RANZCOG q Flashcards
A 19 year old woman is referred by the GP with vaginal bleeding in her first pregnancy. The pregnancy is unplanned and of uncertain gestation. Examination shows a 14 week size uterus. An ultrasound arranged by the GP is strongly suggestive of a complete molar pregnancy.
a. Outline the investigations required for this patient. (3 marks)
• Serum hCG
• Full blood count
• Group and screen
• Consider:
o Chest Xray if clinically indicated
o Renal function tests, electrolytes, liver function tests if dehydrated
o TFTs if features of hyperthyroidism presen
b. Describe the initial management and follow up you would put in place for her. (5 marks) (for complete molar, after initial diagnosis)
• Consent: surgery and blood products (higher risk given molar pregnancy)
• Surgical evacuation of the uterus by an experienced operator using a large suction curette
o Misoprostol safe for cervical ripening
o Avoid oxytocics until evacuation complete
o Send POCs for histology + ancillary testing
• Anti-D if Rh negative
• Follow-up:
o Histology 1 week
o hCG 1 week (give form to have weekly bloods)
o Early pregnancy clinic review once histology and hCG back
Advice to use barrier contraception until HCG negative
c. Histology confirms a complete molar pregnancy.
i) How would you explain the cause of molar pregnancy to this woman? (1 mark)
• Occur when sperm fertilise an empty egg (an egg that has no genetic material)
o Either two sperm or one sperm that divides fertilise the egg
• The empty egg contains no maternal DNA and a fetus cannot develop- so a normal pregnancy cannot result
• The cells that make up the placenta divide abnormally and rapidly, filling up the uterus
ii) What are the characteristic histopathological features? (1 mark)
Embryo/fetus absent Widespread villous oedema Trophoblastic proliferation and atypia P57 immunostaining negative XX or XY on karyotype (no triploidy)
d. What is the long term risk associated with molar pregnancy? Outline the principles of its management. (3 marks)
Gestational trophoblastic neoplasia
• Metastatic workup:
o MDT review,
o Bloods: hCG, UEC, LFTs, tumour hCG, TFTs, G&H
o CT head/chest/abdo/pelvis
• Calculate WHO risk score based on antecedent pregnancy, age, interval months from antecedent pregnancy, pre-treatment hCG level, largest tumour size (cm), number of metastases, failed chemoX
• If WHO score <7 then low risk protocol with MTX chemotherapy plus folinic acid
• If WHO score >7 then high risk protocol with EMACO (actinomycin D, etoposide, MTX)
• ChemoX until normal hCG level, then further 3 cycles
• Monthly hCG for 12 months- not to conceive during this time
Her ß-hCG levels completely resolve after the affected pregnancy. What are the implications of a molar pregnancy for future pregnancies? (2 marks)
- Fertility rate not affected
- 1:70 risk of repeat molar pregnancy: early USS and hCG level following the completion of future pregnancies, regardless of outcome
A 20 year old primigravid woman presents to the early pregnancy assessment unit at 7 weeks amenorrhoea with a history of vaginal spotting over the last few days. A diagnosis of tubal pregnancy is made on the basis of a transvaginal scan which shows an empty uterus with a 2.5cm left adnexal mass with no visible heartbeat. There is a corpus luteum seen in the left ovary. Her serum quantitative hCG is 2000iu/l at presentation.
a. What information above informs you that expectant management is contraindicated in this woman? (1 mark)
HCG >1,000 - 1,500
Size of the adnexal mass
This is not a pregnancy of unknown location with hcg < 1000 that can be managed expectantly. Serum HCG 2000 with a confirmed left adnexal mass with an empty uterus on transvaginal scan confirming ectopic pregnancy therefore contraindicated for expectant management.
b. Discuss the clinical criteria for the medical management of ectopic pregnancy. In particular, comment on the information available and that which is not available in this scenario. (5 marks)
Available: hCG is < 5000 No intra-uterine pregnancy Size of ectopic is smaller than 35mm No FHR seen
Unavailable:
Haemodynamic stability
No significant pain
No significant free fluid on USS
Normal bloods (FBC, LFTs, renal function)
Information on ability to return for assessment on days 4 &7, access to phone, car and assessment unit
Suitability for surgery (other medical conditions, previous surgery)
c. Assuming she has no clinical contraindications, outline your approach to medical treatment for this patient. (6 marks) (medical rx for ectopic)
Give written information on methotrexate and ectopic pregnancy
Offer condolences and pregnancy loss counsellor
Explain risks (stomatitis, conjunctivitis, GI upset, blood dyscrasias, deranged LFTs) and benefits (avoid surgery and surgical morbidity) and sign a consent form
Investigations: FBC, LFTs, UEC, G&H
USS on day of MTX
MTX dose is 50mg/m2 so use nomogram to calculate accurate dose
Give MTX by deep IM injection with safety precautions as it is a cytotoxic medication
If Rh negative, give anti-D
Return on day 4 and 7 for hCGs
If fall in hCG <15% then give second dose of MTX
Otherwise continue to monitor hCGs weekly until negative via early pregnancy clinic
Advise: refrain from ETOH, sexual intercourse and folic acid until hCG is negative
Advise against conception until 3 months after MTX dose
Discharge with written information and safety advice
With respect to treating ectopic pregnancy in general, list the surgical options available and the indication for each approach. (3 marks)
Laparoscopy vs laparotomy
Laparoscopy preferred management if patient is stable and surgeon available as reduced hospital stay and pain, quicker recovery
Laparotomy required if haemodynamically unstable with ongoing bleeding and deemped to be fastest approach
Salpingectomy vs salpingostomy
Salpingectomy standard of care- removal of the abnormal tube
Salpingostomy- can be performed if the woman requests it and understands that there is a risk of persistent trophoblast and an increased risk of recurrent ectopic and it does not improve the rate of spontaneous conception compared to salpingectomy
.There is a 1:5 chance of treatment failure if salpingostomy performed. Need to repeat HCG weekly until negative.
A 24 year old woman presents at 8 weeks of amenorrhoea with a scan that concludes she has a missed miscarriage / early pregnancy loss.
In Australia and New Zealand, what transvaginal ultrasound criteria are used to diagnose “missed miscarriage” / “early pregnancy loss”? (3 marks)
Intrauterine mean sac diameter 25mm or larger and no visible fetal pole or yolk sac.
Crown-rump length 7mm or larger and no fetal heart pulsation seen over 30 second period.
If uncertain of above findings, no growth in MSD or CRL in 7 days.
She has an empty intrauterine gestation sac measuring 30mm. You are asked to counsel her with respect to her management options.
b. List three management options available for this woman, their respective success rates and rank the effectiveness of each option with respect to success of treatment for missed miscarriage / early pregnancy loss. A table may be used. (6 marks)
conservative/expectant mx, success rate 60% (rank 3)
medical mx with misoprostol- success rate 84% (rank 2)
surgical mx - success rate 97% (rank 1)
The randomised controlled Miscarriage Treatment Trial (MIST trial BMJ 2006) examined the risk of harm for each management option. Choose three outcome measures from this trial and outline the result obtained. (6 marks)
Primary outcome: gynaecological infection
No difference between groups
Secondary outcomes:
Duration of symptoms: earlier cessation of bleeding with surgical management
Pain: higher rates of extra analgesia and pain with expectant management
Unplanned admission and curettage: 50% expectant and 40% medical management
Blood transfusion: no statistically significant difference
Return to work: no difference
Anxiety and depression scores: no difference
A 32 year old woman presents with a history of three miscarriages (G3P0) within the last 2 years at 8, 9 and 8 weeks gestation respectively. No investigations have been performed. You are seeing her and her partner to discuss their management.
a. Describe and evaluate the four recommended investigations which may establish a cause for their recurrent miscarriage prior to another pregnancy. (8 marks)
- USS pelvis: Evaluate uterine abnormalities as a cause eg uterine septum for recurrent first trimester miscarriage, bicornuate uterus second trimester
- Parental karyotype: Evaluates for Robertsonian or balanced translocations as a cause for recurrent miscarriage- 3-5% couples with miscarriage
- Antiphospholipid syndrome: Evaluates for antiphospholipid syndrome- thrombosis and pregnancy criteria plus lab evidence (she would have the clinical criteria based on her recurrent first trimester miscarriage): lupus anticoagulant, anti-cardiolipin, b2 glycoprotein 1 antibodies
Abnormal on 2 occasions 12 weeks apart
15% all women, can improve pregnancy rate with treatment with aspirin/heparin - Thrombophilia screening: 5% of women may have a hereditary thrombophilia- these have been implicated in recurrent miscarriage.
- Cytogenetics on POC: Evaluate for aneuploidy and evidence of other single-gene disorders such as alpha thalassemia
History, examination & investigation did not determine a cause for their previous miscarriages. You are seeing the woman for a follow-up consultation.
b. Outline and justify four issues which are relevant to her next pregnancy. (4 marks)
• Early management should be in a recurrent pregnancy loss clinic as the prognosis for a successful future pregnancy is around 75% with supportive care alone
• Pregnancy vitamins: folic acid and iodine should ideally be taken 1-3 months prior to conception, she should continue these
• Vaccines: if she is rubella or hep B non-immune, she should be vaccinated
• No evidence for the use of:
o Aspirin and heparin
o Progesterone
• Obesity: advise weight loss and exercise to maximise physical condition for healthy pregnancy
• Psychological: offer support
