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.
NICE stipulate clear criteria regarding patient suitability for methotrexate as first line treatment for ectopic pregnancy. What do they suggest as the maximum diameter of the ectopic mass for methotrexate assuming unruptured and no FH activity is seen?
a. 15mm
b. 25mm
c. 35mm
d. 45mm
e. 55mm
C - 35mm
NICE guidelines (which are themselves referenced in the RCOG guideline) suggest medical management with methotrexate is used as first line management in patients:
• With no significant pain
• Who have an unruptured ectopic mass <35mm with no visible cardiac activity on scan
• Beta-hCG between 1500 and 5000
• No intrauterine pregnancy seen on scan
Between what hCG range do NICE recommend methotrexate as first line treatment of ectopic pregnancy?
a. 0 and 500
b. 0 and 1500
c. 500 and 1500
d. 500 and 5000
e. 1500 and 5000
E - 1500 and 5000
NICE guidelines (which are themselves referenced in the RCOG guideline) suggest medical management with methotrexate is used as first line management in patients:
• With no significant pain
• Who have an unruptured ectopic mass <35mm with no visible cardiac activity on scan
• Beta-hCG between 1500 and 5000
• No intrauterine pregnancy seen on scan
Some clinically stable patients may be suitable for expectant management first line in ectopic pregnancy. Assuming all other criteria are met, what pattern of hCG levels is required for expectant management?
a. Falling hCG initially <1500
b. Falling hCG initially <1000
c. Falling hCG initially <500
d. hCG rise <15% initially <1500
e. hCG rise <15% initially <1000
A - Falling hCG initially <1500
Patients who are haemodynamically stable in whom hCG levels are initially <1500 and falling may be suited to expectant management assuming the remainder of the criteria for medical management are met (i.e. no significant pain, mass <35mm, no IUP).
An ST1 trainee asks you about a patient on the gynaecology ward who has undergone an emergency laparotomy earlier in the afternoon for a ruptured ectopic pregnancy. The patient is Rhesus negative and the trainee is wondering whether or not Anti-D is required. What percentage of ruptured ectopic pregnancies are complicated by feto-maternal haemorrhage?
a. 15%
b. 25%
c. 33%
d. 50%
e. 75%
B - 25%
Irrespective of gestation, all women who undergo surgical management of an ectopic pregnancy should receive anti-D if rhesus negative. This is because significant feto-metal haemorrhage is though to complicate as many as 25% of ruptured ectopic pregnancies.
A patient undergoing medical management of ectopic pregnancy with methotrexate enquires about the side effects to be expected, both serious and mild. Which of the following is NOT a recognised potential side effect of systemic methotrexate therapy?
a. Liver cirrhosis
b. Renal failure
c. Diminished ovarian reserve
d. Gastric ulceration
e. Marrow suppression
C - Diminished ovarian reserve
Diminished ovarian reserve is not known to be associated with methotrexate use, though patients should defer further pregnancy for a minimum of 3 months after treatment.
How long after treatment with methotrexate should women be advised to wait prior to trying for a further pregnancy?
a. 2 months
b. 3 months
c. 4 months
d. 6 months
e. 12 months
B - 3 months
Patients who are treated with methotrexate should generally defer trying for a further pregnancy for a minimum of 3 months after treatment. Conceiving within this 3 month window is not in itself an indication for termination of pregnancy however.
You see a patient in the EPAU with a scan at 7 weeks. Sadly, a diagnosis of tubal ectopic pregnancy is made and you explain the diagnosis to the patient with signposting to support groups. What proportion of patients will experience a significant grief reaction with ectopic pregnancy?
a. 3 in 10
b. 5 in 10
c. 7 in 10
d. 8 in 10
e. 9 in 10
B - 5 in 10
50% of patients who suffer an ectopic pregnancy are thought to display a significant grief reaction. Signposting to relevant charitable organisations can be useful.
What transient biochemical abnormality is commonly seen as a side effect of methotrexate treatment?
a. Raised creatinine
b. Raised ALT
c. Low urea
d. Hyponatraemia
e. Hypercalcaemia
B - Raised ALT
Amongst the more common, though typically mild, side effects of methotrexate, a transient rise in liver enzymes is described.
Which of the following drugs/drug classes should be avoided in patients undergoing medical management of ectopic pregnancy with methotrexate?
a. Combined oral contraceptives
b. Enzyme inducing anti-epileptics
c. Monoamine oxidase inhibitors
d. Vitamin D
e. Folic acid
E - Folic Acid
As the main mode of action of methotrexate is as a folate antagonist, folate-containing preparations (as well as alcohol) should be avoided for the duration of treatment.
A patient undergoes medical management of a tubal ectopic pregnancy with methotrexate. Her hCG levels are as follows:
Day 0 1605
Day 4 1879
Day 7 1800
An ultrasound scan is performed which demonstrates unchanged appearances from the initial scan – a scan inhomogeneous 28mm mass in the left adnexa with no pelvic free fluid. She is haemodynamically stable. What is the appropriate management here?
a. Repeat hCG in 48 hours
b. Repeat ultrasound in 7 days
c. Arrange laparoscopic salpingectomy in theatre
d. Repeat methotrexate dose
e. Arrange laparoscopic salpingotomy in theatre
D - Repeat methotrexate dose
Patients undergoing medical management of ectopic pregnancy with methotrexate should have their hCG levels rechecked on days 4 and 7. Providing the patient remains well and hCG falls >15% between days 4 and 7, continuation of medical management is appropriate. In this case there has been only a minimal change in hCG though the scan is unchanged and the patient remains well – repeating the methotrexate dose may be considered.
What is the respective proportion of molar pregnancy account for by complete and partial moles respectively?
Complete Partial
a. 75% 25%
b. 60% 40%
c. 50% 50%
d. 25% 75%
e. 10% 90%
A - 75% Complete; 25% Partial
Complete molar pregnancy (diploid – fertilisation of an empty egg) is more common than partial (tri/tetraploid – two sperm fertilising a normal egg) at a ratio of approximate 75% to 25% (or 3:1)
What percentage of patients with complete molar pregnancy will require chemotherapy?
a. Up to 3%
b. Up to 8%
c. Up to 15%
d. Up to 21%
e. Up to 32%
C - Up to 15%
The overall rate of chemotherapy for patients in the UK is low – 5-8%. It is higher however for patients with complete mole (15%) than partial mole (0.5%)
How long after medical management of miscarriage should a urine pregnancy test be performed, assuming products of conception were not sent for histological analysis?
a. 1 week
b. 2 weeks
c. 3 weeks
d. 6 weeks
e. 8 weeks
C - 3 weeks
Patients who undergo medical management of miscarriage should be advised to take a urine pregnancy test at home 3 weeks after completion especially when products of conception have not been sent for histological analysis.
What is the estimated incidence of molar pregnancy following termination of pregnancy?
a. 1 in 1000
b. 1 in 2000
c. 1 in 5000
d. 1 in 10,000
e. 1 in 20,000
E - 1 in 20,000
There is no routine need to send POC for histology following a therapeutic TOP – on the provision that fetal parts have been identified on USS prior to the procedure. While GTD following TOP Is incredibly rare – est. ~1 in 20,000 – the delay in diagnosis often leads to higher rates of adverse outcomes and life threatening complications.
A patient attends for a dating scan during which it is suspected that the pregnancy may represent a twin pregnancy in which one half is a molar pregnancy and the other apparently developing normally. What is the rate of live birth of the ‘normal’ twin in this scenario?
a. 80%
b. 65%
c. 40%
d. 25%
e. 10%
D - 25%
The outcomes for pregnancies such as that described – normal pregnancy with a concurrent complete mole – is poor, with only a 25% chance of achieving a live birth. These women should be referred to the regional fetal medicine centre for pre-natal invasive testing for fetal karyotype – particular if the precise diagnosis is uncertain – i.e. complete/normal or actually a well developed partial mole. Rates of pre-eclampsia, premature delivery and early fetal loss are unsurprisingly all increased in this scenario.
A patient is referred to the regional centre for trophoblastic disease after undergoing an ERPC for complete molar pregnancy at 6 weeks. Her hCG levels on day 21 post-op are undetectable. For how long should she be followed up?
a. 56 days from ERPC
b. 56 days from first normal hCG result
c. 6 months from first normal hCG result
d. 6 months from ERPC
e. She may be discharged at this point as hCG levels are now normal
D - 6 months from ERPC
Follow up after GTD is increasingly individualised though a few basic principles apply:
• Where hCG has returned to normal within 56 days of the pregnancy event, follow up is for 6 months from the date of uterine evacuation
• Where hCG remains elevated at day 56, follow up should be for 6 months from the date of normalisation of hCG
A patient is reviewed by the regional centre for trophoblastic disease after undergoing ERPC for complete molar pregnancy at 5 weeks. Her hCG levels are checked on day 21 post-op and remain elevated. For how long should she be followed up?
a. 56 days from ERPC
b. 56 days from first normal hCG result
c. 28 days from first normal hCG result
d. 6 months from ERPC
e. 6 months normalisation of hCG
E - 6 months from normalisation of hCG
Follow up after GTD is increasingly individualised though a few basic principles apply:
• Where hCG has returned to normal within 56 days of the pregnancy event, follow up is for 6 months from the date of uterine evacuation
• Where hCG remains elevated at day 56, follow up should be for 6 months from the date of normalisation of hCG
What percentage of patients with partial molar pregnancy will require chemotherapy?
a. 0.5%
b. 2%
c. 10%
d. 15%
e. 25%
A - 0.5%
The overall rate of chemotherapy for patients in the UK is low – 5-8%. It is higher however for patients with complete mole (15%) than partial mole (0.5%)
Using the FIGO scoring system to plan chemotherapy following molar pregnancy, which of the following is associated with an increased likelihood of requiring chemotherapy?
a. Age 38
b. Tumour size 2.5cm
c. Lung metastases
d. Pre-treatment serum hCG 55
e. GI tract metastases
E - GI tract metastases
Determining the need for chemotherapy in patients with GTN is based on the 2000 FIGO scoring system based on assessment undertaken at the treatment centre. It is worth remembering as it doesn’t necessarily follow an immediately clear logic.
Using this system, a score or 6 or less is considered low-risk and treatment with single agent chemo (methotrexate) on alternate days with folic acid for 1 weeks is given and associated with a cure rate of almost 100%. Scores of 7 or higher however are high-risk and command multi-drug IV chemotherapy continued until hCG normalises and for 6 weeks thereafter. Cure rates in the high risk group remain optimistic (95%).
Using the FIGO scoring system to plan chemotherapy following molar pregnancy, which of the following scores is the highest risk factor?
a. Time from index pregnancy-treatment 14 months
b. Tumour size 5cm
c. Metastases to kidney
d. Previous single drug chemotherapy failure
e. GTD following termination of pregnancy
A - Time from index pregnancy-treatment 14 months
Determining the need for chemotherapy in patients with GTN is based on the 2000 FIGO scoring system based on assessment undertaken at the treatment centre. It is worth remembering as it doesn’t necessarily follow an immediately clear logic.
Using this system, a score or 6 or less is considered low-risk and treatment with single agent chemo (methotrexate) on alternate days with folic acid for 1 weeks is given and associated with a cure rate of almost 100%. Scores of 7 or higher however are high-risk and command multi-drug IV chemotherapy continued until hCG normalises and for 6 weeks thereafter. Cure rates in the high risk group remain optimistic (95%).
What treatment is recommended for patients scoring a 6 or lower on the FIGO system?
a. Methotrexate – alternate days for one week
b. Methotrexate – single dose
c. Methotrexate – weekly dosing until hCG normal and for 6 weeks thereafter
d. Vincristine and Dactomycin – single course
e. Vincristine and Dactomycin – for 6 weeks after normalisation of hCG
A - Methotrexate on alternative days for one week
Determining the need for chemotherapy in patients with GTN is based on the 2000 FIGO scoring system based on assessment undertaken at the treatment centre. It is worth remembering as it doesn’t necessarily follow an immediately clear logic.
Using this system, a score or 6 or less is considered low-risk and treatment with single agent chemo (methotrexate) on alternate days with folic acid for 1 weeks is given and associated with a cure rate of almost 100%. Scores of 7 or higher however are high-risk and command multi-drug IV chemotherapy continued until hCG normalises and for 6 weeks thereafter. Cure rates in the high risk group remain optimistic (95%).
What is the risk of a further molar pregnancy in patients with a history of the condition?
a. 1 in 10
b. 1 in 50
c. 1 in 80
d. 1 in 150
e. 1 in 300
C - 1 in 80
The risk of recurrence of molar pregnancy is low at only 1 in 80 – more than 98% of patients who fall pregnant again in the future will not have another molar pregnancy and indeed nor are they deemed to be at increased risk of obstetric complications. Where molar pregnancy does recur, it is the same histological type in 68-80% of cases.
A 23 year old undergoes an ERPC following diagnosis of a molar pregnancy. She comes to the clinic 6 weeks later to discuss contraception options. She remains under the care of the regional centre as her hCG levels have yet to normalise. Which of the following do you advise is the most appropriate contraceptive for her?
a. Injection
b. Implant
c. Mirena IUS
d. Copper IUD
e. Condoms
E - Condoms
Women with GTD should be advised to use barrier methods of contraception until hCG levels return to normal. The copper IUD is contra-indicated until this time due to the risk of uterine perforation at insertion.
By how much on average, does chemotherapy expedite menopause by?
Single Agent Multiple Agent
a. No change 1 year
b. 1 year 3 years
c. 3 years 3 years
d. 1 year 1 year
e. No change No change
B - Single agent: 1 year; Multiple agent: 3 years
Women who receive chemotherapy for GTN are likely to experience an earlier menopause – advanced by 1 year with single drug, and 3 years with multi-drug regimens.
Amongst women of which ethnic background is gestational trophoblastic disease most common?
a. Eastern European
b. South American
c. North African
d. Asian
e. Afro-Caribbean
D - Asian
Among women in the UK, rates of GTD are almost twice as high in women from Asian backgrounds compared with women of other origins.
What is the approximate rate of gestational trophoblastic disease expressed per number of live births in the UK?
a. 1 in 500
b. 1 in 700
c. 1 in 1500
d. 1 in 2500
e. 1 in 5000
B - 1 in 700
The overall incidence of gestational trophoblastic disease in the UK is approximately 1 in 714 live births.
What proportion of partial molar pregnancies are genetically triploid?
a. 10%
b. 25%
c. 50%
d. 75%
e. 90%
E - 90%
The vast majority of partial molar pregnancies are genetically triploid, formed by 2 paternal gametes fertilising a single maternal ovum. The remaining 10% are typically tetraploid.
What is the incidence of GTN following a live birth?
a. 1 in 10,000
b. 1 in 50,000
c. 1 in 100,000
d. 1 in 500,000
e. 1 in 1,000,000
B - 1 in 50,000
The likelihood of developing gestational trophoblastic neoplasia requiring chemotherapy following a live birth is very rare – 1 in 50,000 live births
- What is the overall rate of patients with GTD requiring chemotherapy in the UK?
a. 1-3%
b. 5-8%
c. 10-12%
d. 13-15%
e. 17-20%
B - 5-8%
The overall rate of chemotherapy for patients in the UK is low – 5-8%. It is higher however for patients with complete mole (15%) than partial mole (0.5%)
A patient with a history of molar pregnancy attends the early pregnancy unit 2 years later, pregnant again. Sadly an ultrasound scan demonstrates a 9mm fetal pole with no cardiac activity and a missed miscarriage is diagnosed. After what future pregnancy outcomes should patients with a history of gestational trophoblastic disease be advised to contact their regional centre?
a. Live birth
b. Therapeutic termination
c. Miscarriage
d. Ectopic pregnancy
e. All of the above
E - All of the above
All women with a history of GTD should notify their regional screening centre at the end of ANY future pregnancy irrespective of the outcome. hCG levels are measured 6-8 weeks after the end to exclude disease recurrence.
A woman diagnosed with high-risk gestational trophoblastic neoplasia is to receive multi-agent chemotherapy. What is the expected cure rate?
a. 65%
b. 75%
c. 85%
d. 95%
e. 100%
D - 95%
Cure rates are good following chemotherapy – almost 100% for single dose chemo in low risk cases and 95% in multi-dose regimens for high-risk.
A patient attends the EPAU with bleeding and vomiting in early pregnancy. An ultrasound scan is highly suggestive of molar pregnancy. What is the optimum method of treatment?
a. Medical management with methotrexate
b. Medical management with mifepristone and misoprostol
c. Medical management with misoprostol only
d. Medical management with oxytocin
e. Surgical evacuation
E - Surgical evacuation
Surgical curettage is the methods of choice for evacuation of a molar pregnancy (except in select cases of partial mole where fetal parts are too great to permit this in which case medical may be used). There is a theoretical concern with routine use of oxytocic agents in embolisation or dissemination of trophoblastic tissue through the venous system. Preparation of the cervix with misoprostol immediately prior to surgical evacuation is safe though prolonged preparation should be avoided. Excessive vaginal bleeding during the procedure is common and a senior surgeon should directly supervise all such cases – oxytocin should be avoided wherever possible though may be given on balance of bleeding vs. embolisation risk in cases of significant haemorrhage following evacuation. All who undergo surgical evacutation should receive anti-D if rhesus negative (in the strictest sense, the histology of a complete mole is such that anti-D is not required [as there are no fetal parts and thus no D-antigen present] though is for partial – as there will be a delay of >72 hours between procedure and confirmatory histology, it should always be given).
What percentage of women are affected by some degree of nausea and vomiting in pregnancy?
a. 40%
b. 50%
c. 60%
d. 80%
e. 95%
D - 80%
Nausea and vomiting in pregnancy (NVP) affects up to 80% of pregnant women though true hyperemesis gravidarum (HG) is much less common – affecting only up to ~3.6%. The pathogenesis is thought to be closely tied to rising levels of hCG in early pregnancy and conditions associated with increased hCG levels (molar pregnancy, multiples) are associated with increased severity of NVP. Women can be reassured that NVP is a very much an early pregnancy problem and over 90% of cases will resolve by 20/40.
What proportion of pregnant women are affected by hyperemesis gravidarum in pregnancy?
a. Up to 2%
b. Up to 3.6%
c. Up to 10.3%
d. Up to 15.4%
e. Up to 20.1%
B - Up to 3.6%
Nausea and vomiting in pregnancy (NVP) affects up to 80% of pregnant women though true hyperemesis gravidarum (HG) is much less common – affecting only up to ~3.6%. The pathogenesis is thought to be closely tied to rising levels of hCG in early pregnancy and conditions associated with increased hCG levels (molar pregnancy, multiples) are associated with increased severity of NVP. Women can be reassured that NVP is a very much an early pregnancy problem and over 90% of cases will resolve by 20/40.
What early pregnancy hormone is thought to be responsible for the majority of cases of hyperemesis gravidarum?
a. Estradiol
b. Progesterone
c. Beta-hCG
d. Alpha-fetoprotein
e. Inhibin
C - Beta-hCG
Nausea and vomiting in pregnancy (NVP) affects up to 80% of pregnant women though true hyperemesis gravidarum (HG) is much less common – affecting only up to ~3.6%. The pathogenesis is thought to be closely tied to rising levels of hCG in early pregnancy and conditions associated with increased hCG levels (molar pregnancy, multiples) are associated with increased severity of NVP. Women can be reassured that NVP is a very much an early pregnancy problem and over 90% of cases will resolve by 20/40.
Patients with nausea and vomiting of pregnancy can be reassured that 90% of cases will resolve by what gestation?
a. 12/40
b. 16/40
c. 20/40
d. 28/40
e. 30/40
C - 20/40
Nausea and vomiting in pregnancy (NVP) affects up to 80% of pregnant women though true hyperemesis gravidarum (HG) is much less common – affecting only up to ~3.6%. The pathogenesis is thought to be closely tied to rising levels of hCG in early pregnancy and conditions associated with increased hCG levels (molar pregnancy, multiples) are associated with increased severity of NVP. Women can be reassured that NVP is a very much an early pregnancy problem and over 90% of cases will resolve by 20/40.
A primigravida presents to her GP at 9/40 requesting anti-emetics. Since realising she was pregnant she has been vomiting every day and noticed her clothes feel looser. What degree of pre-pregnancy weight loss is typically associated with hyperemesis?
a. >2%
b. >5%
c. >10%
d. >20%
e. >25%
B - >5%
Many patients with straightforward NVP are incorrectly labelled as having HG. Diagnosis of HG depends on the presence of clinical dehydration, biochemical derangement/electrolyte imbalance and >5% pre-pregnancy weight loss.
One means by which the severity of nausea and vomiting in pregnancy is by use of the PUQE score. What score indicates severe nausea and vomiting?
a. >5
b. >8
c. >13
d. >20
e. >24
C - >13
A score of ^ or less is considered mild, 7-12 moderate and 13-15 severe
What proportion of patients with hyperemesis will have transiently abnormal thyroid function on testing?
a. 1/5
b. 1/4
c. 1/3
d. 2/5
e. 2/3
E - 2/3
There is a structural similarity between TSH and hCG which can give rise, in ~2/3 of cases to a biochemical thyrotoxicosis with raised free thyroxine levels (though not necessarily always with a suppressed TSH). These patients are usually clinically euthyroid - the biochemical changes improve alongside the NVP and treatment with anti-thyroid medication is not indicated.
A patient is admitted at 13/40 - her third admission for hyperemesis. During this admission, thyroid function testing is performed in view of refractory symptoms and noted to be deranged. What treatment is recommended for the thyroid function abnormalities seen in hyperemesis?
a. Propylthiouracil
b. Carbimazole
c. Levothyroxine
d. Methimazole
e. No treatment required
E - No treatment required
There is a structural similarity between TSH and hCG which can give rise, in ~2/3 of cases to a biochemical thyrotoxicosis with raised free thyroxine levels (though not necessarily always with a suppressed TSH). These patients are usually clinically euthyroid - the biochemical changes improve alongside the NVP and treatment with anti-thyroid medication is not indicated.
What is the typical derangement in liver function seen in ~40% of patients with hyperemesis?
a. Raised ALP
b. Raised bilirubin
c. Low albumin
d. Raised ALT
e. Low AST
D - Raised ALT
40% of patients with NVP will display transiently abnormal LFTs – a rise in transaminases the most common though bilirubin and amylase levels can be slightly raised too. Again these improve along with the NVP.
A patient with severe nausea and vomiting of pregnancy returns to her GP complaining that she is achieving little relief from first line therapy. After discussion, the GP issues a prescription for metoclopramide. What is the recommended dose of metoclopramide for treatment of nausea and vomiting of pregnancy?
a. 5-10mg 8 hourly
b. 4-8mg 6 hourly
c. 50-100mg 8 hourly
d. 150mg 8 hourly
e. 250-500mg 6 hourly
A - 5-10mg 8 hourly
A patient with severe nausea and vomiting of pregnancy returns to her GP complaining that she is achieving little relief from first line therapy. After discussion, the GP issues a prescription for domperidone tablets. What is the recommended dose of oral domperidone for treatment of nausea and vomiting of pregnancy?
a. 5mg 8 hourly
b. 10mg 8 hourly
c. 30mg 6 hourly
d. 100mg 8 hourly
e. 150mg 6 hourly
B - 10mg 8 hourly
A patient with severe nausea and vomiting of pregnancy returns to her GP complaining that she is achieving little relief from first line therapy. After discussion, the GP issues a prescription for ondansetron. What is the recommended dose of metoclopramide for treatment of nausea and vomiting of pregnancy?
a. 5-10mg 8 hourly
b. 4-8mg 6 hourly
c. 16mg 8 hourly
d. 40-80mg 8 hourly
e. 12mg 6 hourly
B - 4-6mg 6 hourly
A patient with nausea and vomiting reports that she is struggling to keep down oral tablets and enquires about other means by which she might take anti-emetics though without the need for inpatient admission. Which of the following anti-emetics can be administered rectally?
a. Cyclizine
b. Metoclopramide
c. Ondansetron
d. Domperidone
e. Prednisolone
D - Domperidone
Of the preparations listed, only domperidone may be administered rectally, albeit at a considerably increased dose to the oral preparation.
Extrapyramidal side effects and oculogyric crises may complicate use of which common anti-emetic?
a. Domperidone
b. Hydrocortisone
c. Cyclizine
d. Ondansetron
e. Metoclopramide
E - Metoclopramide
Women presenting with NVP should be asked about the success and side effects of any previous therapy. Drug-induced extra-pyramidal symptoms and oculogyric crises can occur with the use of both phenothiazines (prochlorperazine et al.) and metoclopramide.
What is the suggested initial regimen in patients requiring corticosteroids for hyperemesis gravidarum when other therapy has failed?
a. Prednisolone 30mg OD
b. Prednisolone 60mg OD
c. Hydrocortisone 100mg BD
d. Hydrocortisone 50mg BD
e. Hydrocortisone 100mg OD
C - Hydrocortisone 100mg BD
Patients with refractory NVP may require consideration of steroids after standard therapy has failed. The suggested dose is 100mg IV Hydrocortisone BD with step-down to 40-50mg Prednisolone orally (on a reducing regimen) once stable.
Thiamine supplementation is recommended in all admitted with protracted vomiting, especially prior to those in whom parenteral nutrition or dextrose infusions are being considered, in order to reduce the risk of Wernicke’s encephalopathy. How is thiamine also known?
a. Vitamin D3
b. Vitamin B1
c. Vitamin B3
d. Vitamin B12
e. Vitamin K
B - Vitamin B1
B-Vitamins of note: B1 Thiamine B2 Riboflavin B6 Pyridoxine B9 Folic acid B12 Cobalamin
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 expressed strong concerns about her future fertility. What is the single best management option?
a. Bilateral salpingectomy
b. Bilateral salpingotomy
c. Medical management
d. Salpingectomy with conservation of contralateral tube
e. Salpingotomy with conservation of contralateral tube
E - Salpingotomy with conservation of the contralateral tube
A 27 year old woman attends the EPAU at 6/40 with mild lower abdominal pain which settles with analgesia and moderate vaginal bleeding. Abdominal and vaginal examinations are normal and a urine pregnancy test is positive. A TV ultrasound shows no intra-uterine gestational sac, both ovaries appear normal and there is no free fluid in the pouch of Douglas. What is the most appropriate management?
a. Diagnose complete miscarriage and advise repeat pregnancy test in 10 days
b. Diagnostic laparoscopy
c. Inpatient admission with monitoring of serum hCG
d. Outpatient management with monitoring of hCG
e. Repeat ultrasound in 7 days
D - Outpatient management with monitoring of hCG
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:
BP: 128/65mmHg Pulse: 77/min Temperature: 36.5C RR: 16/min hCG: 5000iU/L
What is the treatment of choice for this woman?
a. Expectant management
b. Methotrexate
c. Laparoscopic right salpingectomy
d. Laparoscopic right salpingotomy
e. Laparotomy and right salpingectomy
C - Laparoscopic right salpingectomy
A 24 year old primiparous woman at 6 weeks gestation presents to the emergency department with a 2 week history of brown vaginal discharge. TV ultrasound shows an ectopic pregnancy 20 x 14 x 10mm in the left adnexa with absent fluid in the pouch of Douglas. Vaginal examination is negative for excitation. Vitals on arrival were as follows:
BP: 118/68mmHg Pulse: 72/min Temperature: 36.5C RR: 18/min hCG: 527iU/L
What is the treatment of choice for this woman?
a. Conservative management with serial hCG until <20
b. Methotrexate
c. Laparoscopic left salpingectomy
d. Laparoscopic left salpingotomy
e. Laparotomy and left salpingectomy
A - Conservative management with serial βhCG tests until levels falls below 20 iu/l.
RCOG guidance suggests selection criteria for expectant management are clinical stability with no abdominal pain, no evidence of significant haemoperitoneum on ultrasound scan, an ectopic pregnancy measuring less than 30 mm in mean diameter with no evidence of embryonic cardiac activity, a serum b-hCG level of less than 1500 iu/l and the woman’s consent.
A 24 year old woman experiences bleeding at 7 weeks gestation and attends the EPAU for a scan. On TV ultrasound there is a gestational sac containing a fetal pole with a CRL of 6.5mm though without a fetal heart. What is the next step in your management?
a. Arrange a follow up in <7 days for a repeat ultrasound before making a final diagnosis
b. Arrange a follow up in >7 days for a repeat ultrasound before making a final diagnosis
c. Ask a colleague for a second opinion before giving the final diagnosis
d. Discuss surgical management of miscarriage and book into the next available slot
e. Inform the woman she has had a miscarriage and discuss management options
B - Arrange a follow up in >7 days for a repeat ultrasound before making a final diagnosis
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?
a. Expectant management with serial hCG
b. Laparoscopy with left salpingectomy
c. Laparoscopy with left salpingotomy
d. Laparotomy and left salpingectomy
e. Methotrexate
C - Laparoscopy with left salpingotomy
A 34 year old Para 1 presents with mild vaginal spotting at 6 weeks. A TV ultrasound revealed no intrauterine sac but a 2 x 3cm mass was seen in the left adnexa with no free fluid. She opted to have medical management after detailed counselling which was undertaken the same day. The woman is asymptomatic. Her hCG results are as follows:
Day 0 1450iU
Day 2 1650iU
Day 4 1700iU
Day 7 1200iU
What is the most appropriate management option?
a. Advise the woman to do a pregnancy test in 2 weeks
b. Counsel and administer second dose methotrexate
c. Continue weekly hCG until <15 if remains asymptomatic
d. hCG every 48 hours until undetectable
e. Perform laparoscopy and salpingectomy
C - Continue weekly hCG until <15 if remains asymptomatic
Which of the following factors is most likely to significantly increase the FIGO prognostic risk factor shoring for histologically confirmed choriocarcinoma?
a. Pre-treatment hCG 103 - 104 iU/L
b. Residual uterine tumour mass of 2 x 2cm
c. Diagnosis within 4 months of a complete molar pregnancy
d. Metastases to brain
e. Age <40 with metastases to lungs
D - Metastases to brain
Which of the following factors is characteristically associated with partial hydatidiform mole?
a. No evidence of fetal tissue or fetal bloods cells on histology
b. Arise due to dispermic fertilisation of an ovum
c. All cases have triploid karyotype
d. Histology shows diffuse villous hydrops and trophoblast hyperplasia
e. Higher risk than complete mole of requiring chemotherapy
B - Arise due to dispermic fertilisation
Which statement is correct in relation to histological analysis of the products of conception in the diagnosis of gestational trophoblastic disease?
a. In women with a history of molar pregnancy, for all future pregnancies, serum or urine hCG concentrations should be routinely checked 6 and 10 weeks after delivery to ensure no reactive of molar disease
b. Complete molar pregnancies are associated with fetal parts
c. In women with a history of molar pregnancy, the placenta should be routinely sent for histological examination in all future pregnancies to ensure no reactivation of molar disease
d. Products of conception from all terminated pregnancies should be routinely sent for histological examination
e. Histological appearance is consistently more reliable than DNA ploidy status and immunohistochemistry for p57 in distinguishing partial from complete molar pregnancy.
A - In women with a history of molar pregnancy, for all future pregnancies, serum or urine hCG concentrations should be routinely checked 6 and 10 weeks after delivery to ensure no reactive of molar disease
Which statement is correct in relation to contraception and future pregnancy outcomes for women whose last pregnancy was a complete or partial mole?
a. There is an increased risk of future congenital fetal malformation and infertility
b. HRT is contraindicated
c. IUCDs are contraindicated due to an increased risk of perforation
d. The COCP may be safely used once hCG levels have normalised
e. Women requiring chemotherapy should not conceive for 6 months following completion
D - The COCP may be safely used once hCG levels have normalised
Which of the following is not an indication for chemotherapy for gestational trophoblastic disease in the UK?
a. Raised hCG 6 months after evacuation even when still falling
b. Evidence of metastases in the brain, live, GI tract or lung
c. Histological diagnosis of complete mole
d. Heavy vaginal bleeding persisting after uterine evacuation
e. Plateaued or rising hCG concentration after uterine evacuation.
C - Histological diagnosis of a complete mole
A 38-year-old woman underwent a suction evacuation procedure following a diagnosis of a missed miscarriage 8 weeks ago. Histopathology results confirmed a molar pregnancy. She had a blood sample taken to assess serum HCG 2 days ago at her GP surgery, which was 500 iu/ml. She presents to you for her follow up appointment. What is the most appropriate duration of follow up?
a. Follow up for 3 months from date of uterine evacuation
b. Follow up for 3 months from normalisation of hCG
c. Follow up for 6 months from date of uterine evacuation
d. Follow up for 6 months from normalisation of hCG
e. Follow up for 6 months from diagnosis of molar pregnancy
D - Follow up for 6 months from normalisation of HCG.
If the hCG has not reverted to normal within 56 days of the pregnancy event then follow-up will be for 6 months from normalisation of the hCG level.
A 36-year-old woman presents to her GP after a miscarriage with confirmation of gestational trophoblastic disease in the histology. Her HCG levels have not yet normalised and she was using combined oral contraceptive pills prior to her pregnancy. What is the most suitable contraceptive advice that you would offer her?
a. Barrier methods are contraindicated
b. Continue to use the combined pill and advise that progesterone only pill is contraindicated
c. Change to intrauterine contraceptive device as these are safe
d. Stop the oral contraceptives immediately
e. Continue with the oral contraception and she should be advised that there is a potential but low increased risk of developing GTN
E - Continue with the oral contraception and she should be advised that there is a potential but low increased risk of developing GTN
There is no evidence that single-agent progestogens have any effect on GTN.
A 42-year-old woman presents with hyperemesis and irregular vaginal bleeding. She had an ultrasound scan that showed snowstorm vesicular appearance. Her bHCG levels were 120,000 iu/l. Which one of the statements below are true?
a. Cervical ripening with Misoprostol immediately prior to surgical evacuation is contraindicated as it increases the risk of embolization of trophoblastic tissue in complete molar pregnancies
b. Medical evacuation is a suitable option for complete molar pregnancies as these are less likely to embolise & disseminate than partial moles
c. Suction curettage is the method of choice of evacuation for complete molar pregnancies
d. Suction evacuation should be avoided in complete molar pregnancies due to increased risk of uterine perforation due to the enlarged uterine cavity
e. The use of oxytocic agents during the operative procedure must not be used even if bleeding is severe as it increases the risk of tissue embolisation
C - Suction curettage is the method of choice of evacuation for complete molar pregnancies
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?
a. Continuation of pregnancy is an option as 25% women may proceed to deliver healthy babies without an increased risk of complications
b. Continuation of pregnancy should be offered as there is a 60% chance of achieving a live birth with a coexisting complete mole
c. 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
d. Termination of pregnancy should be only offered in those cases where there is a coexistent partial mole as opposed to a complete mole
e. Termination of pregnancy should not be offered as there are no risks to the viable twin
A - Continuation of pregnancy is an option as 25% women may proceed to deliver healthy babies without an increased risk of complications
The outcome for a normal pregnancy with a coexisting complete mole is poor, with approximately a 25% chance of achieving a live birth. There is an increased risk of early fetal loss (40%) and premature delivery (36%). In a large UK series, there was no increase in the risk of developing GTN after such a twin pregnancy and outcome after chemotherapy was unaffected.
A 36 year old woman presents to the recurrent miscarriage clinic with a history of one first trimester loss and two second trimester losses. Which of the following is NOT a recommended investigation?
a. TORCH screen
b. Screening for APLS antibodies
c. Pelvic ultrasound
d. Parental karyotyping
e. Cytogenic analysis of retained products of conception
A - TORCH Screening
Parental karyotyping and cytogenetic analysis of the products of conception of the third and subsequent miscarriage should be done. In 2–5% of couples with recurrent miscarriage, one of the partners carries a structural chromosomal anomaly, mainly balanced translocations or Robertsonian translocations. The reported prevalence of uterine anomalies in the miscarriage population is between 1.8% and 37.6%. For an infective agent to cause repeated miscarriage, it must be capable of residing in the genital tract without causing the woman any symptoms and avoiding detection. TORCH agents do not fulfil these criteria and hence TORCH screening should not be performed for recurrent miscarriage.
A 30 year old woman attends the scan department. She has been spotting for the last few days. There is no pain and UPT is positive. A 6mm fetal pole is identified on TV ultrasound. No heartbeat is detected. Chose the single most appropriate management option:
a. Repeat scan in 14 days
b. Repeat scan in 7 days
c. Offer MVA
d. Offer medical management of miscarriage
e. Offer surgical management of miscarriage
B - Repeat scan in 7 days
A 30 year old woman attends the scan department. A 25mm gestational sac is identified on TV USS. No fetal pole is seen. What is the most appropriate management?
a. Repeat scan in 2 weeks
b. Repeat scan in 7 days
c. Offer MVA
d. Offer medical management of miscarriage
e. Offer surgical management of miscarriage
B - Repeat scan in 7 days
If there is no option regarding seeking a second opinion there and then – repeat the scan in 7 days (if TV) or 14 days (if TA).
A 38 year old patient is reviewed in the recurrent miscarriage clinic. She has had 2 positive tests, 12 weeks apart, for anticardiolipin antibodies. What is the best management option for her next pregnancy?
a. Aspirin 75mg + LMWH daily
b. Aspirin 75mg + unfractioned heparin daily
c. Aspirin 300mg + LMWH daily
d. Aspirin 300mg daily
e. Aspirin 75mg daily
A - Aspirin 75mg + LMWH daily
A 27 year old primigravida who has had 2 previous early miscarriages presents at 9 weeks with brown PV spotting. Examination is normal and USS shows a fetus with CRL of 9mm but no fetal heart. Findings are confirmed by a second sonographer. What is the most appropriate next step in the management?
a. Administer 800 micrograms of misoprostol vaginally
b. Book for ERPC
c. Perform MVA under local anaesthetic in clinic
d. Refer to recurrent miscarriage service
e. Repeat scan in 7 days
E - Repeat scan in 7 days
Choose the single best answer regarding the management of GTD:
a. Women whose last pregnancy was a partial or complete hydratidiform mole can conceive immediately after evacuation
b. Women can use the contraception of their choice following treatment of GTD
c. Women who undergo chemotherapy are advised not to conceive for a year after completion of treatment
d. HRT is not safe in women who have had GTD
e. All women should be followed up for a year after surgical evacuation for molar pregnancy
C - Women who undergo chemotherapy are advised not to conceive for a year after completion of treatment
A woman presents to the early pregnancy assessment unit with lower abdominal pain and PV spotting at 6 weeks of gestation. This is her second pregnancy, having undergone a caesarean section 2 years earlier. In women with one previous caesarean and a diagnosis of ectopic pregnancy, what is the likelihood of the ectopic being in the caesarean scar?
a. 1-2%
b. 6-7%
c. 14-15%
d. 19-20%
e. 24-25%
B - 6-7%
What is the estimated recurrence risk of caesarean scar ectopic?
a. Up to 5%
b. Up to 15%
c. Up to 25%
d. Up to 50%
e. Up to 75%
A - Up to 5%
A diagnosis of a caesarean scar pregnancy has been made in a 23-year-old woman who had an elective caesarean section for breech presentation last year. She has been counselled and elects to have methotrexate. What baseline investigations should be performed prior to administering this systemic treatment?
a. Full blood count
b. Full blood count and liver function test
c. Full blood count, liver, lung and renal function tests
d. Full blood count, renal and liver function tests
e. Lung, liver and renal function test
D - Full blood count, renal and liver function tests
A 30-year-old woman has been referred for an early ultrasound scan and booking for antenatal care on account or a past history that was complicated by an emergency CS that resulted in massive haemorrhage and blood transfusion. She is 7 weeks’ pregnant by her last menstrual period. An ultrasound scan is performed and this is suggestive of a caesarean scar pregnancy. Assuming that this diagnosis is correct what would be the most appropriate initial treatment approach for this patient?
a. Combined systemic and local methotrexate
b. Hysteroscopic resection
c. Local injection with embryocides such as methotrexate
d. Systemic methotrexate
e. Uterine artery embolisation
D - Systemic methotrexate
What is the incidence of hetero-ectopic pregnancy in association with assisted reproduction technology?
a. 1 in 30,000
b. 1 in 10,000
c. 1 in 1000
d. 3 in 1000
e. 8 in 1000
E - 8 in 1000
What is the prevalence of ectopic pregnancy amongst women undergoing assisted reproductive treatment?
a. 1-2%
b. 2-10%
c. 5-15%
d. 10-15%
e. 15-20%
B - 2-10%
A Para 3 (1 caesarean section, 2 vaginal births) is seen on the early pregnancy unit with a missed miscarriage and opts for manual vacuum aspiration. Scan has revealed a fetal pole with a CRL of 35mm as well 2 intramural fibroids measuring 3cm each in diameter. You note from her record that 5 months earlier she completed a course of antibiotics for chlamydial infection. What feature in this history renders MVA an unacceptable choice for this patient?
a. Previous Caesarean
b. History of Chlamydia
c. Uterine fibroid
d. Multiparity
e. CRL 35mm
E - CRL 35mm
A patient attends the EPAU for a viability scan after experiencing some light vaginal bleeding around 6 weeks since her last menstrual period. A transvaginal scan demonstrates an empty gestational sac within the uterine cavity with dimensions 30 x 20 x 25mm. What management plan is most appropriate here?
a. Beta-hCG now and in 48 hours
b. Second opinion by sonographer to confirm miscarriage
c. Diagnose miscarriage and initiate management
d. Pipelle endometrial biopsy
e. Repeat scan in 14 days
B - Second opinion by a sonographer to confirm
A patient attends the gynaecology ward overnight after experiencing some cramping lower abdominal pain around 7 weeks since her last menstrual period. You perform a transvaginal scan which demonstrates an intrauterine gestational sac containing a yolk sac and fetal pole measuring 7mm in CRL with no evidence of cardiac activity on colour doppler. The patient is clinically well. What management is appropriate here?
a. Diagnose and initiate management of missed miscarriage
b. Measure beta-hCG now and again in 48 hours
c. Repeat scan in 7 days
d. Administer progesterone pessaries
e. Reassure the patient and discharge
C - Repeat scan in 7 days
A patient admitted to the gynaecology ward with hyperemesis gravidarum is found to be tachycardic. Her biochemistry results demonstrate a high T4 and low TSH on thyroid function testing. What management is most appropriate here?
a. Carbimazole
b. Propylthiouracil
c. Thyroxine
d. Propranolol
e. Do nothing
E - Do nothing
What is the approximate risk of miscarriage in mothers age 40-45 at conception?
a. 25%
b. 40%
c. 50%
d. 75%
e. 95%
C - 50%
The risk of miscarriage is known to rise with advancing maternal age – owing to a decline in number and quality of oocytes - as follows:
12-19 years 13% 20-24 years 11% 25-29 years 12% 30-34 years 15% 35-39 years 25% 40-44 years 51% >45 years 93%
This demonstrates a gradual rise throughout the 20s and 30s with a drastic increase (doubling) at age 40 and then again at 45. A role for advanced paternal age is also speculated, though maternal age remains one of the most important factors in counselling couples on this topic. The risk of miscarriage is highest in couples where the women is 35 years or older, and the male partner 40 or over
The risk of miscarriage appears to increase with each successive loss. What is the risk of miscarriage quoted in a subsequent pregnancy after 3 successive losses?
a. 25%
b. 40%
c. 55%
d. 75%
e. 80%
B - 40%
Previous reproductive history is an independent risk factor for women experiencing miscarriage, cumulating in a 40% risk of further loss after 3 consecutive miscarriages.
APLS is recognised as an important, treatable cause of recurrent miscarriage though anti-phospholipid antibodies may also be encountered in the general population. What is the incidence of anti-phospholipid antibodies in a recurrent miscarriage and the general obstetric populations respectively?
Recurrent Miscarriage General Obstetric
a. 2% 0.5%
b. 5% 1%
c. 15% 2%
d. 25% 5%
e. 33% 3%
C - 15% Rec. misc.; 2% General
Antiphospholipid syndrome refers to the association between antiphospholipid antibodies – lupus anticoagulant, anticardiolipin antibodies and anti-B2 glycoprotein-I antibodies – and adverse pregnancy outcome or vascular thrombosis. The incidence of antiphospholipid antibodies in women with a ‘low-risk’ obstetric history is ~2% though as high as 15% in the recurrent miscarriage population. The mechanisms by which antiphospholipid antibodies cause pregnancy morbidity include inhibition of trophoblastic function and differentiation, activation of complement pathways at the maternal–fetal interface resulting in a local inflammatory response and, in later pregnancy, thrombosis of the utero-placental vasculature. These changes are though to be reversible – in part – by heparin.
You see a couple in the gynaecology clinic with recurrent miscarriage. Testing has identified the female partner to have APLS and you discuss treatment options. What is the estimated live birth rate without intervention in couples with recurrent miscarriage and APLS?
a. 10%
b. 25%
c. 50%
d. 75%
e. 80%
A - 10%
In a recurrent miscarriage population, APLS without treatment is thought to carry a live birth rate of less than 10%
You see a couple in the clinic with recurrent miscarriage. They have researched online and enquire about genetic testing for a translocation. In what proportion of couples with recurrent miscarriage, will a balanced chromosomal abnormality be found?
a. <1%
b. 2-5%
c. 5-8%
d. 9-12%
e. >15%
B - 2-5%
Parental karyotyping is only indicated when an unbalanced, structural chromosomal abnormality is detected when cytogenic analysis of the products of conception is performed and this is only indicated on that of the third consecutive miscarriage onwards. Around 2-5% of couples in the recurrent miscarriage population are found to be affected by a structural chromosomal abnormality – typically a balanced reciprocal or Robertsonian translocation.
Which of the following denotes the diagnostic criteria for APLS?
a. Single positive test to lupus anticoagulant and anti-mitochondrial antibodies
b. Single positive test to either lupus anticoagulant or anticardiolipin antibodies
c. Two positive tests, 6 weeks apart to anti-Ro/La and anti-smooth muscle antibodies
d. Two positive tests, 6 weeks apart to anti-nuclear antibody
e. Two positive tests, 12 weeks apart to either lupus anticoagulant or anti-cardiolipin antibodies
E - Two positive tests, 12 weeks apart to either lupus anticoagulant or anti-cardiolipin antibodies
To diagnose antiphospholipid syndrome it is mandatory that the woman has two positive tests at least 12 weeks apart for either lupus anticoagulant or anticardiolipin antibodies of IgG and/or IgM present in a medium or high titre (over 40 g/l or ml/l or > 99th centile). The detection of antiphospholipid antibodies is subject to considerable inter-laboratory variation due to temporal fluctuation of antiphospholipid antibody titres in individual women, transient positivity secondary to infections, suboptimal sample collection and preparation and lack of standardisation of laboratory tests for their detection.
Which of the following tests is not part of routine testing in couples with a history of recurrent first trimester miscarriage?
a. Thrombophilia testing
b. Pelvic Ultrasound
c. Genetic analysis of products of conception
d. Testing for anti-phospholipid syndrome
e. Genetic testing of parents where a chromosomal abnormality identified in the conceptus
A - Thrombophilia testing
Women with a history of second, though not first, trimester miscarriage should be offered screening for inheritable thrombophilia. While there may be a link between the two, the there is insufficient evidence to support LMWH as a treatment modality for first trimester miscarriage (though small cohort studies appear promising). There is however evidence to support such treatment in second trimester miscarriage.
What treatment is suggested for women identified as having APLS in the context of recurrent miscarriage?
a. Aspirin 75mg alone
b. Prophylactic dose LMWH and aspirin 75mg
c. Treatment dose LMWH and aspirin 75mg
d. Prophylactic dose LMWH alone
e. No treatment known to be of benefit
B - Prophylactic dose LMWH and aspirin 75mg
Low-dose aspirin together with heparin is the only treatment combination leading to a significant increase in live birth rate amongst women with APLS and a history of recurrent miscarriage and reduces the miscarriage rate by 54%. LMWH is generally preferred over unfractioned heparin owing to similar efficacy though easier administration and lower rates of thrombocytopenia and osteoporosis.
Which of the following women should be considered for prophylactic cervical cerclage?
a. 28 year old Para 1, 15/40 with a history of LLETZ 3 years ago and a term stillbirth aged 26.
b. 40 year old primigravidae, 32/40, with unexplained recurrent first trimester miscarriage, previous 2x LLETZ, and an incidental cervical length of 24mm with funnelling
c. 34 year old Para 3, 23/40 with a history of preterm labour and one second trimester loss; cervical length on scan is 25mm
d. 29 year old primigravidae, 12/40 with a history of cone biopsy to the cervix
e. 33 year old primigravidae, 18/40 DCDA twin pregnancy with a history of painless second trimester loss
C - 34 year old Para 3, 23/40 with a history of preterm labour and one second trimester loss; cervical length on scan is 25mm
Women with a history of second-trimester miscarriage and suspected cervical weakness who have not undergone a history-indicated cerclage may be offered serial cervical sonographic surveillance. In women with a singleton pregnancy and a history of one second-trimester miscarriage attributable to cervical factors, an ultrasound-indicated cerclage should be offered if a cervical length of 25 mm or less is detected by transvaginal scan before 24 weeks of gestation. There is no firm guidance at present on cervical cerclage or scanning in women with a history of colposcopic treatment (although the NICE guideline on preterm labour, somewhat open to interpretation, suggests a history of cervical ‘trauma’ may warrant scanning) or multiple pregnancy.
You see a 25 year old couple in the recurrent miscarriage clinic. They have suffered 3 successive early pregnancy losses and have no history of previous live birth. Numerous investigations have failed to elicit a treatable cause for the recurrence and you diagnose ‘unexplained’ recurrent miscarriage. The couple wish to discuss their future fertility prognosis. What is the estimated live birth rate in otherwise healthy couples with unexplained recurrent miscarriage?
a. 15%
b. 25%
c. 50%
d. 75%
e. 90%
D - 75%
In couples who undergo investigation for recurrent miscarriage and no cause is found (i.e. unexplained), they can be reassured that in 75% of cases, live birth does follow such a history.
A couple in their 30s are referred to the gynaecology clinic for review. They have now suffered 4 consecutive miscarriages. To date, no investigations have yet been performed. Which of the following specific tests is an appropriate first line investigation in this situation?
a. Paternal karyotyping
b. Hysterosalpingram
c. Dilute Russell Viper Venom test
d. Glucose tolerance test
e. Factor V Leiden mutation testing
C - Dilute Russell Viper Venom Test
The dilute Russell Viper Venom test is the most sensitive and specific in the detection of lupus anti-coagulant, which forms part of testing for antiphospholipid syndrome. Parental karyotyping is only indicated where an unbalanced structural chromosomal abnormality is found in the conceptus. Hysterosalpingram is a test used in investigation of tubal patency and uterine anatomy in a subfertility population – it has no role in this setting. While a link exists between maternal diabetes and recurrent miscarriage, routine screening does not feature in current guidelines on recurrent miscarriage. FVL mutation testing forms part of thrombophilia testing which is indicated following second, though not first, trimester loss.
What is the estimated incidence of second trimester miscarriage?
a. 0.5-1%
b. 1-2%
c. 2-3%
d. 4-5%
e. 7-8%
B - 1-2%
The overall incidence of second trimester miscarriage is estimated to be much lower than first – around 1-2%
Data on the role of environmental factors in miscarriage is somewhat lacking and at times conflicting. Based on the best available evidence, which of the following is NOT thought to increase the risk of miscarriage?
a. Caffeine consumption
b. Obesity
c. Smoking
d. Alcohol consumption
e. Working with video display terminals
E - Working with video display terminals
Much of the work on environmental factors in early pregnancy loss has been on a population affected by sporadic, rather than recurrent, miscarriage though findings may still be of some relevance in selected couples. Caffeine and smoking are thought to play a dose-dependent role, while alcohol consumption is known to be toxic to the developing fetus and embryo even as little as 5 units/week. There is no evidence of an effect from working at video display terminals. An association with anaesthetic gases for those working in operating theatres is unclear.
A 23 year old primigravida presents to the emergency department at weeks of gestation with threatened miscarriage. On examination, her vital signs were normal and her abdomen soft with minimal tenderness on deep palpation. On speculum examination there was a small amount of old brown blood in the vagina. A transvaginal ultrasound scan showed an intrauterine gestational sac measuring 18 x 15 x 12mm. No yolk sac or fetal pole was visible. What would be the best management plan?
a. Arrange a dating scan at 12 weeks of gestation
b. Arrange a repeat scan after 7 days
c. Arrange serial beta-hCG levels
d. Arrange serum progesterone levels
e. Arrange surgical management of miscarriage
B - Arrange a repeat scan after 7 days
For anembryonic pregnancy, if the MSD is <25mm with a TVUSS and there is no visible fetal pole, a second scan a minimum of 7 days later should be performed before making a diagnosis of miscarriage. Once a gestational sac is identified there is no role for testing of neither serum-hCG nor progesterone.
A 36 year old woman presents to the early pregnancy assessment unit with a history of mild bleeding for 3 days and lower abdominal pain. She has had two vaginal deliveries in the past. She has Factor V leiden deficiency which was diagnosed during her first pregnancy. Her LMP was 7 weeks ago and this is an unplanned pregnancy. She has no other significant medical nor surgical history. She lives with her husband and children. On ultrasound scan, she was found to have an intrauterine gestational sac with a fetal pole measuring 8mm. No fetal heart beat was seen and was confirmed by two ultrasonographers. What is the best initial management for this woman?
a. Book a repeat scan in 7-10 days
b. Counsel her regarding expectant management of miscarriage
c. Discuss medical management of miscarriage and prescribe oral administration of 600 micrograms of misoprostol
d. Discuss medical management of miscarriage and prescribe oral administration of 200mg mifepristone
e. Prescribe antibiotics for 7 days and discuss expectant management of miscarriage
B – Counsel her regarding expectant management of miscarriage
Expectant management should be offered as first line to all women with a confirmed diagnosis of miscarriage. Mifepristone is not indicated in the management of a non-viable pregnancy.
A 27 year old woman has had three successive first trimester miscarriages. Investigations show that she has antiphospholipid syndrome. What treatment option will improve chances of a successful pregnancy?
a. Aspirin and heparin
b. Corticosteroids and intravenous immunoglobulins
c. Human chorionic gonadotrophin
d. Metformin
e. Progesterone
A – Aspirin and heparin
APLS is present in 15% of women with recurrent miscarriage. Without treatment, live birth rate is as low as 10%.
A 23 year old woman had an ultrasound that was suggestive of a missed miscarriage. She underwent evacuation of the uterus and products of conception were sent for histology. The histology report confirmed that this had been a partial molar pregnancy. What are the most likely genetic features of a partial molar pregnancy?
a. 46 XY
b. 46 YY
c. 46 YYY
d. 69 XYY
e. 69 YYY
D – 69XYY
Complete moles are usually diploid and all chromosomes of paternal origin. Partial moles are usually triploid with the additional set of maternal origin.
A 26 year old woman has been admitted with late onset severe ovarian hyperstimulation syndrome 10 days after embryo transfer in an IVF cycle. She reports generalised abdominal pain and sickness for two days. Abdominal examination revealed significant ascites whilst abdominal ultrasound showed bilateral enlarged ovaries with a maximal diameter of 10cm. Which of the following combinations of blood results is correctly observed on admission?
a. Haematocrit decreased, fibrinogen increased, albumin increased
b. Haematocrit increased, fibrinogen decreased, albumin decreased
c. Haematocrit increased, fibrinogen decreased, albumin increased
d. Haematocrit increased, fibrinogen increased, albumin decreased
e. Haematocrit increased, fibrinogen increased, albumin increased
D – Haematocrit increased, fibrinogen increased, albumin decreased
Severe OHSS is usually associated with an increased capillary permeability resulting in a reduction of intravascular volume and haemoconcentration (increased haematocrit) and a shift of fluid into the third space (reduced serum albumin). The woman is also at risk of developing thrombosis (increased fibrinogen levels)
A 26 year old woman has a normal delivery of a healthy male infant following an induction of labour at term for reduced fetal movement. Her last pregnancy, 2 years earlier was a molar pregnancy and she was appropriately followed up by the regional trophoblastic disease centre. What is the most appropriate follow up plan for this pregnancy?
a. hCG measurement in 4 weeks
b. hCG measurement in 6 weeks
c. hCG measurement monthly for 3 months
d. hCG measurement monthly for 6 months
e. No follow up
B - hCG measurement in 6 weeks
All women with a history of GTD should notify their regional centre at the conclusion of any subsequent pregnancy irrespective of outcome (incl. miscarriage, ectopic et al.) - they should have an hCG measurement taken 6-8 weeks following delivery.
Complete hydatidiform moles are androgenic in origin. What proportion of complete moles arise as a consequence of duplication of a single sperm following fertilisation of an empty ovum?
a. 5-10%
b. 20-25%
c. 35-40%
d. 60-65%
e. 75-80%
E - 75-80%
A patient is diagnosed with a complete molar pregnancy following surgical evacuation of retained products of conception. She comes to the clinic for advice as she wishes to start trying again. How long after completing treatment for a molar pregnancy should patients be advised to wait prior to trying again?
a. 1 month
b. 3 months
c. 6 months
d. 12 months
e. 3 years
D - 12 months
A patient with pregnancy of unknown location on ultrasound scanning re-attends the early pregnancy assessment unit for a repeat Beta-hCG after an initial reading on presentation 48 hours earlier was 750iu/L. What percentage rise in Beta-hCG would be consistent with a viable intrauterine pregnancy?
a. 33%
b. 50%
c. 63%
d. 75%
e. 100%
C - 63%
