Podcast.
Tonight we started with an EMQ. I wrote it just before the tutorial and have not yet had time to write the answer. Send me your answer and I'll send mine as soon as it is done.
Early pregnancy complications.
Lead-in.
The following scenarios relate to early pregnancy. For each, select the most appropriate answer from the option list.
Each option can be used once, more than once or not at all.
Abbreviations.
AFC. antral follicle count.
AMH. anti-Mullerian hormone.
CRL. crown-rump length.
EPU. early pregnancy unit.
FSH. follicle stimulating hormone.
GTD. gestational trophoblastic disease.
GTG 17. RCOG Green-top Guideline 17. ”Recurrent Miscarriage.” 2003.
GTG 25. RCOG Green-top Guideline 25. ”The Management of Early Pregnancy Loss.“ 2006.
hCG. human chorionic gonadotrophin
MEUC. medical evacuation of uterine contents.
PUL. pregnancy of unknown location.
PUV. pregnancy of uncertain viability.
RM. recurrent miscarriage.
SEUC. surgical evacuation of uterine contents.
TVS. trans-vaginal scan
USS. ultrasound scan
Scenario 1.
A nulliparous woman attends the booking clinic at 8 weeks’ gestation. An ultrasound scan shows a missed miscarriage of a size commensurate with the gestation. What will be your management?
Scenario 2.
A nulliparous woman attends the booking clinic at 8 weeks’ gestation. An ultrasound scan shows a missed miscarriage of a size commensurate with the gestation. She has had two previous pregnancies; both resulted in 1st. trimester miscarriage. What will be your management?
Scenario 3.
A primigravid woman attends the A&E department with abdominal pain and vaginal bleeding. A home pregnancy test was +ve 1 week ago; the date of the LMP is uncertain. What will be your management?
Scenario 4.
A 40-year old woman is pregnant for the first time. Her periods have been erratic for 12 months and she has occasional hot flushes. She attends the A&E department with abdominal pain and vaginal bleeding. The bleeding is slight and her condition is good. An hCG is +ve and a TVS shows an incomplete miscarriage. What will be your management?
Scenario 5.
A 35-year-old woman has had two normal pregnancies. She attends the booking clinic after an unplanned conception. Her hCG is +ve. A TVS shows endometrial thickening but no evidence of intra-uterine pregnancy. No pelvic abnormality is seen. What will be your management?
Scenario 6.
A 35-year-old woman has had two normal pregnancies. She attends the booking clinic after an unplanned conception. Her hCG is +ve. A TVS shows a 15 mm. intra-uterine sac, but no fetus or yolk sac. What will be your management?
Scenario 7.
A 35-year-old woman has had two normal pregnancies. She attends the booking clinic after an unplanned conception. Her hCG is +ve. A TVS shows a 30 mm. intra-uterine sac, but no fetus. What will be your management?
Scenario 8.
A 35-year-old woman has had two normal pregnancies. She attends the booking clinic after an unplanned conception. Her hCG is +ve. A TVS shows an intra-uterine fetus with crown rump length of 5 mm., but no evidence of fetal heart activity. What will be your management?
Scenario 9.
A 35-year-old woman has had two normal pregnancies. She attends the booking clinic after an unplanned conception. Her hCG is +ve. A TVS shows an intra-uterine fetus with crown rump length of 6 mm. Fetal heart activity is seen. What will be your management?
Scenario 10.
A 35-year-old woman attends the A&E department at 6 weeks’ gestation with pain and bleeding. She became pregnant after IVF. An ultrasound scan shows a viable intrauterine pregnancy of a size compatible with the gestation. What will be your management?
Option List.
A. Admit as an emergency case.
B. Counsel and arrange TVS in 1 week.
C. Counsel and arrange TV colour Doppler scan.
D. Counsel re expectant management.
E. Explain diagnosis and counsel re MEUC and SEUC.
F. Explain diagnosis and counsel re expectant management and MEUC and SEUC.
G. Explain diagnosis and counsel re expectant management, MEUC and SEUC and refer to the EPU.
H. Explain diagnosis and counsel re treatment options with accent on the relative merits of SEUC and refer to the EPU.
I. Explain diagnosis and counsel re treatment options with accent on the relative merits of MEUC and refer to the EPU.
J. Counsel re missed miscarriage and refer to the EPU.
K. Explain diagnosis and refer to the EPU for PUL protocol.
L. Explain diagnosis and refer to the EPU for PUV protocol.
M. Manage as ectopic pregnancy until proven otherwise.
N. Arrange progesterone assay.
O. Arrange AFC.
P. Arrange AMH assay.
Q. Arrange serial hCG monitoring for 48 hours.
R. Administer anti-D immunoglobulin.
S. Administer ergometrine 0.5 mg i.m.
T. Prescribe mifepristone.
U. Prescribe misoprostol for vaginal use.
V. Continue with routine booking.
Then we moved on to essay plans.
81. A woman attends for a routine fetal anomaly scan at 20 weeks. Hydrops fetalis is diagnosed.
1. List the main causes of hydrops fetalis at 20 weeks. 8 marks.
2. Justify the history you will take. 4 marks.
3. Justify the investigations you will arrange. 4 marks.
4. Justify your management. 4 marks.
82. A woman attends for a routine fetal anomaly scan at 20 weeks. Echogenic bowel is seen.
1. List the main causes of echogenic bowel at 20 weeks. 6 marks.
2. Justify the history you will take. 4 marks.
3. Justify the investigations you will arrange. 4 marks.
4. Justify your management. 6 marks.
83. A woman attends for a routine fetal anomaly scan at 20 weeks. Bilateral choroid plexus cysts are noted.
1. List the main associations of choroid plexus cysts at 20 weeks. 6 marks.
2. Justify the history you will take. 4 marks.
3. Justify the investigations you will arrange. 4 marks.
4. Justify your management. 6 marks.
84. A 32 year-old woman with learning difficulty attends the gynaecology clinic with her mother. The referral is because of severe dysmenorrhoea and menorrhagia. The mother is keen for her to have hysterectomy and is prepared to give her consent.
1. What factors will you take into consideration before offering treatment? 8 marks.
2. Outline the treatment options, not including hysterectomy, that you will discuss. 6 marks.
3. If it is concluded that hysterectomy is the best option, justify the steps you will take to arrange this. 6 marks.
Next week we will not meet to allow last-minute revision. The next week is the week of the exam and we won't meet. The next tutorial will be on Monday 14th. March.
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