Implantation and Early Pregnancy

Question 1

Define miscarriage

Answer 1

Spontaneous end of pregnancy before 24 weeks’ gestation

Question 2

What is the most common sign of miscarriage

Answer 2

Vaginal bleeding

Question 3

How does a threatened miscarriage typically present?

Answer 3

Abdo pain and PV bleeding. Cervical os closed. USS shows intrauterine pregnancy with a fetal heartbeat.

Question 4

How does an inevitable miscarriage typically present?

Answer 4

Abdo pain and PV bleeding. Cervical os open. USS shows intrauterine pregnancy with no fetal heartbeat.

Question 5

How does an incomplete miscarriage typically present?

Answer 5

Abdo pain and PV bleeding. Cervical os open, retained products may be visible in os. USS shows retained products of conception.

Question 6

How does a complete miscarriage typically present?

Answer 6

Resolved abdo pain and PV bleeding. Cervical os closed. USS shows empty uterus (if no previous USS to demonstrate an intrauterine pregnancy then an hCG test required to exclude ectopic pregnancy).

Question 7

What drug is used for medical management of an inevitable, incomplete or missed miscarriage?

Answer 7

Misoprostol

Single, or repeated, vaginal or sublingual dose of the prostaglandin E analogue misoprostol.

Question 8

What are the key risk factors for ectopic pregnancy?

Answer 8

Tubal damage

• PID (often due to previous infection such as chlamydia, gonorrhoea)
• Previous ectopic
• Tubal surgery

Functional tubal alterations due to smoking and/or maternal age.

Previous abdominal surgery, subfertility, IVF, IUS, COCP, endometriosis.

Question 9

What are the main investigations for ectopic pregnancy in a non-acute scenario?

Answer 9

Pregnancy test

TVUSS

Consecutive bhCG 48hrs apart

Question 10

True or false: Expectant management is a viable option for ectopic pregnancy.

Answer 10

True.

Many EPs resolve spontaneously so if a mother is hemodynamically stable then expectant management is an option. They must be closely monitored, however, and serial hCG’s are required until levels are undetectable.

Question 11

What is the widely-used medical management of ectopic pregnancy?

Answer 11

IM Methotrexate.

Methotrexate is a folic acid antagonist; it blocks DNA synthesis and causes the pregnancy to fail.

hCG levels are then measured on days 4, 7, 11 and then weekly until undetectable.

Question 12

How is ectopic pregnancy surgically managed?

Answer 12

Laparoscopic (or, rarely, laparotomy) salpingectomy or salpingostomy.

Which is done depends on the condition of the other fallopian tube. Salpingectomy is preferred unless the other tube is absent or visibly damaged. Then, a salpingostomy is done to preserve fertility.

Anti-D must be given to all rhesus negative women who undergo surgical management of EP or miscarriage.

Question 13

What is gestational trophoblastic disease?

Answer 13

Abnormal trophoblast proliferation.

Spectrum.of conditions that includes complete and partial hydatidiform mole, invasive mole and choriocarcinoma.

Question 14

What risk factors are associated with gestational trophoblastic disease?

Answer 14

Previous molar pregnancy

High or low maternal age

Asian origin

Question 15

What is the typical clinical presentation of gestational trophoblastic disease?

Answer 15

Ultrasound features of intrauterine vesicles (cluster of grapes).

Persistently raised hCG levels after miscarriage.

Question 16

How is gestational trophoblastic disease managed?

Answer 16

Registration (at a nationally recognised centre for treatment of GTD)

Uterine evacuation by suction curretage (without misoprostol)

Serial hCG levels

Avoid oestrogens

Question 17

True or false: Multiple pregnancy is a risk factor for hyperemesis gravidarum.

Answer 17

True.

Question 18

How should pain in early pregnancy be investigated?

Answer 18

• TVUSS to establish location of pregnancy
• Serial hCG levels may help
• MSU sample will help diagnose a UTI
• FBC for baseline and infection markers

Question 19

How is ectopic pregnancy actively managed?

Answer 19

Either methotrexate or salpingectomy/salpingostomy depending on patient’s condition.

Question 20

How is miscarriage actively managed?

Answer 20

Suction curretage or misoprostol, depending on patient preference.

Question 21

How would you manage hydatidiform mole?

Answer 21

Suction curretage

Avoid oestrogens (reduce risk of choriocarcinoma)

Question 22

Which of the following is the most suitable option to offer a woman with a non-viable intrauterine pregnancy?

A) Laparoscopy
B) Methotrexate
C) Misoprostol
D) Progesterone
E) Serum hCG measurement

Answer 22

C) Misoprostol

A non-viable intrauterine pregnancy should be managed with suction curretage or misoprostol.

hCG has no role here as it is used only to help manage a pregnancy of unknown location or monitor and ectopic.

Laparoscopy is not relevant as there is no mention of an EP.

Methotrexate is not used for an intrauterine pregnancy.

Progesterone is incorrect and would actually prolong the time to completion of miscarriage.

Question 23

Following surgical curettage for miscarriage, the pathology report confirms a partial hydatidiform mole. What should be done?

A) Arrange an urgent TVUSS
B) Prescribe methotrexate
C) Register patient at a nationally-recognised centre for treatment of GTD
D) Start antibiotics
E) Start COCP
F) Start serial hCG monitoring

Answer 23

C) Register patient at a nationally-recognised centre for treatment of GTD

All moles, partial or complete, should be registered via the recognised centre, who perform hCG monitoring themselves. Oestrogens should be avoided in women with molar pregnancy.

TVUSS will not be necessary as evacuation of the uterus has been performed.

Antibiotics and methotrexate have no role in the management of a molar pregnancy.