Obstetrics Marrow Pg 435-444 (Obstetrics Complications)
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Obstetrics Marrow Pg 435-444 (Obstetrics Complications)

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Questions and Answers

What does a fall in hCG of less than 15% indicate in the management of ectopic pregnancies?

  • Complete resolution of the pregnancy
  • Successful medical therapy
  • Inadequate dose of methotrexate (correct)
  • Need for follow-up only

    • 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?

    3 doses

    If a fall in hCG is less than 15%, the treatment management for ectopic pregnancy may involve repeating the entire dose of __________.

    <p>methotrexate</p> Signup and view all the answers

    Match the following outcomes to their corresponding hCG fall percentages:

    <p>≥ 15% = Successful medical therapy &lt; 15% = Inadequate dose or failed therapy Maximum 3 doses = Repeat methotrexate Surgical management = Failed therapy</p> Signup and view all the answers

    What is considered the gold standard for investigating obstetric complications?

    <p>Laparoscopy</p> Signup and view all the answers

    A serum progesterone level of less than 25ng/mL indicates a live intrauterine pregnancy.

    <p>False</p> Signup and view all the answers

    What serum progesterone level indicates a live intrauterine pregnancy?

    <p>≥25ng/mL</p> Signup and view all the answers

    The gold standard investigation for obstetric complications is __________.

    <p>laparoscopy</p> Signup and view all the answers

    Match the obstetric investigation to its significance:

    <p>Laparoscopy = Gold standard for investigation Serum progesterone = Indicates viability of pregnancy Ultrasound = Commonly used for monitoring MRI = Used for complex imaging needs</p> Signup and view all the answers

    Which type of gestational trophoblastic disease is considered malignant?

    <p>Choriocarcinoma</p> Signup and view all the answers

    Molar pregnancy can only occur in women under 25 years old.

    <p>False</p> Signup and view all the answers

    What is a common symptom of molar pregnancy?

    <p>Vaginal bleeding</p> Signup and view all the answers

    Gestational trophoblastic neoplasia includes various types such as invasive mole and __________.

    <p>choriocarcinoma</p> Signup and view all the answers

    Match the following features of molar pregnancy with their descriptions:

    <p>Vaginal bleeding = Occurs in first trimester Hydropic degeneration = Excessive swelling of the tissue Grape-like vesicles = Characteristic appearance in moles Benign disease = Potential for malignancy</p> Signup and view all the answers

    What is one of the symptoms that suggests a ruptured ectopic pregnancy?

    <p>Shoulder tip pain</p> Signup and view all the answers

    The triad of ectopic pregnancy consists of amenorrhea, abdominal pain, and vaginal discharge.

    <p>False</p> Signup and view all the answers

    What is the most specific and consistent symptom of ectopic pregnancy?

    <p>Pain in abdomen</p> Signup and view all the answers

    In cases of ruptured ectopic pregnancy, the patient may experience an urge to __________.

    <p>defecate</p> Signup and view all the answers

    Match the site of ectopic pregnancy with the appropriate timing for termination:

    <p>Isthmus = 6-8 weeks Ampulla = 8-10 weeks Interstitium = 12 weeks</p> Signup and view all the answers

    What is the primary initial treatment for a patient showing signs of obstetric complications?

    <p>Suction evacuation followed by sharp curettage</p> Signup and view all the answers

    Doughy consistency in the abdomen is a sign of obstetric complications.

    <p>True</p> Signup and view all the answers

    What follow-up measure is taken 48 hours after suction evacuation?

    <p>Beta-hCG levels</p> Signup and view all the answers

    Hysterectomy is indicated for women aged _____ years and above who have completed their family.

    <p>40</p> Signup and view all the answers

    Match the follow-up procedures with their descriptions:

    <p>Baseline Beta-hCG = Measured before any procedure Beta-hCG 48 hours after = Measured to check for changes post-procedure Weekly Beta-hCG = Continued until 3 consecutive normal values are reached Monthly Beta-hCG = Continued until 6 months post-procedure</p> Signup and view all the answers

    Which type of gestational trophoblastic neoplasia is most commonly associated with molar pregnancy?

    <p>Invasive mole</p> Signup and view all the answers

    The presence of β-hCG plateau for 4 consecutive weeks is indicative of choriocarcinoma.

    <p>False</p> Signup and view all the answers

    What is the most common site for metastatic choriocarcinoma?

    <p>Lung</p> Signup and view all the answers

    A persistent theca lutein cyst typically resolves in _______ after the suction evacuation of molar pregnancy.

    <p>2 months</p> Signup and view all the answers

    Match the following clinical features with their associated gestational trophoblastic neoplasia:

    <p>Persistent bleeding after evacuation = Invasive Mole Cannon ball appearance on CXR = Choriocarcinoma Suburethral nodules = PSTT β-hCG plateau for 4 consecutive weeks = Invasive Mole</p> Signup and view all the answers

    What procedure is indicated for a ruptured ectopic pregnancy?

    <p>Culdocentesis</p> Signup and view all the answers

    A U/L salpingectomy is performed only if family completion is desired.

    <p>False</p> Signup and view all the answers

    What does cervical motion tenderness typically indicate in an obstetric assessment?

    <p>Peritonitis</p> Signup and view all the answers

    If blood does not clot during culdocentesis, this suggests ___ in the pouch of Douglas.

    <p>hemoperitoneum</p> Signup and view all the answers

    Match the surgical management procedures with their indications:

    <p>U/L salpingectomy = Performed irrespective of family planning Oophorectomy = Only for ovarian ectopic Laparoscopy = For stable vitals Laparotomy = For unstable vitals</p> Signup and view all the answers

    What is the karyotype of a complete mole?

    <p>Diploid (46)</p> Signup and view all the answers

    Maternal genes are absent in a complete mole.

    <p>True</p> Signup and view all the answers

    What is the appearance of ultrasound in a complete mole?

    <p>Snowstorm appearance</p> Signup and view all the answers

    A partial mole is primarily caused by 1 ovum and _______ sperms.

    <p>2</p> Signup and view all the answers

    Match the following features of molar pregnancy with the correct type:

    <p>Triploid karyotype = Partial Mole Avascular villi = Complete Mole Presence of maternal genes = Partial Mole Monospermic origin = Complete Mole</p> Signup and view all the answers

    What is indicated by a β hCG value of ≥2000 IU with no gestational sac visible?

    <p>Unruptured ectopic pregnancy</p> Signup and view all the answers

    The presence of a complex adnexal mass is a common sign in an unruptured ectopic pregnancy.

    <p>True</p> Signup and view all the answers

    What is the first step in the investigation of a suspected ectopic pregnancy?

    <p>UPT (Urine Pregnancy Test)</p> Signup and view all the answers

    The __________ sign indicates increased vascularity around an ectopic pregnancy.

    <p>Ring of fire</p> Signup and view all the answers

    Match the following diagnostic signs with their significance:

    <p>Tubal sign = Indicates a dilated fallopian tube Ring of fire = Increased vascularity around ectopic Empty uterus = No intrauterine pregnancy found Complex adnexal mass = Associated with hemorrhage</p> Signup and view all the answers

    Which type of ectopic pregnancy is specifically located in the near angle or cornua of the uterus?

    <p>Cornual pregnancy</p> Signup and view all the answers

    Angular pregnancy is located in the interstitium of the fallopian tube.

    <p>False</p> Signup and view all the answers

    Name one of the criteria for diagnosing cervical ectopic pregnancy.

    <p>Internal os closed</p> Signup and view all the answers

    An ovarian ectopic pregnancy is characterized by the gestational sac being attached to the uterus by the __________.

    <p>ovarian ligament</p> Signup and view all the answers

    Match the following types of ectopic pregnancies with their primary characteristics:

    <p>Cervical ectopic = Attached to endocervix Ovarian ectopic = Sac present in ovary Abdominal ectopic = Pregnancy attached to peritoneum Cornual pregnancy = Lateral to round ligament</p> Signup and view all the answers

    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)
    • 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
    • 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)

    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

    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)
    • 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
    • Risk of choriocarcinoma:
      • Higher in complete mole
      • Lower in partial mole

    Unruptured Ectopic Pregnancy: Investigations

    • Steps:
      1. Positive UPT
      2. 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:
        1. Internal os closed
        2. External os partially open
        3. Sac attached to endocervix
        4. Bleeding without uterine cramps
    • Ovarian ectopic:
      • Spigelberg criteria:
        1. Sac present in ovary
        2. Tubes normal
        3. Gestational sac attached to uterus by ovarian ligament
        4. Histopathology: Ovarian tissue in gestational sac
    • Abdominal ectopic:
      • Studdiform criteria:
        1. Uteroperitoneal fistula
        2. Tubes and ovary normal
        3. Pregnancy attached to peritoneum
        • Note: Secondary abdominal ectopic most common

    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.

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