Threatened Abortion

Question 0

HCG threshold – Definition? Normal value? If level exceeds threshold, but not visible on ultrasound – Suggests?

Answer 0

Level of hCG such that an intrauterine pregnancy should be visible on ultrasound

1500 to 2000

Ectopic pregnancy

Question 1

Threatened abortion?

Answer 1

vaginal spotting during the first half of pregnancy

Question 2

Patient under threshold with vaginal spotting and hCG under threshold – options and interpretation?

Answer 2

1. Repeat hCG in 48 hours to establish viability of pregnancy
2. Single progesterone level – levels greater than 25 indicate normal intrauterine gestation (levels less than 5 indicate nonviable gestation – either Ectopic pregnancy or spontaneous abortion)

Question 3

Patient with uterine bleeding and single progesterone assay less than 5 – next step?

Other indication for same management?

Answer 3

Uterine curettage – chorionic
Villi suggests miscarriage versus no villi suggests ectopic pregnancy

If repeat hCG shows abnormal rise

Question 4

Women with asymptomatic, ectopic pregnancy <3.5 cm – treat with?

Treatment for nonviable intrauterine pregnancy?

Answer 4

Methotrexate

Misoprostol or D&C

Question 5

Patient with vaginal spotting and hCG level over threshold – Next steps?

Answer 5

1. If transvaginal ultrasound shows intrauterine gestational sack – diagnose threatened abortion and have close follow-up
2. If no evidence of intrauterine pregnancy, laparoscopy to diagnose/treat ectopic pregnancy

Question 6

When to consider laparoscopy or laparotomy without measuring serum hCG or doing ultrasound?

Answer 6

1. Hypertension or volume depletion
2. Severe abdominal/pelvic pain
3. Adnexal mass

Question 7

Expected side effects of treatment with methotrexate for ectopic pregnancy?

Symptoms that would cause concern? Management?

Answer 7

Mild abdominal pain without hypotension

hypotension or signs of rupture – laparotomy