Early pregnancy

Question 1

A 34-year-old nullipara attends the early pregnancy unit with moderate vaginal bleeding and left iliac fossa discomfort. Her LMP was 5 weeks ago on the background of regular cycles and not using contraception. A TVUSS indicates a pregnancy of unknown location with no free and no probe tenderness. The initial serum b-HCG is 380 IU/L.

What is the most appropriate investigation for this patient?

a-Diagnostic laparoscopy

b-Serum progesterone level

c-Repeat ultrasound in 7 days

d-Repeat serum β-hCG after 48 hours

e-Urinary pregnancy test in one week

Answer 1

For PUL, should do 2 hCGs 48 hours apart
- Rise >= 63%: likely IUP –> repeat TVUSS in 7-14 days or earlier if >1500
- Decline >50% –> unlikely viable. repeat UPT in 14 days

D

Question 2

A 19-year-old primigravida presents to A+E with sudden onset severe lower abdominal pain and vaginal spotting. She is haemodynamically stable. An urgent TVUS shows an inhomogeneous mass in the left adnexa measuring 11mm, consistent with a left tubal ectopic pregnancy with minimal free fluid. The serum b-hCG level is 1200 IU/L. She has a history of a right tubal ectopic pregnancy managed with a laparoscopic right salpingectomy. She wishes for a pregnancy in the future.

What is the most appropriate management for this patient?

a-Surgical management with left salpingectomy

b-Parenteral methotrexate

c-Expectant management with repeat serum β-hCG in 48 hours

d-Surgical management with salpingotomy

e-Oral gefitinib and parenteral methotrexate

Answer 2

• SEVERE pain - not for expectant/MTX
• previous salpingectomy - consider salpingotomy

D

Question 3

A 41-year-old Para 1+1 (one caesarean birth, one surgical termination of pregnancy) attends the early pregnancy unit with amenorrhea of 7 weeks, mild lower abdominal discomfort and vaginal spotting. On TVUS, there is a gestational sac containing a yolk sac and fetal pole measuring 8mm. No fetal heart pulsations are visible. It is sited just below the level of the internal cervical OS. There is significant peripheral vascularity and a negative sliding sign. The endometrial cavity is empty.

What is the most likely diagnosis in this patient?

Inevitable miscarriage

Caesarean scar pregnancy

Intrauterine pregnancy with low implantation

Cervical ectopic pregnancy

Delayed miscarriage

Answer 3

cervical ectopic

Question 4

A 34-year-old Para 2 with two previous caesarean births attends the early pregnancy unit at 6 weeks of gestation due to crampy pelvic pain and vaginal spotting. She is concerned about the risk of a cesarean scar ectopic pregnancy.

What is the estimated prevalence of this type of pregnancy?

a-1 in 200 pregnancies

b-1 in 850 pregnancies
c-1 in 1200 pregnancies
d-1 in 2000 pregnancies

e-1 in 4500 pregnancies

Question 5

A 35-year-old nulliparous woman with a history of primary infertility is referred to the early pregnancy unit with mild vaginal bleeding at 6 weeks gestation. A TVUSS is performed and shows a 12mm left tubal ectopic pregnancy with no free fluid.
Initial serum b-hCG: 943IU/L
48 hour serum b-hCG: 1290IU/L
She has a history of previous right salpingectomy for a tubal ectopic pregnancy

Diagnostic laparoscopy

a-Expectant management with serial β-hCGs

b-Expectant management with urinary pregnancy test in 2 weeks

c-Local injection of methotrexate under USS guidance

d-Laparoscopy and salpingectomy

e-Laparotomy and salpingectomy

f-Laparoscopy and salpingotomy

g-Laparoscopy and bilateral salpingectomy

h-Second dose of systemic methotrexate

i-Systemic methotrexate

j-Transvaginal ultrasound in 7 days

Answer 5

I

Question 6

A 27-year-old nulliparous lady presents at 6 weeks gestation with severe lower abdominal pain. Following a transvaginal ultrasound, she is diagnosed with a left tubal ectopic pregnancy measuring 18mm. On ultrasound, a right-sided hydrosalpinx is noted, and there is no free fluid. Observations are unremarkable. The serum b-hCG level is 2563IU/L.

aa- diagnostic laparoscopy
a-Expectant management with serial β-hCGs

b-Expectant management with urinary pregnancy test in 2 weeks

c-Local injection of methotrexate under USS guidance

d-Laparoscopy and salpingectomy

e-Laparotomy and salpingectomy

f-Laparoscopy and salpingotomy

g-Laparoscopy and bilateral salpingectomy

h-Second dose of systemic methotrexate

i-Systemic methotrexate

j-Transvaginal ultrasound in 7 days

Answer 6

F

• hCG <1000 and well: expectant
• hCG <1,500 and well: MTX
• hCG 1,500 - 5,000: MTX or Sx
• hCG >5,000: Sx

F

Question 7

A 24-year-old woman is seen in the early pregnancy unit at 6 weeks gestation with a history of heavy vaginal bleeding and minimal abdominal discomfort. She is haemodynamically stable. On TVUS, the endometrium appears regular with no evidence of an intrauterine pregnancy. The ovaries appear normal bilaterally, and no adnexal masses or free fluid are seen.
Initial serum b-hCG: 3452IU/L
48-hour serum b-hCG: 1228IU/L.

aa- diagnostic laparoscopy

a-Expectant management with serial β-hCGs

b-Expectant management with urinary pregnancy test in 2 weeks

c-Local injection of methotrexate under USS guidance

d-Laparoscopy and salpingectomy

e-Laparotomy and salpingectomy

f-Laparoscopy and salpingotomy

g-Laparoscopy and bilateral salpingectomy

h-Second dose of systemic methotrexate

i-Systemic methotrexate

j-Transvaginal ultrasound in 7 days

Answer 7

• drop more than 50% in PUL –> unlikely to continue. Repeat UPT in 2 weeks

B

Question 8

****A 31-year-old woman with two-term vaginal deliveries is given systemic methotrexate for the management of a right tubal ectopic pregnancy. She is reviewed following her day 7 serum b-hCG results. She remains clinically well throughout her follow-up with no abdominal pain.

**Day 1 serum β-hCG: 4432IU/L

Day 4 serum β-hCG: 4728IU/L

Day 7 serum β-hCG: 5012IU/L**

aa- diagnostic laparoscopy

a-Expectant management with serial β-hCGs

b-Expectant management with urinary pregnancy test in 2 weeks

c-Local injection of methotrexate under USS guidance

d-Laparoscopy and salpingectomy

e-Laparotomy and salpingectomy

f-Laparoscopy and salpingotomy

g-Laparoscopy and bilateral salpingectomy

h-Second dose of systemic methotrexate

i-Systemic methotrexate

j-Transvaginal ultrasound in 7 days

Answer 8

• hCG has not fallen
• hCG is now above 5,000 therefore onlu surgery recommended

D

Question 9

A 30-year-old woman with a history of irregular periods presents at 5 weeks gestation with light spotting and mild lower abdominal pain. An ultrasound scan shows an endometrial thickness of 13mm without evidence of an intrauterine pregnancy. The ovaries appear normal, with evidence of a possible corpus luteal cyst right side. No adnexal masses or free fluid are seen.
Initial serum b-hCG: 120IU/L
48-hour serum b-hCG: 302IU/L

aa- diagnostic laparoscopy

a-Expectant management with serial β-hCGs

b-Expectant management with urinary pregnancy test in 2 weeks

c-Local injection of methotrexate under USS guidance

d-Laparoscopy and salpingectomy

e-Laparotomy and salpingectomy

f-Laparoscopy and salpingotomy

g-Laparoscopy and bilateral salpingectomy

h-Second dose of systemic methotrexate

i-Systemic methotrexate

j-Transvaginal ultrasound in 7 days

Answer 9

• PUL –> hCG shouuld be repeated in 48 hours
• i if rising by more than 63%: likely viable, therefore repeaty USS in 7-14 days or earlier if >1500

J

Question 10

A 34 year old lady is referred to the Early Pregnancy Unit at 7 weeks gestation with a 3 day history of spotting. She is diagnosed with a right interstitial ectopic pregnancy.

In regards to interstitial ectopic pregnancies which of the following is correct?

a-Surgical management can be performed via a laparoscopic or hysteroscopic route

b-Given their location, patients with an interstitial ectopic pregnancy will often present earlier than those with tubal ectopic pregnancies

c-The term cornual ectopic pregnancy is synonymous with interstitial ectopic pregnancy

d-An angular pregnancy cannot be distinguished from an interstitial ectopic pregnancy on ultrasound

e-Expectant management is not recommended

Answer 10

A

Question 11

A 34 year old lady presents to ED at 6 weeks gestation with heavy vaginal bleeding and moderate lower abdominal pain. She undergoes a transvaginal ultrasound scan and is diagnosed with a pregnancy of unknown location. The serum β-hCG level is 4857IU/L.

Which of the following is correct regarding quantitative serum β-hCG?

a-A prolonged serum β-hCG doubling rate is diagnostic for ectopic pregnancy

b-Quantitative serum β-hCG is only of value when combined with ultrasound examination

c-Serum β-hCG levels can be used in combination with progesterone to diagnose a miscarriage

d-A negative urinary pregnancy test excludes an ectopic pregnancy

e-Following the diagnosis of a pregnancy of unknown location a drop in the serum β-hCG level after 48 hours of more than 50% excludes an ectopic pregnancy

Answer 11

B

Question 12

A 24-year-old nulliparous woman undergoes surgical management of a tubal ectopic pregnancy. At laparoscopy, the contralateral tube is examined and noted to be damaged. The woman has strongly expressed her concern about future fertility.

Which is the single best management option?

Bilateral salpingectomy

Bilateral salpingotomy

Medical management of ectopic pregnancy

Salpingectomy with conservation of contralateral tube

Salpingotomy with conservation of contralateral tube

Answer 12

E

Question 13

A 27-year-old woman attends the Early Pregnancy Unit at 6 weeks of gestation with mild lower abdominal pain that settles with analgesia and moderate bleeding vaginally. Abdominal and vaginal examination is normal and a urine pregnancy test is positive. A transvaginal scan shows no intrauterine gestational sac, both ovaries appear normal and there is no free fluid in the pouch of Douglas.

What is the most appropriate management?

Diagnostic laparoscopy

Diagnose complete miscarriage and advise to repeat pregnancy test in 10 days

Inpatient admission for observation with monitoring of serum βhCG

Outpatient management with monitoring of βhCG

Repeat ultrasound in 7 days

Answer 13

D

Question 14

A 32-year-old primiparous woman presents to the emergency department with sudden onset of lower abdominal pain, mainly localised in the right iliac fossa. The pain is sharp in nature and is radiating to the right flank. Her last menstrual period was 8 weeks ago. A urine pregnancy test is positive. On transvaginal scan the right adnexa was seen to contain an ectopic pregnancy measuring 22 mm x 18 mm x 15 mm with cardiac activity and an absent haemoperitoneum. Vital signs on arrival are:

blood pressure = 128/68 mmHg
pulse = 72 beats/min
temperature = 36.5°C
respiratory rate = 16
hCG level = 5000 iu/l.
What is the treatment of choice for this woman?

Expectant management

Methotrexate regimen

Laparotomy and right salpingectomy

Laparoscopic right salpingectomy

Laparoscopic right salpingotomy

Answer 14

D

Question 15

A 24-year-old P0 woman at 6 weeks of gestation presents to the emergency department with a 2 week history of brown vaginal discharge. On transvaginal scan, the left adnexa is seen to contain an ectopic pregnancy measuring 20 mm x 14 mm x 10 mm with absent fluid in the pouch of Douglas. Vital signs on arrival were:

blood pressure = 118/68 mmHg
pulse = 72 beats/min
temperature = 36.5°C
respiratory rate = 18.
Vaginal examination is negative for cervical excitation.

On her recent blood tests serum βHCG was 527 ui/l.

What is the treatment of choice for this woman?

Conservative management with serial βhCG tests every 48 hour until levels falls below 20 iu/l

Laparotomy and left salpingectomy

Laparoscopic left salpingectomy

Laparoscopic left salpingotomy

Answer 15

A

Question 16

A 24-year-old woman experiences bleeding at 7 weeks of gestation and attends the Early Pregnancy Unit for a scan. On transvaginal ultrasound there is a gestational sac containing a fetal pole with a CRL of 6.5 mm without a fetal heart.

What is the next step in your management?

Arrange a follow up in >7 days for a repeat ultrasound before making a final diagnosis

Arrange a follow up in <7 days for a repeat ultrasound before making a final diagnosis

Ask a colleague for a second opinion before giving the final diagnosis

Discuss surgical management of miscarriage and book for the woman for surgery in the next available slot

Inform the woman that she had a miscarriage and discuss management options of miscarriage

Answer 16

A

Question 17

A 32-year-old G3P0 presents at 8 weeks of gestation to the Early Pregnancy Unit for an early scan. She has previously had one miscarriage at 6 weeks of gestation that was managed expectantly, and one ectopic pregnancy that was managed by laparoscopic salpingectomy. On transvaginal ultrasound the left adnexa contains an ectopic pregnancy with fetal activity confirmed. There is an absent haemato-perinoneum.

What is the management of choice for this woman?

Expectant management with serial βhCG tests

Laparotomy and left salpingectomy

Laparoscopy and left salpingotomy

Laparoscopy with left salpingectomy

Methotrexate regimen

Answer 17

C

Question 18

A 34-year-old woman who is G2P1 presents with mild vaginal spotting at 6 weeks of gestation. A transvaginal scan revealed no intrauterine sac but a 2 x 3 cm mass was seen in the left adnexa with no free fluid. She opted to have medical management after detailed counselling. This was undertaken the same day. The woman was asymptomatic.

The following are her serum hCG results:

Serum hCG results
At presentation 1450 IU
48 hours post-presentation

1650 IU
Day 4 post-medical management 1700 IU
Day 7 post-medical management 1500 IU

What is the most appropriate management option?

Advise patient to do pregnancy test in 2 weeks as hCG is decreasing

Continue weekly hCG until <15 if woman remains asymptomatic

Counsel and administer second dose methotrexate

hCG every 48 hours till it is undetectable

Perform laparoscopy and salpingectomy

Answer 18

C

Question 19

A 28-year-old woman who is 7 weeks by LMP attends the early pregnancy unit with vaginal bleeding. A transvaginal ultrasound shows a right tubal ectopic pregnancy, which contains a small gestational sac. She is managed with systemic methotrexate after a discussion of the treatment choices.

Below are the serum b-HCG levels:

Initial serum b-hCG: 1012 IU/L
48 hour serum b-hCG : 1021 IU/L
Day 1 serum b-hCG (day of treatment): 1054 IU/L
Day 4 serum b-hCG: 932 IU/L

Which of the above clinical features will increase the risk of treatment failure with methotrexate?

The pre-treatment changes in b-hCG levels

Gestation at presentation

Presence of gestational sac

Initial serum b-hCG level

Day 4 serum b-HCG level

Answer 19

There are a number of predictors of successful treatment with methotrexate including:

Low initial serum bhCG level
Pre-treatment changes in serum bhCG levels (higher success if lower
rate of bhCG rise)
Drop in bhCG levels between Day 1 and Day 4
Absence of gestational sac, yolk sac and fetal pole
This patient has a gestational sac present on TVUSS which is known to decrease the chance of successful treatment.

C

Question 20

A 32-year-old multiparous woman (two prior vaginal births) presents to the emergency department with lower abdominal pain and vaginal spotting. Her last menstrual period was 8 weeks ago. A urine pregnancy test is positive. A transvaginal ultrasound demonstrates a right tubal ectopic pregnancy measuring 22 mm x 18 mm x 15 mm with cardiac activity and no evidence of free fluid or probe tenderness. The initial serum b-hCG level is 4213IU/L. She is haemodynamically stable.

What is the most appropriate management for this woman?

Expectant management with repeat serum b-HCG in 48 hours

Laparoscopic right salpingectomy

Laparotomy and right salpingectomy

Oral gefitinib and parenteral methotrexate

Systemic methotrexate

Answer 20

B

Question 21

A 34-year-old woman presents with mild vaginal spotting at 6 weeks gestation. A transvaginal scan shows a 22mm left tubal ectopic pregnancy with no evidence of free fluid. She opts to have medical management after a discussion of the treatment options. She has a history of two previous midline laparotomies and bowel resections due to IBD.

Serum hCG results
At presentation 1450 IU
Day 1 (methotrexate given)

1650 IU
Day 4 post-medical management 1700 IU
Day 7 post-medical management 1500 IU

She remains asymptomatic throughout follow-up and is reviewed with her serum b-hCG levels on day 7 following treatment. Her TVUS shows the mass is smaller at 17mm, with no free fluid and probe tenderness.
What is the most appropriate ongoing management option?

Laparoscopic salpingectomy

Second dose of methotrexate

Serum b-hCG every 48 hours until negative

Urine pregnancy test in 2 weeks

Weekly serum b-hCG monitoring until negative

Answer 21

There is less than a 15% drop in the serum b-hCG between day 4 and day 7. Further treatment is therefore recommended. A second dose of methotrexate can be given if the patient remains asymptomatic and there is no evidence of cardiac activity or haemoperitoneum on TVUS. The other option would be surgical management.

Detailed counselling is required in this scenario, and the woman’s wishes must be considered.

Given her history of abdominal surgery, surgical intervention should not be the first line option.

B

Question 22

A 38-year-old lady is referred to EPU at 5 weeks gestation with moderate vaginal bleeding. She has no significant past medical history and one previous vaginal delivery at term. On transvaginal ultrasound an inhomogenous mass is seen adjacent to the left ovary, measuring 21mm. The endometrium is cystic but no clear evidence of an intrauterine pregnancy is seen. There is no free fluid or probe tenderness. Initial serum b-HCG is 990 IU/L.

What is the most appropriate management?

Systemic methotrexate

Repeat serum b-HCG in 48 hours

Laparoscopic salpingectomy

Repeat TVUSS in 48 hours

Laparoscopic salpingotomy

Answer 22

B

Question 23

A 43 year old women is 6 weeks pregnant following IVF with a double embryo transfer. She has a reassurance ultrasound performed by the fertility unit, which shows a single viable intrauterine pregnancy and an inhomogeneous mass measuring 11mm, with increased vascularity, adjacent to the left ovary. There is no free fluid.

What is the most appropriate management for this patient?

Serum b-hCG level

Laparotomy and salpingectomy

Systemic methotrexate

Expectant management with repeat TVUSS

MRI pelvis

Answer 23

A heterotopic pregnancy is the development of an intrauterine pregnancy and an ectopic pregnancy simultaneously. It is a diagnosis almost universally associated with fertility treatments with an incidence of approximately 1/30,000 in spontaneous conceptions compared to 1/100 in those having IVF.

The intrauterine pregnancy must always be considered and methotrexate (systemic or local) given only if the intrauterine pregnancy is not viable or the patient does not wish to continue with the pregnancy, in which case the Abortion Act will apply.

Expectant management is an option in heterotopic pregnancies where the ultrasound findings are of a nonviable pregnancy.

Local injection of potassium chloride or hyperosmolar glucose with aspiration of the sac contents is an option for clinically stable women.

Surgical removal of the ectopic pregnancy is the method of choice for hemodynamically unstable women but is also an option for hemodynamically stable women.

Serum b-hCG is of limited value in a heterotopic pregnancy.

D

Question 24

A 31 year old women, who is a Jehovah’s Witness, is referred to the early pregnancy unit at 6 weeks gestation with a history of mild RIF pain and spotting. She has had 3 previous uncomplicated vaginal deliveries at term. Following a transvaginal ultrasound she is diagnosed with a left tubal ectopic pregnancy measuring 14mm. No free fluid is seen and there is no probe tenderness. Initial serum b-HCG is 890 IU/litre and 48 hours later is 1015Iu/litre.

What is the most appropriate management?

Surgical management with salpingectomy

Outpatient medical management with systemic methotrexate

Expectant management with serial serum b-hCG levels

Surgical management with salpingotomy

Medical management with local injection of methotrexate under USS guidance

Answer 24

• as JW and success of medical Mx is unpredictable, best to do surgical

A

Question 25

A 28-year-old woman attends the early pregnancy unit at 6 weeks gestation with mild vaginal bleeding. She is diagnosed with a 2cm right tubal ectopic pregnancy with no free fluid on TVUS. She is managed with systemic methotrexate. She remains asymptomatic throughout follow-up.

Serum b-hCG results
Day 1 serum b-hCG

1890 IU/L
Day 4 serum b-hCG 2400 IU/L
Day 7 serum b-hCG 2200 IU/L

a-Blood test for FBC, renal function, liver function

b-Transvaginal ultrasound scan

c-Diagnostic laparoscopy

d-Weekly serum b-hCG until negative

e-Urinary pregnancy test in 2 weeks

f-Transabdominal ultrasound scan

g-MRI pelvis

h-Serum progesterone

i-FAST scan

j-Serum b-hCG

k-Reassure

Answer 25

There has been a less than 15% drop in the serum b-hCG between day 4 and day 7. The patient should be advised that further treatment would be recommended. A repeat transvaginal ultrasound should be performed to exclude the presence of cardiac activity or a significant haemoperitoneumm, which would be a contraindication to a second dose of methotrexate.

B

Question 26

A 39-year-old woman presents to the emergency department with severe lower abdominal pain and an episode of loss of consciousness. Her last menstrual period was 6 weeks ago. A urinary pregnancy test is positive.

Her vital signs are as follows:
Heart rate: 115bpm
BP: 95/55 mm of Hg
Temperature: 37.0 C
Respiratory rate: 20/min
SaO2 100% in room air

VBG result:
pH: 7.28
Haemoglobin: 84g/L
Lactate 3.4
BE: -7.6

a-Blood test for FBC, renal function, liver function

b-Transvaginal ultrasound scan

c-Diagnostic laparoscopy

d-Weekly serum b-hCG until negative

e-Urinary pregnancy test in 2 weeks

f-Transabdominal ultrasound scan

g-MRI pelvis

h-Serum progesterone

i-FAST scan

j-Serum b-hCG

k-Reassure

Answer 26

I

Question 27

A 19-year-old woman presents to the early pregnancy unit with heavy vaginal bleeding and mild lower abdominal pain at 8 weeks gestation. A TVUS is performed and indicates a pregnancy of unknown location with no evidence of haemoperitoneum. She is haemodynamically stable:

Initial serum b-hCG: 4672IU/L
48 hour serum b-hCG: 1292 IU/L

a-Blood test for FBC, renal function, liver function

b-Transvaginal ultrasound scan

c-Diagnostic laparoscopy

d-Weekly serum b-hCG until negative

e-Urinary pregnancy test in 2 weeks

f-Transabdominal ultrasound scan

g-MRI pelvis

h-Serum progesterone

i-FAST scan

j-Serum b-hCG

k-Reassure

Answer 27

E

Question 28

A 26-year-old lady is given systemic methotrexate for the management of a left tubal ectopic pregnancy. She presents to the early pregnancy unit on day 4 following treatment with worsening abdominal pain. She is haemodynamically stable. Clinical examination suggests a soft abdomen, tender over the left iliac fossa. There is no evidence of peritonism. Her FBC is equivocal.

Serum b-HCG.
Day 1 serum b-hCG: 1220IU/L
Day 4 serum b-hCG: 960IU/L

a-Blood test for FBC, renal function, liver function

b-Transvaginal ultrasound scan

c-Diagnostic laparoscopy

d-Weekly serum b-hCG until negative

e-Urinary pregnancy test in 2 weeks

f-Transabdominal ultrasound scan

g-MRI pelvis

h-Serum progesterone

i-FAST scan

j-Serum b-hCG

k-Reassure

Answer 28

• abdominal pain after MTX commmon, usually 3-10 days after
• difficult to distinguish from pathological process
• if significant or worsening, needs USS to exclude significant haemoperitoneum

B

Question 29

In regard to ectopic pregnancies, choosed the single best answer:
a) In women affected by subfertility, expectant or medical management is associated with improved reproductive outcomes in comparison to radical surgery
b) MTX is associated with a small reduction in ovarial reserve
c) 11% of women with a previous ovarian ectopic will experience subfertility
d) MTX treatment is associated with a slightly increased risk of future ectopic pregnancy

Answer 29

• In the absence of a history of subfertility or tubal pathology, women should be advised that there is no difference in the rate of fertility, the risk of future tubal ectopic pregnancy or tubal patency rates between the different management methods. [New 2016]
• Women with a previous history of subfertility should be advised that treatment of their tubal ectopic pregnancy with expectant or medical management is associated with improved reproductive outcomes compared with radical surgery. [New 2016]
• Women receiving methotrexate for the management of tubal ectopic pregnancy can be advised that there is no effect on ovarian reserve. [New 2016]
• Women undergoing treatment with uterine artery embolisation and systemic methotrexate for nontubal ectopic pregnancies can be advised that live births have been reported in subsequent pregnancies. [New 2016]
• Women undergoing laparoscopic management of ovarian pregnancies can be advised that their future fertility prospects are good. [New 2016

A

Question 30

A 35-year-old woman presents to the early pregnancy unit (EPU) with vaginal spotting at 8 weeks’ gestation. Investigations reveal a serum hCG of 200,000 mIU/ml and ultrasound scan suggests (images in this link) a ‘snowstorm appearance’.

What is the appropriate next step in her management?

Conservative management with serial hCG monitoring

Medical management with prostaglandins

Referral to a national centre for specialist care for gestational trophoblastic disease

Repeat ultrasound in 1 week

Surgical evacuation of products of conception

Answer 30

Surgical evacuation

• Medical management increases risk of incomplete removal (15% in complete moles; 1% in partial moles)
• Should be reserved for cases where fetal parts do not allow Sx (such as twins with twin demise or TOP)

Question 31

A women who has recently had an SMM confirming molar pregnancy on histology presents with heavy vaginal bleeding and haemodynamic compromise.

For each scenario, choose an option from the list. Each option can be used once more than once or not at all.

FUP for 6 months from the date of surgical uterine evacuation

Referred to GTD centre

Repeat ERPC

No FUP

Serial hCG until normal on two samples at least 4 weeks apart

Answer 31

Repet ERPC

Question 32

A women diagnosed with molar pregnancy on histology after routine surgical management of miscarriage presented with positive urine pregnancy test 3 weeks later and retained products of conception on scan.

FUP for 6 months from the date of surgical uterine evacuation

Referred to GTD centre

Repeat ERPC

No FUP

Serial hCG until normal on two samples at least 4 weeks apart

Answer 32

Refer to GTD centre –> although repeat removal may decrease need for chemo, it should only be carried out in the scenario of acute haemodynamic compromise. Otherwise, should be discussed with the GTD centre

Question 33

A women with previous history of molar pregnancy managed surgically has a successful delivery of a healthy baby boy.

FUP for 6 months from the date of surgical uterine evacuation

Referred to GTD centre

Repeat ERPC

No FUP

Serial hCG until normal on two samples at least 4 weeks apart

Answer 33

No FUP –> women who managed without chemo have a 1:4000 chance of recurrence. Therefore they do not need any follow-up after a successful pregnancy. 80% will have a successful pregnancy

Question 34

A women who has a complete molar pregnancy managed surgically has a negative hCG within 56 days.

FUP for 6 months from the date of surgical uterine evacuation

Referred to GTD centre

Repeat ERPC

No FUP

Serial hCG until normal on two samples at least 4 weeks apart

Answer 34

FUP 6 months –> for complete molar: repeat hCG after 56 days. If negative, FUP for 6 months after removal. If positive, FUP 6 omths after negative hCG

Partial: follow-up until two negative hCGs, 4 weeks apart.

Question 35

A women with a surgically managed partial molar pregnancy.

FUP for 6 months from the date of surgical uterine evacuation

Referred to GTD centre

Repeat ERPC

No FUP

Serial hCG until normal on two samples at least 4 weeks apart

Answer 35

Serial hCGs until two normal samples 4 weeks apart –> for complete molar: repeat hCG after 56 days. If negative, FUP for 6 months after removal. If positive, FUP 6 omths after negative hCG

Partial: follow-up until two negative hCGs, 4 weeks apart.

Question 36

A 44-year-old para 2 presented for her fetal viability scan at 12 weeks. Ultrasound showed twin gestation with one live fetus and possibility of a coexistent complete mole. What advice will you offer her?

Continuation of pregnancy is an option as 40% women may proceed to deliver healthy babies without an increased risk of complications

Continuation of pregnancy should be offered as there is a 60% chance of achieving a live birth with a coexisting complete mole

Termination of pregnancy is advisable in all cases as there is a 100% increased risk of congenital fetal abnormalities, perinatal mortality and malignant GTN in the viable twin

Termination of pregnancy should be only offered in those cases where there is a coexistent partial mole as opposed to a complete mole

Termination of pregnancy should not be offered as there are no risks to the viable twin

Answer 36

A. There is
- 40% risk of early loss
- 40% risk of PTB
- 20% risk of PET
- Only 25% chance of live birth

Question 37

A 38-year-old woman attends for HCG monitoring following suction evacuation of the uterus for a complete molar pregnancy 9 weeks ago. Her HCG levels are decreasing but have not normalised.

What is the most appropriate follow-up in her case?

Follow up for 3 months from date of uterine evacuation

Follow up for 3 months from normalisation of hCG

Follow up for 6 months from date of uterine evacuation

Follow up once the hCG has returned to normal on two samples, at least 4 weeks apart

Follow up for 6 months from normalisation of hCG

Answer 37

6 months from normal hCG

Question 38

A 36-year-old woman presents 3 weeks after surgical management of gestational trophoblastic disease, seeking contraception. Her HCG levels are decreasing but have not normalised.

What contraceptive is most appropriate in her case?

Abstinence until HCG levels are undetectable

Barrier method

Copper intrauterine device

Combined oral contraception

Levonorgestrel intrauterine system

Answer 38

COCP
- Any oral contraception, implant or Depo can be used after molar, regardless of hCG, and can be started immediately after evacuation
- IUD/IUS can only be used if undetectable hCG –> not if unknown, rising, still declining or malignancy

Question 39

A woman diagnosed with GTD is undergoing pre-chemotherapy investigations. What statement is incorrect?
a) Blood evaluation should include baseline hCG, TFTs, LFTs, U&E, FBC
b) Doppler ultrasound can help determine vascularity and risk
c) An MRI brain can be considered after neurological assessment
d) CT Chest is preferred to CXR as it can detect lung micrometastases in 40% of cases
e) A pelvic and abdominal USS should be done

Answer 39

D) is incorrect. A CXR is part of routine work-up. Although micromets are found in 40% in CT Chest, this does not change prognosis and therefore is not an indication to have CT done routinely

Question 40

A 41-year-old woman presents with abnormal uterine bleeding 10 months following her third-term vaginal delivery. Uterine evacuation identifies choriocarcinoma on histological diagnosis. Ultrasound shows a 5 cm lesion in the myometrium and chest x-ray shows multiple (more than eight) lung nodules.
What is the most appropriate treatment option this case?

Actinomycin D

Etoposide, Methotrexate, Actinomycin D and Folinic acid plus Vincristine and Cyclophosphamide (EMA-CO regimen)

Etoposide, Methotrexate, Actinomycin, Folinic acid and Cisplatin (EP/EMA regime)

Hysterectomy

Methotrexate/folinic acid

Answer 40

B (EMA-CO regimen)

• Score 0-6: MTX only
• Score >=7: RMA-CO regimen

Question 41

A 45-year-old woman has a hydatidiform mole evacuated uneventfully. The hCG decreases from a pre-evacuation value of 80 000 to 1000 IU/l 4 weeks after the evacuation but then persists at 1000 mIU/ml for 4 weeks. Clinical examination shows no abnormality or evidence of metastases. Ultrasound of the uterus shows a 2-cm lesion in the myometrium. Chest x-ray is negative.

What is the most appropriate treatment option this case?

Actinomycin D

Etoposide, Methotrexate, Actinomycin, Folinic acid and Cisplatin (EP/EMA regime)

Etoposide, Methotrexate, Actinomycin D and Folinic acid plus Vincristine and Cyclophosphamide (EMA-CO regimen)

Hysterectomy

Methotrexate and folinic acid

Answer 41

E

• Score 0-6: MTX only
• Score >=7: RMA-CO regimen

Question 42

Which one of the following factors is most likely to significantly increase the FIGO prognostic risk factor scoring for histologically diagnosed choriocarcinoma?

Age <40 with metastases to the lungs

Diagnosis occurred within 4 months following complete molar pregnancy

Metastases to the brain

Pre-treatment hCG 103 to 104 IU/l

Residual uterine tumour mass measuring 2 × 2 cm

Answer 42

Metastases to brain

Question 43

Which one of the following is not an indication for chemotherapy for gestational trophoblastic disease in the UK?

Evidence of metastases in the brain, liver, gastrointestinal tract or lung

Heavy vaginal bleeding persisting after uterine evacuation

Histological diagnosis of complete hydatidiform mole

Plateaued or rising hCG concentration after uterine evacuation

Raised hCG concentration 6 months after evacuation, even when still decreasing

Answer 43

Histological diagnosis of complete hydatidiform mole