mass within an enlarged uterus
- Invasion of the myometrium
- Cystic spaces associated with haemorrhage
- No fetal parts
What proportion of complete molar pregnancies result in choriocarcinoma?
2%
How common is gestational choriocarcinoma (GTN)?
1 in 50,000 pregnancies
How common is GTD (hydatidiform mole, invasive mole, choriocarcinoma, PSTT) overall?
1 in 714 live births
What is the chemotherapy rate in GTN?
Chemotherapy rate of 0.5–1.0% for GTN after partial molar pregnancy and 13–16% after complete molar pregnancy
How is treatment option decided upon for GTN?
FIGO 2000 scoring system
Score of 6 or less = IM MTX
Score of 7 or more = IV multi-agent chemo
Treatment continued until hCG normalised, and then for 6 consecutive weeks after
In GTN, a FIGO 2000 score of >/= 13 suggest?
Higher risk of early death (within 4 weeks), often due to bleeding into organs, or late death due to multihyphenate drug-resistant disease
How long is an embryo an embryo?
10 weeks
When is a pregnancy considered a fetus?
> 10 weeks
What is the rate of growth of an embryo?
1mm per day from 1-2mm (i.e. when first detectable on USS, between 5-6 weeks)
Cleavage at days 1-3 (morula stage) results in what type of twin pregnancy?
Dichorionic, diamniotic
Cleavage at days 4-8 (blastocyst stage) results in what type of twin pregnancy?
Monochorionic, diamniotic
Cleavage at days 8-13 (implantation stage) results in what type of twin pregnancy?
Monochorionic, monoamniotic
What proportion of pregnancies are monochorionic, monoamniotic?
1%
What are the more unique risks of monochorionic, monoamniotic twin pregnancies?
Cord entanglement and pregnancy loss <24 weeks
Dichorionic, diamniotic twins result from cleavage at what stage?
Days 1-3 (Morula)
Monochorionic, diamniotic twins result from cleavage at what stage?
Days 4-8 (Blastocyst)
Monochorionic, monoamniotic twins result from cleavage at what stage?
Days 8-13 (Implantation)
When is the gestational sac visible on USS?
4.5 weeks
When is the fetal pole visible on USS?
From 6 weeks - when 1-2mm
When is cardiac activity normally visible on USS?
6 weeks
If the CRL is 7mm or MORE and cardiac activity is not visible, this is diagnostic of pregnancy loss (after a 2nd opinion - if no 2nd opinion available, will also need a F/U in 7 days).
If these is no cardiac activity and CRL is LESS than 7mm, what should be done?
PUV - scan again in 7 days, before diagnosis made
What should you do if you measure a CRL, with no cardiac activity by means of a TRANSABDOMINAL scan?
Repeat scan in 14 days (rather than 7 days as with a TVUS)
At what size embryo is cardiac activity usually present?
2mm+
When should the fetal pole be visible on TVUS, relative to the size of the MSD
Should be visible once the MSD has reached 15-20mm
If the MSD >25mm, with no fetal pole, this is diagnostic of pregnancy loss
On TVUS, if the MSD is <25mm, and there is not fetal pole, what should happen?
PUV
Scan again in 7 days to confirm Dx
On TVUS, if the MSD is >25mm, and there is not fetal pole, what should happen?
Seek a 2nd opinion to confirm Dx, or if no 2nd opinion available, again, wait 7 days and re-scan to confirm Dx
If the MSD is measured by TA scan, and there is not fetal pole, what should happen?
Repeat scan in 14 days
From what does the primary yolk sac develop?
The hypoblast, derived from the inner cell mass (inner cell mass differentiates into the hypoblast and epiblast)
When does the primary yolk sac develop?
Weeks 1-2
When does the secondary yolk sac develop?
After week 2, it is the first structure visible within the gestational sac on TVUS, normally visible at week 5
When does the yolk sac disappear?
After the first trimester
What is the incidence of ectopic pregnancy?
11 in 1000 (1 in 90)
What is ‘sliding sign’ on TVUS?
An adnexal mass, moving separate to the ovary
What is ‘tubal ring’ or ‘bagel sign’?
An adnexal mass, moving separately to the ovary with an empty gestational sac
When there is an empty uterus and positive pregnancy test and a 48hr bhCG shows a 63%+ increase, what should be done?
TVUS between 7-14 days later
Consider an earlier scan for women with a serum hCG level greater than or equal to 1,500 IU/litre.
When there is an empty uterus and positive pregnancy test and a 48hr bhCG shows a decrease in serum hCG levels greater than 50%, what should be done?
Urine pregnancy test 14 days after the second serum hCG test - if negative no further action required
If a woman has a threatened miscarriage (bleeding, but FH), and has had a previous miscarriage, what should be done?
Offer vaginal micronised progesterone 400 mg twice daily until 16 weeks gestation
For what time period should expectant management be used?
7-14 days, except if there is concerns in relation to bleeding (later trimester, coagulopathy etc.); infection or prev. traumatic experience
When can expectant management of ectopic pregnancy be offered?
Clinically stable and pain free
AND
Tubal ectopic pregnancy <35mm, no FH
AND
Serum hCG levels of 1,000 IU/L or less
AND
Able to attend F/U
When can expectant management of ectopic pregnancy be considered?
Clinically stable and pain free
AND
Tubal ectopic <35mm, no FH
AND
Serum hCG levels 1,000 IU/L-1,500 IU/L
AND
Able to return for F/U
What monitoring is put in place for expectant management of ectopic pregnancy?
Repeat hCG levels on days 2, 4 and 7 after the original test:
- If hCG levels drop by 15% or more from the previous value then repeat weekly until a negative result (less than 20 IU/L) is obtained
- If hCG levels do not fall by 15%, stay the same or rise from the previous value, review
When can medical management be offered in ectopic pregnancy?
No significant pain
AND
Unruptured, adnexal mass <35 mm, no FH
AND
Serum hCG <1,500 IU/litre
AND
Do not have an IUP
AND
Able to attend F/U
When should surgical management be offered for ectopic pregnancy?
- Significant pain
- Adnexal mass >/= 35 mm
- Live ectopic
- Serum hCG level >/= 5,000 IU/litre
- Unable to attend for F/U
With what progesterone level, can a PUL be discharged with a F/U PT in 14 days?
<2 (as probably FPUL)
What types of tests are urinary pregnancy tests?
A type of sandwich enzyme-linked immunosorbent assay (ELISA) and utilises monoclonal antibodies to detect HCG present within urine
What are the different zones of a urine pregnancy test?
Reaction zone; Test zone; Control zone