Ectopic/Miscarriage

Question 1

Ectopic pregnancy is

Answer 1

Implantation of a fertilized ovum outside the uterus results in an ectopic pregnancy

Question 2

Ectopic pregnancy - A typical history is

Answer 2

a female with a history of 6-8 weeks amenorrhoea who presents with lower abdominal pain and later develops vaginal bleeding

Question 3

Ectopic pregnancy describe lower abdominal pain

Answer 3

due to tubal spasm
typically the first symptom
pain is usually constant and may be unilateral.

Question 4

Ectopic pregnancy describe vaginal bleeding

Answer 4

usually less than a normal period

may be dark brown in colour

Question 5

Ectopic pregnancy describe history of recent amenorrhoea

Answer 5

typically 6-8 weeks from the start of last period
if longer (e.g. 10 wks) this suggest another causes e.g. inevitable abortion

Question 6

Ectopic pregnancy peritoneal bleeding can cause

Answer 6

peritoneal bleeding can cause shoulder tip pain and pain on defecation / urination

Question 7

Ectopic pregnancy can cause symptoms of pregnancy such as breast tenderness

Answer 7

true

Question 8

Ectopic pregnancy Examination findings

Answer 8

abdominal tenderness
cervical excitation (also known as cervical motion tenderness)
adnexal mass: NICE advise NOT to examine for an adnexal mass due to an increased risk of rupturing the pregnancy. A pelvic examination to check for cervical excitation is however recommended

Question 9

diagnosis of an ectopic pregnancy

Answer 9

In the case of pregnancy of unknown location, serum bHCG levels >1,500 points toward a diagnosis of an ectopic pregnancy

Question 10

Ectopic pregnancy Epidemiology

Answer 10

Epidemiology

incidence = c. 0.5% of all pregnancies

Question 11

Ectopic pregnancy Risk factors

Answer 11

Risk factors (anything slowing the ovum’s passage to the uterus)
damage to tubes (pelvic inflammatory disease, surgery)
previous ectopic
endometriosis
IUCD
progesterone only pill
IVF (3% of pregnancies are ectopic)

Question 12

Ectopic pregnancy ix

Answer 12

A pregnancy test will be positive.

The investigation of choice for ectopic pregnancy is a transvaginal ultrasound.

Question 13

Ectopic pregnancy:
Women who are stable are typically investigated and managed in an early pregnancy assessment unit. If a woman is unstable then she should be referred to the emergency department.

Answer 13

true

Question 14

There are 3 ways to manage ectopic pregnancies:

Answer 14

Expectant management Medical management Surgical management

Question 15

ectopic pregnancies Surgical management

Answer 15

Size >35mm
Can be ruptured
Pain
Visible fetal heartbeat
serum B-hCG >1,500IU/L

Question 16

ectopic pregnancy which mx options compatible with another intrauterine pregnancy

Answer 16

Expectant management Surgical management

Question 17

ectopic pregnancy Surgical management can involve

Answer 17

salpingectomy or salpingotomy

Question 18

ectopic pregnancy Size <35mm & unruptured options mx

Answer 18

Expectant management Medical management

Question 19

Serum bhcg and mx for ectopic pregnancy

Answer 19

Expectant management serum B-hCG <1,000IU/L Medical management serum B-hCG <1,500IU/L Surgical management serum B-hCG >1,500IU/L

Question 20

Expectant management and mx for ectopic pregnancy

Answer 20

Size <35mm
Unruptured
Asymptomatic
No fetal heartbeat
serum B-hCG <1,000IU/L
Compatible if another intrauterine pregnancy

Question 21

Expectant management involves for ectopic pregnancy

Answer 21

closely monitoring the patient over 48 hours and if B-hCG levels rise again or symptoms manifest intervention is performed.

Question 22

Medical management and mx for ectopic pregnancy

Answer 22

Size <35mm
Unruptured
No significant pain
No fetal heartbeat
serum B-hCG <1,500IU/L
Not suitable if intrauterine pregnancy

Question 23

ectopic pregnancy Medical management

Answer 23

involves giving the patient methotrexate and can only be done if the patient is willing to attend follow up.

Question 24

Ectopic pregnancy: pathophysiology

Answer 24

97% are tubal, with most in ampulla
more dangerous if in isthmus
3% in ovary, cervix or peritoneum
trophoblast invades the tubal wall, producing bleeding which may dislodge the embryo

Question 25

Ectopic pregnancy: Natural history

Answer 25

most common are absorption and tubal abortion
tubal abortion
tubal absorption: if the tube does not rupture, the blood and embryo may be shed or converted into a tubal mole and absorbed
tubal rupture

Question 26

Threatened miscarriage

Answer 26

painless vaginal bleeding occurring before 24 weeks, but typically occurs at 6 - 9 weeks
the bleeding is often less than menstruation
cervical os is closed
complicates up to 25% of all pregnancies

Question 27

Missed (delayed) miscarriage

Answer 27

a gestational sac which contains a dead fetus before 20 weeks without the symptoms of expulsion
mother may have light vaginal bleeding / discharge and the symptoms of pregnancy which disappear. Pain is not usually a feature
cervical os is closed
when the gestational sac is > 25 mm and no embryonic/fetal part can be seen it is sometimes described as a ‘blighted ovum’ or ‘anembryonic pregnancy’

Question 28

Inevitable miscarriage

Answer 28

heavy bleeding with clots and pain

cervical os is open

Question 29

Incomplete miscarriage

Answer 29

not all products of conception have been expelled
pain and vaginal bleeding
cervical os is open

Question 30

Miscarriage: epidemiology

Answer 30

15-20% of diagnosed pregnancies will miscarry in early pregnancies
non-development of the blastocyst within 14 days occurs in up to 50% of conceptions
recurrent spontaneous miscarriage affects 1% of women

Question 31

An abortion is

Answer 31

the expulsion of the products of conception before 24 weeks. The term miscarriage is used often to avoid any misunderstandings

Question 32

Miscarriage Expectant management

Answer 32

‘Waiting for a spontaneous miscarriage’
First-line and involves waiting for 7-14 days for the miscarriage to complete spontaneously
If expectant management is unsuccessful then medical or surgical management may be offered

Question 33

Miscarriage Some situations are better managed with medically or surgically. NICE list the following:

Answer 33

increased risk of haemorrhage
she is in the late first trimester
if she has coagulopathies or is unable to have a blood transfusion
previous adverse and/or traumatic experience associated with pregnancy (for example, stillbirth, miscarriage or antepartum haemorrhage)
evidence of infection

Question 34

Miscarriage Medical management:

Answer 34

‘Using tablets to expedite the miscarriage’
Vaginal misoprostol
The addition of oral mifepristone is not currently recommended by NICE in contrast to US guidelines
Advise them to contact the doctor if the bleeding hasn’t started in 24 hours.
Should be given with antiemetics and pain relief

Question 35

Miscarriage Vaginal misoprostol works by

Answer 35

Prostaglandin analogue, binds to myometrial cells to cause strong myometrial contractions leading to the expulsion of tissue

Question 36

Miscarriage Surgical management

Answer 36

‘Undergoing a surgical procedure under local or general anaesthetic’
The two main options are vacuum aspiration (suction curettage) or surgical management in theatre
Vacuum aspiration is done under local anaesthetic as an outpatient

Question 37

Recurrent miscarriage is defined as

Answer 37

3 or more consecutive spontaneous abortions. It occurs in around 1% of women

Question 38

Recurrent miscarriage Causes

Answer 38

antiphospholipid syndrome
endocrine disorders: poorly controlled diabetes mellitus/thyroid disorders. Polycystic ovarian syndrome
uterine abnormality: e.g. uterine septum
parental chromosomal abnormalities
smoking

Question 39

1967 Abortion Act

Answer 39

that the pregnancy has not exceeded its 24th week and that the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman or any existing children of her family; or
that the termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman; or
that the continuance of the pregnancy would involve risk to the life of the pregnant woman, greater than if the pregnancy were terminated; or
that there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped.

Question 40

Paperwork abortion

Answer 40

two registered medical practitioners must sign a legal document (in an emergency only one is needed)
only a registered medical practitioner can perform an abortion, which must be in a NHS hospital or licensed premise

Question 41

The method used to terminate pregnancy depend upon gestation less than 9 weeks

Answer 41

mifepristone (an anti-progestogen, often referred to as RU486) followed 48 hours later by prostaglandins to stimulate uterine contractions

Question 42

The method used to terminate pregnancy depend upon gestation less than 13 weeks

Answer 42

surgical dilation and suction of uterine contents

Question 43

The method used to terminate pregnancy depend upon gestation more than 15 weeks:

Answer 43

surgical dilation and evacuation of uterine contents or late medical abortion (induces ‘mini-labour’)