MBBS Miscarriage and ectopic pregnancies revision notes

A 32 year old woman, who had her last period 8 weeks ago, returns for review. She presented 2 days ago with light vaginal bleeding, but no pain. A pelvic ultrasound scan showed an empty uterus and a 2cm x 1.6cm echogenic mass around the left ovary. No free fluid was seen. Her beta HCG was 625 iu/L 48 hours ago. On examination today, she is non tender with blood pressure of 116/68 mmHg and a pulse of 80 beats/min. Her repeat beta HCG is 642 iu/L. What is the most appropriate management in this case?

Answer: METHOTREXATE INJECTION - this patient has been managed as expectantly with 48 hour review as she is clinically stable. The ultrasound scan suggests an ectopic in the left ovary but there is no evidence of rupture, as she is haemodynamically stable and there is no free fluid in the pelvis. Her serum HCG has plateaued, which suggests ectopic pregnancy rather than an intrauterine pregnancy (where levels would be expected to double) or a miscarriage (where levels would fall)

A 31 year old woman presents with a 2 day history of sharp right iliac fossa pain and one episode of vaginal bleeding. She is unsure of her last menstrual period, but had a positive pregnancy test 1 month ago. Her past obstetric history is G5P3 +1. On examination she has right adnexal tendernous, with blood pressure of 95/55 mmHg and a pulse of 76 beats/min. An ultrasound scan shows an empty uterus, free fluid in the pouch of douglas and a 4cm dilated right fallopian tube. She has no desire to have any more children. What is the most appropriate management in this case?

Answer: LAPAROSCOPY +/- SALPINGECTOMY. This patient is presenting with an ectopic pregnancy. There is a 20 fold risk of ectopic pregnancy in patients who have had one before. She needs to have a laparoscopy and removal of the tube containing the ectopic pregnancy.

A 29 year old woman is referred from the emergency department with severe left iliac fossa pain. Her last menstrual period was 8 weeks ago and she had a positive pregnancy test. Past obstetric history is G1P1. On examination she appears unwell, with a blood pressure of 80/42mmHg and a pulse of 120 beats/min. She has left iliac fossa tendernous and cervical tendernous on vaginal examination. Pelvic ultrasound shows a left adnexal mass, obscured by free fluid demonstrating a foetal heartbeat. What is the most appropriate management in this case?

Answer: URGENT LAPAROTOMY - this woman requires emergency laparotomy due to haemodynamic instability and a live, bleeding ectopic pregnancy. The aim is rapid cessation of bleeding.

The 32 year old woman from flashcard 1 returns four days later. She has had some cramping lower abdominal pain with no bleeding. Blood pressure is 110/83 mmHg and pulse 75 beats/min, A repeat Beta HCG is 587 iu/L. What is the most appropriate management option?

Answer: METHOTREXATE INJECTION - she is still stable with acceptable but plateaued beta HCG. The required 15% fall in beta HCG has not been reached, so in this case a second dose of methotrexate is required. The cramping abdominal pain is likely a side effect of the methotrexate. Pregnancy should be avoided 3 months after methotrexate.

A 25 year old woman presents to the emergency department with 3 days of heavy vaginal bleeding which is now settling and left sided lower abdominal pain. Her last menstrual period was 6 weeks ago. Blood pressure is 124/80 mmHg and pulse 84 beats/min. Pelvic ultrasound showed no gestational sac or pole. The Beta HCG was 841 iu/L initially and 631 iu/L 48 hours later. What is the most appropriate management option?

Answer: Repeat Beta HCG in 48 hours. In this case, no mass or free fluid could be see on the ultrasound and Beta HCG results are falling satisfactorily with expectant management. She can therefore continue with observation by repeating Beta HCG in 48 hours. Weekly Beta HCG tests are taken until levels are less than 50 iu/L