Early Pregnancy Loss

Question 1

A 25F G1P0 K10 presents with PV bleeding, RLQ abdominal and shoulder tip pain. She is tachycardic at 120, hypotensive at 80/40. What would be your initial management?

Answer 1

Resuscitation as per DRS ABCD.
Speculum exam to remove POC.
IDC
Urgent bHCG
Gynaecology review.
USS
FBC, G+H
Consider surgery

Question 2

How do you manage a pregnancy of unknown location?

Answer 2

Specialist review
2 x bHCG 48-72hrs apart.
- If you see a rise >/- 66%, likely IUP however ectopic cannot be excluded. If bHCG < 2000 repeat TVS in 1-2 weeks.
- If bHCG >/= 2000 repeat TVS within 1 week OR when MSD estimated to be > 25 mm

• If you see a fall in bHCG >/= 50%, -> likely non-viable (IUP OR ectopic) pregnancy. Continue serial bHCG and manage as appropriate.
• If you see a rise of < 66% or a fall of < 50% -> repeat TVS (depending on bHCG levels, described above). If no IUP observed - > likely ectopic. If IUP observed determine viability

Question 3

What are the steps in determining (ultrasonographically) the viability of an IUP?

Answer 3

1. Fetal heart beat. If yes, then viable.
2. If fetal HB not visible, assess for fetal pole visible.
   3 If fetal pole visible, is CRL >/=7mm - > (Y) NVP. If CRL NOT >/=7mm, suspicious for NVP.
3. Fetal pole not visible - > MSD >/= 25mm -> yes -> NVP.
4. MSD not >/=25mm -&raquo_space; suspicious for NVP.
5. If suspicious for NVP, undertake serial b-hCG and repeat TVS in 7-10days.

Question 4

What are the non-viable diagnostic criteria (TVS)?

Answer 4

MSD >/= 25mm and NO fetus present.

Fetus with CRL >/=7mm is visible, but no fetal heart movements demonstrated after observation >/=30secs.

Absence of embryo with heartbeat >/= 2weeks after a scan that showed a gestational sac without a yolk sac.

Absence of embryo with heartbeat >/11 days after a scan that showed a gestational sac with a yolk sac.

Question 5

How do you estimate repeat TVS interval?

Answer 5

Estimate repeat TVS interval based on expected normal gestational sac growth rate of 1mm/day. E.g. If MSD = 12mm, repeat TVS in 13 days or more (12mm MSD + 13mm growth over 13 days equals expected MSD of 25mm).

Question 6

What is the clinical presentation of ectopic pregnancy (may or may not include)?

Answer 6

Absence of menses.
Irregular vaginal bleeding (spotting)
Abdominal/shoulder tip pain.
Cervical motion tenderness.
Tachycardia or hypotension (if in shock)
Palpable adnexal mass (50%) 
Absence of IUP on USS, with a positive bHCG.

Question 7

What are the treatment options for ectopic pregnancy?

Answer 7

Expectant, medical or surgical.

Question 8

What are the indications for expectant management of ectopic pregnancy? (7)

Answer 8

Indicated only if:

1. Haemodynamically stable
2. No evidence of rupture
3. Low and falling serum b-hCG (< 1500 IU/L at initial presentation)
4. Minimal or no fluid in pelvis on USS
5. Tubal mass < 3cm
6. Pain free
7. Woman understands need for follow-up and can access medical services.

Caution: If potential for non-compliance with follow-up.

Question 9

A woman is being expectantly managed for an ectopic pregnancy. What is required for ongoing management?

Answer 9

Ongoing management:

1. EPAS or equivalent.
2. b-hCG every 48hours for 8 days.
3. If resolution occurring, then weekly b-hCG until negative.
4. USS if clinically indicated.
5. Avoid conception until sonographic resolution.

Question 10

What are the indications for medical management of ectopic pregnancy? (4)

Answer 10

Indications:

1. Haemodynamically stable.
2. No evidence of rupture.
3. No signs of active bleeding.
4. Normal FBC, ELFT.

Question 11

What are the contraindications to medical management of an ectopic pregnancy? (5)
What are the cautions? (4)

Answer 11

Contraindications:

1. Allergy to MTX
2. Geographic isolation
3. Potential non-compliance.
4. Presence of medical conditions (review on individual basis)
5. Breastfeeding.

Caution:

1. Baseline b-hCG > 5000IU/L
2. Ectopic > 3cm on TVS
3. Fetal heart motion present
4. Blood transfusion not an option.

Question 12

What is the medical treatment for ectopic pregnancy?

Answer 12

• If b-hCG =3000 IU/L, IMI
• If b-hCG > 3000 IU/L, IVI.

Ongoing management:

• EPAS or equivalent.
• Serial b-hCG as per MTX protocol.
• USS in one week then as clinically indicated. If fetal heart rate present, refer to MFM.
• Avoid conception for 4 months due to potential teratogenicity.

Question 13

What other advice would you give to those opting for medical/expectant management of an ectopic pregnancy?

Answer 13

Risk of rupture in acute phase from sexual intercourse or pelvic exam.
We made need to consider alternative management if b-HCG is not falling, at woman’s request, tubal rupture or ongoing pain/bleeding.

Question 14

What are the (other) general considerations in managing ectopic pregnancy? (5)

Answer 14

1. Review histopath of POC
2. If indicated, recommend RhD-Ig
3. Analgesia prn
4. Communicate info to other care providers (e.g. GP)
5. Early USS (5-6 weeks) in next pregnancy.

Question 15

What are the indications (2) and absolute indications (4) for surgical management of ectopic pregnancy?

Answer 15

Indications:

1. Woman’s preference
2. Unsuccessful expectant or medical management.

Absolute indications:

1. Haemodynamic instability.
2. Persistent excessive bleeding.
3. Evidence of infected POC
4. Suspected GTD.

Cautions:

• Risk of haemorrhage or effects of haemorrhage (i?Jehova’s witnesses)
• Previous uterine perforation.

Question 16

Care provision in surgical management (3)

Answer 16

Misoprostol for cervical priming
Routine antibiotics not required.
USS at time of suction curettage (if indicated).

Question 17

In which locations can an ectopic pregnancy occur?

Answer 17

Fallopian tubes.

Cornu, cervix, caesarean section scar, ovary..or other sites.

Question 18

What is a heterotopic pregnancy?

Answer 18

Multiple pregnancy with an intrauterine plus ectopic pregnancy.

Question 19

Define a miscarriage?

Answer 19

Pregnancy loss occurring before 20 completed weeks of gestation or less than 400g birth weight.

Question 20

Defined a missed miscarriage?

Answer 20

US confirmed non-viable pregnancy with no bleeding.

Question 21

Define recurrent miscarriage?

Answer 21

Three or more consecutive miscarriages.

Question 22

Define threatened miscarriage?

Answer 22

Any vaginal bleeding other than spotting before 20 weeks completed gestation with evidence of a progressive, viable pregnancy at US.

Question 23

What are some physical and psychological complications of early pregnancy loss?

Answer 23

Infection, haemorrhage, embolism, damage to uterus and associated structures, anaesthetic complications.

Grief, depression, anxiety.

Question 24

What advice would you give to a woman regarding return to normal menstrual cycle?

Answer 24

• Resumption of normal menstrual cycle indicates resolution of EPL complications and completion of management.
• Ongoing, irregular bleeding requires follow-up - consider:
  • b-hCG to exclude GTD
  • Retained productions or infection

Question 25

What advice would you give to all women following EPL? | i.e. When to seek emergency assistance.

Answer 25

If experiencing strong pain unrelieved by paracetamol. Shoulder tip or diaphragmatic pain. Soaking of more than one pad within 60 minutes. Fainting. Elevated temperature.

Question 26

A 25F G4P2 at K14 comes in with PV bleeding. Outline your history.

Answer 26

Menstrual history and LNMP. Date of positive pregnancy test. Previous pregnancies and outcomes, particularly miscarriages. Other significant gynaecological history. If assisted contraception, identify method of conception. Relevant USS and quantitative b-hCG Symptoms of early pregnancy. Presence of associated symptoms: - Vaginal bleeding (timing, extent, severity). - Pain (lower abdo cramping or backache) - Postural syncope - Vomiting - Shoulder tip/daphragmatic pain Passage of POC

Question 27

A negative b-hCG essentially excludes an ectopic pregnancy, true or false?

Answer 27

True (except in the case of a chronic ectopic hwere b-hCG has been positive in the recent past).

Question 28

A 25F G4P2 at K14 comes in with PV bleeding. You have already gained a history. Outline your physical examination.

Answer 28

Baseline observations. Abdominal examination - Tenderness (rigidity/guarding) - Distension PV blood loss (check loss on pad) Vaginal examination (individualised as clinically indicated): - Spec exam: - Source and amount of bleeding. - Evidence of POC in the cervical os (if present, remove and submit for histology) - Bimanual examination: - Cervical motion tenderness - State of the internal cervical os - Assess for adnexal masses (ectopic pregnancy or other massess) Size of uterus relative to menstrual dates.

Question 29

A 25F G4P2 at K14 comes in with confirmed inevitable miscarriage. What investigations will you order?

Answer 29

USS (preferably a TVS) FBC, blood group, antibody screen. Midstream specimen or urine for microscopy, culture and sensitivity as clinically indicated. Scree for STIs as indicated.

Question 30

Following conception, how many days does it take for serum b-hcG to become positive? Bonus: at what level b-hCG confirms pregnancy

Answer 30

1. 9 Bonus: 5 IU/L confirms pregnancy. NB: a single b-hCG does not differentiate between a viable and nonviable pregnancy.

Question 31

What is the basis for undertaking serial b-HCG levels 48-72 hours apart?

Answer 31

For a potentially viable IUP up to 6-7 weeks gestation: - Mean doubling time for b-hCG is 1.4-2.1 days. - 85% show serial b-hCG rise of at least 66% every 48 hours. - 15% show serial b-hCG rise between 53-66% every 48 hours.

Question 32

How do you diagnose a complete miscarriage?

Answer 32

A dx of complete miscarriage requires f/u with serum quantitative b-hCG until negative and TVS if clinically indicated, to exclude undiagnosed ectopic. NB: an IUP can only be confirmed conclusively after identification of a yolk sac. Cannot dx complete miscarriage based on US findings of an 'empty uterus'.

Question 33

Describe the use of progesterone in PUL?

Answer 33

If PUL, a single progesterone level may assist in identifying women with a low risk of having an ectopic pregnancy or persistent PUL. In two studies the negative predictive value was 98% and 97% (refer to EPL guidelines, page 12).

Question 34

b-hCG > 2000 and no IUP with complex adnexal mass and/or free fluid on TVS suggests what diagnosis?

Answer 34

High probability of ectopic pregnancy.

Question 35

Diagnosis of a NVP cannot be made until the MSD is (or has failed to reach) 25mm, true or false.

Answer 35

True.

Question 36

A 25F G4P2 at K14 presents with uncontrolled PV bleeding in context of incomplete miscarriage. Her BP is 84/59. You have begun acute resuscitation protocol. You have excluded ectopic pregnancy. What pharmacological agents could you use to control bleeding in this case?

Answer 36

1. Ergometrine maleate 250mcg IV or IM 2. Misoprostol 800 - 1000 micg PR 3. Critical bleeding massive transfusion protocol.

Question 37

What is the frequency of ectopic pregnancies?

Answer 37

1.5 - 2%

Question 38

What is the most common location of ectopic pregnancy and what is the %?

Answer 38

Fallopian tube (95%)

Question 39

Falling or stationary b-hCG excludes the risk of rupture following medical or expectant management, true or false?

Answer 39

False.

Question 40

Name risk factors for ectopic pregnancy (11)

Answer 40

Previous tubal surgery (OR 4.0) Previous ectopic pregnancy (8.3) Infertility (risk increases with length of) (2.1-2.7) Previous genital infection confirmed (3.4) Previous miscarriage (3.0) Current smoker (risk increases with amount/day) (1.7-3.9) Smoking (past or ever) (1.5*) Intrauterine device use more than 2 years (2.9*) Age 40 or older (compared to 25-29yrs) (2.9*) Sterilisation (9.3) Documented tubal pathology (3.7)

Question 41

A woman with a confirmed ectopic pregnancy opts for expectant management. What should you always warn her of?

Answer 41

The possibility of tubal rupture despite decreasing b-hCG.

Question 42

What are the indications for expectant management for ectopic pregnancy? (6)

Answer 42

Haemodynamically stable. Low and falling b-hCG (less than 1500IU/L at initial presentation). Tubal mass less than 3cm. No pain Nil to minimal evidence of blood in the pelvis on USS. No geographical isolation.

Question 43

A woman with confirmed ectopic pregnancy opts for expectant management. What is involved in ongoing management of her?

Answer 43

Follow-up via EPAS b-hCG: - Every 48 hours for 8 days (to confirm levels are falling) - If satisfactory resolution occurring, may commence weekly levels until negative. USS not routinely recommended. Consider if b-hCG not falling OR clinically indicated. Offer surgical or medical mng: - At the woman's request - If there is ongoing or increasing pain or bleeding - b-hCG is not consistently falling - Tubal rupture with haemoperitoneum occurs.

Question 44

What advice would you give to women undergoing expectant mng for an ectopic pregnancy?

Answer 44

Pelvic examination and sexual intercourse carry risk of rupture in acute phase of resolution. Avoid future pregnancy until sonographic resolution of mass, noting that sonographic resolution of mass takes longer than biochemical resolution of b-hCG. Early USS in next pregnancy (5-6 weeks gestation).

Question 45

What is the MOI of methotrexate?

Answer 45

It is a folic acid antagonist which prevents the growth of rapidly dividing cells by interfering with DNA synthesis.

Question 46

What are the indications for medical mng for ectopic pregnancy? (4)

Answer 46

Unruptured ectopic pregnancy; haemodynamically stable and no signs of active bleeding. Unusual sites (e.g. cervical ectopic, interstitial, caesarean scar). Low initial serum b-hCG. - Best results achieved if b-hCG less than 5000 IU/L but may be used at any b-hCG level in hte unruptured ectopic. FBC, electrolytes and LFTs are WNL.

Question 47

What are the C/Is to medical mng of ectopic pregnancy? (13)

Answer 47

Haemodynamically unstable. Allergy to MTX Evidence of significant haemoperitoneum on TVS Renal disease/insufficiency (MTX is cleared renally) Abnormal FBC, ELFT Acute liver disease, aplastic anaemia, thrombocytopenia Immunodeficiency Active pulmonary disease Active peptic ulcer disease. Coexistent viable IUP (heterotopic pregnancy) Breastfeeding. Potential for non-compiance with prolonged follow-up (35- 109 days) Geographic isolation Cautions: Baseline serum b-hCG greater than 5000IU/L Ectopic preg > 3-4cm diameter on TVS Presence of fetal heart motion on TVS When blood transfusion is not acceptable to the woman If BMI >/= to 40, and IMI dosage is capped at 2m2 BSA, an additional dose is more likely to be required to achieve complete resolution.

Question 48

With a confirmed ectopic pregnancy, what should you do if a fetal heart is present on USS?

Answer 48

Refer urgently to MFM for follow-up - direct injection of KCl may be indicated.

Question 49

What advice would you give for women undergoing medical management for ectopic pregnancy?

Answer 49

Provide women information on cytotoxic precautions post treatment with MTX. Avoid: - Sun exposure (to limit skin inflammation) - Foods and vitamins containing folate/folic acid Advise: - Pelvic examination and sexual intercourse carry risk of rupture in acute phase of resolution. - Common side effects of MTX include: nausea, tiredness, altered bowel habits and mouth ulcers which usually settle without tx w/i a few days. Advise to delay next pregancy for four months post administration of mtx due to potential teratogenicity of mtx. (ensure sonographic resolution of mass prior ot future pregnancy). Early USS in next pregnancy (5-6wks gestation).

Question 50

What are the indications for surgical mng of ectopic pregnancy? (3)

Answer 50

Women's preference Haemodynamic instability. Persistent excessive bleeding.

Question 51

What follow-up is required following surgical mng of ectopic pregnancy?

Answer 51

GP f/u in around 2 weeks post surgery. USS not routinely required. If salpingostomy, weekly b-hCG until negative. If salpingectomy, - Unusually may see abdominal implantation especially after ruptured ectopic with haemoperitoneum. Rarely may see ongoing intrauterine gestation if undiagnosed heterotopic pregnancy. - Urinary b-hCG 3 weeks after surgery. Advised early USS in next preganncy (5-6 weeks gestation).

Question 52

What is the risk of recurrent ectopic pregnancy after one and two ectopic pregnancies?

Answer 52

Risk of recurrent EP is approximately: - 15% after one EP - 30% after two EP.

Question 53

True or false. There are no significant differences between expectant, medical and surgical management for rates of infection, psycological outcomes, resumption of normal activities or subsequent fertility.

Answer 53

True

Question 54

Name risk factors for non-viable intrauterine pregnancy. | Fetal/placental; maternal; other

Answer 54

Fetal/placental: - Chromosomal abnormalities - Congenital abnormalities. - GtD Maternal: - Maternal age: EPL 7% in 25-29 years vs 43% in 40-44 years. - Recurrent miscarriage history: risk of EPL 20-70% after three losses. - Anatomic factors (e.g. uterine septum) - Endocrinopathy (e.g. thyroid disease) - Immunologic factors (e.g. SLE) - Infection (e.g. CMV) - Severe acute illness - Thrombophilia (e.g. FVL) - Uncontrolled chronic illness (e.g. HTN, diabetes) - Very high or very low pre-pregnancy BMI Other: - Drug use/smoking - Teratogen exposure - Trauma (e.g. physical abuse)

Question 55

Expectant management for non-viable IUP is most suited to which type of miscarriage?

Answer 55

Incomplete miscarriage

Question 56

What are the C/Is to expectant management of non-viable IUP? (5)

Answer 56

``` Suspected GTD Haemodynamically unstable IUD (requires removal) Women at increased risk of haemorrhage (e.g. late in first pregnancy) or effects (e.g. unable to have a blood transfusion or coagulopathies). Evidence of infection ```

Question 57

What are some of the risks of expectant mng of non-viable IUP? (Some risks that you would counsel the woman about)

Answer 57

Expect bleeding for up to two weeks (or longer in individual cases). Advise surgical or medical management can be chosen at a later date. Access to a telephone and 24 hour emergency hospital admission is required plan for access with geographical isolation. I'm the setting of missed miscarriage, complete resolution may take several weeks and overall efficacy rates are lower. Timeframe to complete miscarriage is unpredictable. The proportion of women who subsequently require surgery is unpredictable.

Question 58

Expectant management of non-viable IUP is most suited to which type of miscarriage?

Answer 58

Incomplete

Question 59

What are the contraindications to expectant mng of non-viable IUP? (5)

Answer 59

1. Suspected GDM 2. Haemodynamically unstable 3. IUD (requires removal) 4. Women at increased risk of haemorrhage (i.e. late in first trimester) or effects of (e.g. unable to have a blood transfusion or coagulopathies) 5. Evidence of infection

Question 60

What are some of the risks of expectant mng and what other advice would you give to women opting for expectant mng for non-viable IUP?

Answer 60

More days of bleeding and a greater amount of bleeding when compared to surgical treatment. Some women will go on to require surgery (varies between 2- 44%). Timeframe to complete miscarriage is unpredictable. In setting of missed miscarriage, complete resolution may take several weeks and overall efficacy rates are lower. Access to telephone and 24 hour emergency hospital admission is required or a plan for access where there is geographical/social isolation. Expect bleeding for up to two weeks (or longer in individual cases). Surgical or medical mng can be chosen at a later date.

Question 61

A women opts for medical mng of non-viable IUP. What follow-up and ongoing mng would you recommend?

Answer 61

Arrange f/u within 7-10 days at GP or EPAS. !Remain vigilant for GTD and/or ectopic. Repeat bHCG day 8. Consider USS if: clinically indicated (symptomatic), to ax for RPOC; if b-hCG level has not fallen more than 90% over 7 days. Options for medical or surgical mng if woman wishes, ongoing heavy bleeding, pain or persistent intrauterine gestational sac on USS, other clinical conerns. If infection suspected, recommend early surgical management with antibiotic cover. Recommend repeat urinary pregnancy test at 3-6 weeks if: - no POC on histopath - Failure to return to normal menstruation by 4-6 weeks. - Ongoing abnormal bleeding.

Question 62

Medical mng of non-viable IUP is most suited to which type of miscarriage?

Answer 62

Missed miscarriage

Question 63

What are the contraindications to medical mng for NVIUP? (6)

Answer 63

1. Suspected GDM 2. Haemodynamically unstable 3. Increased risk of haemorrhage (e.g. late first trimester) or effects of haemorrhage (eg.. coagulopathy, unable to have blood transfusion) 4. Evidence of infection 5. IUD (requires removal) 6. Medical contraindications (e.g. HTN, allergy to prostaglandins

Question 64

Risks of medical mng for NVIUP?

Answer 64

Bleeding is heavier and more prolonged after medical treatment with misoprostal than with curettage.

Question 65

With respect to medical mng for NVIUP, what is the QLD health regimen for misoprostal administration?

Answer 65

Day 1: misoprostol 400-800 micrograms PV, PO or S/L Day 2 or day 3: repeat misoprostol 400-800mcg PV/PO/S/L. NB: if good history of POC passed, second dose may be omittted. NB: OPD or day procedure. Offer analgesia and antiemetic.

Question 66

Describe ongoing mng for medical mng of NVIUP?

Answer 66

Remain vigilant for GTD and/or ectopic. bHCG day 1 (of misoprostol) and day 8 (to confirm levels are falling). Consider USS: - If clinically indicated (symptomatic) - To assess for RPOC - If bHCG level ahs not fallen more than 90% over 7 days. Surgical mng if woman requests it or other concern, ongoing heavy bleeding. Recommend repeat urinary preg test in 3-6 weeks if: - no POC histopath. - Failure to return to normal menstruation by 4-6 weeks. - Ongoing abnormal bleeding.

Question 67

What advice would you give to women opting for medical mng of NVIUP?

Answer 67

1. Bleeding heavier than menses is likely. 2. Cramping may accompany bleeding. 3. If bleeding has not commenced by 24 hours following treatment, to contact healthcare provider to determine ongoign care. 4. Potential side effects include pain, diarrhoea and vomiting.

Question 68

What are the absolute clinical indications for surgical mng for NVIUP?

Answer 68

1. Haemodynamic instability 2. Persistent excessive vaginal bleeding. 3. Evidence of infected retained tissue 4. Suspected GTD.

Question 69

What is the recommended surgical method for NVIUP?

Answer 69

Suction curettage.

Question 70

What are the risks/benefits of surgical mng for NVIUP?

Answer 70

As a primary approach, surgical mng results in a more immediate outcome with less follow-up. Standard risks a/w procedure and anaesthesia. ?Risk of Ashermann's syndrome

Question 71

What would make you proceed with caution with surgical mng of NVIUP?

Answer 71

1. increased risk of haemorrhage (e.g. suspected AVM or coagulopathy. 2. Previous uterine perforation.

Question 72

Describe the process of cervical priming wrt surgical mng of NVIUP?

Answer 72

1. Misoprostol 400mcg PV 3-4 hours prior to surgery OR | 2. Misoprostol 400mcg PO, S/L, buccal 2-3 hours prior to surgery

Question 73

Describe follow-up following surgical mng of NVIUP?

Answer 73

Advise GP f/u if ongoing clinical concerns bHCG not usually indicated. USS not routinely recommended.

Question 74

Describe potential aetiologies of 2nd trimester pregnancy loss.

Answer 74

Fetal: - Chromosomal abnormalities - Congential abnormalities Maternal - Previous 2nd trimester loss - Uterine malformations - Maternal medical illness (e.g. cardiac disease, autoimmune disease, thrombophilia) - PROM - Placental complications (e.g. abruption) - Cervical insufficiency - Infection-estimated to be implicated in 10% to 25% of cases.

Question 75

Describe medical mng of 2nd trimester pregnancy loss where cx is closed and membranes are intact vs membranes ruptured and/or the cx is dilated...

Answer 75

If cx is closed and membranes are intact, mifepristone and misoprostol are 1st line agents for IOL. (misoprostol alone may be used). If membranes are ruptured and/or cx is dilated, consider misoprostol or IV oxytocin. Active mng is recommended if 3rd stage not complete in 30mins. If not complete within 1 hour consider MROP. Retain cord, membranes and placenta for histopath

Question 76

When might surgical mng be recommended for 2nd trimester preg loss?

Answer 76

persistent excessive bleeding, haemodynamic instability, evidence of RPOC, suspected GTD. Generally suitable for gestations up to 15 weeks. Beyond 16 weeks, may be suitable where baby has died at an earlier gestation.

Question 77

In a woman who has had a 2nd trimester pregnancy loss, what advice could you give her to help with lactation suppression?

Answer 77

Conservative and comfort measures. Minimal breast stimulation Cold compresses Analgesia.

Question 78

What are the contraindications to RhD immunoglobulin?

Answer 78

1. RhD positive women 2. RhD negative women with preformed anti-D antibodies 3. Previous sensitivity or allergy to RhD immunoglobulin 4. Woman declines.

Question 79

Indications for RhD IgG for 1-12+6 weeks gestation? (5)

Answer 79

1. Miscarriage 2. TOP 3. Ectopic pregnancy 4. CVS 5. Hydatidiform mole.

Question 80

Indications for RhD IgG 13+0 weeks and beyond (5)

Answer 80

1. CVS, amniocentesis, cordocentesis or fetoscopy 2. Abdominal trauma considered sufficient to cause fetomaternal haemorrhage (even if Kleihauer negative, as 0.001ml fetal blood sensitises an RhD negative mother). 3. Each occasion of revealed or concealed antepartum haemorrhage. 4. External cephalic version (performed or attempted) 5. Miscarriage or TOP

Question 81

When do you quantify FMH and how do you do this?

Answer 81

If gestation > 13 weeks, quantifiy FMH. - Each 100 IU of RhD-Ig protects against 1ml fetal red cells (2mls whole blood) If the Kleihauer test is negative, nil further dose required. If Kleihauer test indicates FMH is greater than that covered by RhD-Ig dose administered, give an additional dose within 72 hours. Most accurate quantitative test for FMH is flow cytometry. Interpret FMH with caution in women with persistent fetal Hg (i.e. African women, especially if sickle cell traits)

Question 82

What should you tell women before giving them RhD? (1)

Answer 82

RhD-Ig is a blood product.

Question 83

How quickly should you give anti-D?

Answer 83

Within 72 hours of a sensitising event.

Question 84

What is the dose and routine of anti-D?

Answer 84

Deep IMI Singleton pregnancy of 1-12+6 weeks gestation - > 250IU IMI 625IU IMI for: - Multiple pregnancy (any gestation) - Gestation uncertain but possibly 13 or more weeks - Gestation 13+0 weeks or beyond. NB: If BMI greater than 30 and FMH > 6mls, IV administration may be considered.

Question 85

Do you give Anti-D in threatened miscarriage?

Answer 85

1-12+6: Insufficient evidence to support routine use of anti-D for bleeding in an ongoing pregnancy. If there is heavy or repeat bleeding, or bleeding associated with abdo pain, significant abdo traum or a visible subchorionic haematoma, individualise RhD-Ig administration according to clinical circumstances. 13+0 weeks and beyond: Quantify FMH at 1-2 weekly intervals. Monitor for new sensitising events.. If Kleihauer positive, give additional RhD-Ig

Question 86

How is GTD classified?

Answer 86

Two premalignant diseases: 1. Complete hydatidiform mole 2. Partial HM Four invasive malignant disorders (i.e. gestational trophoblastic neoplasia): 1. Invasive mole/persistent trophoblast neoplasia 3. Choriocarcinoma 3. Placental site trophoblastic tumour (PSTT) 4. Epithelioid trophoblastic tumour.

Question 87

GTD is more common in which demographic? i.e. Asian, European or North American women

Answer 87

More common in Asia (as high as 2 per 1000 pregnancies) compared with Euorpe and North Amergica (less than 1 per 1000 pregnancies).

Question 88

How is definitive dx of GTD made?

Answer 88

histological examination of POC

Question 89

How to you treat GTD?

Answer 89

suction curettage with concomitant administration of IV uterotonic agents.

Question 90

What features may suggest to you persistent GTD?

Answer 90

Increased, stationary or inadequately falling b-hCG trend on 3 consecutive weeks at any time following surgical evacuation. Continued PV bleeding and detectable b-hCG Evidence of metastases in the presence of detectable bhCG.

Question 91

Describe the f/u for partial HM vs complete HM?

Answer 91

Partial HM: Weekly serum bhCG levels until negative for three consecutive weeks. Conception may be attempted immediately after three consecutive negative b-hCG results. Annual f/u for 5 years with QTC Complete HM Weekly serum bhCG until negative for three consecutive weeks. Then monthly for 6 months after the 3rd negative result. Conception may be attempted immediately after the 6 months of consecutive negative bhCG resutls are finalised. Annual f/u for 5 years with QTC

Question 92

Describe RFs for EPL? (epidemiological, anatomical, endocrine, genetic, others)

Answer 92

Epidemiological: Advanced maternal age (>40) Risk of EPL increases after each successive loss . Anatomical eg. congenital uterine malformations. Endocrine: e.g. DM, thyroid, PCOS. Genetic: chromosomal abnormalities of the embryo account for 30-57% of further EPL. Chromosomal anomaly present in one partner in 2-5% of couples. Antiphospholipid antibodies: present in 15% of women with recurrent EPL Infective agents. Inherited and acquired thrombophilia.

Question 93

What investigations would you arranged for work-up of recurrent EPL?

Answer 93

``` FBC ELFT Thrombophilia screen Fasting homocysteine and MTHFR (methylenetetrahydrofolate reductase) APL antibodies TFTs Fasting insulin Fasting blood glucose level POC for fetal karyotyping Parental chromosomes Pelvic USS to assess anatomy of the uterus and fallopian tubes. Sperm testing. ```

Question 94

When is it compulsory to register the birth of a baby born in QLD?

Answer 94

Born alive (a baby who's heart has beaten after delivery of the baby is completed) 20 weeks or more gestation. 400g or more. NB: If a birth registration is compulsory, a death certificate and burial cremation are also compulsory.

Question 95

When is the embryonic period?

Answer 95

From 6-10 weeks

Question 96

When is cardiac activity routinely detected on USS?

Answer 96

6-6.5 weeks gestation

Question 97

What is the earliest sonographic finding on USS? (to suggest a pregnancy?)

Answer 97

Gestational sac

Question 98

How do you determine gestational age prior to CRL?

Answer 98

MSD. | Usually visible from 4 weeks and 3 days after LNMP.

Question 99

What is the first structure usually visible within the gestational sac and at what gestation is this visible?

Answer 99

Yolk sac. Visible by 5.5 weeks gestation or MSD of 8-10mm. No. of yolk sacs usually indicates the no. of amniotic sacs in the case of twin pregnancies

Question 100

When is the fetal pole usually visible on US?

Answer 100

5-6 weeks gestation | CRL at 6 weeks and 0 is 4mmm.

Question 101

During which period does the CRL increase by 1mm/day?

Answer 101

Embryonic period, week 6-10

Question 102

Describe the key landmarks in embryonic development and how these are used in early first trimester dating?

Answer 102

Gestational sac (no yolk sac, embryo or heartbeat) = 5 weeks. Gestational sac and yolk sac (no embryo, no heart beat) = 5.5 weeks. Gestational sac and yolk sac (living embryo, CRL < 5mm (too small to measure) = 6 weeks. When CRL available, usu this to date date.

Question 103

What are the indications for IMI MTX for ectopic pregnancy? (3)

Answer 103

Unruptured tubal ectopic pregancy with all of the of the following: - b-HCG less than 3000IU - fetal sac less than 3.5cm - NO fetal cardiac activity.

Question 104

Describe the IMI MTX protocol used for unruptured tubal ectopic pregnancy?

Answer 104

Dose calculated based on BSA Routine bloods + bHCG prior to administration. Antiemetic 30minsprior. Give antiemetic for 2/7 following. D1: bhCG and MTX 50mg/m2 BSA IMI D4: bhCG D7: bhCG. If D7 bHCG reduction is less than 15% of day 4 bhCG or less than 25% of D1 bhCG, give 2nd dose of MTX at 50mg/m2 BSA. D14: bhCG. if bhCG reduction < 15% of D7 bhCG, give 3rd dose. Monitor bHCG weekly until less than 5IU/L.

Question 105

What are the indications for IV MTX in ectopic pregnancy?

Answer 105

Any stable EP at the discretion of the physician, particularly if any of the following: - bHCG >3000IU/L - Fetal sac > 3000 IU/L - Presence of cardiac activity.