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Questions and Answers
What does a fall in hCG of less than 15% indicate in the management of ectopic pregnancies?
What does a fall in hCG of less than 15% indicate in the management of ectopic pregnancies?
A drop in hCG levels of 15% or more indicates a failed therapy for ectopic pregnancy.
A drop in hCG levels of 15% or more indicates a failed therapy for ectopic pregnancy.
False
What is the maximum number of doses of methotrexate (MTX) that can be given for ectopic pregnancy management?
What is the maximum number of doses of methotrexate (MTX) that can be given for ectopic pregnancy management?
3 doses
If a fall in hCG is less than 15%, the treatment management for ectopic pregnancy may involve repeating the entire dose of __________.
If a fall in hCG is less than 15%, the treatment management for ectopic pregnancy may involve repeating the entire dose of __________.
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Match the following outcomes to their corresponding hCG fall percentages:
Match the following outcomes to their corresponding hCG fall percentages:
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What is considered the gold standard for investigating obstetric complications?
What is considered the gold standard for investigating obstetric complications?
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A serum progesterone level of less than 25ng/mL indicates a live intrauterine pregnancy.
A serum progesterone level of less than 25ng/mL indicates a live intrauterine pregnancy.
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What serum progesterone level indicates a live intrauterine pregnancy?
What serum progesterone level indicates a live intrauterine pregnancy?
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The gold standard investigation for obstetric complications is __________.
The gold standard investigation for obstetric complications is __________.
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Match the obstetric investigation to its significance:
Match the obstetric investigation to its significance:
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Which type of gestational trophoblastic disease is considered malignant?
Which type of gestational trophoblastic disease is considered malignant?
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Molar pregnancy can only occur in women under 25 years old.
Molar pregnancy can only occur in women under 25 years old.
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What is a common symptom of molar pregnancy?
What is a common symptom of molar pregnancy?
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Gestational trophoblastic neoplasia includes various types such as invasive mole and __________.
Gestational trophoblastic neoplasia includes various types such as invasive mole and __________.
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Match the following features of molar pregnancy with their descriptions:
Match the following features of molar pregnancy with their descriptions:
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What is one of the symptoms that suggests a ruptured ectopic pregnancy?
What is one of the symptoms that suggests a ruptured ectopic pregnancy?
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The triad of ectopic pregnancy consists of amenorrhea, abdominal pain, and vaginal discharge.
The triad of ectopic pregnancy consists of amenorrhea, abdominal pain, and vaginal discharge.
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What is the most specific and consistent symptom of ectopic pregnancy?
What is the most specific and consistent symptom of ectopic pregnancy?
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In cases of ruptured ectopic pregnancy, the patient may experience an urge to __________.
In cases of ruptured ectopic pregnancy, the patient may experience an urge to __________.
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Match the site of ectopic pregnancy with the appropriate timing for termination:
Match the site of ectopic pregnancy with the appropriate timing for termination:
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What is the primary initial treatment for a patient showing signs of obstetric complications?
What is the primary initial treatment for a patient showing signs of obstetric complications?
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Doughy consistency in the abdomen is a sign of obstetric complications.
Doughy consistency in the abdomen is a sign of obstetric complications.
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What follow-up measure is taken 48 hours after suction evacuation?
What follow-up measure is taken 48 hours after suction evacuation?
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Hysterectomy is indicated for women aged _____ years and above who have completed their family.
Hysterectomy is indicated for women aged _____ years and above who have completed their family.
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Match the follow-up procedures with their descriptions:
Match the follow-up procedures with their descriptions:
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Which type of gestational trophoblastic neoplasia is most commonly associated with molar pregnancy?
Which type of gestational trophoblastic neoplasia is most commonly associated with molar pregnancy?
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The presence of β-hCG plateau for 4 consecutive weeks is indicative of choriocarcinoma.
The presence of β-hCG plateau for 4 consecutive weeks is indicative of choriocarcinoma.
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What is the most common site for metastatic choriocarcinoma?
What is the most common site for metastatic choriocarcinoma?
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A persistent theca lutein cyst typically resolves in _______ after the suction evacuation of molar pregnancy.
A persistent theca lutein cyst typically resolves in _______ after the suction evacuation of molar pregnancy.
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Match the following clinical features with their associated gestational trophoblastic neoplasia:
Match the following clinical features with their associated gestational trophoblastic neoplasia:
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What procedure is indicated for a ruptured ectopic pregnancy?
What procedure is indicated for a ruptured ectopic pregnancy?
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A U/L salpingectomy is performed only if family completion is desired.
A U/L salpingectomy is performed only if family completion is desired.
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What does cervical motion tenderness typically indicate in an obstetric assessment?
What does cervical motion tenderness typically indicate in an obstetric assessment?
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If blood does not clot during culdocentesis, this suggests ___ in the pouch of Douglas.
If blood does not clot during culdocentesis, this suggests ___ in the pouch of Douglas.
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Match the surgical management procedures with their indications:
Match the surgical management procedures with their indications:
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What is the karyotype of a complete mole?
What is the karyotype of a complete mole?
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Maternal genes are absent in a complete mole.
Maternal genes are absent in a complete mole.
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What is the appearance of ultrasound in a complete mole?
What is the appearance of ultrasound in a complete mole?
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A partial mole is primarily caused by 1 ovum and _______ sperms.
A partial mole is primarily caused by 1 ovum and _______ sperms.
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Match the following features of molar pregnancy with the correct type:
Match the following features of molar pregnancy with the correct type:
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What is indicated by a β hCG value of ≥2000 IU with no gestational sac visible?
What is indicated by a β hCG value of ≥2000 IU with no gestational sac visible?
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The presence of a complex adnexal mass is a common sign in an unruptured ectopic pregnancy.
The presence of a complex adnexal mass is a common sign in an unruptured ectopic pregnancy.
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What is the first step in the investigation of a suspected ectopic pregnancy?
What is the first step in the investigation of a suspected ectopic pregnancy?
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The __________ sign indicates increased vascularity around an ectopic pregnancy.
The __________ sign indicates increased vascularity around an ectopic pregnancy.
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Match the following diagnostic signs with their significance:
Match the following diagnostic signs with their significance:
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Which type of ectopic pregnancy is specifically located in the near angle or cornua of the uterus?
Which type of ectopic pregnancy is specifically located in the near angle or cornua of the uterus?
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Angular pregnancy is located in the interstitium of the fallopian tube.
Angular pregnancy is located in the interstitium of the fallopian tube.
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Name one of the criteria for diagnosing cervical ectopic pregnancy.
Name one of the criteria for diagnosing cervical ectopic pregnancy.
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An ovarian ectopic pregnancy is characterized by the gestational sac being attached to the uterus by the __________.
An ovarian ectopic pregnancy is characterized by the gestational sac being attached to the uterus by the __________.
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Match the following types of ectopic pregnancies with their primary characteristics:
Match the following types of ectopic pregnancies with their primary characteristics:
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Study Notes
Medical Management of Ectopic Pregnancy
-
hCG Levels:
- Successful medical therapy: ≥15% decrease in hCG
- Repeat methotrexate (MTX) dose: <15% decrease in hCG
- Surgical management: Failed MTX therapy
-
Surgical management:
- Laparoscopy: For stable vital signs
- Laparotomy: For unstable vital signs
-
Specific surgical procedures:
- Unilateral salpingectomy: Regardless of family completion
- Oophorectomy: Only for ovarian ectopic
-
Post-surgical management:
- Expectorant or medical management may precede surgery (except for salpingectomy)
Gestational Trophoblastic Disease (GTD)
-
Types of GTD:
- Molar Pregnancy/Hydatidiform mole: Benign with potential for malignancy
-
Gestational trophoblastic neoplasia:
- Invasive mole
- Choriocarcinoma
- Placental site trophoblastic tumor (PSTT)
- Epithelioid trophoblastic tumor (ETT)
-
Risk Factors for Molar Pregnancy:
- Previous history of molar pregnancy
- South East Asian countries
- Extreme ages (very young or very old)
-
Clinical Features of Molar Pregnancy:
- Vaginal bleeding (first or early second trimester)
- Grape-like vesicles in the vagina
- Preeclampsia at an early stage
- Active space
-
Molar Pregnancy Investigations:
- Laparoscopy: Gold standard
- Serum progesterone: ≥25 ng/mL: Live intrauterine pregnancy
- Active space
Clinical Features of Ectopic Pregnancy
-
Triad of Ectopic Pregnancy:
- Amenorrhea
- Pain in the abdomen
- Bleeding per vagina
- Most specific/consistent symptom: Pain in the abdomen
-
Pain characteristics:
- Site: Lower abdomen (localized)
- Nature: Sharp or dull, unilateral
-
Pathophysiology of pain:
-
Ruptured ectopic:
- Hemoperitoneum (blood in the abdominal cavity)
- Mid/upper abdominal pain
- Danforth sign: Shoulder tip pain (diaphragm irritation)
- Urge to defecate
- Blood in the rectum (cul-de-sac pressure)
-
Ruptured ectopic:
-
Timing of Pregnancy Termination:
- Isthmus: 6-8 weeks
- Ampulla: 8-10 weeks
- Interstitium: 12 weeks
Ruptured Ectopic Pregnancy
- Diagnosis: Positive urine pregnancy test (UPT)
-
Symptoms:
- Triad of ectopic pregnancy + any of the following:
- Shoulder tip pain
- Urge to defecate
- Orthostatic hypotension
- Triad of ectopic pregnancy + any of the following:
-
Examination findings:
- Shock: May or may not be present
- Abdomen:
- Distension
- Rigidity
- Guarding
- Localizing signs
- Rebound tenderness
- Uterus: Enlarged but smaller than the period of gestation (POG)
Signs of Ectopic Pregnancy on Pelvic Examination
- Fundal Height: Greater than the period of gestation (POG) (Rarely ≤ POG)
- Fetal parts: Not palpable
- Fetal heart sounds: Absent
- Consistency: Doughy
Molar Pregnancy: Follow Up
-
Beta-hCG Levels:
- Baseline: Before procedures
- 48 hours after suction evacuation
- Weekly until 3 consecutive normal values (hCG ≤51U)
- Monthly for 6 months
-
Advice:
- Avoid pregnancy for 6 months
- OCP: Contraceptive of choice
- IUCD: Contraindicated
Gestational Trophoblastic Neoplasia (GTN)
-
Causes:
- Invasive mole (most common GTN)
- PSTT (most common cause of choriocarcinoma)
- Choriocarcinoma
-
Clinical Features after Hydatidiform Mole:
-
Signs & Symptoms:
- Persistent bleeding after evacuation
- Persistent theca lutein cyst
- Subinvolution of uterus
- Shock due to invasive mole
- Metastasis
-
Lab Criteria:
- β-hCG plateau for 4 consecutive weeks (D1, 7, 14): Suggestive of invasive mole, ±10% of previous value
- Increase in β-hCG ≥10% of previous value for 3 weeks (D1, 7, 14): Suggestive of choriocarcinoma
- β-hCG present after 6 months of evaluation (old criteria)
- Histopathology examination (HPE)
-
Signs & Symptoms:
Metastasis of Choriocarcinoma
-
Common Sites:
- Lung (most common):
- Stage 3
- Chest X-Ray (CXR):
- Cannon ball appearance
- Snowstorm appearance
- Vagina:
- Presentation: Suburethral nodules (most common)
- Recommendation: Biopsy
- Lung (most common):
Active Space
-
Pelvic Examination Findings:
- Most significant: Cervical motion tenderness (due to peritonitis)
-
Note:
- Pelvic inflammatory disease (PID): Negative UPT
- Cervical motion tenderness: Positive UPT / increased β-hCG: Suggestive of ectopic pregnancy
Management of Ectopic Pregnancy
- Triad of symptoms + positive UPT + localizing signs → FAST (Focused Assessment with Sonography for Trauma) → Surgical management
-
Route:
- Stable vitals: Laparoscopy
- Unstable vitals: Laparotomy
-
Surgery:
- Unilateral salpingectomy: Regardless of family completion
- Oophorectomy: Only in ovarian ectopic
Culdocentesis
- Indication: Ruptured ectopic
- Principle: Pouch of Douglas - Introduce syringe into cul-de-sac via posterior fornix - Aspirate after a while - Blood clots: Needle in blood vessel - Blood does not clot: Needle in pouch of Douglas, hemoperitoneum of ruptured ectopic
Partial vs Complete Mole
-
Pathogenesis:
-
Partial mole:
- Origin: One ovum + two sperms
- Karyotype: Triploid (69 XXY most common; 69XXX also possible; dispermic)
-
Complete mole:
- Origin: Empty ovum (no genetic material) + two sperms
- Karyotype: 46, XXX (monospermic)
-
Partial mole:
-
Karyotype:
- Partial mole: Triploid (69)
- Complete mole: Diploid (46)
-
Other Features:
-
Partial mole:
- Dispermic
- Maternal genes present
- p57 Ki67 staining (maternal genes): (+)
- Symptoms: Less common
- Height of uterus: N/A
- Ultrasound (IOC): Cystic spaces in placenta; Fetal tissues (+)
- Diameter of gestational sac: Transverse > AP
- Histopathological examination (HPE): Some fetal tissue; Vascular villi; Hydropic degeneration less
-
Complete mole:
- Monospermic
- Maternal genes absent
- p57 Ki67 staining: (-)
- Symptoms: More common
- Height of uterus: N/A
- Ultrasound: Snowstorm appearance; No fetal tissue; Absent amniotic fluid; Bilateral theca lutein cysts
- Diameter of gestational sac: N/A
- Histopathology: No fetal tissue; Avascular villi; Extensive hydropic degeneration
-
Partial mole:
-
Risk of choriocarcinoma:
- Higher in complete mole
- Lower in partial mole
Unruptured Ectopic Pregnancy: Investigations
-
Steps:
- Positive UPT
- Transvaginal sonography (TVS):
- Presence of gestational sac and yolk sac in the fallopian tube: Medical management
- Tubal sign/Bagel sign: Fallopian tube
- Ring of fire sign: Increased vascularity around the ectopic sac
- Empty uterus
- Complex adnexal mass (due to hemorrhage)
- Inconclusive findings: Further investigations
-
β-hCG:
- Critical titre: Value at which gestational sac is visible in an intrauterine pregnancy
- ≥2000 IU + No gestational sac: Unruptured ectopic: Medical management
Angular vs Cornual Pregnancy
-
Types of ectopic pregnancies:
- Cornual pregnancy: Near angle/cornua of uterus, lateral to the round ligament
- Ectopic pregnancy: Interstitium of fallopian tube/rudimentary horn of uterus, location varies
- Intrauterine pregnancy: Inside the uterus, medial to the round ligament
- Angular pregnancy: Near angle/cornua of uterus, location varies
Criteria for Non-Tubal Ectopic Pregnancies
-
Cervical ectopic:
- Paalman criteria:
- Internal os closed
- External os partially open
- Sac attached to endocervix
- Bleeding without uterine cramps
- Paalman criteria:
-
Ovarian ectopic:
- Spigelberg criteria:
- Sac present in ovary
- Tubes normal
- Gestational sac attached to uterus by ovarian ligament
- Histopathology: Ovarian tissue in gestational sac
- Spigelberg criteria:
-
Abdominal ectopic:
- Studdiform criteria:
- Uteroperitoneal fistula
- Tubes and ovary normal
- Pregnancy attached to peritoneum
- Note: Secondary abdominal ectopic most common
- Studdiform criteria:
Diagrams
- Diagram: Illustrates the location of each type of ectopic pregnancy, showing the uterine wall and its openings.
- Two diagrams: Closed and partially open external os
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Description
This quiz covers the medical and surgical management of ectopic pregnancy along with the understanding of Gestational Trophoblastic Disease (GTD). Test your knowledge on hCG levels, surgical procedures, and types of GTD, including risk factors and treatment options. Perfect for medical students and professionals looking to enhance their understanding of these conditions.
