Early Pregnancy Problems Flashcards
What pattern of electrolyte disturbance is typically seen in severe ovarian hyperstimulation syndrome?
a. Raised sodium, raised potassium, low osmolality
b. Raised sodium, low potassium, raised osmolality
c. Low sodium, raised potassium, low osmolality
d. Low sodium, low potassium, raised osmolality
e. Low sodium, raised potassium, raised osmolality
C - Low sodium, low potassium, Low osmolality
Typically more severe forms of OHSS are characterised by hypovolaemia with fluid loss into the third space (ascites most commonly, though also pleural and pericardial effusions are possible in severe cases). This hypovolaemia is associated with a fall in plasma osmolality and sodium concentration due to ‘resetting’ of the osmotic thresholds and urine being concentrated to these new thresholds. Potassium is generally elevated.
What is the incidence of moderate/severe ovarian hyperstimulation syndrome in an IVF cycle?
a. 0.5-0.8%
b. 2-5%
c. 3-8%
d. 5-10%
e. 25-30%
C - 3-8%
Around 30% of IVF cycles are complicated by some degree of OHSS, the vast majority of which are mild, self-limiting cases. Around 3-8% of patients will experience more severe forms though inpatient treatment is indicated in <1%.
You review a patient 11 days following an hCG injection as part of an IVF cycle. She complains of bloating, abdominal pain and vomiting. The abdomen is soft to palpation with only mild tenderness. On USS the ovarian size is 9.5cm on the left and 10cm on the right. There is evidence of ascites on scan though not on examination. Haematocrit is elevated at 0.40. Serum electrolytes and coagulation screen are normal. You suspect ovarian hyperstimulation syndrome (OHSS) – what grade do you diagnose?
a. Mild
b. Moderate
c. Severe
d. Critical
e. Features not suggestive of OHSS
B - Moderate
This is moderate OHSS based on ovarian size, mildly elevated haematocrit and clinical symptoms. Clinical evidence of ascites would up-stage the presentation to severe – as would any biochemical derangement - though here it is seen on scan only.
What is the relative risk of VTE in the first trimester in an IVF pregnancy compared with a spontaneous pregnancy?
a. 20x
b. 10x
c. 6x
d. 4x
e. 2x
D - 4x
The overall risk of VTE in the first trimester is low – 0.2 per 1000 spontaneous pregnancies - though rises four-fold to 0.8 per 1000 with IVF. If the pregnancy is complicated by OHSS there is a further 21x rise to 16.8 per 1000.
What is the risk of VTE in the first trimester of pregnancies complicated by ovarian hyperstimulation syndrome?
a. 2.4 per 1000
b. 5.3 per 1000
c. 7.9 per 1000
d. 12.6 per 1000
e. 16.8 per 1000
E - 16.8 per 100
The overall risk of VTE in the first trimester is low – 0.2 per 1000 spontaneous pregnancies - though rises four-fold to 0.8 per 1000 with IVF. If the pregnancy is complicated by OHSS there is a further 21x rise to 16.8 per 1000.
A 37 year old patient is undergoing IVF after extensive investigation revealed idiopathic infertility. She has undergone egg retrieval following hCG administration followed by implantation of 2 embryos. She wishes to know what the likelihood is of developing ovarian hyperstimulation syndrome. What do you advise?
a. 10%
b. 20%
c. 30%
d. 50%
e. 65%
C - 30%
Around 30% of IVF cycles are complicated by some degree of OHSS, the vast majority of which are mild, self-limiting cases. Around 3-8% of patients will experience more severe forms though inpatient treatment is indicated in <1%.
A patient presents with a case of severe ovarian hyperstimulation syndrome – she has tense ascites , oliguria and a haematocrit of 0.48. After being treated with appropriate fluid replacement, she remains markedly oliguric though her haematocrit has normalised. What is the most appropriate management?
a. Paracentesis
b. Furosemide IV
c. Bendroflumethizide Orally
d. Spironolactone Orally
e. 500ml crystalloid fluid challenge
A - Paracentesis
Patients who fail to respond to conservative treatment may require paracentesis, the indications for which are as follows:
- Severe abdominal pain/distension
- Shortness of breath/respiratory compromise
- Oliguria despite adequate volume replacement
50-100mg of 25% human albumin solution may be used in patients with persistently elevated haematocrit despite fluid rehydration and there may be a role for diuretics in select cases, though the scenario here requires ascitic drainage in the first instance.
Following an IVF cycle and positive pregnancy test, a patient presents with abdominal pain, nausea and vomiting and mild shortness of breath. Further examination reveals normal lung sounds though palpable ascites abdominally. Chest x-ray is normal, haematocrit 0.4 and ultrasound of the pelvis demonstrates ovaries approximately 9cm in maximum diameter. Which of the following renders this presentation of ovarian hyperstimulation syndrome ‘severe’?
a. Shortness of breath
b. Haematocrit
c. Palpable ascites
d. Ovarian size
e. All of the above
C - Palpable ascites
Severe OHSS is defined by:
- Clinical ascites
- Oliguria
- H’crit >0.45
- Electrolyte disturbance
- Hypo-osmolality
- Ovarian size >12cm
Which of the following is typically associated with increased severity of ovarian hyperstimulation syndrome?
a. Increased pre-treatment antral follicle count
b. Ovarian stimulation with recombinant rather than urinary gonadotrophins
c. Successful, on-going pregnancy
d. Increased maternal BMI
e. Maternal age >35
C - Successful ongoing pregnancy
OHSS can be broadly divided into early and late presentation. Late cases, typically associated with successful pregnancy, tend to be more severe, thought to be complicated by the rising hCG levels.
Which of the following is NOT a risk factor for ovarian hyperstimulation syndrome (OHSS)?
a. Previous OHSS
b. High Anti-Müllerian Hormone (AMH) levels
c. Polycystic Ovarian Syndrome
d. High Antral Follicle Count
e. Maternal age >40
E - Maternal age >40
Patients with previous OHSS are at increased risk of recurrence, due in part to the persistence of the other risk factors quoted – i.e. those with PCOS or evidence of high ovarian reserve. There is no known association with maternal age.
What is the overall risk per cycle of ovarian hyperstimulation syndrome in patients undergoing IVF?
a. 1 in 2
b. 1 in 3
c. 1 in 4
d. 1 in 5
e. 1 in 10
B - 1 in 3
Around 30% of IVF cycles are complicated by some degree of OHSS, the vast majority of which are mild, self-limiting cases. Around 3-8% of patients will experience more severe forms though inpatient treatment is indicated in <1%.
A patient is admitted to the gynaecology ward 10 days after completing an IVF cycle, reporting bloating and abdominal pain. Bloods are normal though USS is performed which demonstrates increased ovarian size of 78mm on the right and 69mm on the left. What is the most likely diagnosis here?
a. Corpus luteum
b. Dermoid cysts
c. Mild OHSS
d. Moderate OHSS
e. Severe OHSS
C - Mild OHSS
This is mild OHSS – the ovarian volume is <8cm and the patient described has mild symptoms only with no ascites nor biochemical derangement. The corpus luteum is usually unilateral and to be of the size described would be unusual. While bilateral dermoid cysts is a possibility, there is little else in the history to support such a diagnosis. The background of IVF means OHSS is the most likely scenario here.
What are the legal obligations on medical practitioners in respect of mandatory reporting cases of ovarian hyperstimulation syndrome (OHSS) to the HFEA?
a. All cases of OHSS however mild must be reported
b. Any case considered moderate or greater must be reported
c. Any case considered severe or critical must be reported
d. Only critical cases must be reported
e. No mandatory reporting
C - Any case considered severe or critical must be reported
The HFEA mandates that only severe and critical cases must be reported. This means that true prevalence of the condition is difficult to assess. Deaths occurring in women with OHSS must be reported to MBBRACE irrespective of whether or not pregnancy occurs.
A patient with moderate ovarian hyperstimulation syndrome (OHSS) is reviewed on the gynaecology assessment unit. She is well and it is felt that continued outpatient management remains appropriate. How often should patients with OHSS being managed on an outpatient basis be reviewed?
a. Daily
b. 2-3 days
c. Weekly
d. 11-14 days
e. Only if symptoms worsen
B - 2-3 days
Most patients with OHSS can be managed as outpatients with review in an ambulatory setting every 2-3 days or sooner if symptoms worsening.
The vast majority of cases of ovarian hyperstimulation syndrome are self limiting. How long typically do cases persist?
a. 4-5 days
b. 7-10 days
c. 11-14 days
d. 3-4 weeks
e. 2-3 months
B - 7-10 days
Most cases of OHSS will resolve with supportive measures only in 7-10 days
What is the increased risk of miscarriage amongst pregnancies affected by ovarian hyperstimulation syndrome?
a. 2x
b. 4x
c. 8x
d. 15x
e. No increased risk
E - No increased risk
Rates of pre-eclampsia and preterm delivery are found to be increased in women with pregnancies complicated by OHSS though perhaps curiously, miscarriage rates appear unchanged.
What is the incidence of ectopic pregnancy amongst women presenting to early pregnancy units in the UK?
a. 2-3%
b. 4-5%
c. 8-9%
d. 10-12%
e. 13-15%
A - 2-3%
Ectopic pregnancy is seen in approximately 11 in every 1000 pregnancies in the UK – equivalent to around 11,000 cases per year or 1.1% of the obstetric population. Amongst the sub-group of the obstetric population seen in early pregnancy units, rates are predictably higher - 2-3% in this cohort will have ectopic pregnancy.
What is the recurrence rate of ectopic pregnancy?
a. 2.5%
b. 5%
c. 13.5%
d. 16%
e. 18.5%
E - 18.5%
Based on best available evidence, the overall recurrence risk for ectopic pregnancy is ~18.5% - which seems to be the same whether expectant, medical or surgical management is employed in the index case.
The most common ultrasound finding in tubal ectopic pregnancy is that of a non-cystic adnexal mass. In what percentage of tubal ectopic pregnancies will a clear gestational sac containing a yolk sac +/- fetal pole be seen?
a. 5-10%
b. 10-15%
c. 15-20%
d. 25-25%
e. 25-30%
C - 15-20%
An empty extra-uterine gestational sac is seen in 20-40% of ectopic pregnancies though a yolk sac and fetal pole are less common, visualised in only 15-20%. A non-cystic adnexal mass is by far the most common finding and is seen in up to 60%.
What is the length of the interstitial portion of the fallopian tube?
a. 0.5-1cm
b. 1-2cm
c. 2.5-3cm
d. 3-4cm
e. 4-5cm
B - 1-2cm
The interstitium is the final 1-2cm portion of the fallopian tube as it enters the uterus traversing the muscular myometrium of the uterine wall. Pregnancies implanting into the interstitial tube account for up to 6.3% of all ectopics. The classic appearance on USS is of a gestational sac in the upper, lateral corner of the uterus surrounded by >5mm of myometrium in all planes and of the ‘interstitial line sign’ – a thin echogenic line running between the centre of the uterus and the gestational sac. MRI may be used as an adjunct in making this, often difficult, diagnosis.
You see a patient post-op after a laparoscopy for tubal ectopic pregnancy. Intra-operatively, there was significant bilateral tubal damage with adhesions and contralateral hydrosalpinx noted, thus a decision was made to perform a salpingotomy on the affected tube in lieu of a planned salpingectomy. You explain to the patient the possibility of requiring further treatment for persistent trophoblast tissue – in what percentage of patients is further treatment needed after salpingotomy?
a. 4-11%
b. 8-15%
c. 15-20%
d. 21-27%
e. 30-33%
A - 4-11%
In patients with contralateral tubal damage, subsequent live birth rates appear considerably improved where salpingotomy rather than salpingectomy is performed for tubal ectopic pregnancy. Persistent trophoblast tissue requiring either adjunctive medical or further surgical treatment is an issue however and is seen in 4-11% of patients.
What is the most appropriate follow up after discharge for patients who undergo salpingotomy over salpingectomy for management of tubal ectopic pregnancy?
a. Urine pregnancy test in 2 weeks
b. Serum hCG in 48 hours and 48-hourly thereafter until negative
c. Serum hCG in 7 days and 48-hourly thereafter until negative
d. Serum hCG in 7 days and weekly thereafter until negative
e. No routine follow up required unless symptomatic
D - Serum hCG in 7 days and weekly thereafter until negative
Owing to the risks of persistent trophoblast (4-11%), patients who undergo salpingotomy rather than salpingectomy for ectopic pregnancy require follow up with serial hCG readings – the first reading should be taken at 7 days then weekly thereafter until returned to normal. Plateauing or rising levels should prompt consideration of the need for further management.
You see a patient in the EPAU with a diagnosis of tubal ectopic pregnancy. On review of the notes and ultrasound findings, it is felt that medical treatment with methotrexate is appropriate as the patient is keen to avoid surgery. What is the dose of methotrexate for medical management of ectopic pregnancy?
a. 25mg/kg
b. 25mg/m2
c. 30mg/m2
d. 50mg/m2
e. 50mg/kg
D - 50mg/m2
Methotrexate is dosed by body surface area rather than weight – the standard dose in medical management of ectopic pregnancy is 50mg/m2.
What follow up would you arrange for a patient who has received methotrexate for a tubal ectopic pregnancy?’
a. hCG on days 4 and 7 – if fall >15% between 4 and 7; for weekly hCG until negative
b. hCG on days 4 and 7 – if fall >25% between 4 and 7; for weekly hCG until negative
c. hCG on day 4 – if fall >15% between 1 and 4; for weekly hCG until negative
d. Repeat scan in 7 days with hCG
e. Repeat hCG in 48 hours then on days 4 and 7 if not falling
A - hCG on days 4 and 7 – if fall >15% between 4 and 7; for weekly hCG until negative
Patients treated with methotrexate should have their hCG level repeated on days 4 and 7 post treatment. While a rise may be seen between levels on days 0 and 4, it is a fall between days 4 and 7 of >15% that indicates suitability to continue with medical management. Where levels do not fall sufficiently between days 4 and 7, a repeat ultrasound scan should be performed to exclude fetal cardiac activity or haemoperitoneum and assess on-going suitability. Where the ultrasound is normal, consideration may be given to repeating the dose of methotrexate at this point.