MC/Ectopic

Question 1

Mx of early preg PVB (PUL)

Answer 1

DDx
- MC - threat/inevitable/missed/septic
- Ectopic - tubal/cervical…
- Gestational trophoblastic

• bHCG/FBE/UEC/LFT/G&S
• +/- TFT +/- aPLs +/- thrombotic screen
• +/- STI screen
• Pelvic USS
• if unsited - refer to EPAS
• rpt bHCG + pelvic USS in 48/24
• written information
• monitor sx/KWTCI

Question 2

Mx of post MC PVB

Answer 2

DDx
- Endometritis
- RPOC
- GTD
- new preg

• bHCG/FBE/UEC/LFT/CRP/G&S
• pelvic USS
• abx +/- expectant v med v D&C

Question 3

Mx of acute early preg PVB

Scenario 1 - 25yo multi, missed mc, bkg of Hashi + Ix for low plt + lupus (stem may have contained info that suggest GTD not sure pre or post-op - seems to be post-op on scan & evacuated POC)

Answer 3

• risk anemia/shock/death
• emergency
• call for help
• MDI - gyn/ano/heam
• simul resus/stabilize/rx
• ABC - IVC -> bloods + x-match
• NBM/IVT/IDC
• consent for EUA +/- D&E
• USS guidance w senior support
• avoid miso/synt after cavity empty
• POC for histo to exclude GTD
• Debrief/Document - cx/mx/fu
• +/- anemia mx
• F/U +/- referral to molar registry

Question 4

Counselling re: MC mx options

Answer 4

• follow local guidelines
• 3 options - expectant/med/surg
• same risk for infection

Surg
- allow sampling, most effective 99%
- RPOC/perf/Asherman/cervical tear

Exp/Med
- avoid surg
- not as effective 80%/90%
- need surg/timing/sample

If choose exp/med
- need support person
- access to hospital
- analgesia/antiemetic
- F/U with EPAS

Question 5

Counselling re: Ectopic mx options

Answer 5

• follow local guideline
• 3 options - exp/med/surg
• exp - <1000, asx, no cardiac, F/U
• med - <5000, <35, asx, no cardiac, F/U
• surg - >=5000, >=35, sx, cardiac
• written information
• advice post rx - early preg USS

MTX
- initial workup to exclude CI
- advice: no folate/nsaid/etoh/contracep
- pro - avoid surg, no impact on fert
- con - rupture/SE - GIT/wait time/rpt rx

Surg
- pro - quick resolution/histo
- con - fertility/surg risk

Question 6

Mx of cervical ectopic

Answer 6

DDx
- mc in progress
- cervical ectopic
- low implantation of IUP

• risk of rupture/bleeding
• emergency
• refer urgently to tertiary center
• MDI - gyn/anesthetic/radiology
• admit/NBM/IVC - bloods+x-match/IVT
• repeat tertiary scan to confirm
• surg = safest/most effective
• surg = D&C or Lap wedge resection
• exp/med - high FR/bleed/hyster
• written information
• advice post rx - early preg USS

Question 7

Mx of interstitial ectopic preg

Answer 7

• M risk - rupture/bleed/hyster
• Ref tertiary
• Confirm Dx - COGU scan
• MDI - Gyn/Ano/OT
• Admit for mx planning
• NBM/IVC/bloods+xmatch+IVT
• Exp - if falling bHCG
• MTX - pros/cons/eligibility/FU
• Surg - breach/preg imp/hyster
• written information
• advice post rx - early preg USS
• advice specific to MTX of preg imp