Homework – Week 9
A 27 year old woman presents with painless vaginal bleeding six weeks after her last period. Her urine pregnancy test was positive 10 days ago. A transvaginal ultrasound scan shows a gestation sac containing a yolk sac and a fetal pole of 6.3mm. Fetal cardiac activity is absent. Her serum BhCG level is 1500 iu/l. Select the correct description of the scan findings from the list below. a.
Missed miscarriage b.
Pregnancy of unknown location c.
Pregnancy of uncertain viability d.
Partial mole e.
Complete miscarriage
Answer [ ]
A 27 year old woman presents with painless vaginal bleeding six weeks after her last period. Her urine pregnancy test was positive 10 days ago. A transvaginal ultrasound scan shows a gestation sac containing a yolk sac and a fetal pole of 6.3mm. Fetal cardiac activity is absent. Her serum BhCG level is 1500 iu/l. Select the most appropriate management plan from the list below. a.
Advise expectant management b.
Offer surgical evacuation of products of conception c.
Offer medical management of miscarriage d.
Re scan in seven days e.
Re scan by a more experienced sonographer
Answer [ ]
A 23 year old woman attends the early pregnancy unit at 7 weeks gestation with vaginal spotting, left iliac fossa pain and one episode of diarrhoea. A transvaginal scan has shown a 2x4mm echolucent area in the uterine cavity with no yolk sac or fetal pole. There is a moderate amount of free fluid in the pelvis. The serum BhCG level is 2300 iu/l. Her observations are: temperature 36.5
o C, blood pressure 100/65mmHg, pulse 120 bpm, oxygen saturation 98%, respiratory rate 24 per minute, pain score moderate. Select the most appropriate initial management from the options below. a.
Repeat quantitative BhCG in 48 hours b.
Rescan in seven days c.
Intramuscular methotrexate d.
laparoscopy e.
laparotomy
Answer [ ]

Homework – Week 9
A 34 year old woman presents with painless vaginal bleeding at 8 weeks gestation in her third pregnancy. She has a three year old child and her last pregnancy resulted in a spontaneous miscarriage at 7 weeks gestation six months ago. She is known to be rhesus negative. Which of the following statements is correct? a.
Complete bed rest for two weeks is recommended b.
Anti D isn’t required c.
Low molecular weight heparin should be commenced and continued till 12 weeks gestation d.
There is an increased risk of congenital abnormalities if the pregnancy continues e.
She should commence 75mg aspirin daily until 12 weeks gestation
Answer [ ]
A 35 year old woman has been fully investigated after her third first trimester miscarriage and all of the results are normal. Which of the following interventions have been shown to be effective in reducing the risk of further miscarriage in unexplained recurrent miscarriage:
A. Laparoscopic ovarian drilling
B. Weekly BhCG injections
C. support and counselling
D. Cervical cerclage
E. Progesterone supplements
Answer [ ]

Homework – Week 9
Option list
I
J
G
H
A
B
C
D
E
F
Conservative management
Cornual resection
Cornual resection with dye test
Methotrexate intravenously
Methotrexate orally
Mifepristone and misoprostol
Salpingectomy
Salpingo-oophorectomy
Salpingostomy
Tubal injection of potassium chloride
Each of the following clinical scenarios below relate to women with ectopic pregnancy. For each patient select the single most appropriate management option from the list above. Each option may be used once, more than once or not at all.
1. A 28 year old woman in her third planned pregnancy was referred to the Early Pregnancy
Assessment Unit. She has had two previous caesarean sections and is now 6-7 weeks gestation with a two day history of left iliac fossa pain and dark vaginal bleeding. An ultrasound scan showed and empty uterus, left adnexal mass and the serum BhCG level was 3,500 iu. She agrees to a laparoscopy. The findings are: normal uterus, both ovaries and right tube, left tube distended by an unruptured ectopic pregnancy 4x5cm in diameter. There is blood trickling from the fimbrial end and approximately 200 mls of blood in the pouch of Douglas.
2. You are asked to review a 32 year old woman in the Early Pregnancy Unit to make a management plan. This is her third pregnancy, the first resulted in an early miscarriage and the second was a left sided ectopic which was treated by laparoscopic salpingectomy. She presented at approximately 6 weeks gestation with right iliac fossa pain. The scan showed an empty uterus and the BhCG levels were initially 480 iu, 48 hours later were 595 iu and a further 48 hours later had risen to 612 iu. She wants to retain her remaining tube if possible.
3. A 25 year old woman presents with right sided pain and bleeding to the Early Pregnancy Unit at 7-
8 weeks gestation in her second pregnancy. The first pregnancy was a forceps delivery with a retained placenta and postnatally she received antibiotics for endometritis. A scan has shown an empty uterus with a 3x4cm right adnexal mass with a gestation scan, fetal pole and fetal heart seen within the mass. The serum BhCG level is 4,800iu, she is very reluctant to consider surgery as she really wants more children.