Module 16 - Early Pregnancy Care Flashcards
You have been talking to a patient about her diagnosis of tubal ectopic pregnancy. She has opted for treatment with IM methotrexate. What would you advise her is the percentage of women who require a second methotrexate injection?
14%
14% of women who have medical management of ectopic pregnancy will require two or more doses of methotrexate
What are the maternal Mortality rates for ectopic pregnancy in the UK?
2 in 1,000
0.2%
What proportion of women who have medical management of ectopic with methotrexate will require surgery?
<10%
At what gestation is the fetus most sensitive to fetal growth restriction as a side effect of radiation?
3-10 weeks
What is the incidence of ectopic pregnancy in the UK?
11 in 1,000 pregnancies are ectopic in the UK
What is the incidence of gestational trophoblastic disease (molar pregnancy) in the UK?
1 in 1,000 pregnancies
A 28 year old patient is referred to see you in clinic. She wishes to conceive but is concerned as her only previous pregnancy was a molar pregnancy 4 years ago. What is her risk of a further molar pregnancy if she were to become pregnant?
1 in 80
Women with one previous molar pregnancy have a 1 in 80 chance of the subsequent pregnancy being molar
A 27 year old patient consults you as you fitted her with a copper intrauterine device (IUCD) 3 months ago and she has just done a positive pregnancy test. She is concerned about ectopic pregnancy.
If the patient with an IUCD becomes pregnant what is the incidence of ectopic pregnancy?
1 in 20
It is rare for patients with an IUCD in place to become pregnant.
If a patient with an IUCD in situ does become pregnant the risk of it being ectopic is around 1 in 20
A 28 year old patient requests a laparoscopic salpingotomy for her right tubal ectopic pregnancy, due to having a previous left salpgingectomy.
What should you inform this patient is the risk of requiring further treatment which may include methotrexate and/or salpingectomy?
1 in 5
Women should be advised that following salpingotomy there is a 1 in 5 risk of requiring further treatment
What is the risk of further miscarriage after 3 subsequent reccurent miscarriages?
40%
A woman undergoes ERPC for delayed miscarriage. Histopathology shows a complete mole. What is the risk of developing an invasive mole?
15%
1 in 6
A woman is admitted with severe hyperemesis gradvidarum at 12/40. Her LFTs are markedly deranged. How common is abnormal LFTs among patients with HG?
40%
A woman attends the TOP centre. She is 20 weeks gestation. Her TOP is under grounds C.
What is the percentage of patients who have had surgical TOP at this stage?
60%
A woman undergoes ERPC for delayed miscarriage. Histopathology shows a partial mole. What is the risk of developing choriocarcinoma?
5%
What is the risk of infection with ERPC?
4%
What is the risk of uterine perforation with ERPC?
1 in 1,000
What is the risk of cervical trauma with ERPC?
<1 in 1,000
What is the risk of retained placenta/fetal tissue with ERPC?
4%
What is the risk of intrauterine adhesions with ERPC?
20%
What is the most common cause of 1st trimester miscarriage, and what proportion does it make?
Chromosomal abnormalities cause 70% of 1st trimester miscarriages
What proportion of 2nd trimester miscarriages are caused by chromosomal abnormalities?
20%
What is the normal range for crown rump length?
45 - 84mm
What proportion of miscarriages do first trimester miscarriages constitute?
85%
What is the risk of miscarriage for ages 12 -19?
13%
What is the risk of miscarriage for ages 20-24?
9%
What is the risk of miscarriage for ages 25-29%
12%
What is the risk of miscarriage for ages 30-34?
15%
What is the risk of miscarriage for ages 35-39?
25%
What is the risk of miscarriage for ages 40-44?
51%
What is the risk of miscarriage for ages >45?
93%
In the Abortion Act 1967 which clause is most commonly used?
Clause C
98% of cases
Usually C-E
What is the definition of Clause A of the Termination of Pregnancy Act?
Continuing the pregnancy would risk the LIFE of the woman
What is the definition of Clause B of the Termination of Pregnancy Act?
Continuing the pregnancy would risk GRAVE PERMANENT INJURY to the PHYSICAL or MENTAL HEALTH of the woman
What is the definition of Clause C of the Termination of Pregnancy Act?
<24/40 and continuing would cause PHYSICAL or MENTAL HARM to the woman
What is the definition of Clause D of the Termination of Pregnancy Act?
<24/40 and continuing would cause PHYSICAL or MENTAL HARM to any EXISTING CHILDREN
What is the definition of Clause E of the Termination of Pregnancy Act?
Child would likely be DISABLED
(Physical and mental abnormalities as to be severely handicapped)
What is the definition of Clause F of the Termination of Pregnancy Act?
To save the life of the pregnant woman
Only 1 doctor needed to grant this
What is the definition of Clause G of the Termination of Pregnancy Act?
To prevent grave permanent injury to the physical or mental health of the woman
How many ectopic pregnancies occur each year?
11,000
What proportion of pregnancies do ectopics make up?
11 in 1,000 pregnancies
What proportion of pregnancies end in miscarriage?
10-20%
What are some of the inclusion criteria for MVA?
1) <10/40 gestation
2) RPOC <5cm
3) CRL <25mm
4) Fibroid uterus <12/40 size
A woman is diagnosed with a complete mole. What is the risk of recurrence of molar pregnancy?
1 in 80
What is the risk of recurrence of ectopic pregnancy?
18.5%
Following treatment of ectopic pregnancy the risk of a future pregnancy being ectopic is 18.5% regardless of treatment modality
How do you diagnose a tubal ectopic pregnancy?
An adnexal mass that moves separate to the ovary
What are the 5 US criteria for diagnosing a cervical ectopic pregnancy?
1) Empty uterus
2) Barrel-shaped cervix
3) Absence of ‘sliding side’
4) Gestational sac below the level of internal os
5) Blood flow on Colour Doppler of gestational sac
What imaging modalities do you use to diagnose caesarean scar ectopic?
1) TVS + TAS US
2) MRI pelvis - 2nd line
When do you perform hCG follow-up for women following laparoscopic salpingotomy for ectopic pregnancy?
D7 post-op
Then weekly until hCG negative
What are the rates of persistent trophoblast after salpingotomy?
10-20%
Factors that increase the risk are:
1) High pre-treatment hCG
2) High/rapid increase in hCG pre-treatment
3) Larger ectopic masses
What are the 3 US criteria for diagnosing an interstitial ectopic pregnancy?
1) Empty uterus
2) Gestational sac located laterally in the interstitial/intramural part of the tube + surrounded by <5mm myometrium in all imaging planes
3) Interstitial line sign
What imaging modalities do you use to diagnose interstitial ectopic?
1) TVS pelvis - can use 3-D US to confirm the diagnosis
2) MRI pelvis
In which circumstances do you consider salpingotomy for ectopic over salpingectomy?
If the woman has other fertility-reducing risk factors:
1) Previous ectopic pregnancy
2) Damaged contralateral tube
3) Previous abdominal surgery
4) Previous PID
If a woman has a salpingotomy for ectopic pregnancy what do you need to counsel her for?
Inform of risks of:
1) Persistent trophoblast - thus need for FU with serum hCG - 10%
2) Small increased risk of further management with methotrexate or salpginectomy - 20% (1 in 5)
What proportion of women who have a salpingotomy for ectopic pregnancy will need further management?
1 in 5 (20%) will need further management with methotrexate or salpingectomy
How are women managed with salpingotomy for ectopic pregnancy followed-up?
Test hCG on DAY 7 post-op
Then repeat hCG weekly until negative
What are the required criteria for expectant management of ectopic pregnancy? (5 points)
1) Pain-free + Haemodynamically stable
2) Tubal ectopic <3.5cm
3) No FH
4) Initial hCG <1,500
5) Willing to attend FU
When do you do hCG follow-up testing for women managed expectantly?
Test hCG on day 2, 4 and 7 after original test
If >15% decrease in hCG test weekly until <20
If decrease is <15%, static levels or increase then review and scan
What are the required criteria for medical management of ectopic pregnancy? (8 points)
1) No significant pain
2) Haemodynamically stable
3) Unruptured tubal ectopic <3.5cm
4) No FH
5) Initial hCG <5,000
6) Willing to attend for FU
7) No Haemoperitoneum
8) No viable IUP
When do you do hCG follow-up testing for women managed medically?
Test hCG day 1 of administration of methotrexate
Test hCG - day 4 and 7 after methotrexate
If decrease is >15% then repeat hCG weekly until <15
If decrease is <15% then review and scan
What are the most common adverse effects from taking methotrexate?
1) Excessive flatulence and abdominal bloating - from intestinal gas formation
2) Mild elevated liver enzymes
3) Stomatitis
What is the management of cervical ectopic?
1) Medical management is preferred
2) Surgical management is reserved for women with life-threatening bleeding. It is associated with high failure rate
What is the management of caesarean scar ectopic?
1) Surgical management is preferred to medical
Women need to be counselled on the association with severe maternal morbidity and mortality
What is the management of interstitial ectopic?
Expectant or medical management if they are clinically stable
Expectant - if hCG is low or significantly falling levels, where addition of MTX may not improve the outcome
Medical - either systemic or local MTX
Surgical - laparoscopic cornual resection or salpgingotomy or hysteroscopic resection under laparoscopic or US-guidance
What is the management of cornual ectopic?
Surgical - excision of rudimentary horn via laparoscopy or laparotomy
They occur in 2-4% of all ectopic pregnancies
What is the management of ovarian ectopic?
Surgery - if laparoscopy is required to make the diagnosis
Medical - MTX given post-op if there is persistent residual trophoblast, persistently high hCG or the risk from surgery is too high
What is the management of abdominal ectopic?
Early pregnancy:
Surgery - laparoscopic removal
Medical - MTX injection locally
Advanced pregnancy:
Surgery - removal via laparotomy
What is the management of heterotopic ectopic?
If the IUP is non-viable or unwanted:
1) Expectant management - if non-viable
2) Methotrexate
If the IUP is viable or wanted:
1) Local injection of KCL into the fetal pole or aspiration of GS and injection of hyperosmolar glucose
Haemodynamically unstable women:
Laparoscopic/laparotomy excision of ectopic
When do you give Anti-D to Rh -ve women diagnosed with ectopic pregnancy?
If surgical removal of ectopic
OR
where bleeding is repeated, heavy or associated with abdominal pain
Which is the most effective route of misoprostol used for the medical management of miscarriage?
Sublingual
Sublingual misoprostol of 600 ug or vaginal misoprostol of 800 ug may be a good choice for the first dose
A healthy 32 year old woman has suffered 3 consecutive first trimester miscarriages. What are the chances of her next pregnancy ending in miscarriage?
40%
What is the overall significant surgical complication rate for surgical evacuation of the uterus?
6%
How do you manage a PUL with serial hCGs with a rise >63% 48 hours apart?
1) Repeat TVS scan in 7-14 days to check for viable IUP
How do you manage a PUL with serial hCGs with a decrease >50% 48 hours apart?
1) Urine PT in 14 days
If negative - no further action
If positive - to contact EPAU within 24 hours for further assessment
How do you manage a PUL with serial hCGs with a decrease <50% or increase <63% 48 hours apart?
Present to EPAU within 24 hours
What is the most common presentation of GTD?
- Irregular vaginal beeding
- Positive pregnancy test
- US features of molar pregnancy
What are the least common presentation features of GTD?
- Hyperthyroidism
- Hyperemesis
- Increased uterine enlargement
- Early onset PET
- Abdo distension from theca lutein cysts
What is the typical spread of choriocarcinoma?
Haematogeneous spread to lungs, brain and liver
What are the very rare presentation features of GTD?
- Dyspnoea
- Haemoptysis
- Seizures
What is the method of choice for removal of a complete molar pregnancy?
ERPC
suction curettage is the method of choice for removal
What is the method of choice for removal of a partial molar pregnancy?
ERPC if <15/40
Medical management/evacuation if >15/40 or fetal parts are too large for suction curettage
Which women should be investigated for GTN after a non-molar pregnancy?
Any woman with persistent or irregular vaginal bleeding >8/52 after a pregnancy event needs a UPT to exclude molar pregnancy
When do you perform prenatal invasive testing for fetal karyotyping in cases of GTD?
1) If you are unable to diagnose whether it is a twin pregnancy with a complete mole and a viable twin or a singleton partial mole. (Partial mole histology shows trophoblast hyperplasia)
2) In cases of abnormal placenta, i.e. mesenchymal hyperplasia of the placenta (enlargement of the placenta with multiple grape-like vesicles that can resemble a molar pregnancy. May cause - IUGR, stillbirth or normal pregnancy)
Which cases/conditions do you refer to GTD centres? (5 points)
1) GTD - complete or partial mole
2) Twin pregnancy with either complete or partial mole
3) Limited macroscopic or microscopic molar change, suggesting early complete mole, partial mole or choriocarcinoma
4) PSTT (Placental Site Trophoblastic Tumour) or ETT (Epithelioid Trophoblastic Tumour)
5) Atypical PSN (Placental Site Nodule)
What is the optimum follow-up of complete molar pregnancy?
1) If hCG normal <8 weeks (56 days) from the pregnancy event, then FU for 6 months after ERPC
2) If hCG normal >8 weeks (56 days) from the pregnancy event, then FU for 6 months after normalisation of the hCG
What is the optimum follow-up of partial molar pregnancy?
FU until 2x hCGs normal 4 weeks apart
How are PSTT (Placental Site Trophoblastic Tumour) and ETT (Epithelioid Trophoblastic Tumour) managed?
Managed with ERPC
They are less sensitive to chemotherapy
They are variants of GTN
How is management of GTN determined?
FIGO 2000 scoring system
The management of GTN is based on the FIGO 2000 scoring system. Based on this, how are cases of GTN classified and managed?
<6 - low risk - Methotrexate I.M. and folinic acid alternating daily for 1 week, followed by 6 rest days
7 or more - high risk - i.v. multi-system chemotherapy (methotrexate, etoposide, cyclophosphamide, vincristine, dactinomycin)
Continue treatment until hCG normal, and then for a further 6 weeks
> 13 - high risk of early death (within 4 weeks). Usually due to bleeding into organs
If choriocarcinoma is suspected, which investigations are performed in GTD centres?
1) CT thorax, abdo + pelvis with contrast
2) MRI head + pelvis with contrast
3) hCG
4) Doppler US pelvis
How long should women wait to conceive after a diagnosis of GTD?
Advise women not to conceive until their treatment is complete
Complete mole - until 6 months after ERPC (if hCG normal <56 days), or until 6 months from normalisation of hcG (if hCG normal >56 days)
Partial - once 2x hCGs normal within 4 week period
If received chemotherapy for GTN - advise to not conceive until 1 year after treatment
How are future pregnancies managed in women with a history of GTD?
Women with a previous hx of GTD who did not receive chemotherapy, do not need hCG FU after any subsequent pregnancy event or any placental histology to be sent
What is the overall cure rate of GTN?
Close to 100%
What is the overall rate of future pregnancy with GTN?
Future pregnancy is achieved in nearly 80% of women following treatment for GTN with either methotrexate or multi-agent chemotherapy
There is an increased risk of premature ovarian insufficiency in women treated with multi-agent chemotherapy
If approaching 40 years old, discuss potential negative effect on fertility with chemotherapy
How do you distinguish between partial moles and complete moles?
p57 staining
Positive in partial moles
Negative in complete moles
How do you manage a caesarean section scar ectopic?
Surgical:
If endometrium >2mm and inside the cavity - suction curettage or hysteroscopic resection
If outside the cavity - laparoscopic resection
Medical:
<8/40
hCG <5,000
In the Abortion Act 1967 which clause is most commonly used?
Clause C
98% of cases
Usually C-E
