Implantation and Early Pregnancy

Question 1

Miscarriage Ix

Answer 1

1  Urine Pregnancy test
2 Speculum (Os open/closed?)
3 Bimanual to rule out ddx (ectopic)
4 TVUSS
5 Ix for other ddx endocervival/high vaginal swab, FBC, CRP, Urine dip
6 G+S (inc Rhesus)

Question 2

Threatened miscarriage

Answer 2

PV bleed and confirmed IU pregnancy w/foetal heart beat
Hospital if bleeding worse or >14/7
Continue routine AN care if bleed stops

Question 3

Expectant Miscarriage

Answer 3

Use expectant management first line for 7-14d in women w/confirmed MC
- Consider alternative management:
Inc. risk haemorrhage (late T1), evidence of infection, unable to receive transfusions, prev. traumatic pregnancy events,

Question 4

Expectant management of miscarriage

Answer 4

Wait and see - use first line for 7-14d.
If bleed/pn stops advise take pregnancy test 3 wks later, present if positive
Offer repeat scan if bleeding and pain has not started or is persisting/increasing (incomplete miscarriage)

Question 5

Medical Management of MC

Answer 5

NOT mifepristone
PV misoprostol (oral if preferred)
Repeat on day 3 if incomplete expulsion
If no bleed by 24hr consult HCP
Offer: pain-relief, antiemetic to ALL
Inform: expect bleed, pain, diarrhoea and vomiting
Pregnancy test after 3/52
NB. 10% failure rate

Question 6

Surgical Management of MC

Answer 6

Manual vacuum aspiration under LA
PV/sublingual misoprostol to ripen cervix
Anti-D proph. to all Rh-ve

Question 7

Risk Factors for miscarriage

Answer 7

Age,

Previous miscarriage, chronic dx (DM), uterine/cervical abnormality, smoking and alcohol, under/overweight

Question 8

Recurrent Miscarriage Ix

Answer 8

Screen APLS:
  Lupus anti-coag
  Anti-cardiolipin
  dx: 2 +ve results >12w apart
Cytogenetics:
  of products of conception of last miscarriage
  of both partner peripheral blood
TVUSS: uterine anomaly
Screen for inherited thrombophilia (V Leiden)

Question 9

Recurrent miscarriage Mx

Answer 9

ALPS: Low dose aspirin + LMWH in future preg. reduces risk of mc by 50%
Steroids/IVIG no benefit
Abnormal genetics -> clinical geneticist
Cervical cerclage if cerival issue

Question 10

When to Ix miscarriage?

Answer 10

after 3

Question 11

Ectopic Pregnancy Ix

Answer 11

ABCDE
Urine pregnancy
Bimanual and Speculum
Bloods: serum bHCG, FBC, G+S
TVUSS

Question 12

Expectant Mx of ectopic

Answer 12

Significant number will self resolve
suitable for: asymptomatic and Hb stable
serial bHCG until undetectable

Question 13

Requirements for expectant Mx of ectopic

Answer 13

Size: <30mm
Asymptomatic 
No foetal heartbeat
Serum bHCG <200 and decreasing
Possible if IU preg present

Question 14

Medical Management of Ectopic

Answer 14

IM Methotrexate if able to attend FU. ONLY OFFER MEDICAL Providing:

• No sig pn
• Unruptured ectopic with mass <35mm and no FHB
• Serum bHCG <1500
• No IU preg

Question 15

Follow up of Medical Mx ectopic

Answer 15

2 serum bHCG: d4 and d7
then
1 serum bCHG/week until -ve
avoid intercourse
avoid conception for 3 mo. after MTX
Avoid alcohol and prolonged sunlight

Question 16

When to offer Surgical Mx Ectopic

Answer 16

Offer first line if unable to attend FU, or if:

• sig pn
• adnexal mass >35mm
• Ectopic w/FHB on USS
• Serum bHCG >5000

Question 17

Surgical Mx ectopic

Answer 17

Laparoscopic salpingectomy (unless RF for infertility/CL tubal damage - then offer salpingotomy)
NB 1/5 salpingotomy req. MTX or salpingectomy
FU:
- otomy = 1 serum bHCG/wk until -ve
- ectomy = urine pregnancy test 3 wks

Question 18

When to offer choice of medical or surgical management of ectopic

Answer 18

bHCG 1500-5000 and:
- no sig pn
- unruptured ectopic <35mm w/o FHB
- no IU pregnancy
NB. MTX carries >risk of  urgent re-admission

Question 19

Anti-D proph. in Mx of ectopic/miscarriage

Answer 19

Offer 250 iU to Rh-ve who have SURGICAL mx 
NO Kleihauer test
NO Anti-D if:
- solely medical mx
-Threatened mc
- complete mc
- preg of unkown origin

Question 20

RFs for ectopic

Answer 20

PID, smoking, IUD, assisted reproduction, tubal surg

Question 21

Explain Medical Mx to pt

Answer 21

1 IM inj
Abdo pn, nausea, diarrhoea
Can go home but need to come for bloods
avoid sex/alcohol/sun during mx, no conception for 3/12,

Question 22

Explain Surgical Mx of ectopic to pt

Answer 22

Salpingectomy best
Salpingotomy 1/5 fail
Salpingectomy does not reduce fertility > otomy
discuss ongoing contraception

Question 23

Molar pregnancy Presentation

Answer 23

Irregular PV bleed
Hyperemesis
Large for date uterus
HTN

Question 24

Molar pregnancy Ix

Answer 24

urine pregnancy test
bimanual
speculum
USS - helpful not definitive 
     snowstorm/cluster of grapes
serum bHCG v high for gestation
FBC, G+s, TSH (hCG can mimic TSH)

Question 25

Molar Pregnancy Mx

Answer 25

1st line: Suction curettage 
  - GA, ?surgical ripening
  - Anti-D proph. req
Should send to histo ALL failed preg. If not: 
  Pregnancy test after 3 
  wks mx for failed 
  pregnancy
Refer to trophoblastic screening centre
-6 mo follow up from surgery or date of bHCG normalisation

Question 26

Mx gestational trophoblastic neoplasia

Answer 26

Single/multi agent chemotherapy (may use MTX)

Rx -> >risk of early menoause and secondary cancesr

Question 27

Future pregnancy after molar

Answer 27

DO NOT conceive until FU complete
Recommend barrier contraception until normal hCG normal, then COCP
Avoid IUD until hCG normal (uterine perf risk)
IF chemo: no conception for 1yr

Question 28

RF for molar preg

Answer 28

Age (advanced or <20), Hx, prior mc, Asian